Your Questions

Q: Dr. Eppley, I have a bump on my forehead which is the result of a fall. I’ve tried putting ice bags on it as well as the white of an egg to shrink it’s size. It’s become smaller but I can’t seem to find a way to get rid of it. I’ve been in the hospital after the fall and ice bags were applied to the bump and a test was done to determine that there are no broken bones. Please help me get rid of the bump. Thanks!

A: One key question is how long has it been since this head injury has occurred. Often times small hematomas may occur and this, combined with swelling, can take months to resolve on their own. But they usually will go away completely on their own if given enough time. If the hematoma is big enough, and one can tell that it is if it feels very spongy and compressible, then the hematoma should be aspirated for more rapid and assured resolution. If the injury was more than 3 to 6 months ago, a hematoma may becoming calcified which could result in a bump which will not go away on its own without surgical intervention. (limited cranial reduction)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a skull problem that bugs me and I would like it corrected. I have taken some pictures of my head so you can see. They are not the best but they show that my skull shape problem is that I have a bony growth and a deep groove on my crown area and the back of my head has several bumps and grooves!! I was wondering if you can use the bone cement kryptonite to fill in the grooves all over my head?? Please let me know as I really want to have this done. Thank you so much for your time.

A: I see that you have two distinct skull contour problems. The first is a deep groove on the top of your head along the course of the original coronal sutures on both sides. It runs identically along the suture line into the temporal regions. The second issue are the multiple irregularities, lumps and bumps, on the back of your head. There are two approached that can be used to improve these skull contour irregularities. The first approach is an open technique where the entire skull can be filled in and smoothed out. While this would produce the best result, the placement of a scalp scar makes it unacceptable for most male patients. The second approach, as you have mentioned, is an injectable technique using Kryptonite cranioplasty material. While this can certainly be done, an external ‘blind’ approach will help fill in many of these cranial depressions but it will be perfectly smooth. The trade-off of not having any significant scalp scar is that the skull contour can not be made perfectly smooth. You have to accept the concept of improvement but not perfection of your skull reshaping effort.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard of facelifts being done under just local anesthesia. How safe and comfortable is that approach for this kind of surgery? It is appealing to me but it makes me nervous being awake.

A: There is little question that limited or mini-facelifts are very popular today and are widely advertised. Many surgeons and companies have even named their own versions of these mini-facelifts. Their premise is based on being performed under local anesthesia for a quick recovery and usually a lower cost. While there is merit to this approach, the key is whether a more limited facelift result will meet a patient’s expectations based on their degree of neck and jowl sagging beforehand. While eliminating the risks, cost and recovery from anesthesia is appealing, that can be a poor trade-off if the ‘problem is bigger than the solution’. Such mini-facelifts are best used in younger patients who have early signs of facial aging or in older patients, while really needing a fuller facelift, simply doesn’t have the time, resources or desire to completely address the extent of their aging issues.

Local anesthetic facelifts can be made fairly comfortable through the use of oral or IV sedation drugs. The wonders of modern pharmacology allow one to reach a pleasant and relaxed state of mind so local anesthesia can be adequately injected for the facelift procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need some help in selecting the right breast implant size for me. I am 5’ 2” with a 32B cup size. After having breastfed two babies, I need some breast volume back. It has been sucked out of me.. I am going to get 500cc high profile gel implants. My doctor suggested 450cc but I want 500cc. Do you think this is a big difference. I don’t mind if they are a little big and look somewhat fake. I actually like that look. Are there any health risks from going big? I value your opinion.

