Your Questions

Q: Dr. Eppley, I would like a straighter more refined nose and a stronger jawline. This may require a chin augmentation but I am not sure what I really need. I just want to look more refreshed and have a more attractive face. I have attached some pictures for you to see and give me your recommendations.

A:  Thank you for your inquiry and sending your pictures. I have taken a look at them and can give you the following thoughts.

Your chin deficiency is as much a vertical one as it is a horizontal one. This can not be treated by a traditional chin implant as they can only provide increased horizontal projection. Vertical increase is very important in your chin augmentation. Either a custom chin implant needs to be fabricated or a chin osteotomy needs to be done. Either approach can be successful and I have done many both ways. There are advantages and disadvantages to either approach and they can be discussed in detail further by phone or by Skype.

Your nose shows a lack of tip projection and definition. The nasal tip is rounded and more ball-like. I do not see the lack of straightness in your nose that you have indicated in your inquiry. This can be improved by an open rhinoplasty with the use of a columellar strut graft alar rim grafts and tip reshaping. 

I have attached some before and after computer imaging to show the potential changes of the nose and chin based on these approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orthognathic surgery three years ago when my upper jaw was moved forward. While the surgery was successful and my underbite was fixed, I have a persistent problem with my lower lip. My lower lip hangs down and I have too much tooth show. I notice now that when I pull my lower jaw back, the lower lip comes up and corrects the problem. I am now thinking that instead of having my upper jaw brought forward, I should have had my lower jaw moved back. What do you think?

A:  It is hard for me to pass any comment on your previous orthognathic surgery, not having seen any preoperative x-rays or work-up. It can be difficult to determine in a Class III malocclusion (cross-bite) whether the upper jaw should come forward or the lower jaw to go back. Either manuever will correct the malocclusion but they can have different aesthetic outcomes, even if that can be somewhat subtle.

Everyone when they move their jaw backward creates more lower lip and allows it to move upward on the front teeth. So I don’t necessarily think that you doing so proves that a sagittal split setback of the mandible was a better procedure than the LeFort advancement.  

At this point, this discussion is somewhat irrelevant. You can’t undo your jaw relationship without repeating your orthodontics and undergoing further orthognathic surgery…a process that would take years and likely result in some permanent loss of sensation of the lower lip from the mandibular setback.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First of all I would like to appreciate your approach to educate general people like me about plastic, reconstructive and cosmetic procedures. I have a question regarding my scar revision. I have done scar revision yesterday. The revision was done to revise a pox scar on the lower middle forehead about 1 cm up of the starting of nose bridge. The scar was 5mm in wide and 6mm in length. Right now I am very much concerned about the post scar it will leave. I am hoping for a linear scar rather than the circular one. I would really appreciate your feedback regarding this.

A: Not having any knowledge of how your scar revision was performed, this is a question you should ask the doctor who performed it. By your description, I would assume that a simple horizontally-oriented elliptical excision of the forehead pox mark would be done with a resultant linear scar trade-off.  This circular scar result is a bit confusing to me unless some form of subcision was done in an effort to raise up a depressed scar rather than excising it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can silicone implants be replaced and the procedure partially paid for by your insurance company if they are entirely encapsulated?

A: No physician can tell you for sure whether your health insurance company will cover any plastic surgery procedure. There is a process known as predetermination which makes that decision about any elective non-urgent procedure. This requires a written letter by the plastic surgeon to the insurance company with the medical issues, diagnosis and proposed surgery outlined. The insurance company will then review it and make its determination to you, a process that will take at least several weeks.

That being said, a general rule is that insurance will not pay for any implant-related plastic surgery procedures in which the implant was not initially placed for a medically necessary reason. This refers to breast reconstruction procedures with an implant done to restore a breast partially or fully removed after cancer. It is unlikely that capsular contracture in breast implants placed for cosmetic reasons, unless there is evidence of an implant rupture, would be covered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am female, 35, interested in brow bone shaving. My brow bone is a bit too thick, and I feel it looks a bit masculine. Is there any risks to shaving the bone in the glabella area? Would this make the bone there too thin and easier to fracture in the event of an injury? I don’t need too much shaved, but wondering if even a bit of shaving is risky. Thank you.

