Your Questions

Q: Dr. Eppley, I am seeking an Asian rhinoplasty. I want the maximal amount of nasal tip projection and thinning that can be achieved. What can be done to give the nose these tip changes and want can I realistically expect if I do them?

A: In every single case of an Asian rhinoplasty that I have ever done, improved tip projection and shape is always a primary aesthetic goal. There is a limit, however, as to how much nasal tip definition can be achieved based on the thickness of one’s skin. The most nasal tip definition can only be achieved by the combination of a columellar strut, lower alar cartilage dome narrowing and stacked shield grafts on top of it. (if using rib it would be an L-shaped construct)  In every case of an  Asian rhinoplasty that I have done this i always the objective and the maximum tip lengthening procedures are done to achieve it. The only caveat I would add is that the amount of tip projection created can not cause some much pressure on the tip skin that it blanches it on closure. This will set up the  potential tip skin necrosis.

Whether this approach can achieve what you are expecting is a bit of an unknown as you can not simply make ay Asian nose as long or as thin as some patients would like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to know if I can have a breast lift with implants in place. I had breast augmentation before I had children at 26 years old. Seven years later after two children my breasts have gotten so heavy and saggy. I saw one plastic surgeon who said he could just do a breast lift using my current implants. My concern is having a lift then having to go back in in a few years to have saline implants replaced when they eventually deflate. Would love to get good result with breasts that are lifted with more upper pole fullness using my current implants.

A: As long as the implants are in good position, one can always have a breast lift on top of them. No one can predict how long your current saline implants will function before they fail. It could be next month or ten years from now. To get the best value from your current implants, I would recommend having the breast lift and leaving the implants alone. They are not that old and you should get more than a few years of use out of them. You can always replace them with silicone implants when they fail as such a replacement surgery is very easy with next to no real recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, thank you for the great fat grafting done to my cheeks a few weeks ago. It has helped a lot and I know that it is too early to tell how much fat will survve. But should a significant or at least enough fat go way that I want more at the three month time after the surgery, would you be able to go in and get more fat to put into that cheek?  I was looking at some publications by Coleman and it appears that it is OK to inject more into the face after a three month waiting period.  Also, is it true that you can extract a lot of fat and then freeze it for use in future treatments?  What does the literature say about this type of procedure?

A: Secondary fat grafting can be done anytime after the initial procedure. The reason that the three month time period is given is so that one has enough time to fully appreciate how much fat has taken. Three months is the generally accepted time period to see the balance between what fat has died and been absorbed and how much has survived…thus making the final achieved contour change visible. Harvested fat can be stored in a frozen state for future use. Despite its appeal, however, the medical literature indicates that the thawed and re-injected fat quickly undergoes complete resorption. While not completely understood, the freezing and thawing process apparently is very detrimental to fat cells. (adipocytes)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am debating on a sliding genioplasty vs silicone implant for chin augmentation.. I know that up to 10mms in vertical length can be achieved by a genioplasty, as well as width changes through hydroxyapatite blocks. I would like to get your personal opinion on this. For a male, what would be a normal range of chin length from lowest part of the bottom lip to the end of the chin? What length would the chin need to be for a male in order to warrant a lengthening genioplasty or to declare it unnecessary? I want to add as much size to my face as possible, length and width wise.

A: For chin augmentation, both a sliding genioplasty and an implant can be used to create vertical length for a more profound or dominant chin. However, there is no standard or normal range for how vertically long one’s chin should be. It is more of a ratio to the other vertical facial thirds and how dominant one prefers their lower third of the face. As a general rule in my experience, few patients need the vertical length of the chin increased by as much as 10mm. That would be too long for even many men, particularly when other dimensions of the chin are being added as well.

While a sliding genioplasty is traditionally perceived as being the only method to vertically lengthen the chin, custom designed implants can also be used today.  However they may not do it equally well. Because of the limits of the bone cuts of a sliding genioplasty, significant vertical lengthening may look ‘unusual‘ as only the chin of the jawline drops down. In contrast,  custom designed implant can vertically lengthen a larger portion or the entire jawline for a more natural blending of the vertical lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty a few months and this dent has appeared between my lip and chin that was not there before the surgery. Why has this dent occured and can it be fixed. While I like my new chin position, I do not like this dent and want it fixed if possible.

