Your Questions

Q:  Dr. Eppley, I have been bothered by the appearance of my nose for a long time. The problem is that the  tip is big, long, and droopy. Because the tip hangs down, it also affects my smile. It makes my smile look unnatural as the upper front teeth are barely visible. I have spent a lot of money on orthodontic work and I want them to show. Would a rhinoplasty improve this problem?

A:  I think you have to separate the nose problem from the lack of upper tooth show. While the nose and lip are next to each other, they do not often directly cause a cosmetic problem for the other. A long downturned nasal tip does not cause the upper lip to be pushed downward. Therefore, while a rhinoplasty will make a very visible difference in the shape of the nose and how the overall face looks, it will not have the effect of improving upper tooth show. Pulling the tip of the nose up will not create a shorter upper lip or at least not significantly. You will need to consider some type of upper lip shortening to create that effect, such as a subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need to get rid of my saddlebags. I don’t know why they are there as they do not fit the rest of my body. I am 5’4″ and about 110 pounds. My body fat percentage is quite low as you can probably tell from my weight. I work out all the time and no matter what I do I can not get rid of these pesky saddlebags. Quite frankly, it drives me insane as I just hate them. I was trying on clothes in the store this past weekend and could really get a good view of them from behind in the jeans I was trying on. Given my small size do you think liposuction will work to get rid of them?

A:  Despite being lean and very weight appropriate for their height, I have seen many women who have this saddlebag problem. While I suspect it is a problem of small saddlebags given your height and weight, they are nonetheless disproportionate. The good news is that this is an easy problem to solve with liposuction. Just because you are small doesn’t mean they are not abnormal collections of fat. I would guess your saddlebag problem could be treated by an office procedure under local anesthesia using Smartlipo. This would minimize the process and recovery and provide a solution that truly matches the problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction of my neck and jowls several days ago. The doctor who did my surgery told me to keep my head elevated when sleeping with two pillows and wear a neck  compression garment. How important is it to wear this garment and does it affect the final result?

A: The purpose of the compression garment, as the name suggests and it is probably obvious, is that it applies some pressure on the treated area. Its only benefit is that it may help keep down some of the swelling in the first week after sugery. In most cases of liposuction, compression doesn’t usually make a big difference long-term in the result. You undoubtably are asking this question because neck compression garments, in particular, are a nuisance to wear. What I tell my patients, whether it is neck liposuction or a facelift, is to wear it regularly for the first two days after surgery and then just at night for the first week after surgery. Thereafter it may be discarded as it no longer provides any benefit and the patient’s tolerance for it has been reached.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a rather big nose (and it become much more bigger when I smile or grimace). How much of it can be reduced by rhinoplasty? Can I have nose like, for example, Angelina Jolie? And the other question is will my nose get bigger the (when I smile or grimace) after nose job?

A: The first concept to grasp about rhinoplasty surgery is that you can not have  a nose like someone else. While it is important to have a surgical goal, looking like someone else’s nose is not realistic. This is particularly true when it comes to a large nose with thick skin. There are simply limits as to what can be achieved based on the amount and thickness of the nasal skin cover. Whether rhinoplasty is worthwhile for you, or any patient, requires some sense of what the result may be using computer imaging. When done carefully by an experienced rhinoplasty surgeon themselves, you will get a much better sense of whether rhinoplasty can make enough of a difference to justify the effort. When I do rhinoplasty computer imaging, I always show the most conservative or least achieveable result that I think can happen. That way if the patient chooses to have rhinoplasty surgery, they will not be disappointed and make even be pleasantly surprised if even more of a result develops.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting my cheeks lifted. I am 48 years old and my cheeks sag which makes me look sad.  My face is plenty full as it is very round. What is the best non-invasive method to lift them up?