A: The issue with brow bone shaving is not one of real medical risk. The only issues with brow bone reduction are two-fold. First, you need a scalp incision and turn down flap to do it. So there will be a resultant fine line scar in the scalp. Secondly, and more relevant to your question, shaving the brow bone has the risk of burring right into the frontal sinus cavity. Most of the brow prominence is not composed by bone at all, but by air from the sinus cavity undermeath. How significantly one can burr down the brow bone depends on how thick the outer cortical table of the frontal sinus is. Often times it is no thicker than 2 to 3mms. The glabellar area, the part of the brow bone between the eyebrows, often will have no frontal sinus cavity underneath so it may be able to be reduced much more.

For these reasons, it is necessary to determine a patient’s eligibility for brow bone reduction knowing in advance the location of the frontal sinuses and measuring the thickness of the bone. This can be done with simple plain x-rays taken from the front and side views. For some patients, brow bone reduction by burring is adequate (minority of patients), but other patients need to have done an osteoplastic bone flap technique due to their thin outer bone covering of the sinus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is about face fillers. I had some permanent filler injections done on my cheeks 4 years ago. I am now developing hypersensitivity, not at the site of the filler, but over the sinus and neck muscles and headaches. Plus my eyebrows are thinning .The surgeon told me the filler used is BIOALCAMID .What is your opinion on can the filler be removed?

A:  Bio-AlCamid is a gel polymer filler that is composed of a 3% to  4% concentration of alky-amide polymer and 96% water. It is used around the world but is not approved in the U.S.  It maintains it volume through the attraction of water to the non-resorbable polymer which is then surrounded by a scar capsule. The manufacturer says that it can be removed relatively easily and this may be true if it is well encapsulated and can be palpated. Once the capsule is entered, the material will likely be expressible. The other key question is what to do after the material is removed as there may likely be a deflation effect seen on the outside of the face. While one could use any of the available temporary hyaluronic injectable fillers, I would strongly think about fat injection replacement. Otherwise, I see no direct correlation between it and your hypersensitivity symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read and would like to have rhinoplasty done with you if its possible. However I don’t have a visa to come to Indiana. I don’t know if it’s possible but I am just inquiring, is it possible for me to travel to indiana without a visa if I have a doctor’s letter from you? And that letter can be posted to me in my home country? Thanks.

A: I could not answer your question about traveling to the U.S. without a visa. That is a question for your country’s immigration department and U.S. foreign visitor policy. We do not provide medical letters of necessity for cosmetic surgery procedures, such as rhinoplasty,  to any international inquires or consultations. One has to work through the proper visitor/immigration procedures for their country and abide by the regulations for U.S. foreign visitors.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to improve the appearance of my lips, acne scars, and face contouring. I have very large lips and the upper lip is very full and bigger than the lower one, it gives me a duck lip appearance. The upper lip rests above the lower lip instead if the other way around. What would be the best thing to do about that? I have also attempted to loose weight to slim the face yet there is much fat around the lip area and the cheek bone area which does not go well with the full cheeks. I am attempting to achieve a slim-defined male model type of face as well as diminish the appearance of my acne marks. Somehow my facial features don’t mix well with one another. I believe my face is feminine in a way, is there a way to give it a more masculine look?

A: While many people want to achieve an upper lip size that matches the  lower one, you have an opposite concern. The upper lip can be reduced by an internal vermilion reduction to reduce its size and roll back the pout of the upper lip. That leaves any scar on the inside of the upper lip.

From a face standpoint, I don’t see large buccal fat pads to remove but I could see some benefit by perioral liposuction to reduce the perioral mounds out to the side of the lips. While you did not provide a side profile view, chin augmentation with more width and horizontal projection may be more masculinizing for you. But I would need to see some additional photos to be sure that is of benefit.

Acne scars can be improved by fractional laser resurfacing but it is important first to have the acne eruptions under control. With laser resurfacing the ointments needed afterwards as it heals can cause a lot of pore obstruction and an onset of new eruptions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast augmentation and the new gummy bear breasts implants have me intrigued. They seem like they would be so much better than a bag of water or a bag of liquid silcone gel. Can you give me some more information about them? What happens to the material if they rupture? Do they feel soft and natural? How long do they last?