A: On a volume ratio basis, the difference between a 450cc and 500cc implant is not that significant, around a 10% size difference. A sized difference in implants that is barely visible. Since you appear to have no fears about being too big, I would definitely go with the slightly larger 500cc implant. While there are no health risks with larger silicone breast implants, there is always the consideration however of loss of tissue support over time. When a breast implant becomes too big for the tissues that must envelop and support it, there is the risk of bottoming out or dropping of the implant position. Whether this is a potential issue with you can not be determined based on this discussion alone. The key determinant of that is whether the base diameter of the implant stays within your own natural breast base diameter. That is a simple measurement that can quickly be done in an examination. The use of HP or high profile implants is helpful in keeping a good implant-breast base compatibility.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two inverted nipple correction surgeries by two different doctors, both of which were unsuccessful. My nipples are grade III inverted. I am at a loss as to what to do. Do you think that breast implants would help in my inverted nipple correction. Would they help push the nipple out once it has been released?

A: Inverted nipple correction has a high rate of recurrent contracture/inversion after release. Your experience is not completely rare. Many methods have been described in plastic surgery for the correction of inverted nipples which speaks to the fact that it is both a difficult problem and that none of them work that well. Once the nipple has been released and brought out by suture traction during surgery, there remains a dead space or tissue deficiency underneath. I have found that filling this in with either a dermal-fat grafts or allogeneic dermis is the best way to prevent recurrent inversion. The fill must be immediately underneath the released nipple. The push from a much deeper breast implants will not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the Exilis device for my stomach area. I am only 5’4″ and weight about just under 120 lbs. Despite my rigorous workout schedule of running and working with a trainer 3 to 5 days a week, I just can’t get rid of my lower  stomach fat. At 42 years old, I do not want invasive surgery so I believe this device currently offers me my best hope of  solving this problem. Do you think I am a good candidate? I am going on vacation in March so I would like to have some tummy reduction before I get into this season’s swimwear? I am currently training for a marathon in the summer so would I still be able to run? Please let me know! Thanks so very much!

A: By your description, I could not imagine a more ideal candidate for Exilis fat reduction treatments. This is a spot reduction problem and undoubtably is not a large area. In addition, with your high level of physical activity you will helping the treatments work better by enhanced fat breakdown. One of the really nice things about Exilis is that there is no recovery or restrictions after any of the treatments. Each treatment is about 30 to 40 minutes so you can just get and go right afterwards. It usually takes 4 to 6 treatment sessions to get the best result and we like to space them, if possible, no more than a week apart.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in dire need of a nose job.  My nose is extremely wide and my profile slopes terribly, which explains my insecurity. I was hoping I could get an estimate for the surgery. I have attached pictures so you can see what needs to be done. Thank you for your time.

A: Thank you for sending your pictures. What you have is a a very specific type of aesthetic nasal deformity in which the lower alar cartilages are very thick and strong. They overproject beyond the tip of the nose making it very broad and fleshy. With that comes broad widely-spaced nostrils. Since the tip is so broad, the area above it (known as the middle vault) looks collapsed and sunken in on profile. This then makes the upper part of the nose where the bones are also appear wide. This can be treated by an open rhinoplasty procedure that narrows the nasal tip cartilages, narrows the width of the nostrils at their base, builds up the middle vault and narrows the upper nose by osteotomies. Together this will help change your nose to one that is less broad and more refined looking. This is a 2 hour rhinoplasty procedure done as an outpatient under general anesthesia. All costs combined place the price of such surgery between $ 6,000 to $ 7,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two children, the last one being two years ago. As a result of my pregnancies, I have some loose skin and stretch marks which are greatest right around my belly button. I would like to get rid of how my belly button area looks as I just hate it paticularly when I bend over or sit down. I know because I am very small and thin that I don’t have enough loose skin to do a full tummy tuck. But I want to have a completely flat stomach with no loose skin. I am thinking that if I have the skin cut out from around my belly button, rather than low like done in a traditional tummy tuck, that I will get the tightest result. I know this will leave me without a bellybutton but that would not bother me. Have you ever done a high tummy tuck like this?

