Your Questions

Q: Dr. Eppley, While searching the internet I found a program that allows one to change things on their face. I have always been interested in having a nosejob so I went ahead and did my own picture. I really like how it turned out as I have always wanted a thinner looking nose. My question is whether you think I could get such a result from actual surgery. The skin on my nose is thick so I don’t know how realistic this program is?

A: Morphing or imaging programs are very valuable is aesthetic facial surgery, particularly in rhinoplasty surgery. Their accuracy in predicting achieveable results, however, is primarily determined by whom is doing the imaging. The computer software is just a tool and has no ability on its own to predict how body tissues will respond to surgical manipulations and healing. Only the user of the computer tools who is a rhinoplasty surgeon can use them to demonstrate results that may actually occur.

 What you have demonstrated by doing your imaging is what you would like. While I agree the change is very favorable, it is not realistic. One of the most difficult problems in rhinoplasty is the male with thick nasal skin. While the cartilage underneath the skin can be changed and reduced, the thick nasal skin often dampens what is seen on the outside. Realistically, you can achieve the amount of nasal thinning that is about half of what you have imaged.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 57 years old and have just discovered that my hidden penis condition can be treated and improved. I have suffered through my teenage years and adulthood with the taunts  in gym and the odd looks of women when I could of had something done about it! Doctors told me that I was OK and said that some men have an inee and others have an outee. I knew that something wasn”t right. My folks and the doctors back then could circumsize me, but they couldn’t fix this! While most of my sex life has passed me by at this point, I’d still like to look normal before I die.

A:  While having either an inner or an outie may be normal for the appearance of the bellybutton, it definitely is not normal for penile exposure. The buried and hidden penis is often a developmental condition that can become apparent early as a child or in the teenager years. It is caused by a tethered or retracted penis that is often accompanied by a larger surrounding suprapubic mound. This combination can frequently result in partial or complete coverage of the penis. While a majority of buried penis cases do occur  in males that are overweight, it is not exclusively so. This penile problem can be improved by a combination urologic and plastic surgery approach. The buried penis needs to be released while the suprapubic fat mound needs to be reduced by liposuction with or without a suprapubic lift. While there are some cases where suprapubic mound reduction alone is sufficient, most long-standing cases in adults benefits by dealing with both anatomic issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead contouring surgery. My forehead is kind of rounded and I would like to have it more like square-shaped. When looking at a profile view my forehead sticks out where my brows are and my eyes look deep in the face. I also have attached a picture of a gentleman that his forehead looks more like square and that is exactly what I’m looking for or something close that will reduce my forehead. Thank You

A: Thank you for sending your pictures. Your forehead shape is a combination of brow bone protrusion and an upper forehead that slopes backward. Together this gives your forehead a 50 to 55 degree backward slant in a profile view. The desired forehead shape that you have shown is almost completely vertical. While that is not completely possible from the forehead shape that you have now, you can make significant improvement in your current shape. To change the slant of your forehead, you need to address the two components of the problem, brow bone protrusion and upper forehead retrusion. This is done through a combination of brow bone protrusion and forehead augmentation above the brow bone area. Neither brow bone reduction or forehead augmentation alone will make this improved shape. It takes this combination ‘ying and yang’ approach to create the substabtial forehead shape change that you desire. I have attached an imaged result of what I can think can be achieved by this approach. This would be done through an open coronal incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year-old female who has been considering breast enlargement for a long time. My right breast is significantly smaller than my left breast and I have never been comfortable with them being so lopsided. I am pretty sure that I want this procedure done but I am a bit nervous about how they will be made more even. I don’t want to larger breasts that are just as lopsided. How would you go about making my breasts more even?

A: Congenital or developmental breast asymmetry is one of the most challenging problems in breast augmentation. This is because the two breasts are not different in just mound size but also in the amount of overlying skin and in the position and size of the nipple-areolar complex. While implants are an integral part of this ‘reconstructive’breast augmentation, consideration must be given to adjustment of the nipple position as well as a possible staged approach using  a tissue expander if the asymmetry is severe enough.