A: The first thing that I would tell you is that there is not a non-surgical way to lift up the cheeks. There is almost nothing that I know that can lift any part of the body without some form of surgery. Some doctors may tout that they can lift up parts of your face with injectable fillers and in some small amounts that may be possible for some patients in some facial areas. However, with an already full and round face this injectable approach is likely to make you even rounder…and have no real lifting effect anyway. There are cheek lifting operations but really good results from these procedures come from very careful patient selection. Whether you would be a good candidate or not would depend on seeing some pictures of you. As a general rule, very round and full faces are chcallenges for any lifting operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to get breast implants and need some help in selecting size. I am currently a 34B with one breast about a quarter of cup larger than the other. They are perky but just not full. I am uncertain on whether to get saline or silicone implants and am looking for the most natural result possible.

A: When it comes to getting a natural breast augmentation result, it does not matter whether a saline or silicone implant is used. That has nothing to do with making a difference between looking augmented or not. Rather it is a function of implant size and implant location (above or below the muscle) as well as what your breast tissues look like now. As a general rule, it is almost always better  to go below the muscle so that there is a natural slope in the upper pole of the breast. If you keep the implant base width at the same size or less than that of your natural breast base width, you will almost always look fairly natural. The size of breast implants is directly related to their base diameter. The larger the base diameter, the larger the implant. A simple tape measurement of your breast base diameter would help considerably in making a good implant size selection for you. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am a young women and am very insecure about my forehead. It’s very large and I’m tired of bangs. As you can see in the pictures, my forehead sticks out because of the “horns” I have smacked in the middle of my forehead. It feels hard. It may just be the bone but I still want to see if any procedure can be done to make them go away or, if not, make them less noticeable when light is shown on them.

A: I can see by your pictures that you have an upper frontal bone bulges, often what people refer to as ‘horns’. There are two approaches to making your forehead smooth and less prominent. The simplest approach, and I suspect the one of most interest to you, is to do a burring reduction of these bumps to make your forehead smooth and less prominent. This would be done through an incision way back in the scalp. The other approach to forehead smoothness is to build up the forehead below and around it with a cranioplasty material. This would not only make your forehead smooth but would also give it greater convexity which is viewed by many women as a desireable forehead feature. Both of these forehead reshaping/reduction approaches will work to make the forehead smooth adn get rid of the bumps, it is just that the shape of the forehead in profile view will be different depending upon which one you would choose.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I had a submaxillary Gore-Tex implant placed at the same time as a rhinoplasty over fifteen years ago. It was done to elevate the area below my nose to improve the shape of the angle between my lip and nose. Later it was determined by an oral surgeon that I needed upper jaw surgery but that would be extremely difficult as this implant sticks to the bone and therefore he would not operate on me. I can live with all of the above; however, this implant is annoying as on the right side it continues to dig down into my right upper gum area. I have been told that this type of implant can be very difficult to remove and that it would be best to just leave it alone. What is your opinion on getting it removed?

A:  To clarify the issues in regards to your Gore-tex facial implant, here is what I think:

1) To be exact, it is a premaxillary implant not a submaxillary implant. Because it is Gore-Tex and placed during a rhinoplasty, it was inserted through a nostril base incision initially. It was done to open up the nasolabial angle.

2) Gore-tex does not adhere to the bone and is the one of the least ‘sticky’ implants to remove. It is smooth and the body places a capsule around it.

3) Because it was placed long ago, it is likely a multi-stranded Gore-tex implant rather than a solid one-piece implant composition. This makes it a little more difficult to remove but certainly far from impossible.

4) Your premaxillary implant can be removed through an incision inside the mouth as that is just as close as going through a nasal base incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am 32 years old and two years ago I weighed 220 pounds. By diet and exercise, I have been able to get down to 170 lbs and I seem to be stuck at this weight now. It won’t budge no matter what I do. The skin on my stomach is very loose and I have old stretch marks that I want removed. I want a tummy tuck but do I need to lose more weight before having surgery?