A:  It is very common that many of the stretch marks and loose skin that results from pregnancies is around the belly button. This is because this is the region of the stomach that undergoes the greatest amount of skin expansion. After delivery, wrinkling and belly button deformities are common. While the type of ‘high’ tummy tuck that you are describing can certainly be done, I would advise against it. Regardless of how flat and tight the abdominal skin would be, having a horizontal scar across the center of your stomach without a bellybutton would create a secondary cosmetic deformity of its own that would not be very natural looking. You would be better served by having a mini tummy tuck with an umbilical float technique. This would create a very low horizontal scar just about the pubic hairline and keep a belly button that is positioned lower with less wrinkled skin around it. While this may not create the supertight abdominal skin that you desire, you would have substantial improvement but having a more natural look.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lipodissolve or laser liposuction of the lower abdomen. I am having a breast reduction done next month. My question is when is the best time for me to have the lipo procedures performed, before surgery or after surgery? I was informed that the best time would be during the same time as my breast reduction surgery. However, my insurance is covering the breast reduction and it does not cover the liposuction. I am also unsure if the doctor performing my surgery performs the lipo procedures I am interested in receiving. I was hoping for a lipo procedure that was less invasive such as lipodissolve or laser lipo.

A: Let me clarify some misconceptions that you have about various ‘lipo’ procedures. Lipodissolve injections are only useful for very small fat collections, no more than the size of one’s hand. I suspect your lower abdominal issue is bigger than that in size. Laser liposuction (aka Smartlipo) is simply an advanced form of liposuction and is just as invasive, it is not a minimally invasive procedure. In short, there is no non-surgical way to get rid of your abdominal fat concerns that would be as effective as liposuction. You could try Exilis radiofrequency treatments which does have some fat reduction effects.

In reality, there would be no better time than doing abdominal liposuction with your breast reduction and this is a common combination of cosmetic procedures. Otherwise you will have to have liposuction done separately where the out of pocket expenses will be higher.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering skull reduction done through an open approach and have afew questions about the scar. In your opinion is the scar with very obvious to you. I always grow my hair out so with that, what level do you think it may affect me? I am not bald or shave my head so I assume the hair will help hide it. More in depth, could I see pictures of the scars from open cranioplasty? How long are they and such. I’m really leaning towards this, would like to know all about it.

A:  It is important to recognize that there will be a scalp scar in any open cranioplasty procedure. That does not mean, however,  that it is necessarily a bad scar that is wide and highly visible. It almost never is. But in men, whose hair pattern is less than stable over their lifetime in over 50% of the male population, it is important to consider this aesthetic trade-off. It is obviously a lot more relevant issue in men who are bald or shave their head. You do not so this is one favorable factor for you. I harp on this issue so every patient gives it careful consideration. The incision/scar usually runs from about one inch above the ear across the top of the head. It is hard to get good pictures of the scalp scars to show since most patient’s hair obscures it.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my head is mildly deformed looking from the side. The forehead bulges out at the top and makes my head look too long from the side view. I want my forehead to have a more curved look that angles backward. I have attached a side view which shows me before and after I have done some computer imaging to show the forehead shape I am after. Can this look be surgically achieved?

A: Thank you for your inquiry and sending the photo attachments. What you are talking about is a cranial reduction/forehead reshaping which would be done by a burring removal technique. The important question is whether it can be reduced enough to achieve the result you are looking for. That is best answered by knowing how think the outer table of the cranial bone is. That can be evaluated by simple plain x-rays of the skull (AP and lateral views). From these films the amount of bone that can physically be removed (outer table) can be measured. There is no question some reduction be done, I (and you) would want to know the best we can beforehand if it is enough to justify undergoing surgery for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a chin osteotomy as opposed to a chin implant for my weak chin. What I am most concerned about, however, is the complications that may be involved (numbness around the area and using titanium plates/screws inside my bod). As I have decided not to correct my overbite, would you still recommend that a sliding genioplasty would be a good option for me? Thank you very much.