The key phrase here is ‘making your breasts more even’ or decreasing the magnitude of the breast asymmetry. Perfect breast symmetry is not possible in these cases and one has to be prepared for a higher risk of the need for revisional surgery to try and achieve the best result. Breast implants alone, while making the breasts bigger, often unmask or reveal the many differences between the two sides in breast asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a zygomatic surgery four weeks ago. My right cheekbone was broken.  The swelling has not completely gone down yet, but I can not understand the asymmetry in my face. My question is when these swellings will go away completely?  I feel very anxious about if my cheekbones will  have good symmetry again. It seems like I still have a collapse in my cheek bone even though there still is swelling present.

A: There is no question that zygomatic fracture repair can be associated with a large amount of eye and cheek swelling, particularly if it required a combined intraoral and eyelid incisional approach. Less swelling occurs from a more simple intraoral reduction. Since I don’t know the classification and magnitude of your cheekbone fracture and how it was treated, I can not say with any certainty about when most of the swelling will subside. But six weeks is a good time period to judge the results even though it may take until three months for all swelling and tissue contraction to occur.

However if in the face of swelling a cheek bone fracture repair shows persistent asymmetry, it may well be that the fracture repair was inadequate or not stabilized ideally. If this is the case, it is still possible at six to twelve weeks after surgery to do a revisional fracture repair with an improved outcome. (secondary facial fracture repair) Very delayed zygomatic fracture repairs may require camouflage procedures such as a cheek implant and/or combined with an orbital floor implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I gave birth to twins over three years ago and since then I now have an abdominal hernia and umbilical hernia due to my abs splitting from being pregnant with twins. I also just have extra skin that exercise will not help with. I currently have surgery scheduled for next month with a general surgeon to fix my hernias. He is doing it laproscopic. I was curious if you would be able to fix my hernias by repairing my abdomen muscles and removing my excess skin. Or if you could do the tummy tuck the same time as my surgery with the general surgeon so that would reduce my anesthesia cost and then my insurance would cover some costs. Please let me know your thoughts.

A: Your questions are good ones and fairly routinue inquiries in regards to combining tummy tucks with hernia repairs. Let me discuss the aspects of such a combination from both a medical and financial standpoint.

Most hernias from childbirth are going to be in the midline between the rectus muscles and around the umbilicus. This would be the standard location for a woman who has been considerably stretched from having twins. In a tummy tuck procedure an umbilical hernia would be encountered, reduced and repaired with the midline rectus muscle fascial plication that is almost routinue in most tummy tucks. I have done this many times and there is good logic in combining these procedures in terms of operative efficiency and recovery. If an open tummy tuck is being done then there would be no need to do a laparoscopic approach to a hernia repair.

The issue of doing the two together through insurance is the intriguing twist to this combination. Contrary to popular perception, there is no financial benefit to putting these procedures together. Many years ago there was but those days have long passed. The hospital is fully aware that a tummy tuck is being done and will charge a full rate for the tummy tuck procedure including OR and anesthesia charges. There is no such thing anymore as the insurance covering the OR and anesthesia charges for a cosmetic procedure when done with an insurance covered operation. Both the hospital and the insurance company consider that fraud so there are extremely vigilant about that issue. Interestingly, doing a cosmetic procedure with a covered insurance procedure in a hospital could very well end up costing you more, a lot more, than having a tummy tuck and the hernia repair being done in a surgery center on a purely cosmetic basis. These are the realities of today’s hospital and insurance economics.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had a bone cement for 10 months on my forehead and this was done by my neurosurgeon. He had to elevate the depression on my forehead and on my frontal sinuses due to an accident 10 years ago. I am planning to learn mixed martial arts in a few months but I am worried that my bone cement will get hit and break. Is my bone cement as strong as the rest of my skull? Thank you very much!

A: The term ‘bone cements’ refers to a family of synthetic materials that can be used for cranioplasty purposes. Historically, this used to refer to the material PMMA or acrylic which has been used for over fifty years in cranioplasty surgery. This is still a very common material that is used by many neurosurgeons in particular. It is mixed together and creates a very strong composition similar to what most people known as plexiglass. This would resist any type of trauma much like normal skull bone would do. In the past decade new cranioplasty materials composed  of various forms of hydroxyapatite have emerged which are also known as hydroxyapatite cements (HAC) or bone cements. These are not nearly as strong and are much more brittle. These are more likely to fracture if exposed to trauma.