A: The use of the term ‘gummy bear’ breast implant is an urban term, not a medical one or one used by any manufacturer of them. That is a term given to them many years ago by a plastic surgeon because of how the material feels and behaves. This is a more cohesive high-strength silicone gel that does act somewhat similar to the also named candy, although I think they do feel a little softer than the candy. If you cut the implant in half and squeeze on it, it does behave like the candy. The material stays together, does not run, and only puffs out when the implant sides are completely squeezed together. I have attached a video to this answer so you can see better how they behave once cut. This would represent the most extreme form of an implant ‘rupture’ so there are no concerns about the material migrating elsewhere in the body. Since the material does not leave the shell or containment bag if it should develop a hole or tear, the outward appearance of the breast will not change. (deflate or become deformed) The lifespan of the new gummy bear implants is not known although it would be fair to say that they are going to last longer than saline implants or any older generation silicone gel breast implant. This is without a doubt the best breast implant that I have  ever seen and is the most common one I use for my breast augmentation patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been thinking about getting a breast procedure since I was 13. I have 34DD and I’m 5’1 ½. I’m very self conscious about them but my boyfriend thinks they are fine but I do not. They are too big and saggy (gross) I just hate them! If I got a breast reduction how much smaller would my breast’s be and would you recommend having implants put in?

A:  Breast reduction surgery not only reduces the size of one’s breast but also incorporates a lift of the breasts as well. There would be no reason to place implants during a breast reduction, that would partially defeat the purpose of the procedure. The amount of breast reduction that can be achieved in the procedure is different for each patient. There is great variability in how much breast tissue would be removed and takes into account how much or little breast tissue one wants to remove. One could easily go from a saggy DD breasts to an uplifted and more perky full C cup. It is important to remember that the trade-off for that amount of breast shape improvement are permanent scars. You are trading off one breast problem for another, just be sure the scar issue is less of a concern than the way your breasts look now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to do something about my breast shape but am confused as to what to do. I have a little sag to them after two pregnancies and would love for them to be a little fuller and up higher. So I think that is why I need a breast lift but I really don’t want any scars on my breasts if I don’t have to. On the other hand, I am not opposed to breast implants if it will lift up the breasts and avoid any obvious scars on them. I have attached some pictures of my breasts for you to see. What is your recommendation?

A: Your breast dilemma is a common one in that you are what I call a ‘tweener’. You have some sagging so breast implants will add volume but the breast position will likely stay low.  A larger than desired breast implant may be needed to get the lifting effect you are after. A breast lift alone will changhe the position of the nipple and the breast mound but often the breasts may look smaller afterwards despite the better shape. A lift with an implant will allow you to have a smaller implant and slightly higher positioned breasts but that comes with the trade-off of scars.

Either way you have to accept some disadvantages with either approach and different plastic surgeons will have different preferences for either approach. You must think it through and decide which of the trade-offs is the better choice for you.

In ‘tweener’ patients like you, I wil often choose the middle of the road choice…breast implants with a superior or crescent nipple lift. This provides a slight upward nipple repositoning with minimal scars (no scars on the breast mound)  while relying on the implant to add volume and provide a bit of an upward push.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  about three months ago my plastic surgeon cut out a chunk of skin out from the center of my forehead that had pock-like scarring and sutured it together. He told me that once the line heals, it would barely be noticeable and flow in into the creases of my forehead. He did a v-shaped straight line which looks anything at this point but a natural horizontal forehead crease. Is it normal right now for the closure line to appear indented and red and would you recommend Fraxel lasers and silicon strips at this point in time. Is all that i’m seeing pretty normal or did this doctor jack up my face?

A: I do not know what you looked like before and was not involved in how the decision for that approach was decided. I can make no educated comment on the decision for that particular approach to your problem. This is not an approach that I have ever used for pock scarring issues in the forehead. Most certainly if I would have done that large forehead excision I would not have made it v-shaped. There is nothing natural about that scar orientation in the forehead. What I can say is that for three months out in thick pigmented skin, the scar is what I would antiipate…very red and noticeable. It is going to take considerable time for any amount of fading that may occur. Given the way it was done, your scar appearance does not surprise me at this point. I do envision the eventual need for some additional work, whether it is scar revision or fractional laser resurfacing remains to be seen with more time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 30 years old and have had one child. Last year, I had liposuction to get rid of some ugly fat deposits on my stomach and thighs. It turned out very well and I am overall very pleased with the contour reduction of the treated areas. But I have noticed a little loose skin on my stmach and there are a few small uneven areas. My skin doesn’t look quite as tight as it did before the procedure.  Is this normal? Is there anything that can be done to help tighten and smooth out the skin any further?