A:  Your question is both a good and a common one. While many people have been successful with a fair degree of weight loss, they sooner or later ‘hit the wall’ and can just not lose anymore. Ideally, I tell my patients that if you are within 15 to 20 lbs of the weight they desire then a tummy tuck is reasonable. If you weigh much more than that then you should wait until you lose the extra weight so you do not create loose skin after surgery should you undergo more weight loss. Realistically, however, once the weight wall is hit for most people that is as far as they will usually get so that has to be taken into consideration. Most patients that I see for tummy tucks appear when they are frustrated with their ongoing lack of weight loss results. You should also understand that only the stretch marks from your belly button to you pubic hair line will be removed.  Any stretch marks above the navel will still be present after surgery, they will just be moved lower to a new position below the belly button.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I had a browlift several months using a hairline approach. While the surgery was uneventful, I have had a persistent scab along one side of the scalp incision that only recently I was able to get off.  The scab was stuck to what appears to be the dissolveable sutures that were used. It now looks like an area of infection with some sort of red tissue between the scalp and foreheads of a few millimeters wide. Why is this and what do I do now? I have attached a picture of the area so you can see what it looks like.

A: It is now clear as to why you have had this scab this long and why it looks the way it does now. The scalp has a tremendous blood supply and this is why infection and necrosis of skin and scalp tissues is very uncommon. Neither of these have been what has happened to you. It appears that you have had separation of the wound edges in the early weeks after surgery, undoubtably due to the combination of tension on the scalp closure (which is normal) and the dissolveable sutures used. It appears that in your case those dissolveable sutures were just not sturdy enough to hold the skin edges together as they were healing. I used these all the time and have never seen this problem before.  

Whenskin edges come apart, the body then creates its own bandage (i.e., scab) to cover the open wound it as it heals underneath it. This explains why the scab was stuck on so well for so long. That is a natural reaction of the body to an open wound. Once the gap in the skin edges fills in with granulation tissue (beefy red tissue that you see in your wound), the scab will get loose and be capable of being removed. This now leaves the gap filled in with granulation tissue that is now level with the surrounding skin. This is a good and healthy sign of a healing wound despite how it may look. This granulation tissue looks very red and angry but this is just due to the many blood vessels that it contains.

What will now happen is that the surrounding skin can now grow over it to make it a completely healed wound. This should take just a few more weeks to happen. The combination of granulation tissue, with a very high level of cells that contract, and the new skin will make the width of the wound and final scar once it heals much smaller. In the interim, of course, you have to persist with this unsightly wound in an area that is impossible to hide.

This leaves you with two approaches at this point and each has its own advantages and disadvantages. The first approach is to let the wound heal and contract and manage the residual scar at a later date. This is the most ideal approach from a long-term scar standpoint. This will leave a much more narrow scar area to excise and the tissues will be of better quality to manipulate so there is not a recurrent problem. The disadvantage is that you have to exist with this unsightly area in the interim. The other approach is to intervene earlier before it heals and excise and re-close the wound now. This has the advantage that it deals with the cosmetic appearance of it earlier but the tissue quality is not as good and how well the wound edges will hold together is a bit unpredictable.

 Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about nose hump removal. I know that rhinoplasty surgery works well for taking down a large bump on the bridge of the nose. But I would like to avoid surgery if possible. May I ask if you`re familiar with nose magic product? Is it worth trying? The company responded quickly to my inquiry, saying that it can help by moving cartilage.

A: I am very familiar with Nose Magic and use a companion device occasionally on my postoperative patients to manage their persistent tip swelling. Do I think it will work to permanently take down a nasal hump…no. Did I think you have anything to lose by using it…no. It has its effect by temporarily squeezing the fluid out of the tissues causing a slight change in shape, just like when you pinch it and hold it for awhile. The problem with a nasal hump is that at least half of it is bone whose shape will not be altered by any form of external pressure. While nothing sells like hope, at least you can prove to yourself one way of the other, of this non-surgical approach to nose reshaping. You will find in the end, however, that only a surgical rhinoplasty will really work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Earlier this year I had breast augmentation using 400cc saline implants under the muscle. I really wanted bigger implants above the muscle but my surgeon told me that they would ripple too much and the folds of the implant would be seen when I bent over. I went from a 32A to A DD cup but they don’t look that big at all. I would like to go bigger but still want to look natural. Would I have looked bigger if I had the implants placed above the muscle? If I wanted to go bigger can I have them switched to above the muscle?

A: There are a lot of advantages to having breast implants under the muscle, only one of which is less risk of rippling. Lack of mammographic interference, a less acute transition at the upper pole into the implant, and most importantly, a thicker and more vascularized soft tissue cover. (even if only the upper half of the implant is covered) I think you are confused that there will be some perceptible size difference if the same implant is placed above or below the muscle…there is no appreciable difference. While you certainly can increase the size of your existing implants, I would leave them in the same submuscular location. Being a thin-framed woman I would be cautious about getting too big of an implant that may not have adequate soft tissue support in the long-run. This can result in the breast implants bottoming out, a difficult problem to fix satisfactorily.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two large earlobes and would like for them to be smaller. They seem to be getting bigger as I get older. I am now 57 years of age and I don’t think they were this big when I was younger. Do earlobes grow as one ages? I am also wondering about the cost for this type of earlobe surgery. Could I get an estimate and would any permanent scars result from it? Also how long does it take to heal or until I can take the bandages off? Thank you very much for your time.

A: Earlobes do in fact grow with age somewhat although not in the classic sense of growth. They do not grow anymore than your sagging jowls and neck grows. Rather it is an elongation process where the tissues stretch due to gravity and ear ring wear. As the earlobe is the only part of the ear that does not contain cartilage, the skin and fat has no resistant internal structure. Earlobe reduction is an office procedure done under local anesthesia. There are different earlobe reduction techniques that vary only in where the final scars are located. The scar locations can be down the central area of the earlobe, at the junction of the earlobe and the face, and along the bottom rim of the earlobe. Which one is best depends on the shape of your earlobe and where you would prefer the scar. There really is no recovery after this procedure nor are they any bandages used afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am interested in getting a rhinoplasty and I want to know if my expectations for the result are realistic and achievable. I would like my nose to have a more delicate and feminine appearance as it is too wide. I think it doesn’t fit my face as fat as it is now. I would like it to be less wide and fat and to not project as much. My nose seems to stick straight out with very little sloping. Can this be fixed and how much can the fat tip be reduced? My nostrils also flare out considerably when I smile which I also dislike very much.

A: Rhinoplasty surgery can make very visible improvements in making a wide nose smaller but there are limitations in how much can be achieved. While the underlying cartilage framework can be resculpted and narrowed, how much that is reflected on the outside is highly influenced by the thickness of the overlying skin. Thick nasal skin not only retains swelling for a long period of time but it can only shrink so much. Taking a wide fat nose and making it a delicate one is a virtual impossibility. That dramatic a change may not be realistic. You should have computer imaging done first to determine if rhinoplasty can make enough of a change, particularly in the tip of the nose, to make surgery for you worthwhile.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a lipoma of size 4″ on my back shoulder which happens to be most common place for a lipoma for many apparently. I want to be cured non-surgical way. I can travel to your location if needed. I heard about Lipostabil treating lipomas. Is it something I should consider? Please advise.

A: The standard method of a lipoma removal is complete surgical excision. While this is the proven medical method, it will result in a scar in the shoulder area. Scars in that area are very prone to becoming hypertrophic and red, although not all will. The use of a chemical injection (Lipostabil in Europe, generic name of Lipodissolve or mesotherapy in the U.S) to treat lipomas is not new. I have injected quite a few lipomas in the last five years for patients who did not want surgery. I have made the following observations about this treatment method. Lipodisolve injections have always made a visible reduction in their size. In some patients it has been a cure but some regrowth is possible if all the fat tumor cells are not adequately treated. It will take at least two and sometimes three injection sessions, spaced a month apart, to get the maximal response. There is some swelling and mild discomfort of the injection site for a week after treatment but it is in no way physically limiting.

While Lipodissolve injections can be effective, it is important to realize that neither the compounds used nor their use in lipoma treatments are FDA-approved.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have a very flat butt and have been researching buttock augmentation with fat transfer. (aka the Brazilian Butt Lift) I have a good amount of fat to take from my stomach area so I think I am a good candidate for the procedure. I know that not all fat survives after it is injected, so how does one compensate for that problem? What are realistic expectations for how much fat will survive? How does one know how much fat to transfer in a buttock augmentation surgery? How much fat can I expect to retain with my new butt and will it be permanent?

A: While fat grafting is very popular and can be highly successful, it is far from an exact science.  There are so many unknown variables in doing it that no one can predict with any accuracy how much fat will or will not survive afterwards. Every patient and their fat is somewhat different leading to a wide variety of results. What we do know about fat grafting is that it is very safe and many people have more than enough to donate. What I have observed about fat injections into the  buttocks (aka Brazilian Butt Lift) is that it often will produce less of an effect than many patients want. This is because of the combination of unrealistic buttock size expectations for some and the variable retention of the injected fat. As a general rule, I inject as much fat as possible (between 300 to 500cc per buttock) and judge the final outcome at three month after surgery. There is never a fear that the result will be too big. The real question is whether it will be big enough.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting breast augmentation. At 25 years of age with one child I have a height of 5’ 3” and a weight of 137 lbs. What size breast implants do you think I need? I have attached a picture of my breasts to help you decide.

A: In looking at your breasts, your most important decision about breast augmentation is not what size implant should be used. You have a moderate degree of breast sagging, meaning the position of your nipples is at or below your lower breast fold. Contrary to the perception of many, breast implants will not have a breast lifting effect. You are in need of some type of a lift if you are going to get breast implants. With implants alone your sagging breasts will be pushed lower, a look that I doubt you will find as an improvement. All breast lifts result in some scarring, a definite cosmetic liability. Whether larger and more uplifted breasts are worth the scars as a trade-off is what you need to think about first and foremost.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 28 years old and I have lost about 95 pounds over the past year and a half. While I am very happy with my weight loss, I now have.a bit of loose skin around my stomach area. I work out a lot and do a lot of core work and abdominal crunches but this loose skin won’t go away. Is there some type of cream or device that will tighten this skin or do I need plastic surgery?

A:  You are to be congratulated on your weight loss efforts and results. Reduction of fat can be rewarded with diet and exercise but your loose abdominal skin will not. Skin is not metabolically responsive like fat nor can it be toned like muscle. Do not waste your money and hopes on miracles in a jar or an exercise device. Only the manufacturer will benefit from your purchase. You will need to consider some form of a tummy tuck to get rid of this loose skin and tighten your abdomen. Whether the scar and the surgery expense is worth it merits a thorough discussion with a board-certified plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a bad car accident three years ago which left me with many scars. Most of them are on my arms and back and and don’t bother me much because I can’t see some of them and I am tan enough so that they don’t show. However, the one on my face is awful. It isn’t a flat scar, but more of a jagged edge, indented spot on my face. It looks like a large unnatural dimple when I smile along my jawline. Can this scar be removed? I am planning a wedding for next year and would love scar free photos!

A: In looking at a picture of the scar, it can be seen to be a wide and indented scar along the jawline. Scars that cross the jawline rarely do well because of going over a transition zone between two facial planes and being exposed to tension. This will cause the scar to become wide. I think scar revision can make a big improvement but it is important to realize two important realities about scar revision. First, there is no such thing as scar removal or being scar free. There is improvements that can be made to an existing scar and it is all about how inconspicuous it can be made. But you will always have some permanent scar. Secondly, scar revisions take time to mature meaning that it will be red for months afterwards before the color blends in better to the surrounding skin.With a wedding coming up sometime next year, the sooner you undergo the scar revision the better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a small area of fullness on my chest that I just hate. There are bulges on both sides near my armpit that sticks out and it has always bothered me. While I am not fat and am actually fairly lean, this unusual fat bulge exists for not apparent reason. I can’t get rid of it by exercise and it does not fit the look of the rest of my chest. How can I get rid of these unsightly armpit bulges?

A:  Most of the time when one refers to ‘fat in or under the armpit’ , they are speaking of fullness at the top of the bra around the strap creating what is often called ‘axillary breasts’. Most of the time this is not true breast tissue but simply fat as it is sitting above the pectoralis muscle. This can be removed very effectively by liposuction. If the fullness is more towards the inner aspect of the armpit below the edge of the pectoralis muscle then it may be real breast tissue. This needs to be removed by direct excision with a resultant scar as opposed to liposuction.

Q: I had my nose broken seven years ago that has left me with a crookedness to it that I am pretty sure is due to the bone. I also have had trouble breathing since the injury through the left side of my nose. I would like to get my breathing problem fixed and the nose straightened again like it was before. In addition at the same time I would like to get the tip narrowed and shortened which I think would make it look better overall as well. Will insurance cover all the costs of the procedure since most of my nose problems were due to the injury?

A: The complete corrective procedure to which you refer is known as a septorhinoplasty. This is a combined  reconstructive and cosmetic procedure. Insurance will usually cover the medical necessary parts of the operation that relate to breathing improvement, the septoplasty and turbinate reductions. Changing the outward appearance of the nose known as the rhinoplasty portion, however, is not covered by insurance since it results in improvement in appearance not function. Both septoplasty and rhinoplasty are commonly done together and the out of pocket expense for the rhinoplasty is often less when done together with an insurance procedure than when done as a stand alone operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I have done a lot of reading on your website and interested in the cranioplasty procedure to fix the flat spot on the back of my head  (on the top area on the back).  I am a female and have noticed this since my teens and always thought there was no help until I came upon your website, now I am hopeful.  I am scared and nervous about this procedure and have several questions:

1)  Is this a new procedure because I don’t see where this has been performed for purely cosmetic purposes before by other doctors?

2)  Would you say the injectable approach doesn’t achieve as much as an effect as the open incision approach?

3)  Also, in the open incision approach, I know you use either PMMA or HA materials.  If the PMMA is used, does that mean you will need to use screws to attach the material?  Is it riskier than using HA since screws are used?

4)  When did you first start performing this procedure and approx how many have you done? 

5)  Have there been any complications with any of them?  If so, what were the complications and how did you fix them?

6)  I live in Houston, TX and would be traveling alone.  From what I read, this is an outpatient procedure, therefore I am concerned about being without care the first night after surgery.  Would you recommend that I get this done in the hospital as inpatient, so I am under care?  

7)  Also, how do you determine how much material to add? 

8)  Do you place expanders to stretch out the skin if I want more material added to achieve my desired result?   

9)  Will there be a noticeable difference afterwards? 

10) Do you take any sort of imaging to determine the shape you plan to mold?

11) Will you ‘sketch’ out the final shape beforehand so I know what results to expect?

12) How many visits will this procedure require?  Including pre-op and post op/follow-up visits? 

13) What is the recovery?  How many nights will I need to spend in IN? When am I ok to fly back home? When can I go back to work? 

A: In answer to our detailed questions:

1)      Although this is a relatively ‘new’ procedure from a cosmetic standpoint, it is based on the decades old principle of reconstructive cranioplasty from craniofacial plastic surgery. The only thing that is really new about it has been the development of some new cranioplasty materials to use.

2)      The injectable approach can achieve just as much as an open approach. It is about volume of material used and its costs that partially controls the result achieved.

3)      There is no increased risk of screw fixation for a PMMA cranioplasty technique.

4)      I have done cranioplasties for nearly twenty years. In the past three years, I have developed some techniques for cosmetic skull augmentation.

5)      The main complication with an injectable approach is getting a smooth contour to the material. I have had one wound healing complication from an open PMMA cranioplasty when using an old hair transplant scar for access.

6)      Having an occipital cranioplasty as an outpatient is just fine. Patients report virtually no pain afterwards.

7)      One of the key issues is how much material to use. That will be determined by the approach used and what the scalp tissues can tolerate. My experience has shown that open cranioplasties through small incision use about 30 to 40 grams with either PMMA or HA. Injectable kryptonite usually uses 25 grams for the occipital region.

8)      While the use of tissue expanders does allow for more material to be placed, it has not been necessary in my experience. This would also make the procedure an unappealing two-step process.

9)      There will be a noticeable appearance afterwards. It is a question of how much.

10)   No imaging is required. It is an artistic molding based on the extent of the defect and the patient’s after surgery shape desires.

11)  Computer imaging can be helpful in understanding what to expect.

12)  There are no after surgery visits required for an occipital cranioplasty. A good presurgical consultation can be done by phone or Skype video in addition to seeing patient pictures. Patients come in the day before surgery for a formal consultation.

13)  Most patients return home the very next day and return to work in just a few days after

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How long does it take for the tissues to shrink back down and stick to the bone after cheek implant removal? I had anatomical malar shell implants placed three months ago and then had them removed after being in for just six weeks. I think all of the swelling is now gone but my cheeks don’t look like they did before. I have more cheek sagging and my nasolabial folds are deeper than before. I thought the stretching caused by the cheek implants was reversible and would just shrink back down. What can be done now? I want my old cheeks back!

A: When undergoing any form of facial implants, it takes time to see the final results as the tissues settle down around the implant and you adapt to your new facial look. Removing your cheek implants just six weeks after having them placed may have been premature. One of the reasons you do not want to be quick about reversing facial implant surgery is because of tissue deformation. There is no guarantee that the tissues will return to their pre-implant state. In placing cheek implants, the tissues must be stripped off of the bone over a wide area to get the implants into proper position. This not only stretches the tissues (actually a relatively minor effect) but, more importantly, the tissue attachments to the bone is forever altered. It would be natural after implant removal that the cheek tissues can sag somewhat since these tissue attachments will not jump back up into their original position. Once can see that the bigger the implant and size, the more significant that this cheek sagging problem can be. With more cheek sagging, the deeper the nasolabial folds can be. Improvement would either require implant augmentation or some form of a cheek lift or resuspension.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I’m interested in buttock implants but I want to know what implant (oval or round) will give me the most volume. Also does round implants pull up enough muscle to give you a round booty or do you have to get fat grafting added? My butt isn’t flat at all but needs volume. Will the round implant give me upper buttock volume or all over volume (upper, middle, lower buttock). I was told only the oval can give you upper, mid, lower buttock fullness but not as much volume as a round. Thank you.

A: The answer to your question starts with what you have now and where you ideally want it to be. Buttock implants differ in the amounts of volume projection and generally a rounder buttock implant will have more projection. When patients use the word ’round booty’ that almost always means to me that they want a lot of volume projection. That may not be possible for some patients no matter what technique is used and, for others, may require that they ultimately need a  implant and then fat grafting. (although this combinatio is very rare)

The effects of buttock implants is also influenced by whether they are placed subfascial or submuscular. Only subfascial placement can give the entire buttock fullness. Submuscular buttock implants mainly add mid- and upper volume enhancement. The location of the implant is often just as important as the style of implant used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I seem to be resistant to Botox . Recently 50u was injected into my masseter muscle on both sides and very minimal improvement was seen. It has been a month now and the ever so slight response is disappearing. I have a long and fond history with Botox for my masseter muscles even before it was approved for this use in the US. My last Botox of 100u was diluted with 1cc NS, a more concentrated mix compared to the previous times which was 100u with 1 1/2 cc NS. Should I go for Xeomin now and should I start with 100u for both sides? What is your take on this?

A: In my experience, Botox has worked well for masseteric muscle hypertrophy and I have not seen any patient that has developed a proven resistance to the drug. While it is entirely possible that you may be that rare patient that has developed such a resistance, there are other factors that can also affect how well Botox work. Reconstitution and the age of Botox since it was reconstituted are common culprits that can affect its potency. I would also question why such a concentrated dose was used this last time when the diffusion of Botox is not that great. It is important when injecting the masseter because of its muscle size to cover as much of the lower half of the muscle as possible. A less concentrated mixture with more injections may prove more effective. If this is not effective then I would consider changing to Dysport or Xeomin.

By the way, the use of Botox for masseter muscle hypertrophy and spasm is not an FDA-approved use even to this day. This is an off-label use of the drug.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am possibly going to have a chin reduction. Here is my serious concerns. I have a very thin face with hollow cheeks. My forehead is large and my chin is small. The problem is I have a projected or jutted out chin which is very pointy, especially when I smile. I have a very strong jaw line, and I just want to to get rid of the witch’s chin look but keep the exact same frontal look. I cannot afford to have my chin shortened. I want a softer look, but I am terrified that I am in for serious dissapointment. If I did this, I would want to do the submental approach and the burring teqnique because I don’t have a long chin. It seems safer, and by your articles it seems I may be correct. I want a softer, more feminine look without making my face look any thinner, and the projection gone. Is this possible?

A: Thank you for sending your inquiry and your pictures. I would take a slightly different approach to your chin. In the frontal view your chin is very square for a female and it needs tubercle reduction (side chin reduction) to soften it. From the side view, it needs some slight horizontal reduction and soft tissue tightening. I would not do any vertical length reduction. You need the length to fit the rest of your face.

This chin reduction procedure is best done, as you have mentioned, from the submental approach to manage the excess soft tissues that will result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in a rhinoplasty to build out my nose as it is very short. I am of Asian background and have a small flat nose which is inherited.  I have read that it can be done with either a rib graft or using a synthetic implant. I would definitely prefer using rib as that would be more natural. I have done some imaging of my nose in profile to show how I would like it to look afterwards. Can this type of result be done?

A: In looking at your profile and predictive imaging, I would make two points. First, using a rib graft for the short nose is the best long-term approach. This is particularly true when there is a significant amount of augmentation desired. Large amounts of synthetic material will put the nose skin under tension ultimately leading to thinning of the skin and tissues and risks of exposre or extrusion. A little synthetic material on the dorsum of the nose can work well. A lot  is a recipe for complications. Secondly and of equal importance, you have unrealistic results. That amount of augmentation is not possible no matter how it is done. The skin of the nose will simply not stretch enough to accommodate that much augmentation. And even if it would, you would not want it to. You should realistically expect about half of that rhinoplasty result that you are showing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a big overhanging belly that I want to get rid off. I have two small children and have lost over 30 lbs since my last one but the sagging belly persists. Will exercise be enough or do you think I need a tummy tuck?

A: While I have not seen a picture of you, your description alone of your belly has already answered the question. The idea of an overhang suggests a lot of loose abdominal skin. If some weight loss has not made a difference in its size, then you know exercise is not the final answer. Undoubtably some form of a tummy tuck is what you need. You can’t exercise off loose skin no matter how hard you try. Just ask any gastric bypass patient who undergo a lot more weight loss than you have. This is a surgical problem. When it comes to exercise and weight loss, however, I would recommend that you get in the best shape as possible for a tummy tuck. Preparing for such surgery, like training for an athletic event, will have you recover faster and may also help you achieve a better result.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Is Xeomin used in masseter hypertrophy? If it is, is the amount of diluent used the same as Botox. Thanks.

A: Xeomin will work the same as Botox for masseter muscle hypertrophy. It is just as potent and has the same onset of action as a full week after the injections. Like Botox’s other competitor Dysport, the unit dosing may be somewhat different from Botox and an exact replicative dose is not well established. For a cosmetic effect in the frown lines, reports indicate that Xeomin has similar dosing to that of Botox on a 1:1 unit basis. Whether such a dosing method works the same in the masseter muscle is completely unknown. If I was a patient knowing what I know, I would not switch from Botox for massteric hypertrophy if it is working. It will take a lot more clinical experience to determine what dosing comparisons are between Xeomin and Botox. For now, there is no known advantageous reason to make that switch and there is the risk of less effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I have been researching for a while now on getting a procedure done before my husband whose is in the service returns home from Afghanistan. I came across your page and was wondering if I could have a little more information on your Patriot Program? I am interested in getting a tummy tuck done. After having 3 children and losing a lot of weight, i am left with a loose stretch marked covered skin. I only weigh 120 lbs and am happy at the weight I’m at. But I just do not the appearance of my stomach. Any information would be greatly appreciated. Thanks so much!

A: It sounds like what you may need is some form of a tummy tuck. Whether this is a full tummy tuck or a more limited variety will depend on how much loose skin you have. In most cases if one can tolerate a longer scar, a much better abdominal result is obtained with a full tummy tuck. The Patriot Plastic Surgery Program was established to provide some reward for those and their families that are in the active military. It is not a free surgery program but substantial cost reductions are offered. To get an exact cost, please send me some pictures of your stomach for my review and my assistant will forward you that information.

Dr. Barry Eppley

Indianapolis, Indiana