Your cranioplasty was an onlay or augmentative one in which whatever material was used was placed on top of existing but depressed skull bone. This is much more supportive of the cranioplasty material than if it was used to replace a full-thickness cranial defect so impact resistance is greater regardless of the material used.

If you had a PMMA cranioplasty I would have no concerns whatsoever about sustained implacts. If this was a HAC cranioplasty, however, I would be more cautious.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Many years ago I had an absessed septum in my nose and had to have emergency surgery. The doctor wanted to do plastic surgery after the procedure due to the excessive loss of cartilage in the nose, but because of the trauma of the initial surgery, I did not want it. After many years, I wish I had done the corrective surgery. Is there a chance that insurance might cover some of a corrective nose surgery for me after so long?

A: Loss of portions of the septum due to infection or hematomas creates, sooner or later, collapse of the overlying nose. This creates what is known as a saddle nose deformity with collapse or inward deviation of the dorsal line of the nose. With the sinking in of the middle vault, the tip of the nose will turn upward with excessive nostril show. With loss of portions of the septum there may also be a hole or perforation of varying sizes between the two sides of the nasal airway inside.

 Reconstruction of a saddle nose almost always requires a rib graft to rebuild the dorsal line of the nose. The septum usually is not and cannot be rebuilt due to loss of lining nor would it have any influence on the appearance of the outer nose. Such rhinoplasty procedures would most certainly have some coverage under one’s health insurance due to the medical basis (infection, loss of septum) for the cause of the problem. This would be ascertained before surgery through an insurance predetermination process.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation last year and was advised before surgery that I needed a breast lift also to get the look that I wanted. I have had two children and had a bit of breast sagging. But I didn’t want the scars or the extra expense at that time. Now I have come to realize that the doctor was right and feel now that the scars would be better than the way the breasts look now. The implants have actually made my breasts look worse even though they are bigger. Can I still get a breast lift now even though I already have implants in place?

A: For those women who have some minor amounts of breast sagging that present for breast augmentation, the idea that they need a lift as well is often a bit much. Due to concerns about scarring and the extra expense from a simultaneous lift, they may defer and let the results ‘prove’ that a lift is beneficial or not. While in hindsight you may have regretted this decision, the possibility of avoiding scars and saving some money was not an unreasonable one. Now that you have the implants in place you can certainly go on to a have lift as a ‘two-stage’ approach to your breast enhancement. The good news is also that you might get a better breast lift result because of working with an established breast mound underneath from the previously placed implant. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very petite frame and am 5’1”and weight 108 lbs. But despite this small size I have a little area of stubborn belly fat that won’t go away. My weight doesn’t fluctuate that much and runs anywhere from 105 to 110 lbs. If I get this fat removed by liposuction what are the chances that it will come back? Since my weight fluctuates a little while this cause it to return?

A: The retention of liposuction results is definitely influenced by one’s weight. I tell all my liposuction patients that the long-term reduction seen will only be as stable as one’s weight and it also depends on what body area has been treated. The abdomen and waistline for both men and women is the area at greatest risk for fat return after liposuction since it is a primary depot site for excess caloric intake. However given your small frame and the relatively minor weight fluctuation that you have, this should not be a significant concern since you are talking about a weight fluctuation that is around 5% of your  total body weight. Fat return is more likely when weight increases are in the range of 10% to 15% or greater.

Dr. Barry Eppley

Indianapolis, Indiana

Today’s patients are more concerned about treating the early signs of aging and unwanted fat than ever before. Women and men alike are looking for faster, less invasive procedures with little if any downtime that can reduce their wrinkles and improve their figure. While many devices have been touted over the years, most have failed to produce satisfactory results for many patients. But a new technology is now available that offers the  latest advancement in nonsurgical, pain free therapy for the reduction of targeted fatty deposits, skin tightening, and sun damaged and/or wrinkles skin anywhere on the face and body.

Exilis is an FDA approved device that offers a non-surgical solution using radio frequency (RF) energy for fat reduction and tissue tightening anywhere on the body. The procedure uses safe radio waves to heat your skin and targeted fat cells. This thermal energy speeds up the metabolic activity of the fat cells causing them to shrink. At the same time it stimulates and strengthens the collagen network which improves skin texture.