A: A sliding genioplasty moves the chin bone forward but does not change what lies above it. That dent is the labiomental fold/sulcus which is the fixed attachment of the superior mentalis muscle to the bone. It may have become more prominent after surgery due to the chin advancement and/or scar tissue or a tightly restored mental is muscle attachment. I have seen this numerous times after chin advancement procedures particularly sliding genioplasties. It can be improved/fixed by either an intraoral release alone or combined with a dermal-fat graft after the release to prevent it from becoming re-attached.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, I am looking into hairline lowering, jaw reduction with male liposuction (chin too long), brow reduction (I believe I will have to have my brow cut off and reshaped. Also, I have heard of a procedure called the FROST procedure for hairline lowering without a tissue expander. Do you perform this procedure? I have a high forehead and want to make sure it is right.

A: Hairline lowering in men is unique because of the important and unknown stability of the male frontal hairline. The patients has to be selected carefully based on their hairline pattern, density, age and genetics. Having done numerous male procedures that involve an incision along the frontal hairline (hairline lowering, pretrichial brow lifts, brow bone reductions), I have always been impressed with how well the scar usually does despite an always concern about it. Interestingly, recent published research has shown that the hairline incision (in women) seems to preserve hairline stability. (whether the same is true in men is speculative but not necessarily proven) The amount that the hairline can be moved forward depends on the natural stretch of one’s scalp and the technique used to do it. While there is no question a tissue expander always ensures the maximum amount of hairline advancement, most patients do not want that two-step process. (particularly men) There is nothing new or unique about the FROST procedure for hairline lowering. It is a good acronym for the technique but is an approach that I commonly use in men or women. Most surgeons think of hairline lowering a raising up a portion of the top of the scalp to bring it forward. This more limited approach to hairline lowering will usually not get more than about 1 cm of movement at best. But if one raises the entire scalp (behind the hairline incision) in a subgaleal plane the whole to the bottom of the back of the head, scores the galea for further release and then secure its anterior edge to the desired position on the frontal bone with transosseous sutures, advancements of 3 to 5 cms are possible. (this is what is done in the so called FROST procedure) It is just a more aggressive form of scalp mobilization that many surgeons may not feel comfortable doing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ll be getting eyebrow transplants done next Monday. I’ve also been looking at getting some fillers to augment my radix (and possibly glabella). Anyway, my surgeon has advised me that it should be fine to get fillers shortly after the transplants (he suggested doing it next Friday) as they won’t be in the same area as the transplants. Just wondering though, will getting fillers so shortly after the eyebrow transplants have any adverse effects on hair growth? Thank you for taking the time to answer me.

A: In short, there is no correlation between having eyebrow transplants and injectable fillers. Even if the fillers were being injected right under the brow at the same time as having hair transplants, it would not affect the take of the hair transplants or how well they would subsequently grow. Given that the injectable fillers would be placed in the radix of the nose, away from the hair transplants, makes it even ‘safer’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a forehead osteoma removal. I have a bump inthe dead center of my forehead that I would like removed. It sticks out like aore thumb and is very visible and bothersome to me. I have attaches several pictures to show you where it is.

A: It is hard to say based on this picture whether your forehead bump is an osteoma or a natural frontal bone contour. That distinction is critically important as it affects the surgical technique to remove it. An osteoma is a bone growth that develops over time and looks very much like a flattened mushroom sitting on top of the bone. Because of its shape,it can be fairly easily removed by an osteotome (chisel) from a remote incision in the scalp. (endoscopic technique) In essence, it is just swiftly chiseled off of the bone. Conversely, a forehead bump that is just a natural part of the frontal bone has to be taken down by a handpiece and burr. This is much more technically challenging from an equipment standpoint when trying to that with an endoscopic scalp approach. (particularly given that it is way down in the center of his forehead.

The history of the bump goes a long way in defining what it may be. A natural frontal bone contour/bump will have been there since he was born or very young. An osteoma often appears later in life often after a traumatic event.