A: In my opinion, the sliding genioplasty is and has always been your best solution. It solves all your chin issues at the same time. I would not concern about titanium being implant and in your body for the rest of your life. Titanium is the most biocompatible metal that is known in medicine and will be completely overgrown with bone anyway. I have never had to remove titanium plates and screws from a chin nor have I ever seen it to be a problem. This is the best place for such metal materials in the face because it is has a thick bone and soft tissue cover and is not exposed to the stresses of mastication. While there is always the risk of some feeling loss from chin osteotomies, my experience is that it is very low. The key is to do the osteotomy at least 5mms below the mental foramen if not lower to avoid any risk of permanent loss of sensation to the lip and chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think I may have ruptured one of my saline breast implants. I had them placed seven years ago and they have been great since surgery. They look fantastic and they have given me some much more confidence. I was running and slipped and fell on my right side. My right breast ended up bruised for several weeks. Now that the swelling and bruising has gone away, my right breast looks smaller. What should I do now? Will I have to pay for a new breast implant and surgery all over again?

A: Low impact trauma is an unusual cause of shell failure in breast implants but it is possible. If you have noticed a breast size change after such an event, then you should return to your plastic surgeon and have it evaluated. Generally a saline implant failure is easy to detect because breast size will change. Loss of saline volume is the only reason one would have a delayed change in breast size. All breast implants from either manufacturer, either Allergan or Mentor, have lifelong replacement warranties should they need to be replaced due to shell failure. Since you are within 10 years from your original surgery, you will get a new pair of breast implants at no charge and up to $3500 towards the cost of surgery to replace them. So while the bad news is that your breast implant may have failed, you will not suffer a economic hardship to have them replaced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dent in the back of my head and it looks like where the anterior fontanelle is. I have had it as long as I can remember. I like the shape of my head but I want this dent filled so I have a shape that is no longer embarassing. I talked to my GP doc and he couldn’t do anything to help me because it would not be for medical purposes just cosmetic. What would this procedure be called and what specialty of medicine/cosmetics would a doctor be who performs this procedure?

A: What you appear to have is a skull indentation cosmetic deformity in the upper part of the back of your head. This may be where the original posterior fontanelle (not anterior) was. Regardless of why it is there, it is likely a simple contour defect over solid skull bone. This can be treated fairly simply with a variety of onlay cranioplasty materials. Some are placed through small scalp incisions and one of them can even be placed  through a minimal incision injectable approach. These procedures are usually performed by either plastic surgeons with craniofacial training or neurosurgeons. When skull defects are purely cosmetic in nature and have no neurologic basis, it would be treated by a plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a septorhinoplasty done late last year and I just don’t like the way it looks now. I didn’t know that my bridge would be built up to be higher and more prominent. I went in to just have a septoplasty to try and help me breathe better. The doctor suggested that my bridge be changed and the tip narrowed a bit, both changes which I now regret. I used to have a nice slope to my nose before and it looks so different that the bridge is so high. Do you think this could be just swelling? Is there any way to reverse these nose changes?

A: It is extremely common for the outer appearance of the nose to be changed at the same time that the internal breathing function (septoplasty and turbinates) is being improved. While plastic surgeons may suggest these changes in the patient who just appears for breathing problems, such recommendations are often welcomed very enthusiastically. The convenience of having both nose issues addressed simultaneously is obviously appealing…provided that one does have some real concerns about their nose appearance and they are very clear on what is going to be done. It appears you now have some early ‘buyer’s remorse’. This could be premature regret since it has only been a few months from surgery and swelling is most certainly present. It may also be that you did not have a clear understanding of what the objectives of the rhinoplasty were. This could have been avoided by computer imaging analysis before surgery. While you may have a rhinoplasty revision to try and reverse some of these changes,it is too early to consider that now. You should give your nose up to a full year after surgery for all swelling to go away and you to adapt to the new look. It could very be how you feel now may change at this time next year.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always hated my high forehead, to the point where it depresses me. I really want to look into getting it reduced, however I am only 18. I was hoping to be able to do some sort of payment plan, it would be a big help! Email back if a payment plan would even be allowed. Thank you!