Exilis is one of the first systems that produces actual circumferential reduction. By combining RF energy with cooling, all areas of the body where stubborn fatty deposits persist or tighter, firmer skin is desired can be treated. While Exilis is heating the tissues, patients remain relaxed and comfortable. Having no pain alone is a real advancement in non-surgical device treatments.

The most frequent areas treated with Exilis Therapy in men are the love handles, chest, abdomen, face, jowls, and neck. In women they include the face, jowls, neck, decolletage, arms, bra fat, thighs, hips, breasts, buttocks, stomach, and knees. Exilis requires a series of treatments, usually four, to get the best results. The results from Exilis Therapy are gradual and may take from two to four  months to see the maximal effects of the treatments.

During the procedure the Exilis computer-controlled delivery device is guided over the treatment area. One feels a deep heating sensation as the Exilis RF energy is delivered to the deeper layers of the skin. The therapy causes the collagen support tissues to remodel and tighten. The applicator provides cooling to the skin’s surface as the energy is delivered, keeping one comfortable during the treatment. Many patients report the treatment similar to a ‘hot stone massage’. Exilis therapy is performed in the office and takes from 15-30 minutes depending upon the size of the treated area.

The highlights of this new Exilis therapy is NO downtime and NO pain, NO anesthesia, NO numbing creams and NO after care, reasonably quick treatment sessions, progressive results that last, able to treat all areas of the face and body and is scientifically proven and FDA-approved.

Exilis offers a revolutionary non-invasive form of treatment for the reduction of wrinkles and for the reshaping of unwanted fat deposits. Exilis also provides a method of after surgery smoothing and skin tightening from invasive liposuction procedures. Exilis treatments can postpone or eliminate the need for invasive surgery particularly for patients with mild to moderate fat deposits and who may not want liposuction surgery. As the only provider of Exilis therapy in Indianapolis and the state of Indiana, I am very excited to offer my patients a real alternative to fat reduction and skin tightening surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard that some breast augmentations have resulted in a decrease in feeling or sensation in the breast, especially the nipple area. Is it true that a breast lift can be done in a way that will not result in the loss of feeling?

A: While the potential for loss of some or all of nipple sensation can occur with any breast operation, that risk differs based on what type of breast surgery is being done. Breast augmentations and breast lifts are both procedures done to enhance the look of the breasts. But they are completely different operations and should not be confused in their potential effect on nipple sensation. Breast augmentation involves the placing of any implant in a pocket either on top of or under the chest muscle. It is in essence an ‘internal’ breast procedure whose pocket dissection may place at risk nerves that are making their way to the nipple from the chest wall through the breast tissues. Breast lifts are done by removing skin, lifting the breast tissue which contains the attached nipple upwards and tightening the remaining skin around the elevated breast mound. It is thus largely an ‘external’ breast procedure and does not usually involve dissection near the nerves that supply sensation to the nipple. These differences make the risk of decreased nipple sensation greater in breast augmentation than in breast lifts. Often implants and lifts are combined which pose the greatest risk to nipple sensation.

There are different types of breast lifts and some have virtually no risk of changing one’s nipple sensation. These are the first three types of breast lifts (superior crescent, periareolar and vertical) which do not involve dissection around the base of the breast mound.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old African-American female who is in need of a serious tummy tuck. I have had three children, the last two by c-section. I have a large amount of lower stomach skin with a lot of stretch marks. It makes my belly button look odd and almost buried with the loose skin around it. If I get a tummy tuck will they be able use my c-section scar? I need a tummy tuck so bad that if I had to have a new scar above the c-section scar I could live with it. But I would like if possible to keep it low and just have a longer c-section scar.

A: This is a common question and concern and one I think about when doing a tummy tuck in every women that has a c-section scar. I always want to use the c-section scar whenever possible for two reasons. The first is the one which concerns you and that of the unsavory cosmetic issue of adding another scar to the one you already have. But a more important consideration, and the one that I am most concerned with, is the survival of the skin between the two scars if the c-section scar could not be used as part of the tummy tuck. The intervening skin between these two scars may not have a good blood supply and could either not heal well or actually die…which would obviously create a significant after surgery complication. For this reason every effort is made to use a c-section scar in a tummy tuck and if you have as much loose skin as you describe this would not be a problem to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am hoping to reduce the size of my bulging head and brow bone to get an even and a more natural look. Please take a look at my pictures and tell me what you think.