A: It is very common after liposuction to have less than perfectly smooth skin. That is often the trade-off for the volume reduction. Simply put, when you have less fat you need a little less skin. That accounts for what you perceive as skin that is just not as tight as before.  This particularly occurs in the abdominal region in women who have lost a little skin elasticity after pregnancy. There certainly is no harm in trying any of the numerous skin tightening devices that are available, such as  Exilis. The only question will be how effective it may be.

In addition, liposuction is about fat removal but it is a blind procedure. There is no way for the treating doctor to see what they are removing and how even that removal is underneath the skin. This is the art form of liposuction and it takes a lot of experience and attention to detail to get the smoothest result possible. Eventually the healing will reveal how close to even that fat removal was.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in complete removal of the fatty tissue located in my chest area. I don’t know why I have developed actual breasts but it is very embarrassing. I am a 32 year-old male and I have to wear loose fitting shirts to hide my jiggling breast mounds. I am not really much overweight, no more so than some of the pro golfers that I have seen. I wanted to know the average recovery time. Also how long does the procedure usually last as well.

A: Thank you for your inquiry. Gynecomastia deformities the size of yours, where there exists a real breast mound, is a difficult challenge to get the flattest result with the least amount of scarring. It may likely require a two-stage approach. The first stage would be a circumareolar approach with nipple lift/reduction with open excision of underlying gland tissue and surrounding contouring liposuction. Depending upon how it looks and heals, this may be all that is needed. But I like to prepare patients for the high probability of the need for a revision based on how the circumareolar scar heals and contour of the chest looks. This would be known as the second stage if needed. (areolar scar revision, touch-up liposuction) It is difficult, although not impossible, to get a good symmetrical chest result with good-looking scars in one procedure.

This type of gynecomastia reduction procedure is done under general anesthesia as an outpatient. Drains would be needed for up to 5 days after surgery. Recovery time would depend on what type of work/activities you do. For a more physical job, it would be two to three weeks before one should actively stress the chest area. This restriction is done primarily to affect fluid build-up after the removal of the drains. The results of gynecomastia are fairly long-lasting and in many cases would be considered permanent…provided one does not gain a lot of weight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your website while looking for other penises like my husbands. He is an overweight man of 37 and his penis is slightly hidden. referring to this article– http://exploreplasticsurgery.com/category/buried-penis/ I found you can do surgery to help his “show size”. He basically looks like the pictures within this article. He would not let me take pictures of his body. I hope you can still give me a price idea. Thanks!

A: Thank you for your inquiry. Without seeing some pictures of the problem, I can not even tell if it is improveable. As a plastic surgeon, what I can do for buried penises is to decrease the size of the surrounding suprapubic mound through liposuction or lift away overhanging skin that is contributing to penile concealment. Often times both have to be done to get the best result. But many concealed or hidden penises also have penile contraction due to tissue fibrosis which requires the use of an experienced Urologist to diagnose and treat. In this cases, a combination Urologic-Plastic Surgery approach is needed.

But as a general guideline, I will have my assistant contact you to give you a cost for the combined procedure of a suprapubic lift with mound liposuction, which was what was discussed in that article.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 38 year-old female that has chubby cheeks. They make me look ten years older than I am and I just hate them. I have been to several plastic surgeons and they have uniformly said there is nothing to do about them. I have tried injectable fillers around them but that just makes me look puffy and is not an improvement. What do you recommend? I have attached pictures so you can see what they look like in different lighting.

A: Thank you for sending your pictures. I can clearly see your concerns of the ‘fatty or chubby cheeks’. The first question is always what is the diagnosis. Why do your cheeks look chubby? Is it because they are chubby or is what is around has become indented or atrophic? I am going to assume that they did not look like this originally ten or fifteen years ago. Many people with aging will develop malar festoons. These occur because the cheek pad falls off of the bone (ptosis) and in much later years can even become chronically swollen. While your cheek problem initially may appear as festoons, on close examination of the pictures they are not. Your cheek tissues are up high on the bone as would be commensurate with your still young age. It is easy to see that you have little aging around the eyelid area. In short, I do not feel that your chubby cheeks are from soft tissue laxity or ptosis. You clearly have tear troughs and a descending infraorbital groove which goes below the cheek area. This is what I think makes your cheeks look chubby, it is what is around them either from the early signs of aging or genetic predisposition that makes them look fat.

In theory, the correct treatment would not be cheek reduction but augmentation of the tear troughs and infraorbital groove. Having had this done through injectable fillers with an unsatisfactory result, this appears to not be a good option for you. It may be that the injectable fillers were not placed correctly or overdone, but I will assume for now they were and the look from that approach was not an improvement.

This raises the next question of what can be done with the cheek pad tissue. Simple ‘removal’ is not a realistic treatment as you can not liposuction the cheek pads or perform direct excision. Even if that was technically possible, it would leave the cheek skin deflated, possibly wrinkled, and thus create an alternative problem that would not be viewed as an improvement. Treatment possibilities include some higher malar suspension through a transcutaneous lower eyelid incision, possibly combined with a small cheek implant that would augment the lower cheek groove. Even though you don’t have true malar ptosis, lifting and repositioning this cheek tissue slightly higher would help to efface the lower malar groove. One way you can get a feel if this approach might be effective is to push up on the skin by the corner of the eye and see what happens to the appearance of the chubby cheeks.

Another option to consider before surgery is non-invasive skin tightening and fat shrinking devices. There are numerous device options out there. My current favorite is that of Exilis. It is a radiofrequency device that has the ability to perform some small amounts of fat reduction and skin tightening. It always takes a series of treatments, usually four, to get the final result. But I would be very interested in seeing you have this done before any surgical efforts are made. Whether it would solve your cheek issues is unknown, but it would be more reassuring that you tried every less invasive option before you came to the conclusion that surgery was warranted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can stem cells be used for buttock augmentation practically? I mean can we use stem cells to culture enough volume to be used in buttock augmentation ? I am trying to avoid fat harvest .

A:  Fat injections have a certain percentage of stem cells in them so they are used routinuely in the procedure. But stem cells can not be used alone. The sheer quantity of stem cells that would be needed in volume is beyond what can be practically done if used alone. But it would be possible, and maybe even ideal, if cutured stem cells were added in increased numbers to what naturally occurs in fat to get improved volume take and preservation.

On a practical basis, however, stem cells can not be used for buttock augmentation for numerous reasons. It would take 200cc to 300cc of stem cell volume per buttock to be able to do it. This can be done by numerous companies but at around $1500 to $2000 per 3cc to 5cc aliquot, it would be prohibitively expensive. In addition, the FDA has recently clamped down on stem cells being harvested, grown and then returned even to the same patient. So it is now not even allowed by federal regulations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if getting Botox injected into the masseter muscles will cause a slack in the skin on the cheek/loose skin/jowls.  I’d like to try the Botox in that location but am hesitant because I already have some pre-nasolabial folds developing.  I am 27 years old. Thank you for your time!

A: The simple answer is no. The masseter muscles have no impact on the tone or position of the overlying soft tissues. They are rigidly fixed to the mandible, pterygoid plates of the maxilla and the zygoma and never get lax with Botox injections. They may get smaller with some muscle atrophy but will never lose their fixation points or become like a loose rubber band. Any looseness or descent of the overlying soft tissues with time and gravity is due to laxity developing in the osseo-muscular and osteocutaneous ligaments, not the masster muscle proper. Therefore, getting Botox injections into the masseter should not pose any concern in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Approximately 15 years ago, I fell over and knocked my front two teeth out. Today, I suffer from cross-bite and a deviated chin during occlusion. It is quite apparent to me that my jaw has been shunted ever so slightly to one side posteriorly, and slightly superiorly also, this is the side to which my chin deviates. I believe that I could have had a unilateral condylar fracture which has subsequently healed in a dislocated position. Could you advise me as to what diagnostic modality could be used to evaluate a historical condylar fracture, or what factors may suggest a condylar fracture that has thus gone undetected. What methods can be used to correct this issue? Many thanks.

A: The best way to diagnose condylar position is a 3-D CT scan of the face. That will clearly show you the position of the condyles and the entire shape of the lower jaw. At this point you want to only correct the asymmetry through a chin osteotomy and midline realignment. The condylar position, regardless of where it is, is beyond changing at this point as lpng as one has a functional and good interdigitating occlusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had 3 C-sections, bowel obstruction surgery, hernia surgery and hysterectomy. I was wondering if getting a tummy tuck would be possible for me and would this be a feasible avenue to take? Also, would I be a viable candidate for the insurance to cover this procedure? Thanks for your assistance.

A: Thank you for your inquiry. It would be impossible for me to say whether you are a good candidate for a tummy tuck based on your complex abdominal surgical history alone. I have seen many patients with similar histories and they all were perfectly good candidates for tummy tuck surgery. So based on your information alone, I would assume until proven otherwise by actually seeing you that you would be a reasonable candidate. One of the very good benefits of a tummy tuck in patients with complex abdominal surgeries is that many of the abdominal scars as well as the loose skin and fat can be removed and traded off into one single horizontal scar placed low on the abdomen. Often, one gets a simultaneous pubic lift as well. Insurance does not cover nor do we attempt to process it for elective cosmetic tummy tucks. While you have a complex abdominal history and likely numerous contour deformities from them, these are still cosmetic and not functional issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dorsal hump on my nose. I had a consult with another doctor who mentioned using fillers or if electing surgery breaking my nose. I do have breathing problems in my nasal area which we discussed also. But, I am concerned about dramatically breaking my nose. I am African American. I do not want a slender Jackson Family nose. I want to look like myself, just better 🙂

A: While the African-American nose typically has a low and wide nasal bridge, it can still have a dorsal hump. Or in the low nasal bridge a pseudo dorsal hump, a dorsal hump that appears to be there because of a low nasofrontal junction or radix area. There are two approaches to your dorsal hump removal , augmentation or reduction, which has already been discussed with you. Augmentation may be a better approach for you since you already have a breathing problem and you fear too slender of a nose. The only role that fillers would play in my hands for your nose is to determine whether augmentation above the hump produces the desired effect. This is a good simple and reversible test using the non-surgical rhinoplasty concept. If filling above the hump produces a good look, then you can proceed with a rhinoplasty doing dorsal augmentation using either a cartilage graft or an implant. Each has their own advantages and disadvantages which needs to be discussed in detail.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had frontal headaches for about 10 years.  I don’ t like getting toxins, but a low dose Botox injection cut my usual debilitating headache from a 9/10 to about a 5 for seven weeks and then about a month later last week, I am back to a 9/10 again. Can you do a surgical procedure to get me more permanent relief? If so, do you think insurance will cover it?

A: You may have had more significant migraine relief if the dose of Botox was higher than just ‘low dose’. The wearing off of the Botox effects after three months or so is a fairly standard period of time for the duration of its effects. If Botox is effective in the supraorbital area for migraine reduction, then surgical decompression of the supraorbital  and supratrochlear nerves should provide similar (and hopefully greater) and more sustained relief than the injections. The general quoted numbers is 70% of patients will get a noticeable and sustained reduction in the frequency and severity of their headaches with surgical nerve decompression. The remaining 30% is a mixture between ‘cures’ and those with limited to no  benefit.

Insurance is very unequivocal about not covering migraine decompression surgery. They have a hardline stance that it is still ‘experimental’ at this time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I googled “skull reduction” and found out that you are the only one in the world who does skull reduction. I see you need a bicoronal incision for this, which is not a problem. I have a big head and can’t wear hats and I am always teased. I read that reduction is achieved throught a rotatory instrument that shaves done the external layer. You said to think about an oreo cookie. When do you reduce the skull, do you only use this instrument or you do osteotomies as well? If you burr the bone doesn’t the skull become weaker and more susceptible to fractures or soft to the touch? Do you perform a lot of these procedures?

A:  In answer to your questions:

1) Cosmetic skull reduction is done by burring down the bone,, not by osteotomies. Osteotomies are major cranial bone flaps are not indicated for cosmetic improvement.

2) The skull does not get appreciably weaker with outer cranial table reduction as there remains an inner diploic layer as well as an inner cortical bone layer as well to the skull.

3) Various forms of skull reduction/reshaping are done in my practice. Whether anyone is a reasonable candidate depends on many factors and I would have to seem some pictures of one’s head to determine if they are a reasonable candidate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implants. I am 19 years old and currently an A-cup, I would like to go up to a B or maybe even C-cup. Am I too young for this procedure? And what is the average overall cost?

A: You are not too young for breast augmentation. As long as you are 18 years of age and can make an informed and educated decision, you may get breast implants. The one cavest is that you must get saline implants and not silicone gel implants. As of 2006, a patient has to be 22 years of age to be eligible for any type of silicone gel breast implants per the Food and Drug Administration (FDA) and the manufacturers. What size you should increase your breasts to is a personal one. While you think about breast size in cups, plastic surgeons think about breast size in volume. (ccs) Trying to figure out volume:cup size is an art form in any patient and not an exact science. This is why I prefer to use an anatomical breast implant volume sizer system which is very accurate in terms of helping you get the breast size you desire.

The total cost for saline breast augmentation is in the range of $3800 to $4000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Can you answer a few questions about eyebrow transplants? I hardly have any right now since they fell out when I was 21 due to taking birth control pill. They never came back.  Does the transplant last forever or do you have to keep having the transplant? Are the eyebrow hairs normal looking? How is the procedure done?

A:  Eyebrow hair transplants are like any other form of hair transplantation. The goal is to create living hair that is permanent. How much of the hair transplant survives is likely what you are referring to as ‘having to keep having the transplant’.  Normally 100% of the hair transplant does not survive so an additional procedure may be needed to fill in any areas in which the grafts have not taken. Once a hair has taken, it will be permanent because the bulb or follicle has taken. Technically, hair transplantation is about tranferring the hair follicle (the growing portion of the hair) and the actual hair is nothing more than a handle to manipulate and carry the follicle to the recipient site. Once the hair has taken, it will grow faster than normal eyebrow hairs and will require more frequent trimming.

Eyebrow hair transplantation can be done under local or IV sedation anesthesia. The donor site is the scalp, usually taken from the finer hairs behind the ear. It requires at least 50 to 75 hairs per eyebrow or a total of 150 to 200 hairs for both eyebrows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to improve the look of my jawline and my lips. I am enclosing a youtube link to a male model whose lips and jawline seem to match the look I see for myself.  If you have a chance to review model Chad White’s lower face and let me know if that is possible for me based upon your imaging my photo, I would be interested to hear your thoughts. I understand that the end results won’t be an exact replica, but how closely can his lower features be matched.

A: I have taken a look at the video link and you are just one of many who have sent me Chad White’s images as their desired goal. While I think having a defined aesthetic goal is always good, it usually sets up unrealistic expectations. You nor anyone can look like he does. You can only become a better you working with the anatomy you have to get a more defined jawline and larger lips. Will your jawline and lips be better with surgery…yes. Will they look like Chad White’s….no. You and he are quite different ages with different tissues and different faces. That may sound negative but I have yet to have a male patient who comes in with model photos to ever really achieve the look they ideally want.  Using them to illustrate a point is one thing, but having them as the aesthetic target is not realistic. Using model pictures in my extensive experience is often a red flag for what will come after surgery…disappointment and subsequent (and sometimes endless) revisions of the procedure.

It is more important to focus on what can be done with your face and its anatomy rather than a model’s whose face you can never become.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, here is a some photos of my face from both side angles and front on.  Any suggestions you have on improving my chin / side profile will be appreciated.  I’ve already have a very low fat content in my body, but my jawline is still ill-defined.  I’ve been considering a sliding genioplasty to move my chin forward.  I play a lot of contact sports (boxing, wrestling, soccer), so I imagine a chin implant isn’t a great option as it could shift.  Let me know what you think. Thanks a lot for your time.

A:  Thank you for sending your pictures. It is a little hard to see precisely your chin position due to the amount of facial hair, but I have some projected imaging based on much chin advancement I think you would need. I would estimate from 7 to 9mms forward increase. In addition, I have opened up the osteotomy to give some vertical chin lengthening as well of about 3mms. You are correct in assuming that moving your own chin bone long term is better than using an implant if you do participate in a lot of contact sports. Chin implants can be used and screwed into place so shifting with trauma is not a big concern. But it only makes sense to not unnecessarily expose a protruding chin implant to trauma. Your bone is much better designed to withstand that than an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 42 year-old female and have always had a touch of bags on my lower eyelids.  Due to aging no doubt and some weight loss, these bags seem to have become bigger and at least they seem that way to me. I saw one doctor recently and she told me that I should have injectable fillers put in to puff out the indented areas around them. Then I saw another doctor and he  told that the fat should be removed through an eyelid procedure. These two different opinions have me confused. What do you think?

A: Most undereye bags consist primarily of fat that has escaped from under the eyeball. Our eyeballs are encased in a bed of fat inside the eye socket bones. This allows the eye to be padded so it can move around inside its encasement without risk of being ruptured. This fat is held back by a ligament that runs from the lower eyelid down to the bone. With age that supporting ligament is naturally weak or weakens allowing the fat to come out from under the eye. Much like an abdominal hernia and protruding bowel, the lower eyelid develops bags of herniated fat. Some people have a natural weakness of this ligament and develop lower eyebags very early in life. (I suspect this is you) With aging they become much worse. Removal of this fat can be done from inside the eyelid without any external incisions. (transconjunctival lower blepharoplasty) This would make for a far superior result in your case. Adding more volume around the herniated fat is only going to make your lower eyelids even more puffy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One year ago I decided to do laser skin resurfacing in order to get rid of small scars on my leg. They were scars after ingrown hair. I did the last procedure one month ago and the result just scares me. I think that they burned me. It was Cutera Fraxel Laser.They also made a cortisone shot to my scars and didn’t tell me about the possible side effects. Now my skin is a little bit recessed. Now I’m so scared. I do not know what to do. Is that possible for skin to recover after cortisone shot? Is that possible to do a scar revision? Thank you in advance and kind regards.

A: While fractional laser resurfacing can offer improvement for some scars, legs scars from ingrown hairs would not be one of them in my experience. All laser resurfacing  methods basically create a superficial burn, allowing secondary healing and re-epitheliazation to take place. In essence, ‘burning you’ is how the laser works. Fractional laser resurfacing simply burns less of you, hence the term of a fraction of the skin’s surface. But each laser column goes deeper, actually creates a deeper burn injury (but less of it) in the hope of promoting improved collaguen remodeling. While this frequently offers scar appearance improvement in the face, it is less successful below the neck. The thicker and less forgiving leg skin is always risky when it comes to any type of scar revision. It is easier to burn and heals more slowly. It is more prone to hyperpigmentation even after  it is healed.

Another misconception is that of ‘getting rid of scars’ with laser resurfacing. It simply does not work that way. It is not as simple as using the laser like a blackboard eraser. At best, it is about some level of scar improvement. When comparing the risks vs benefits in laser resurfacing of leg scars, you are unfortunately experiencing the very narrow margin between improvement and the risk of further s potential scarring.

Depending upon the dose, steroid injections can cause subcutaneous fat atrophy and even skin thinning, thus the indentation that you are seeing. If this was a single dose, and it appears that it was, then there is a good chance of rebound fat restoration over the next few months. You will not know fully until six months after this injection. No further steroid injections should be done. They do not help the healing of any burn injury and can actually cause other potential problems as you have now know. Patience and further healing is the key to now allowing this scar area to settle and judge the final result.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, a month ago I underwent jaw advancement surgery as well as open rhinoplasty. My surgeon harvested bone from my skull and used it for both the nose and the jaw. Immediately after the surgery I realized that I had a hump, which I never had. I had a droopy nose and flared nostrils, but I had a really nice bridge, no hump. As the inflammation subsided, it became more and more apparent that the bone implant was very visible and crooked. I consulted my surgeon and he said it was just swelling. I saw several other surgeons and they all said it was not swelling, that it will not resolve, and that the bone was poorly shaped and implanted. I now must find a doctor to correct this deformity and I would like your professional opinion as to how long I should wait for a revision.

A: I don’t know the other details of your open rhinoplasty, other than you clearly have had a cranial bone graft augmentation. While cranial bone would not be my first choice for dorsal nasal augmentation, the logic of using it if bone was being harvested anyway for your mandibular osteotomy is logical. While you are only one month out from surgery and there still is persistent swelling, I would agree that the bone graft is oversized. While cranial bone will undergo some remodeling and even potential loss of volume, there is no assurance that this will happen in an even and regular fashion. Most certainly, you can not count on it remodeling into the desired amount and shape of dorsal augmentation that is desired. So the question is not whether a revision rhinoplasty will be needed but when and what exactly to do at the revision. There are arguments to be made for early vs delayed revision and, in my mind, it depends on what else was done to the nose and what the end goals were. If everything is fine and headed in the right direction with the rest of the nose and only the bone graft is the problem, then an earlier revision at 2 to 3 months could be done. If other aspects of the nose are undesired or unknown yet due to swelling, then it may be better to let the whole nose settle down and delay a revision until six months after the original procedure so any other adjustments can be done at the same time. One also has to factor in how much this new hump bothers you now, as if it is causing some distress, a revision can be done quite soon using a closed approach to remove, reshape and reinsert the bone graft so it has a better profile.

Dr. Barry Eppley

Indianapolis, Indiana