By feel, they also can have a different feel to them. Some osteomas almost feel like there is a ‘lip’ at the edge. While a natural born bump will feel smooth with no palpable edge or lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial feminization surgery. I specifically want: 1. lower forehead and brow ridge bone contouring, 2. forehead and eyebrow lift, 3. hairline restoration by scalp advancement and hair transplantation, 4. upper forehead bone augmentation, 5. frown line and crow’s feet surgical correction, 6. feminizing rhinoplasty, 7. cheek (malar or submalar) augmentation, 8. lip lifting, 9. chin contouring (reduction) & sliding genioplasty or chin augmentation by implant 10. jaw contouring (reduction). I also would like to know if possible can i have all these procedures done at the same time ?

A: All of the procedures you have listed are very common and often part of an overall facial feminization surgery (FFS) approach. When it comes to FFS surgery, most of them can be done all at the same time although some work against the others and are best deferred for a second surgery if needed.

Brow bone reduction/reshaping, upper forehead augmentation and scalp (hairline) advancement can all be combined and would need to be due to the same incision used for all of them. At the same time, a rhinoplasty, cheek implants and chin/jawline recontouring can be done.

There is no specific surgery for crow’s feet or frown lines. When doing an open rhinoplasty, a lip lift can not be done at the same time due to blood supply concerns of the intervening columellar skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just wanted a consult to see if a tummy tuck or laser skin tightening would be an option for me. I had a child almost two years ago and lost over 60lbs.

A: The decision between a tummy tuck and another abdominal contouring option is often debated. However, you have said two things that helped define your tummy options, even without seeing pictures of it. (although that would also be helpful) The combination of having a child and losing over 60lbs had made the use of laser skin tightening an impossibility. Even at best, laser skin tightening may be able to tighten about 1 cm. (1/2 inch of skin) I suspect that the amount of loose abdominal skin that you have exceeds that by a considerable amount. Being between stretched by pregnancy and then losing that amount of weight, the elasticity of skin has been broken and its ability to tighten removed. A tummy tuck is undoubtably what you will really need to get the improvement in abdominal tightening that you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a Smartlipo laser liposuction procedure. I have a fatty tumor behind my arm and would like to remove it with the least invasive procedure. I also have fatty tumors in my legs which would love for them to be gone also.

A: Smartlipo or laser liposuction is one possible treatment approach for smaller lipomas. While all of these lipomas could be simply removed by excision, I could understand why you would not want the fine line scars. What is important to understand is that treating them by Smartlipo/laser liposuction is not quite the same as removing traditional unwanted fat. Unwanted fat is soft non-encapsulated fat that extracts easily and thoroughly after being partially liquified by the laser energy by small cannula liposuction. In contrast, lipomas are well encapsulated ‘balls’ of fat that are really benign tumors. The laser energy may break them up into small pieces but it does not necessarily liquify them completely and thus they are not as easy to extract by liposuction. The point being is that the laser liposuction treatment method of lipomas is best viewed as a reduction method that may or may not result in them being completely removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question concerning the jaw implant implants. I read a recent article which talked about disruption of the masseter muscle following jaw implant surgery due to disruption of the pterygomasseteric sling. The article talked about how the muscle could retract up and cause problems. Is this a complication you have seen often? Or is there some technique you have for preventing this?

A: In placing jaw angle implants, it is a submuscular/subperiosteal implant location over the ramus (jaw angle) of the mandible. These tissues must be lifted up to insert the implants. The masseter muscle wraps around the mandible and creates the pterygomasseteric sling. (muscle on both sides of the mandible) Thus when lifting up the muscle along the bottom edge of the bone it is possible to disrupt/tear this sling where it is the thinnest/weakest. If the muscle is completely torn along its entire length when it is being raised. If this happens it is possible that the masseter muscle will retract and could be seen as a bulge above the lower border of the implant.

While I have seen this potential issue discussed/written about, it is not a phenomenon in jaw angle implants or fracture repair or sagittal ramus osteototmies that I have ever seen. (all jaw operations that separate the pterygomaseeteric sling from the bone) The key in elevating this tissue is to do it gently and with attention to not tearing the muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in calf augmentation with fat grafting/lipo filling. I am a 33 year old man with over a decade of weight lifting and exercise experience. I have trouble building muscle particularly in my calfs. I am hoping fat grafting can give me the desired look I’ve been working so long for.