A: There is no question that you have a significant forehead bulge or protrusion. In looking carefully at your pictures you can see a narrowing behind the forehead bulge running down the sides of the skull exactly where the coronal sutures would be. This suggests the reason for your forehead bulging is some variant of coronal craniosynostosis, probably a partial craniosynostosis deformity. Whatever the reason does not change how you might approach forehead reduction. While the most effective procedure would be removal and reshaping of the entire forehead bone flap and the skull bones behind it, this type of craniofacial surgery can only be done in infants and not adults. This is due to the inability to mold bone in an adult skull. Therefore, the only option as an adult is whether external bone reduction by burring would make a significant difference. That question can be answered by plain lateral skull x-rays. This x-ray would allow a measurement to be made as to the thickness of the forehead bone and, more specifically, the thickness of the outer cranial table and underlying diploic space. If up to 5 to 7mms of forehead bone can be reduced over the entire forehead, this may make enough of a difference to justify this approach to forehead reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several keloid scars that need to be treated. I had a submental tuckup procedure done and at the same time had a mole on my chest removed. My submental tuckup procedure was done in an unconventional fashion as it included removing neck skin vertically and not just horizontally under the chin. I now have a wide and raised keloid scar on the vertical scar in the neck as well as the one on my chest. I have done some research and have read about the use of steroids with scar revision. Do you think this combined approach will work for me? I have attached some pictures of the scars in question.

A: In looking at your pictures what you have on your chest and neck are not keloids. Those are known as hypertrophic scars which are quite different biologically from a keloid which is a true pathologic derangement of scar formation. Hypertrophic scars often result in very predictable areas, such as the chest and vertically in the neck, due to the tension that is placed on the scar line. Treatment of hypertrophic scars is excision and reclosure, not steroids. Steroids will likely result in a recurrently wide but depressed scar as it interferes with collagen formation and wound healing. Steroids should only be used in true keloids that are recurrent and not hypertrophic scars. The location of your two scars in question places them in jeopardy for hypertrophic scar formation, even with scar revision consisting of repeat excision and closure. But this is still a worthwhile effort to do and improvement in the appearance of the scars is likely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting some information on breast augmentation, particularly about the costs involved. Also if a lift is needed does that effect the cost and by how much? Thanks.

A:  The cost of breast augmentation is fairly standard and only differs by whether one uses a saline ($4700) or silicone implant ($5800), all costs included. If a lift is needed, there are additional costs. What those costs would be would depend on what type of breast lift is needed. There are four different types of breast lifts that differ based on how much and where the scars are located, the amount of the lifting effect that is created and the time it takes to do it. The complexities of the need for a breast lift and what type is best can only be determined by an actual physical examination and discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get breast implants but I am concerned about them since I work out a lot. Am I at increased risks for problems if I run a lot and lift weights? Also should I have them placed above or below the muscle?  I don’t want them to look and move unnaturally. I also don’t want them to be too big so what size do you think I should get? Thanks!

A:  The debate about whether one should have their breast implants above or below the muscle is largely an historic one for most women. The benefits of being under the muscle, or a dual-plane approach, are significantly superior in the long-term. This would be particularly true in an athletic woman who often has little breast tissue to interface between the skin and the implant. Breast implants placed partially under the muscle tend to have fewer problems with visible rippling, long-term encapsulation, and interference with mammograms.  These advantages outweigh the potential for implant movement that can occur with pectoralis muscle flexion.

When it comes to implant size, this consideration would be of particularly significant in an athletic woman. You don’t want the implant size to interfere with any exercise activity. This basically refers to getting the implants too far to the side so it gets in the way of any arm swing. The best way to avoid this potential problem is to not get an implant whose base diameter is bigger than one’s own natural breast base diameter. This simple linear measurement will always avoid having a breast implant that looks too big as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need some type of implant to correct my severe case of temporal hollowing. I have looked at some of the available temporal implants that are available but they don’t seem thick enough to me. What type of temporal implants do you use? Do you use the silicone ones or the Medpor ones? What is the most thickness that I can get in a temporal implant?