A:  This is the type of surgery that has to be paid for up front, like all of cosmetic surgery. Many patients opt for financing their surgery through such companies as Care Credit to name the most well known. The typical cost of forehead reduction through hairline advancement is in the range of $5500 to $ 6500.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After breast feeding two babies my breasts have gone deflated. I know that I need a breast lift. My breast size now is a small 36C. Since the upper part of my breast (that part I see the most!) is flat, do you think I need an implant as well? I am not looking to be huge but think that it would help make my breast look fuller. If I get an implant with my lift, what type should I get? I’ve read that a silicone implant is more natural looking.

A: You have very astutely pointed out one of the most overlooked deficiences in breast lifts for some women. The fullness that it creates in the upper pole of the breast will likely only be temporary and often an implant is needed as well. When using implants in a breast lift, there are two general size considerations. A smaller implant can be used in which the goal is persistent upper pole fullness but not a significant change in breast size. A larger implant is used for both upper pole fullness and an overall breast size change. That is a decision that requires patient input. Whether the to go with a  saline  or silicone implant is matter of personal choice, the most significant factor is a cost difference (saline less costly) and the risk of eventual implant deflation (saline) versus silent implant rupture. (silicone)

Q: Dr. Eppley, I had gastric bypass surgery in 2005 and I would love to have a tummy tuck. I’m sure this surgery would help me feel better due to other health conditions I have. I have severe depression, lower back bulging disc with nerve blocks and other health issues that have caused me to become disabled and last year I was approved for S.S.D.I benefits. A tummy tuck is a surgery that I have wanted for years because I have lost a lot of weight. But with the way my tummy looks it makes me feel incomplete and sad. I have pain with the sagging skin with my back and extreme rashes underneath the lower flabby skin around the panty line. Please help. I’m so unhappy with the way I look and feel. Thank you for your time.

A:  Your abdominal situation with your weight loss after bariatric surgery is a common one. The weight loss has been great but the abdominal overhang (pannus) is now a ‘new’ problem. Your description of symptoms is classic and I would have no doubt that a tummy tuck would be of great benefit. Your biggest challenge is getting a tummy tuck is an economic one. By being on disability I would assume that your health insurance is through Medicare or Medicaid. This would require you finding a plastic surgeon who participates in those programs which I do not. Even with private health insurance, there are fewer and fewer plastic surgeons today who will perform this surgery through insurance anymore. In addition, there is also the issue of whether you would qualify for an abdominal panniculectomy/tummy tuck which is an insurance determination not a plastic surgery one.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have concerns about my head shape. I know my head shape is not terrible but it bothers me enough to want something done. I know actually looking it over or feeling the shape would give better insight. The way it’s shaped makes it difficult for normal looking haircuts. I really want to try to do something about it so please try and help me. I think the one noticeable thing is that it’s not a smooth shape at the top, it divot’s a lot on the sides. I have attached pictures. Please let me know what you think.

A: I have reviewed your pictures and read your concerns. The exact area to which you refer is the transition zone between the superior attachment of the temporalis muscle and parasagittal bony skull area. There are many people who have an indentation or steep transition between these two aesthetic skull zones. In some people it is more severe and noticeable. That area could be augmented, it is a question of how that can be done. The method that would provide the smoothest and best contour result is an open skull augmentation (cranioplasty) using either PMMA or hydryoxyapatite. The use of an open cranioplasty involves a croronal incision and resultant scar may not be acceptable in many male patients. An alternative approach is an injectable cranioplasty using Kryptonite bone cement. While this does not have any scar concerns, there is a potential issue of visible edges in the anterior aspect of the defect in the upper forehead.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you please tell me the cost of a subnasal lip lift? I am not interested in having surgery on the muscle. I only want the lip lift where the skin is removed.

A: A subnasal lip lift should never have the muscle manipulated in any way. That leads to problems such as tightness, columellar base retrusion and an unnatural upper lip movement and smile appearance. In my hands, it is always a skin only procedure. While this may be associated with a 1 to 2 mm relapse in some cases over the first six months after the procedure, it does not in any way affect how the upper lip moves or alters one’ smile.

A subnasal lip lift for most patients is done as an outpatient procedure in an office setting under local anesthesia. The typical cost would be in the $2,200 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to send some photos so you could tell me the most appropriate surgery to have. I would like a wider face, a less pointy chin, a chin lift and jaw implants. I wore braces to correct an underbite and I had a mandibular osteotomy and genioplasty – the result is a long face. What can I do to bettr improve my overall appearance. I am 39 years old and terribly unhappy with my profile and double chins etc.

A: You have many of the sequeale of orthognathic surgery of the lower jaw which occur from both the surgery and aging. While a sagittal split mandibular advancement osteotomy and genioplasty have undoubtably done wonders for your bite and improved your facial profile, there are some skeletal deficiences from that surgery that have either been created or unmasked with aging that have affected your lower face. Your face has become narrower with that surgery as the jaw angles are usually lost from the ramus osteotomy and the chin becomes more narrower as its u-shape comes further forward. There also appears top be some asymmetry of the lower jaw with the left angular area being more deificient than the right. There is also the effects of aging as the neck has become fuller and dropped down due to soft tissue sagging. Collectively, all of these give you a narrow and longer appearing face with a double chin and obtuse neck angle.

This could be improved by a single procedure combining a chin-prejowl implant, mandibular angle implants, neck liposuction and a limited or short scar facelift. I have done some computer imaging from the front and sides to illustrate what changes may be possible through this approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 19 years old and very thin. But still the skin on my face is very loose. When I pull my cheek and jaw skin towards my ears, my face looks chiseled. Otherwise it looks round and slight chubby. I want to know if a facelift is good for me? If not what I can do to improve my face?

A: It would be hard to imagine under any circumstance that a facelift would be warranted on someone your age. Pulling one’s facial skin back does make  everyone’s face look more defined as the bony prominences, particularly the jawline and chin, become more pronounced. But that does not mean that a facelift (neck-jowl lift) is warranted. A facelift’s primary objective and indication is for skin laxity and sagging not to make the face appear more sculpted. (although it can create that secondary effect) You are likely in need of facial procedures that provide enhancement of your facial bone prominences, such as the chin, cheeks or jaw angles. Such facial implants can help create a more defined or chiseled face. But a facelift is definitely not what you need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 36 yrs old and have been wearing padded underwear since I can remember. I am ready to have a bottom of my own that I can feel good about.This is my only insecurity and I am ready to do something about it. I want to be able to for the first time fill my jeans out and not have a belly that hangs over them.

A: There are two types of patients that seek buttock augmentation. The first and by far the most common is the patient who simply wants to make larger what they already have. They do not really have buttock hypoplasia or underdevelopment but want to enhance what they already have. This is very common in certain ethnic groups, particularly African-Americans and Hispanic women. The second group and the least common is the patient who really has not buttocks at all. They are completely flat and may even have resorted to padding as you have described.

This second group is the most challenging to treat because they have little to no subcutaneous fat in the buttocks and small gluteal muscles. This makes the recipient site for the most common method of treatment, fat injections (aka Brazilian Butt Lift), very limited. Often they may be quite thin as well without adequate fat donor sites. This leaves them the only option of an actual silicone buttock implant. Such implants can be very effective but they are associated with a longer recovery and other implant-related risks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation six months ago and I feel that my implants are way too small. (I got Mentor 275cc silicone moderate plus gel implants placed under the muscle) I thought they were too small from the beginning but my surgeon said I would get used to them and come to feel that they were just the right size. I never have and I wear the same bra size as before surgery. When can I get new implants and what size implant should I get?

A: While some women come to accept the size of their breast implants, whether they are a bit too small or too big, they do not if the size is way off from what they expected. You have given it enough time after your initial surgery to try and accommodate to them and it is obvious that you can not. You can have replacement surgery at any time at this point. The implant size you should have based on your desires is based on information that I do not have such as breast base diameter, what your chest and body looks like and the ‘look’ of your breasts that you visually desire. But when changing out implants for a breast augmentation revision to go to a bigger size, there is one rule that I have learned. Make sure that the new implant volume is at least 30% or more from what you have now. Otherwise it will not create enough of an external visible difference. This means in your case of at least 100cc or 375cc to 400cc implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gastric bypass surgery two years ago. I lost 90 lbs and my weight has been stable over the past year. I am now ready to get rid of my loose skin around my waistline. I want an adominoplasty that is extended to lift up the thighs a little, as demonstrated in some photos that I have attached. I don’t know if that will be enough skin removed though so a belt lipectomy / body lift may be necessary. What do you think?

A: Thank you for sending your pictures. They are well detailed and I have reviewed each one. There is no question about the need for a complete abdominoplasty in the front. Ideally the most abdominal tightening would come from a combined horizontal and vertical cutout pattern. (fleur-de-lis tummy tuck) But the addition of a midline vertical abdominal scar may not be worth the transverse tightening that it provides. You are correct in assuming that a circumferential body lift is really needed to get the type of lifting in the upper thigh and buttocks that you have illustrated. Compared to many extreme weight loss patients, you actually have less excess skin around the waistline and into the back than most. Some such patients may consider the scar goiing across the back as undesireable in order to gain a buttock lift. That is a personal decision and it is just a question of the amount of scar created vs the amount/extent of lifting that one desires.  

While a circumferential body lift will provide some upper thigh lift, it will not deal with much of the loose skin in the thigh that extends nearly down to the knees. This requires an independent thigh procedure which should not be performed at the same time at the body lift due to concerns about the vascularity of the intervening skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift and upper and lower blepharoplasty a year ago.  I always had a youthful round face.  The facelift did give me a nice neckline and tighter skin, but changed the shape of my face which now looks thinner and older.  Now I am considering fat transfer to restore my face to a more rounder look.  Should I have the fat transfer in the malar area or submalar or both.  Iam afraid I could get my jowls back.   My face used to have the shape of Valerie Bertinelli’s if you know that actress. Thanks for your advice.

A: While facelift do a nice job of redefining the jawline and neck, tightening facial skin in some patients can make their face more gaunt in appearance. This can counteract the favorable anti-aging effects of the skin tightening. This is particularly prone to occur in Caucasian females who have a thinner face to begin with. This is why many plastic surgeons today, myself included, advocate a combination of fat injections for volume and less skin tightening for this type of facelift patient. The injections will usually be in the submalar and lateral facial area. Whether the fat injections should extend up onto and across the malar area would depend on what your facial skeletal structure is like. Flatter cheeks would benefit by some volume but strong cheekbones will not. The real benefit of fat injections in facial rejuvenation/facelifts is in the submalar or buccal area and extending outward and down from that area. I would have no concern about recurrent jowling from the fat injections as they do not fall because of their linear placement.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am primarily concerned with the lower third of my face. I think my chin is too long and pointy which contributes to the long, thin face look. Do you think a chin reduction combined with jaw implants or a pre jowls chin implant would do the trick? If so, do you perfom such procedures? Do you have any other suggestions as to how I could improve my facial features? Please do not be afraid to hurt my feelings!

A:Thank you for sending your pictures. Your long thin face is partly the result of a long sweeping jawline with a modestly steep mandibular plane angle.  This makes for a lower face that appears vertically long. This is magnified by the observation that your midface (cheek and paranasal areas) is relatively flat/recessed. That combination makes for what you see,, a face that has a greater vertical component than horizontal projection and width.

To address this concern, I would recommend a chin osteotomy which, based on the angle of the cut, allows the chin to become vertically shorter as it comes forward. You need both a mild amount of horizontal increase with an equal amount of vertical reduction. Only an osteotomy can make this bony chin movement possible. In addition,. I would place jaw angle implants that both widen and vertically drop the jaw angles downward. Between the chin and the jaw angle changes, the lower third of your face would become shorter and wider. That will help counter the long thin face look. I have attached some predictive imaging to illustrate these changes.

The other change that would be helpful is cheek augmentation. That would bring the midface more forward, again a manuever that counters the vertical and thin (horizontally deficient) facial appearance. I have attached an image that shows where this cheek augmentation would be. Your pictures are not of a good enough quality to really show what cheek augmentation can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 56 year-old man who has always had a weak chin. While I have always wanted to do something about it, I could just never get the nerve to go in and see a plastic surgeon. My girlfriend has given me the encouragement to now do and I am going to make the move to see what is possible. Could you give me some direction in what you think I need? I think the problem is more than just a short chin, my overall jaw just seems smaller. I don’t want to get a chin implant placed on the end of my jaw if it does not look right or natural. I have attached some photos of me from the front and side for your evaluation.

A: Having a weaker jaw/chin in an older male always raises questions about both bone and soft tissue management since there is some degree of sagging of the jowls and neck. While you would undoubtably be helped along the jawline with a facelift (neck-jowl lift), I am going to pass over that issue for now as dealing with the bony deficiency should always been done first. Since a lower facelift affects the posterior jawline and neck angle the most, it would have its greatest effect on the jaw angle area. Whether you would benefit by jaw angle augmentation or a total jawline procedure is unclear to me at present. (and also unlikely) Therefore for this discussion I am only going to focus on your chin deficiency and submental fullness which are your biggest facial imbalance issues.

What you need is a chin implant and neck liposuction/submentoplasty. The question is whether a preformed or off-the shelf chin implant will work or whether a custom implant is preferred. Both will make positive changes. It is just a matter of degree and how substantial that change is. You do have both horizontal, vertical, and transverse (width) chin deficiency which is common when the chin is very weak. The problem, as you have accurately pointed out, is really an overall jaw growth issue not just a simple short chin. This makes the entire lower face short in every dimension.

I have done some predictive imaging based on both off-the-shelf and custom implant approaches so you can get a feel for how the two type of chin implants differ. A custom chin implant will address all dimensional deficiences. and produce a more profound change..if one finds that look appealing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just had a old tragus piercing split. Is this something that can be stitched back together or will the skin grow back? Or does it require plastic surgery? If the latter, will it look normal after plastic surgery? Thanks.

A: While piercings are common on both the earlobe and the tragus of the ear, there is one anatomic difference between them. The earlobe is completely comprised of soft tissue, skin and fat only, and this is what holds the piercing in place. The tragus, however, has a central core of cartilage with skin on top. It is the cartilage which holds piercing in place and it is usually much more secure and resistant to stretching unlike the earlobe. When a tragal piercing splits, presumably by it being pulled on, the underlying cartilage may have split as well.

Like the earlobe, a tragal split will heal on its own due to the excellent blood supply. Whether it will heal with a notch or cleft in it is impossible to say. I would allow it to heal on its own and see what it looks like later. Scar revision can always be performed of the contour of the tragus is not perfectly smooth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar from a tummy tuck in 2007. I also have scarring under my breasts from a lift and augmentation at the same time. While the mommy makeover boosted my confidence by not having sagging skin it also left me with these horrible scars. While I can cover them up in a bikini when I couldn’t cover up the sagging skin, it still leaves me very shy and not confident when I have no clothes on. It doesn’t seem fair that I spent so much money in 2007 for a mommy makeover to be left with such embarrassing scars. I don’t know if you can help me but I would appreciate your advice. Thanks so much.

A: While the combination of a tummy tuck and breast implants with a lift can remake the female torso altered by pregnancies, there is always the tradeoff of scars. While these breast and abdominal scars are usually quite acceptable, there is always the risk that they may not be so. When the scars are not aesthetically pleasing it is almost always because they are widened or hypertrophic. Improvement in these scars can be achieved by revision consisting of excision and re-closure. The scar outcome is likely to be improved because the tension or tightness on them will be much less now than the original procedure where much more tissue was removed. While the scars can not be removed or significantly repositioned, they can be narrowed such scar revision surgery.

Dr. Barry Eppley

Indianapolis, Indiana