A: While I appreciate one’s desire to build body contours using one’s own tissues, there are several key issues about injectable fat grafting. First, one has to have enough fat to harvest that, after filtering and purification, has enough volume to augment the calfs as well as any other areas. Whether a young man who is most likely fit has enough fat to accomplish that remains to be seen. Secondly, fat grafts are not like implants. The predictability of their survival to maintain volume is far from assured. Injectable fat grafting is associated with a wide variability in fat volume retention and young lean people usually have a lower retention rate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have there been any improvement to help with outpatient healing for pectoral implants?  Having helped with liposuction recovery and breast implants it looked pretty brutal seeing the fluids and bruising/swelling and that didn’t involve having to fly back home. I’d consider it to get that permanent sculpted definition in the upper chest if possible, just seems like it has be done a little more artistically on a male than female to get the correct look as too large would look too unnatural.

A: Pectoral implants are in some ways very similar to breast implants but are a bit different. Pectoral implants are solid elastomer implants not fluid filled, thus they will never rupture or need replaced. While they are placed below the pectorals major muscle, unlike breast implants they are are not placed below the lower pectoral line which means there is less soft tissue dissection and no disruption of the muscular attachments. There is no the same amount of bruising or swelling as with breast implants an no fluid drainage like in liposuction. While it is a muscular recovery, I would not consider it ‘brutal’ or that severe.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a minor skull reshaping procedure. Can you fix the dent on the right side of my head with relatively minimal invasive surgery? Question 2: I have had the dent as long as I can remember, I’m 42 years young! Is there a formal name for my “condition”? I suspect what we are looking at here is in fact a dent. My only other theory is that my forehead maybe high on my right side thus giving the appearance of a dent toward the back right side? Thank you very much for your time.

A: You at an ideal candidate for a small skull reshaping operation. You do, in fact, have a high forehead dent or groove in the bone. It has no other formal name although it lies parallel or may be over the original coronal skull suture. Thus it may be a malformation of the coronal suture where the two edges of bone come together to fuse. Regardless of its etiology, it can be treated by a minimally invasive cranioplasty procedure. By making a very small scalp incision (less than 1 cm.) the tissues over and around the dent can be elevated. Then through a small tube, a bone cement material can be injected and then smoothed out from the outside as it sets. This could be done under local/IV sedation with really no recovery other than a small amount of swelling. The ‘trick’ to this procedure is to not overfill it and get the entire area smooth and flat. You don’t want to trade off a ridge for a dent.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what are the pros and cons of buttock augmentation by fat grafting? I can’t decide between getting an implant  or having fat injections done. Fat injections seem better but I read about some bad experiences with them.

A: The pros and cons of buttock augmentation by fat injection grafting are well known and are relatively classic between the effects of one’s own tissues vs. a synthetic implant. The pluses of fat injections in the buttocks are the body contouring benefits of the liposuction harvest, a much easier recovery, few if any complications such as infection or seromas, and a natural augmentation effect. Its negatives are the incredible variability and unpredictability of fat graft retention (may have partial or complete resorption of the fat), a small to moderate buttock augmentation result for most patients, and the potential need  for more than one fat grafting session for the best result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the cost of Mommy Makeover surgery? My body has been destroyed by having three children and I desperately need a body makeover. My breasts have shrunken and my stomach is so stretched out. I don’t look anything like I was once was fifteen years ago. 

A: It is a very common request for the cost of Mommy Makeover surgery. This type of plastic surgery, however, is more of a concept that has many components and is not just one standard set of procedures. There are many variations in Mommy Makeover surgery which includes options of breast lifts (4 types), breast implants (2 types), tummy tucks (2 types) and liposuction. (6 areas) Until I know exactly what specific combinations of these breast and abdominal reshaping procedures you need, there is no way to give you any accurate pricing. I would need to see some pictures of your body to be able to determine what you need and what it would cost to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants but for an unusual reason compared to most people who have jaw angle implant surgery. I naturally had well defined and square jaw angle which are not considered aesthetically desirable in Asians. I had jaw angle reduction surgery which I came to now realize is the old style amputation of the jaw angle bone. This has resulted in the soft tissue which has fallen and moved forward and therefore the frontal view of my face is now heavier than before. A CT scan also showed that the angles are not even  and or the same on both sides.  In addition, the angle is a lot steeper than before. Overall, the face is considerably narrower than before as the bone has been cut off. However, the face does not look better as I have a jowl (premature aging) due to this soft tissue which has fallen. Now, I am thinking that I would like some of that angle back as my new jaw has no definition. My questions about this potential surgery are:

1. I’d like to have a bit of an angle back to give the face definition. However, I don’t want the face wider. (I have a short face, and fear jaw implants will make my face rounder.) What would you do to obtain this? 

2. What is the risk of any complications such as infection?

3. What material is the custom jaw implant be made of? I heard some say it’s made of acrylic PMMA? Is this safe? What material is the safest?

4. How many years can I keep this jaw implant? 

5. Is it possible that I send you a CT scan in order for you to make a custom jaw angle implant? How long will it take for you to make this custom implant?

In addition, I have kept the jaw bones which were cut off.

A: In answer to your ‘reconstructive’ jaw angle implants questions:

1) The jaw angles can be replaced by implants that restore the angular shape (in the dimensions of height and length) but that adds no width at all and stays in line with your current jaw width.

2) While infection is always a risk with any implant in the body, I have only ever seen one and that was with a porous implant material. Infection in jaw angle implants, like most facial implants, is very uncommon.

3) I prefer silicone material for all facial implants when possible. This is because it is easy to insert (and remove if necessary), has the lowest risk of infection of any implant material, and is the least expensive to manufacture particularly when it comes to custom made implants. (PMMA implants can also be custom made using a skull model made from your CT scan and hand fashioned)

4) These implants should be permanent, will never break down or need to be replaced. (provided the desired aesthetic objective is achieved)

5) I would need to see the CT scan to see if it is adequate for custom implant manufacture. It would need to be a 3D CT scan done in high resolution.

The other very unique possibility since you still have the cut off pieces of jaw angles is to use them to manufacture the implants by designing directly off of them. I have never done that before but then no one has ever still had the their removed bone specimens.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a nostril narrowing procedure done a few years ago and the scar was hidden underneath the nostril, but now I have these two slits in the nostrils where the skin should be filled out. Is there a way to plump up the skin with filler or cartilage in the nasal still?Will these incision leave a scar? From looking at my pictures, do you think the cartilage grafting will make my nasal sills look natural? Do the cartilages last a long time and is it possible for the cartilage to come out of place from the “slits?” Where would the incision site be?  I hope I can fix my nasal sills, they are so obvious and it makes my nostrils look awkward.

A: To do the surgery, of course, incisions will need to be made. But they will be made within the scars you already have. The way to make your nasal sills look more natural is to remove the slits in them which are not normally present. One would think that just cutting out the slits and put the skin edges together should work (and that alone might) but there is definitely a propensity for scar contracture to ultimately re-create a notch or slit. That is the purpose of a small sliver of cartilage graft. By placing a small sliver of cartilage underneath the skin edges prior to closure, it serves as a bridge of support for the overlying skin to prevent a recurrent slit sill deformity. Cartilage normally does not resorb so its support will likely be permanent. Even if it does ultimately resorb it will do so over time…long after the nasal sills have healed

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, in seeking online consultations I have spoken to several plastic surgeons ti get their cheek implant choice opinions. Most have recommended a 3 to 4mm cheek implant for me. I understand that a small amount of augmentation goes a long way, but even so, 4mm and especially 3mm just seems a little too small, even though I don’t have much in the way of a deficiency. Do you often find a need for bigger cheek implants in men?

A: The reason that no greater than 4mm cheek implants were recommended to you is that 4mms is the thickest or largest in commercially available malar shell implants…the most popular cheek implant used today. While it is true that a few millimeters of augmentation go a long way in the face, you will likely find that inadequate for the cheek look you are after. I have designed custom cheek implants that are as much as 8 to 9mms thick for men seeking that male model look.

But cheek implants for most men can use several of the available styles and sizes that are commercially available. The male model look is a unique and often an extreme variant of what many men and women want for their cheek augmentation results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, regarding cheek implants, what sort of augmentation produces the male model look and you have written that the ‘male model look’ is a vague term, denoting a wide spectrum of shapes. So let me use Johnny Depp as an example of what I envision ad the male model cheek look that I want. There is a distinctive and characterful line that runs around the side of the face and down to the chin. From my perspective it seems like for a cheek implant to create this characteristic look it would need to focus augmentation on the lateral and oblique portions of the cheek. This, is it possible for a custom cheek implant to create this lateral augmentation of the zygomatic arch?

A: When it comes to the male model cheek implants look, Johnny Depp is one of the most classic examples of the look men are seeking. You have described what creates that specific cheek look and as you may be well aware, there is no standard off-the-shelf cheek implant that is really designed to create that look. While one has to have the right midface soft tissue anatomy for a cheek implant to create this effect (thin), no currently designed cheek implant augments the lateral edge of the zygomatic arch and comes forward anteriorly into the submalar region and onto the maxilla. Malar shell and submalar implants exist and are often used to try to create this effect but rarely create that exact cheek look. A custom or semi-custom approach to the design of cheek implants is the most likely method of at least creating the correct amount and location of the bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, regarding jaw implants is it not true that the large masseter muscle goes a very long way to creating the characteristic model look that patients are seeking? If bony anatomy is not the only factor does this not mean that a patient will fail to achieve an authentic looking result, seeing as the implant augments bony anatomy.

A: The concept of the male model look as it relates to the jawline is a variable one that does not have a specific look per se. While it is about a strong and well defined jawline, the front to back angulation of its inferior border and the height and flare of the jaw angles can be quite variable. I have been provided many desired male model jawline pictures from young men which have many variations.

While an exact male model jawline escapes an exact anatomic description, what is not unclear is that it is created by the bony shape of the mandible. While the masseter muscle can be very thick, it is rounded and lacks any defined or sharp edges. It creates bulk and not definition. It is only relevant in how thick it is as well as the thickness of the overlying subcutaneous fat. These tissue thicknesses can obscure any well defined bony shape or implant augmentative effect of the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Earwell ear reshaping. I have a two month old son who has prominent cup like ears. I am emailing you to ask if it is too late to possibly use the Earwell product to prevent possible cosmetic surgery in the future. His ears are still pretty soft and fold over on themselves very easily. Please let me know if this is still an option for him or would even still be successful in treating his prominent ears! 

A: Technically, Earwell ear reshaping works best when initiated within two to three weeks after birth. The ear cartilages do not yet have any memory so they will stiffen up around the molded plastic Earwell framework over the next month or so of use. While this is the ideal time to start Earwell, the reality is that many parents only start to think about therapy for their infant’s misshapen ear(s) weeks to months later. So your request at two months of age is not rare. Having initiated ear reshaping therapy in some cases at 6 to 8 weeks, there usually is some improvement in ear shape but not to the extent of that is seen when the external reshaping framework is applied within a few weeks after birth. The ear may seem floppy and without much cartilage stiffness at two months of age but the cartilage has already started to develop some stiffness (memory and thus is more resistant to cartilage molding forces.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have wanted to have a tummy tuck for the last five years. I have had two children who were both born at over nine pounds. I am 5’ 7” and weigh 135 lbs. I have worked out a lot and got my stomach as toned as it can be. However I still have hanging skin if i lay on my side or bend over. I have no confidence when I have no clothes on.

A: A tummy tuck is often the only solution for loose skin on one’s stomach. Diet and exercise help with loosing fat but can not get rid of loose skin or tighten it up. Stretch out or loose abdominal skin is an irreversible problem short of surgery. Even women who are relatively thin and work out regularly find out that they simply can’t make this skin go away. Such a realization often drives them to seek out tummy tuck surgery. Whether one needs a full or partial tummy tuck depends on how much loose skin exists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eye reshaping surgery. I am 26 years old and interested to have slanted/exotic/cat eyes. I’m not sure if canthoplasty alone will achieve my goals.
I don’t know if canthoplasty alone or canthoplasty combined with a cheek lift would work better. Will the canthoplasty and/or cheek lift fail in the short run due to gravity? such as lasting no more than a few months?

A: Changing one’s eyes to a look that is more ‘exotic’ almost always means the lateral canthus (corner of the eye) needs to be elevated and be substantially higher than the inner  corner. (hence the out to inner ward downward slant. Certainly the basis of doing requires a canthoplasty procedure of which the most secure would be what is known as a drill hole lateral canthoplasty which can really pull up and maintain a new lateral canthal position. This would be far more effective and secure than a canthopexy or even a standard lateral canthoplasty procedure where the tendons is sewn onto itself or to the periosteum of the inner orbital wall. Whether that would be enough depends on the tightness of your lower eyelid and the cheek skin which can really only be determined by a physical examination. The concept of a cheek lift is a supportive one to the corner of eye and/or providing more of an upward and outer sweep to the cheek and outer eye area. At your young age it would seem a cheek lift would most likely be excessive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reshaping. I have two large forehead bumps that can be easily seen, even from a distance. I was wondering if these could be smoothed down and what the cost would be? Also how long it would take to get in for an appointment and if anything else like a CT scan would need to be done?

A: Your forehead reshaping concerns present a common forehead anomaly that I see. Your forehead bumps are classic for what I call ‘forehead horns’. I have seen these many times and why they occur I can not tell you. But they tend to appear exactly where they are in you and are almost always bilateral. (on both sides) They are fairly easy to reduce and do not require a CT scan or x-ray before doing so. They involve the outer cortex of the skull bone and do not go ‘deep’ or past the diploid layer of the skull bone. When taking them down there often is an indentation below the bumps that, when the bumps are taken down, can make the forehead appear sloped backward. In these cases, I often apply a thin layer of bone cement to correct the forehead inclination. Whether this issue applies to you would require assessment of better pictures from different angles.

The forehead inclination issue aside, the far more important issue is how to get in to do the forehead bump reduction. This requires an incision somewhere and it is an issue of whether to use a more wide open scalp incisional approach or more limited incisions directly over the bumps. That is an issue for further discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having breast implants. I am currently a 34B and am interested in a full C or a small D cup. Also, I was previously 190 lbs and am now 135 lbs. I have a flabby area above my belly button which I would love to have tightened. I work out regularly, yet it just doesn’t seem to help. This area would be optional though, as my primary interest would be having breast implants. I saw the general fees for each procedure, and was curious if combining procedures offer any cost reduction. 

A: In answering your breast implants and tummy tightening questions:

1) When it comes to size of breast implants, I do not use the concept of cup size. While women understandably have that as a breast reference, implants come in volume (ccs) not cup size. And regardless of cups size or ccs, in the end all you really care about it how the breast looks…the number attached to it in that regard is not important as long as it looks the way you want. In choosing breast implant size in volume for any patient, I use a Volumetric Implant Sizing System. You can try on the various volumes and see how they look and then choose. I find this to be incredibly accurate which less to a very rare problem of patient dissatisfaction withe the outcome of their breast augmentation procedure.

2) Having lost 55 lbs, this raises the question of whether you have any loose breast skin or sagging. This is an important preoperative consideration since breast implants do not create a ‘breast lift’ effect and can make make a saggy breast look worse even though it is bigger. Seeing some pictures of your breast would help answer that question.

3) Your weight loss is also the source of the flabby area around your belly button. Since the belly button  is the only fixed point on the stomach, weight loss causes the skin around it to sag resulting in flabbiness and sometimes an actual upper belly button overhang. The only method to truly tighten loose abdominal skin is some form of a tummy tuck.

4) Your assumption is correct in that there is some cost savings when procedures are combined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a sliding genioplasty revision. I had sliding genioplasty done which left me with a defect on the right side. The surgeon who performed the initial operation was going to take bone from jaw to fill the defect, but I was thinking it would turn out badly considering how bad it looked directly after the procedure.  That was more than 10 years ago. A second surgeon I consulted stated he would use artificial filler to patch the defect and a very small implant if I wanted a more triangular “pixie-like” look to the chin.  I definitely don’t want my jaw any wider.  In fact I’d like it symmetric and less squared off on the sides. I’m just looking into my options at this point. I had so much trouble after the first operation with permanent anesthesia of the lower gum and my lip being slightly crooked.  Scared it might end up worse.

A: What is have is a rather classic sliding genioplasty revsion problem. When the chin bone is brought forward, it narrows the chin and can leave at the bony tails an indentation or step-off at the back edge of the genioplasty. Whether this occurs depends on how far the chin bone is brought forward and the angle of the bony cut. Sometimes this lower jaw edge defect can only be felt, in other cases it can be seen as in your case. The two approaches to treat it are to fill in the bony defects, often with hydroxyapatite granules, or with an overlying chin-prejowl implant. But either approach will tend to make your chin somewhat wider. The other approach is to narrow or remove the bony edge by making it more v-shaped or narrow. Such a chin reshaping procedure would not be associated with the issues you had during the initial sliding genioplasty since the bone is not being downfractured.

Dr. Barry Eppley

Indianapolis, Indiana