A: Silicone temporal implants are but one type that I use. The largest commercially available temporal implant, in terms of thickness, is the silicone temporal implant. The largest silicone temporal implants measure 6cms x 4cms with 10mm thickness at one end. That would be more than adequate for the vast majority of patients. It can be quite surprising how ‘small’ an implant may look when holding it your hand and then how much change it actually makes when put in place. I have been surprised many times and have learned with many forms of facial implants that changes can be much more dramatic in place than one thinks, no matter who well one has measured and thought about the defect beforehand.

If one really needs a thicker temporal implant, it can be made through a custom fabrication process. But it is important to remember that subfascial temporal implants can only be so thick or they will be very difficult to fit into the tight space. Much thicker temporal implants need to be placed in a submuscular location which requires a more extensive scalp incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very severe case of dark circles under my eyes. I am 30 years old and am of Indian ethnicity. I know this is a common problem in people of my heritage. I have tried numerous topical crèmes for dark circles but none of them have done anything. I am sending you some pictures for your assessment. Do you think there is anything you can do to help me?

 A: Thank you for sending all of your pictures. There is no question that you have is a fairly severe case of dark circles. Much of it is actual skin hyperpigmentation rather than a hollowing effect.  And the zone of skin hyperpigmentation extends fairly far outward from the eyelid area. I don’t think on seeing this extensive collection of photos that you have a really significant tear trough or hollowing problem. There is some mild hollowing but that is not the true cause of the problem, the hyperpigmentation of the skin is.

I don’t know how much improvement can actually be obtain in such a severe case  of dark circles but some effort is certainly justified given the magnitude of the problem. I would approach your dark circles with a combination procedure of fat injections to fill out some mild hollowing, a pinch lower blepharoplasty to remove some excess skin (you do have some despite your young age) and a 25% TCA peel to try and remove some of the superficial hyperpigmentation. 

How effective this combined approach would be is undetermined and I would never assume it to be a complete cure or solution…as there is no such thing with such severe dark circles. The goal is to see what degree of improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been working out for about three months now, and the first thing that always goes first are my breasts. I am currently a 34B, and I would like to be one cup size bigger. I looked at your before and after photos, and they look very good. I know I want them, but the cost is a big factor. Would I have to schedule a consultation with you in order to know how much it would cost? Thanks so much.

 A: Your description of the desire for breast augmentation is a common one. Whether it be from weight loss, exercise or pregnancy, breast tissue shrinkage or involution is one of the most common reasons for why women want breast implants. Their desire is to either return to a breast size that they once had or just get some more volume to fill out deflated and saggy breast skin. When it comes to determining cost of breast augmentation, an actual consultation is not necessary. The pricing of breast augmentation is one procedure in most plastic surgery practices which is fairly ‘standard’ and usually published. In my practice it would be around $4700 for saline breast augmentation and $5800 for silicone breast augmentation, all costs included. This pricing assumes that no other procedures are required such as any form of a breast lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are the various mini- or limited types of facelifts effective and how long will it last?

A: The numerous type of franchised forms of quick recovery facial tuck-ups are well known versions of limited facelifts or a jowl tuck-up procedures. There is nothing magical or unique about this operation or approach. It is a scaled down version of a more complete facelift or a neck-jowl lift. It can be very effective if done well and will get years of sustained improvement which will vary by a patient’s skin type and genetics. It could be anywhere from 5 to 10 years depending upon where one starts and how well one ages. The more relevant question, however, is whether this type of facelift approach is right for you. The vast majority of unhappiness with these franchised named ‘mini-facelift’ is that the patient wasn’t a good candidate. Their facial aging issues were more advanced and they should have had a fuller facelift to get the kind of result that they were expecting. Patients understandably are tempted to choose a facelift operation based on how it would be done (local or IV sedation), a short recovery and/or a low cost rather than choosing a facelift operation that better fits their actual needs. This is the real issue you should be thinking about.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I been looking for a expert on lip reduction for a very long time. About five years ago I had silicone injected into my upper lip and I have regreted it everyday since,  its ruining my life. I would really appreciate it if you could just give me a honest answer as to what be done about it. I want my four front teeth to show again and make the upper lip smaller than my bottom lip. I have attached some pictures of my lip including what it looks like underneath.

 A: Based on your pictures I can see that there are many bumps on the underside of your upper lip on the mucosal surface. This would likely be the location of much of the silicone material, either being pooled collections of the oil or silicone granulomas. While it is probably impossible to ever completely get rid of all of the injected silicone material, the good news is that much of it appears to lie in the tissue zone of excision where an upper lip reduction would be performed. A lip reduction typically removes mucosa from the inside of the lip from the junction at the wet-dry vermilion. This allows the upper lip to roll in and become vertically shortened. Where this tissue is removed is also where most of your bumps are so you would get a dual benefit of a less full upper lip and some of the silicone material removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How could I get any lifts or tucks via my insurance which is Medicare. I know alot of it would be seen as cosmetic. However,  I can assure you  that all I want is to look normal and able to wear real clothes and not tents. I’m 45 and need my life back.

 A: While all plastic surgeons are emphatic to your plight, the reality is that Medicare will simply not provide coverage for any type of so-called ‘lift or tuck’ procedures such as tummy tucks, pubic lifts and thigh lifts. Medicare is unique amongst insurances in that it will provide no predetermination before surgery to validate whether it will or will not pay for such procedures. Having provided a lot of these services in the past only to learn later that Medicare will not pay, many plastic surgeons will no longer  perform such procedures for Medicare patients. They are viewed as cosmetic procedures to be done as a fee-for-service basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck last year but it did not fully correct my sagging mons. I would like now to have that fixed as well. Where are the incisions for a monsplasty placed? Can they be placed in the groin crease to avoid a visible scar? I don’t want any more scars than the long tummy tuck one that I have now. Is it better to have a monsplasty lift or monsplasty by liposuction?

A: With significant amounts of pubic sagging or fullness, a tummy tuck may not ideally reshape the mons area. If recognized before surgery, modifications can be made in the tummy tuck incisional design or through the combined use of liposuction to get a good mons correction as well. When done secondarily, a direct mons lift is done using the central part of the tummy tuck scar so no new incisional locations are needed. Ususlly liposuction is done with a mons lift in most cases as the combination approach produces the greatest amount pubic reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 36 yrs old , weigh 132 lbs and work out three to four times a week. Despite these good numbers, I have big saddlebags that definitely don’t fit the rest of my body. I have had them my entire life ever since I was a teen. They make my bottom half completely mismatched to my small and toned upper half. I have read that after liposuction fat can reappear and in different places. I would not want to ruin my upper half at the expense of improvement in my lower half. Is this something that I should be concerned with?

A: Liposuction of your saddlebags will provide great improvement and patients like yourself are exactly what liposuction was designed for and is best at…spot fat removal. There are many fallacies and inaccuracies about what happens  to fat after liposuction. When it comes to potential future weight gain, the saddlebags unlike the stomach and waistline is not an area that fat will reaccumulate. It is not a metabolic depository site for extra calories. But other body areas are and it is certainly possible that fat can appear in other body areas with weight gain. The concept that you are really referring to is known as ‘fat equilibrium’, the  belief that everyone has a certain amount of fat that they are genetically predisposed to have. And by removing one area of fat, the body in an effort to maintain a fat balance will just have it accumulate elsewhere. This fat concept, while often talked about as if fact, has never been scientifically proven. A recent small study in plastic surgery did show that abdominal and thigh liposuction patients one year after surgery did have some measurable increase in thickness in the arms and upper back. But it was not something that the patients noticed. I would not be concerned that your saddlebag liposuction by Smartlipo will change your upper body shape to any noticeable degree if at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very weak jawline and some fullness to my cheeks and face. My face is sort of round and not very distinct. I went to one plastic surgeon and he said that a chin implant would change  my facial shape. But I have read that many chin implants also have liposuction under the chin as well. This seems to make sense to me but I still don’t see how that will improve my chubby cheeks. What would be your recommendations? I have attached some pictures of me from the side.

 A: I think there is no question that you have a short chin and a rounder fuller face. A chin implant will definitely over good improvement of your profile. But to really ‘deround’ a fuller face it is going to take other adjustments. These would include some fat removal as well. Liposuction under the chin would also be a definite plus and, with the chin implant, can dramatically change the jawline. But the cheek area needs thinning by a partial buccal lipectomy with perioral liposuction. Buccal fat removal only affects the upper cheek area below the cheek bone. Perioral liposuction is needed to remove fat from the lower cheek area at the level of the corners of the mouth. The combination of chin augmentation and fat removal from the neck and cheeks can very effectively make a round face have a much more defined shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline breast augmentation in 2005. Over the past year or so they see, to have gotten smaller. I know they are not broken or deflated but they definitely don’t seem to be as big or firm as they initially were. Is there a way to make the, bigger without having to pay for new implants? My original ones were put in through the armpit.

A: There are two reasons why many women find that their breast implants seem to be smaller years later. The first is a psychological one, the novelty over times passes and they just seem to be smaller. This is what I call cosmetic accommodation and it happens with many cosmetic procedures. The second is a real physical one. The breast tissue between the implant and the skin may actually become thinner due to pressure resorption over time. When combined with natural skin relaxation, there can be a definite looser and smaller feel to the breasts in some women. This is also why in saline implants there may be the feel of implant rippling over time.

A more firm feel and slightly larger implant size can be obtained in saline implants without having to replace them. More saline can be added to them through a very simple procedure of reattaching a filler tube. This can not be done through the old armpit scars, however, and requires a nipple incision for direct access to the fill valve area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I just had a quick question regarding the forehead lowering procedure. I want to get my forehead lowered however I have a “Y” shaped vein that runs right down the middle of my forehead. Is it still safe to perform the surgery with this and have you ever personally encountered this? 

 A: Many people have prominent veins in their forehead that undergo browlift and hairline type procedures. Because the veins are in the subcutaneous level of the forehead tissues, they are out of the plane of dissection which is at the deeper subperiosteal level. So they do not pose any ‘risk’ for a hairline lowering/forehead reduction surgery. If the vein(s) crosses into or from the frontal hairline, it will be tied off or cauterized in a hairline advancement as it will be encountered in the dissection from the skin down to the bone. Either way, veins are not an issue in any type of forehead surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a 50 year-old female. I am bothered by sagging jowls. What are the various procedures and how much do they cost ?

A: There are a variety of options available for sagging jaws from non-surgical (Exilis radiofrequency) to different types of jowl lifts. Which one is best depends on how much jowl sagging one has. While I don’t know what you look like, it is more likely than not that you probably need some form of a jowl-neck lift (which is really known as a facelift) based on your age/ Whether this is a more limited variety or a fuller neck-jowl lift (facelift) again depends on how much jowl sagging you have. If you could send me some pictures, I can answer that question based on this visual information only. Once we know that then accurate surgical costs can be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a combined rhinoplasty and sinus surgery nearly three years ago. The rhinoplasty result turned out to not be so good as the middle part of my nose was too pinched inward. I then underwent a revision about a year ago where cartilage was taken from ear to build up the middle part of my nose. I am still left with one problem that has not been corrected. I have a hanging columella with a slight outward rotation of the cartilage. Is it repairable? What is the cost and since my previous surgery was covered by insurance would the revision be as well?

 A: A hanging columella deformity can occur for two reasons. The underlying caudal end of the septal cartilage may have been adequately reduced or overresected, leaving excess mucosa and skin ‘hanging’ off the cartilage. This usually leaves an outward curve of soft tissue from below the tip down to the base of the nose. The other type of hanging columella, which is not a true columella deformity but may initially appear so, is when the infratip lobular cartilage is too prominent and pushes outward on the columellar skin. This creates more of a ‘hard’ hanging columella because it is composed of cartilage.

Either way, both types of hanging columellas can be corrected fairly easily a minor revisional rhinoplasty procedure.. This type of nasal problem would not be covered by insurance as it is a cosmetic problem, regardless if the original nose procedure was covered by insurance. The cost would be influenced as to whether it is done in the office under local anesthesia or in the operating room under some form of anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana