Your Questions

Q: Dr. Eppley, I am  28 year-old Asian make who is very interested in having cosmetic surgery performed for overall facial reshaping. As you offer a wide range of procedures which may be relevant to my goals, I hope to receive advice on the achievability of my goals.

First of all, I am very conscious in photos of the roundness and wideness of my face. (especially when smiling, at which point my cheeks appear very round and prominent) In addition, I would like to reduce the fullness of my lower face and make it thinner.

Secondly, I was wondering if a sliding genioplasty was advisable, as my chin appears to be relatively normal sized. I wish to make my jawline less round, and increase the vertical dimensions of my face to alleviate the aforementioned wideness.

Thirdly, I was wondering if procedures were available to create a more ‘deep-set’ look for my eyes. This, in addition to rhinoplasty to reduce the hump and raise the nose bridge, to reduce the ‘flatness’ of my face in profile.

I realize that not all of my expectations will be realistic nor all procedures advisable, so thanks for your time and expertise in advance.

A: A wide collection of procedures are available for facial reshaping as you are aware. In addressing all four areas of your facial concerns from top to bottom, I can make the following initial comments as they relate to your face.

1) I am now using performed or custom brow bone implants  to build up the brow ridges. They can be placed through a limited incision endoscopic technique. That is the most effective way to create a more deep-set look to your eyes.

2) Your rhinoplasty would include a humor reduction, radix augmentation and some slight increased tip projection.

3) Cheekbone narrowing is the only way to provide some reduction in the mid-arch bizygomatic distance of probably 4 to 5mms per side.

4) I would consider paranasal augmentation, I have a new paranasal implant that I am really happy with that can not be felt and adds about 5mms projection to the nasal base.

5) I do think that a vertical lengthening genioplasty (which may have to be widened in a male) will help narrow the jawline. You do not need a horizontal advancement but when opening the vertical distance of the chin it does rotate it back a few millimeters so I would do a small advancement as well.

These are some initial thoughts. Computer imaging needs to be done to see how such facial reshaping procedures would look on you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a breast reduction. I would like that fat from my breast to be use for a buttock augmentation. I know this is a very large request but I hope it can be considered. I am a k cup. I’m only 5’3. The pain from my breast are unbearable. I’m only 17 years old. My breast have prevented me from so much and I have been turned down by so many doctors that I have lost count. My only wish is that I can have these procedures done before my senior year so I can finally experience my life as a normal teenager.

A: By your physical description and breast size, there is no question you would benefit physically and psuchologically with a breast reduction. However it is not possible or advised to take breast tissue and use it for buttock augmentation. Breast tissue is not pure fat but a mixture of fat and breast tissue. Within that breast tissue are tissue cells that may or may not in the future, become cancerous. Thus should not transfer any tissue for an elective aesthetic augmentation that has any potential for future malignancy. In addition, a breast reduction procedure does not remove tissue by a liposuction method but by an en bloc excisional method. This does not make it amenable to an injectable method even if it was appropriate fat tissue to use for buttock augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was involved in a fight almost 7 weeks ago and suffered a comminuted zygomatic arch fracture. The result is that the arch is depressed about 4 to 5mms. I was unaware of the fracture and thought it was just some bruising as I did not suffer from any black eye or bleeding. By the time I realized and went to hospital I was told that as 3 weeks had passed the bones would have begun to heal and surgery is risky but they would have to break the healed arch and reset. I now have one side of the face little out of balance with the other side. Not sure what route I can take or you would recommended in place of a full arch reinstatement to its normal position.

A: The zygomatic arch is a very thin sliver of bone that connects the cheek bone with the temporal bone in from of the ear. It is very much like an arched bridge spanning the distance between the two. Because it is thin and has a bowed outward shape, it can be broken right in the maximal point of convexity; These fractures can occur as an inverted V or it can be broken into several pieces. (comminuted) Repair of isolated zygomatic arch fractures is almost done by closed reduction, pushing the depressed bone segments outward trying to restore the convexity. While often successful, it is not uniformly so (particularly in communited fractures) because there is no structural support (like a plate and screws) added to the fracture reduction to stabilize it into its original arched shape. While there are open approaches that can achieve such rigid one fixation, this involves a coronal scalp approach from above which is a bit extreme given the small fracture that it is.

At three weeks after surgery, the bone is far from healed and can be easily manipulated. Again it is a thin bone and would actually take many months to heal and probably only do so by fibrous union in many cases. So this does make it possible to attempt a closed reduction if one so desired and would be no less successful now that it would have dbeen ays after the injury

But at this point, there are also other options to improve better facial symmetry over the depressed arch. Options include injectable fat grafting with or without closed reduction and to wait three months and insert a zygomatic arch implant of the thickness needed to restore facial symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, Just about ten days ago I had forehead augmentation through a hairline incision. Everything appears to have gone well and I have suffered no complications of which I am aware. The swelling has gone down considerably but I doubt if it is all gone. The scar across the hairline is still pretty noticeable. How long does it take for the swelling to go away and when will the scar become less noticeable.

A: I am glad hear that everything so far has gone well after your forehead augmentation and it looks very acceptable at this early point after surgery. At three weeks after surgery, I would say about 85% to 90% of the swelling will be gone. Over the next two months the very final remnants of swelling will subside and the absolute final shape will be seen. In my experience it takes a full three months before one should judge the final result of any craniofacial reshaping procedure. As for the hairline scalp incision, It usually takes several months, and sometimes up to six months, to judge the final outcome of the frontal hairline scar. Usually the frontal hairline scar does really well even in patients of significant pigment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having my upper arms “done” by the best method. Another surgeon recommended Smart Lipo. I am researching the best method and am interested in a second opinion. I am 40 years old, not overweight and exercise daily. 

A: When it comes to your arms, you represent a classic ‘tweaner’, which is someone who has a plastic surgery problem that can not ideally be treated by  either of two different methods.

Your arm problem is not big enough with enough loose skin and fat to justify a formal armlift and its associated scar. No one really wants an armlift but it is the most effective arm reshaping procedure. (because it removes a lot of skin and fat)

Your arm problem is also too big, in my opinion, to have liposuction and GET THE RESULT THAT YOU REALLY WANT. It just isn’t effective enough to make a really big difference or have a dramatic reduction in arm size that any woman that I have ever seen with such arms really wants and hopes the liposuction procedure can achieve. But it is the only procedure that is justified (has no awful scars) and can make somewhat of a difference.

When it comes to liposuction, do not get caught up in all the hype about various liposuction technologies including Smartlipo. Despite widespread internet promulgation about its magical skin tightening properties, Smartlipo offers few if any advantages over any other liposuction method. (I can say this quite objectively since I have owned a Smartlipo device for years) Compared to the skin tightening you would need for your arms, no amount of fat melting and heating the tissues by a fiberoptic laser probe is going to make a big difference in the natural skin contraction that can occur with good skin elasticity. And unfortunately most upper arms that need to be made smaller do not have good skin quality over the back/triceps area.

In short, liposuction of your arms is the only reasonable treatment option. But the key to not being disappointed with the results from such a procedure is to have realistic expectations (modest not dramatic improvement) and choose a surgeon who has a lot of liposuction experience and not one based on a liposuction technology. At the end of the day, the most important predictor of success is the hands that is holding the device, not the device itself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in very large breast implants. I had 2500cc then had a breast lift and now no implants. I would like to start my breast augmentation journey again. What is the largest that you will overfill? I know all the down falls of overfills but still want them.

A: If I understand your breast surgery history, where once you had overfilled saline implants to 2500cc per side, you now have no implants at all. I assume that you got to 2500cc through a staged series of fills using a base size of 800cc implants. (which are the largest base size saline implants made in the USA) To begin the journey, I would start with 800cc saline implants filled to 1200cc to 1400cc and then increase them 500cc at time every 3 months to get to the final volume. Given that the largest postoperative adjustable saline breast implants are 650cc (with a remote port under the skin which could be done as an office procedure for fill), non-remote port implants would have to be used which would require more of a minor surgical procedure for additional fills which could be done under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw a post from last year in which you responded to a question regarding whether PRP/stem cells would be beneficial for Atrophic Rhinitis. I am wondering if you are interested in performing PRP on the turbinates. I have travelled to get PRP injections and have recieved some benefit but need further injections and would perfer to find a way closer to home. In my case, I have sufficient turbinate tissue but it has been damaged from cauterization so I am hoping to get further healing of the tissue.

A: Since you have received benefit from PRP injections to the turbinates previously, there would be no reason that you would not get further benefit by additional injection treatments of your atrophic rhinitis. The one caveat that I would add is that you consider the addition of a small amount fat with the PRP placed into the turbinates or go with fat injections alone. Fat has stem cells, (which PRP does not, and this should produce a more profound long-term rejuvenation of the turbinates than the short-stimulus that PRP provides. PRP can only stimulate the cells that are there while fat can create cellular rejuvenation and mucosal tissue regeneration, which ultimately is responsible for their function.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 years old female. I had a chin implant surgery along with a rhinoplasty three years ago. I was happy with the surgery results until I started to see how I looked in pictures. I think that my face looks too long, and in some pictures it looks really especially when I smile. I also dislike my gummy smile, though I can hide it when I try not to rise my lips. I don’t know what the problem is. What would be the most recommended procedure for me? I would like to look more feminine and balanced. Could a smaller chin implant make my face more balanced? are there any risks involved?
Could cheek fillers or implants help? Or should I also consider the possibility of orthognathic surgery, in case the camouflage would yield very limited results..
What other procedure would you recommend for me? The upper part is me before the surgery, and the lower part is me after the surgery.  And I also attached my X ray.

A: While both your rhinoplasty and chin implant augmentation produced good results, I see the crux of your facial concerns with the chin area. It is a very large implant which was needed but is also the source of your facial imbalance.

You initially have a very retrusive chin due to an underdeveloped lower jaw. When the chin is so short due to an underdeveloped ramus of the back part of the lower jaw, it is also vertically long anteriorly as the chin rotates downward. With a chin implant used for the augmentation, it does bring it forward but also actually makes the chin vertically longer and with a much deeper labiomental fold. A better chin augmentation would have been a sliding genioplasty. This would also bring the chin forward but it vertically shortens the chin and makes it more narrow, both changes which are more feminine.

Thus I would recommend that you replace your large chin implant with a sliding genioplasty that does not create as much horizontal projection but also vertically shortens it as well. It will also make the chin more of a triangular shape rather than have an obvious square shape to it that it has now from the outline of the implant. You may also consider adding small cheek implants to bring a little highlight to the cheek area, which with the genioplasty, would give your face more of a feminine heart shape to it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have inverted nipples that are sometimes worse than other times. The left nipple is much worse. They can be manipulated to come out by squeezing on them but they won’t come out on their own. I’ve been self conscious about it my whole life. Is it possible to correct them permanently?

A: Inverted nipples can be quite variable in their presentation of depth of inversion and duration that it has been present. At least yours can be manipulated outward, which means they are not permanently contracted downward. The success for inverted nipple repair is when you can squeeze the nipple and it can come out on its own. This can be treated by either fat injections and done through a small incision to release it and placing a small fat graft into the space created when the nipple is pulled outward. Take of the fat graft should hold them out on a more permanent basis. A way to test the success of fat grafting for inverted nipples is to do a ‘trial’ of a temporary injectable filler like Juvederm Voluma. If that is successful (and it could last up to a year) then you could proceed with injectable fat grafting for a more permanent nipple inversion treatment. Otherwise if they fail to come out by injection, then they will need a surgical release and fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you take out the inner or outer layer of the lip? How noticeable is it after the procedure? Will people know I had surgery done? Will my lips look bigger then before the procedure for a few weeks? Can lip reduction change the look of my smile? Will I show more teeth when I smile? I’m concerned that when I have a big smile it will show too much of my gums at the top of my teeth. I would like to keep my smile the same. Is this possible?

A: You are asking a lot of good questions about lip reduction. The success of any lip reduction procedure is based on removal of the vermilion portion of the lip, what you probably mean when you say the ‘outer layer’. One incision is made at the wet-dry junction (mucosa-vermilion border of the lip) and the actual reduction comes from what is removed in front of it. (dry vermilion) One should expect fairly significant swelling to appear within the first two days after surgery and not look more normal again for up to ten days after surgery. As long as a lip reduction is not overdone (too much tissue removed), it should not adversely affect one’s smile. Certainly it is not at risk for causing too much gum exposure when smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had rhinoplasty two months ago and am worried that I might have a pollybeak deformity? I was given a steroid injection on the supratip from my surgeon a few weeks back. My surgeon is assuring me that the beak-like appearance I am seeing is a result of swelling, but I am concerned that it is left over cartilage that has not been resected all the way. What are your thoughts? Can swelling mimic a pollybeak deformity? For someone with my skin thickness, how quickly can one expect to see a true pollybeak deformity surface? The first steroid injection appeared to have done absolutely nothing aesthetically. Is this normal?

A: You are correct in your assessment that one cause of a pollybeak deformity after rhinoplasty is residual excessive cartilage in the supratip area. In those rhinoplasty patients who had an original dorsal hump taken down, inadequate removal of the cartilaginous portion of the bump (between the nasal bones and the tip) can create excessive cartilage height in the supratip region, giving the tip of the nose a rounded and downturned appearance. (cartilaginous pollybeak deformity) This may be evident right after the splint is taken off but, often due to swelling of the overall nose, may not become evident until weeks to a month later.

A pseudo pollybeak deformity can also occur due to the development of excessive scar tissue in the supratip area. This can develop due to a small fluid collection which can even be unintentionally created by how the tapes and splint were applied right at the time of surgery. This becomes evident as the swelling resolves where, like excessive remaining cartilage, the supratip gets or remains full.

However, the origin of your pollybeak deformity after rhinoplasty is not clear at just two months after surgery. It may very well be swelling and the injections of low dose steroids is reasonable at this point.  It takes three weeks to see any result from a steroid injection and their effects are cumulative. It is not a fast fix. Also, how effective they can be is partially dose related.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Just wondering what i could do about my midface deficiency. I had a cross bite and underbite correct by braces and now feel like I should have had jaw surgery …Just wondering your views on my situation.

A: I could not tell you based on your current pictures alone whether you should or should not have had maxillary advancement and whether that degree of movement forward would have made a noticeable aesthetic improvement. But after having been orthodontically corrected, that is an irrelevant issue now. The more relevant question now is whether any form of midfacial onlay augmentation will create the aesthetic improvement you seek. Paranasal implants do replicate in some ways at the nasal base level what a mild to moderate maxillary advancement would do in terms of horizontal projection. The next relevant question is whether any augmentation above that level (which is not what a maxillary advancement achieves) would also provide aesthetic improvement (malar vs malar-infraorbital augmentation) with the paranasal augmentation. I will do some computer imaging and get that back to you on both paranasal and cheek augmentation. It is a question of whether paranasal implants alone are adequate or whether a more complete mid facial augmentation is a better approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old male. I’ve had a septorhinoplasty, a chin implant and orthodontic treatment previously. I feel that my previously under projected chin and jaw development are inter-related, however, given that I am fairly satisfied with my corrected bite and improved chin projection, I am interested in augmenting the jaw further (jaw angle implants perhaps) to achieve a more masculine look. There is a bit of asymmetry and the angle of the back of the jaw is more of a 45 degree as opposed to the more masculine 90 degree like angle. It seems that at this point, a sliding genioplasty may not be appropriate without removing the chin implant. I have considered fillers as a temporary ‘trial’ in the short term as a plastic surgeon locally is willing to provide Voluma for free to see if it fits his practice. Any thoughts or observations or anything else that may be beneficial given my facial structure is greatly appreciated.

A: Based on the current position of your chin and the rest of your facial structure, I would have reservations about any type of jaw angle implant augmentation. While you may not like your jaw angle shape now, any change in it would likely make it out of proportion to your chin, particularly if they were changed to a stronger 90 degree shape. That point could be proven, right or wrong, by having some computer imaging done to see how it looks to you. I think that of you do not add some further chin projection (vertical and horizontal) then the back of the jaw will look too ‘heavy’. I don’t think the chin needs to be moved much, maybe 5mm forward and 3mm down, but your chin is too short now to support much jaw angle augmentation.

It is not true that you need to remove a chin implant to do a sliding genioplasty. The osteotomy cut is done right across the top of the implant and the implant is moved forward with the bone as it comes forward and/or down. I have done that exact sliding genioplasty technique numerous times.

You certainly have nothing to lose by having injectable fillers done for jaw angle augmentation. But be aware that they do not produce the exact same effect as to what an implant does at the bone level. So it is not exactly a 1:1 comparative effect. There is probably as much to learn from computer imaging as there is from the filler treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent upper and lower jaw surgery over one year ago. The surgeon did a fairly good job advancing my lower and upper jaw, however, it has (if anything) accentuated the deficiency around my orbital area. I have very deepset eyes, which could pose a challenge with this sort of procedure. What are your initial thoughts – and do you have a lot of experience with infraorbital rim implants?

A: It would not be rare to develop an infraorbital rim deficiency after a lower maxillary/mandibular orthognathic surgery procedure. As the bones are moved below the orbital rim, how that area looks will be affected based on the lower facial skeletal movements. Infraorbital rim augmentation can certainly be done but the relevant question, as you have pointed out, is how will that affect the already appearance of deep set eyes. Will doing so be an aesthetic improvement or not? I have performed numerous orbital rim augmentations either alone or as part of custom malar-infraorbial rim implants. There are different styles/shapes between preformed off-the-shelf and custom infraorbital implants. Off the shelf infraorbital rim implants are designed to augment the front edge of the rim (sit in front of the orbital rim) and, in deep set eyes, such isolated horizontal augmentation may make the eyes look more deep set. In more custom designs, the infraorbital rim augmentation sits more on the top of the orbital rim with some slight overhang, causing a slightly different and more natural effect in my opinion and one that is less likely to cause an adverse effect on your eye appearance. These custom designs also flow into the cheek area with a smooth transition, providing as much augmentation effect in this area as the patient prefers. (or prefers not to have) As an initial thought on what make happen with infraorbital rim augmentation, I will do some computer imaging and get that back to you later today. At this point, I could not tell you whether this would be a favorable facial skeletal change or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am sending you some pictures for consideration for facial feminization surgery. (FFS) I am a 25 year-old transgender who wants to really make the change and be accepted for who I really am on the inside. What FFS procedures do you think I need and how successful will the change be in your opinion?

A: In assessing your pictures, I can see where the following procedures would be very help in achieving your goal of softening and feminizing your face and I would place them in the following order of importance:

1) Forehead Augmentation/Brow Reduction/Browlift  (the issue here is whether a hairline advancement can be done with any appreciable forehead reduction of vertical skin length from the hairline to the brows) But reducing the brow prominence, getting rid of the brow break and increasing the convexity of the forehead are key elements of your facial appearance change.

2) Jawline/Chin Reshaping/Tapering (reduce jaw angles and square chin in the frontal view) The horizontal chin projection as it is now is perfect for a female as you naturally have a convex facial profile due to your chin position)

Lip Advancements  (increase vermilion exposure and cupid’s bow enhancement) While injectable fillers or fat injections could also work on your lips, if you are undergoing surgery for other facial procedures then it makes sense to take this opportunity for a permanent lip enhancement change.

Cheek Augmentation (this is not on your list and may be surprising to you but I actually rate it as more important than the rhinoplasty) The flatness/gaunt appearance of your midface would benefit by some voluminization to create more of an ‘apple cheek’ effect. It not only would look more feminine but also creates a ore healthy appearance as well.

Rhinoplasty Very slight changes to your nose is all that is needed. Some tip narrowing and slight rotation upward would change your already thin nose to a more feminine one.

I think your face is a very good ‘canvas’ to work with to become very feminine and with a few of these changes can become so. Not every patient that undergoes even extensive facial feminization surgery can always become highly feminine in their facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am suffering from an excessive buildup of scar tissue underneath the skin after my rhinoplasty. Multiple Kenolog shots did not help. my nose looks about 30% bigger and more bulbous then it was a few months right after the surgery. (my rhinoplasty was three years ago) I am convinced that 5-fu is the right approach for me now. I know that you are one of the best and most experienced surgeons known for using this post surgery corrective method. Can you please help me?

A: I would not think that 5-FU injections would be helpful for established scar tissue years after the original rhinoplasty surgery. The biology of 5-FU effects is to inhibit the creation or development of scar tissue, not causing it to break down. Steroids, specifically Kenalog, actually work through a dual effect of inhibition and  breakdown of scar tissue. In short, while 5-FU injections can certainly be done, I would not be optimistic that it would achieve the desired effect of nasal size reduction that you desire. It would be better, in my opinion, to have a revisional rhinoplasty for scar removal and then lay in on dissolveable collagen sponges (carrier) a mixture of steroids and 5-FU. This could then be followed by an early and aggressive use of 5-FU injection therapy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am of African descent and I want to improve the shape of my nose and make my lips smaller. Sadly in my attempt to reduce the size of my upper lip and nose I ended up with a crooked nose and lips. The worst part being that my lips remained just about the same size. 

A: My assumption, based on your pictures, is that an implant was placed in your nose since that is about the only thing that can make the nose deviate like that after a rhinoplasty. When trying to improve a nose shape like yours (originally), the fundamental principle is one of a strong columellar strut to support the tip and a good dorsal augmentation. While an implant can be used for the dorsal augmentation, it should never be used for the tip-columellar support as it has a high propensity to deviate…just like yours has done. (not to mention placing the skin over the tip of the nose at jeopardy for vascular compromise) You need a good cartilage graft for support for your revision rhinoplasty and this almost always requires a piece of rib to do so. The implant may be able to be salvaged and used, but once you need a rib graft for the columella you might as well abandon the implant and go with a completely natural graft approach. There are other additive techniques that can be done, such as nostril narrowing, but the dorso-columellar buildup (augmentation) is the key.

From a lip reduction standpoint, if the tissue removal amount and location is not just right, a minimal result is seen and scar contracture can result in the lip. Since you already have a linear contracted lip scar, that would serve as the posterior (inner) incision location with a more aggressive excision done out on the anterior (outer) vermilion. It is the vermilion which needs to be reduced if any size reduction is to be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in possibly getting a testicle implant. I had an undescended testes removed at five years of age. I am 26 years old now and figured I would at least explore the option. I am interested in the details of the procedure, the risks and recovery period. I hear it is relatively minor procedure so I would like to know more. 

A: Testicle implants are made of either soft solid silicone material (soft spongy ball so to speak) or a saline-filled small bag. Either way, they are placed through a small scrotal incision in an outpatient procedure under anesthesia. One should expect some swelling for a week or so, awareness of the procedure having been done for three weeks and avoiding any sexual activity for up to a month after surgery. The risks of the procedure is that of infection which has a very small rate of occurrence. (1% to 3%)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It has been determined that I suffer from brow ptosis by my general doctor, he had recommended orbital rim contouring and a browlift to alleviate the issue and prevent it from happening in the future. I have also checked with my insurance company and they have stated that both procedures would be covered if deemed medically needed by the surgeon of my choice. I would love to be able to submit pictures if needed to assist you in diagnosing brow tosis on your own and would love to hear feedback. I was hoping it would be possible to request that the brow bone can be shaven to a more feminine contour. Please let me know if you are interested in helping me pursue treatment and are able to accept insurance or if we need to make an exception!

A: While there is no question that brow contouring can be done to create a more feminine appearance with or without a browlift, the issue of potential insurance coverage for it is almost certainly not. It is important to understand that when a patient calls up their insurance company, the standard unqualified answer is always ‘if your doctor says there is a medical reason for it, it will be covered’. Unfortunately that person and the section of the insurance company that they work for has nothing to with the department that actually approves the surgery and issues payment for it. That is the Predetermination section and they are tasked with determining whether there is any medical reason for the surgery. The only medical reason for a browlift is upper visual field obstruction and this must be substantiated with a visual field test. This must accompany a predetermination letter on which they will pass judgment about medical coverage. If they deem it is medically necessary based on the evidence, a browlift may be approved as a medical procedure. Any orbital rim/brow bone reduction/shaving never has a medical reason for it being done and is always deemed a cosmetic procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a full tummy tuck three months ago. I opted liposuction with my tummy tuck. I am very pleased with the way the bottom of my abdomen looks, however, I have quite a bit of fat on my upper abdominal. I was under the impression that you would do liposuction on the upper abdominal area during the procedure, however, it wasn’t. Can you advise why? I did pay for the tummy tuck and liposuction. I have researched it quite a bit to make sure I didn’t misunderstand, and it looks like that would be the “norm” if you had a tummy tuck and lipo that it would be done on the upper abdominal area, however, it wasn’t in my case. I look forward to hearing from you.

A: This particular tummy yuck question is not uncommon and there is a very straightforward answer. The concern about fullness in the upper abdominal area is one of the most prevalent after surgery issues after one has had a tummy tuck. One does not have to look too hard on any plastic surgery forums on the internet to see how common this tummy tuck question is.

This question is so common that in every tummy tuck consult I emphasize to patients about this issue and, while liposuction may be done in the flanks and lateral abdominal wall, I do not perform it in the upper abdominal region. Thus, one may be left with an upper abdominal region that may be more protrusive than in the lower area where all of the tissues were cut out if they have any fat thickness in their upper abdomen originally.

It is not the norm in a full tummy tuck to perform full abdominal liposuction on the upper abdominal skin flap. This is avoided by most plastic surgeons because of its devascularizing effect on the skin flap and the risk of causing poor wound healing, central    wound dehiscence and even overt tissue necrosis between the new belly button and the incision line. One also does not have to look to hard online to see some disastrous results when upper abdominal liposuction is done with a full tummy tuck. While it may not occur in every such case, one devastating tissue necrosis event can take months to heal and create a permanent abdominal wall deformity.

This makes going for the very flattest total abdominal result possible by widespread use of liposuction at the time of a full tummy tuck a risky manuever. This is one that I will not do out of concern for patient safety and to avoid risks of a postoperative complication. This is why I point this issue out during the initial consultation and emphasize that secondary liposuction may be needed for flattening the upper abdomen six months or more after the procedure when it is safe to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 56 yrs. old and have developed 2 vertical lines between my brows. They make me look mad or mean. My face has also started to sag. I have the saggy vertical lines from sides of mouth to chin and the sides of my mouth are starting to turn down. I use to have beautiful lips and they are looking thinner and I have vertical lines from smoking. I have always had a high forehead plus I had 40 stitches in my head from a car wreck years ago and my hair never grew back over the scar. I nose is slightly crooked and is showing more now. My face needs refreshed.

A: Many of your facial concerns are very common and there are a variety of surgical options for substantial improvement. I could give you a more detailed description of what they would be if I could see a few pictures of you. Just by description I am envisioning the needs to be a lower facelift (of some type), possible upper and lower lip advancements/lift with corner of the mouth lifts, possible hairline lowering with glabellar muscle excision for the vertical lines, scale scar revision and possible rhinoplasty. As you can see there are a lot of good options here and the issue is just how to put a surgical plan together that will optimize your face and give the most refreshed facial result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born pre mature and have a bad tracheostomy scar that I really want improved. After reading your website I can see that you are a extremely talented surgeon with lost of practice in this area. I have attached two pictures, one where the neck is stretched and one where Im looking straight forward. Can you please tell me what is possible to do here, and what results I can expect?

A: What you have is a vertically oriented tracheostomy scar with a central depression. The best way to treat that type of trach scar would be total excision and contracture release, interpositional dermal-fat graft and linear or partial broken line skin closure. You most certainly should be able to substantially narrow the scar line and even out its contour with the surrounding unscarred skin. In short, there is a lot of room for improvement in your tracheostomy scar. The one negative to your trach scar is that it is vertically oriented, completely perpendicular to the natural horizontal relaxed skin tension lines of the neck. This natural anatomic violation will make any neck scar revision more prone to secondary widening than if the initial scar was horizontal in orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck eight months ago and, although I am happy with most of the results, my belly button afterward has always looked a little funny to me. It looks bloated for lack of a better medical description and bigger than it did before the tummy tuck. It was not a great looking belly button before the surgery but it looks no better now and even looks a little deformed. Can you tell me what is going on and how I can fix it?

A: A ‘bloated’ belly button after a tummy tuck suggests that too much of the umbilical skin is seen on the outside. This usually results from an umbilical stalk that is too long for the thickness of the tissue between the skin and the abdominal wall, pooching outward creating a mushroom or bloated appearance. An umbilicoplasty procedure can be done to shorten the stalk and pull the belly button back inward for an unbloated or more of a funnel effect to create a more natural belly button appearance.

While the creation of the ‘new’ belly button in a tummy tuck is the most minor part of a tummy tuck, it along with the scar line is the most heavily seen feature of the result. Shortening the umbilical stalk, keeping the new opening in the skin small, and removing a funnel of fat between the skin and the abdominal wall all help to create an inward shape or pull to the recreated belly button and allows the scar line to be situated in a more obscure location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck six months ago but am not happy with the result. My lower stomach area around the incision is flat but my upper stomach below my breasts bulges out. Is this swelling, fat or something else? Why isn’t it flat like my lower stomach?

A: It is not rare after a tummy tuck to have the upper stomach area above the belly button remain than the shape of the stomach below the belly button. This can occur in those patients who have thick fat layer to their stomach initially. Because most plastic surgeons avoid debulking the upper stomach area during a full tummy tuck by extensive lipsouction, and repositioning of the upper abdominal flap downward over the excised area is done to ls close the wound, can create a mismatch in fullness of the tissues above and below the belly button. What you have is not swollen or bloated but the natural thickness of the upper abdominal fat layer which has largely been undisturbed. This is why liposuction of the upper abdominal area six months or more after a tummy tuck can reduce this fullness and put the finishing touches on a tummy tuck effort.

I always make it a point of emphasis in presurgical discussions to point out this exact issue in patients that have naturally convex abdominal shapes and thick fat layers on their abdomen. There are many tummy tucks who can not achieve a completely flat abdomen and this is important to point out beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have quite significant nasal deviation and also maxillary retrusion from unilateral cleft lip and palate. To create fullness in that area I have inquired about orthognathic surgery and was told that the removal of teeth when I was younger makes that almost impossible. I was wondering if theoretically it is possible to put premaxillary implants in with a deviated septum that needs correcting. Does the premaxillary implants stabilize the septum?

A: When a Lefort I or maxillary advancement is not possible, onlay facial implants can provide a similar aesthetic effect. (with the exception of the effect on the upper lip by the anterior tooth movement) Midface augmentation could include premaxillary, paranasal, maxillary and/or cheek augmentation. These are all different types of facial implants to augment various areas of the midface. An entire custom midface implant can also be made from a 3D CT scan. Placing any of these implants is not influenced by any form of septal correction. Septal straightening is needed in every cleft patients and how it is straigthened and its stability is not changed or influenced if a premaxillary implant is done at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the most natural lip augmentation filler that you offer?

A: When someone speaks of a ‘natural’ lip augmentation result or procedure, they could mean two distinctly different things…that the material that is implanted is natural or that they want a natural-looking result. For lip injections, the most natural filler is fat. (although by far the most common lip filler materials used are hyaluron-based like Juvederm for example) Fat may be the most natural injectable filler for the lips but it has a poor track record of graft take and requires more of a surgical procedure to do it. (liposuction harvest)

A natural result in lip augmentation is generally one that is not overdone or has had too much filler placed. It is unnatural when the upper lip becomes bigger than the lower lip. Most of the time patients want an upper lip augmentation whose size (vertical vermilion height) matches that of the larger lower lip. That is influenced as much by the technique and volume of injectable filler material added than it is by any specific injectable filler material.

Most likely you are referring to the latter where the result does not appear as if ‘something had be done’ or the dreaded ‘duck lip’ result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am one month post-op from a v-line jaw reduction and sliding genioplasty. Although I am well aware that I am not at my final result due to swelling, observing through my x-rays I can confirm that my chin has actually increased in vertical length when I desperately wanted the opposite. My surgeon is unfortunately non-responsive. My question is, is there any way I could undergo a revision sometime in the next month since the detached part of my chin that is secured with screws is entirely the length of bone that I would like to have removed? I have linked my post-op x-ray with a photoshopped x-ray of what my desired results are to clarify what I am trying to express. Thank you so much for your time!

A: It appears that you have had a set back sliding genioplasty from your x-ray. The severe angle of the bone cut makes vertical lengthening occur when the downfractured bone segment is slide backward. To effect that degree of vertical shortening that you want, you would take out a wedge of bone from above the cut and bring the lower segment up to it. You can not just remove the bottom segment because the muscular and soft tissue attachments to the chin bone would be lost resulting in significant chin and neck soft tissue sag. Given that you have not had any bony healing from your prior sliding genioplasty, you should have such a revision in the next few weeks or month.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have done some research on an occipital augmentation cranioplasty for a flat back of the head. I am still about 18 months away from having the money to receive such an operation but in the meantime I have two questions. 

1.) What are the long term effects of such a operation?

2) How long is the scalp incision to do the surgery?

3) If I sent in a picture, is there any way to get a good estimate of the size of the needed incision? And is there a way to see what possible results would look like on myself?

Thank you for your time!

A:  In answer to your questions:

1) Based on my extensive occipital augmentation experience, I have yet to seen any long-term untoward consequences such as implant problems (infection), skull or scalp issues. There can be some aesthetic issues such as smoothness and edge transition blending into the bone.

2) The size of the incision is going to be based on what implant method is used, preformed implant (6 to 7 cms) or PMMA bone cement. (9 to 10cm) That is predictable up front.

3) Side view pictures can be used to show potential result predictions using computer imaging techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reading an article by a male to female transgender woman who mentioned having a procedure in Mexico where the doctor broke her lower ribs and wrapped them tightly so that they would fuse together in a more narrow position. I am a slim young woman who would like a more narrow rib cage to give me a longer more narrow waist, but would like to keep my ribs if at all possible. I assume this would be called “rib manipulation” since it is the controlled breaking of the lower ribs. Have you heard of this being done for cosmetic purposes and can you give me information on the pros and cons of this procedure?

A: What you are referring to would be known as rib reshaping by osteotomies as opposed to the more traditional rib removal procedure to make a more narrow rib cage. The rib as it extends from the spine and around the side of the body is composed of bone (from the spine out to about halfway around the side of the body) and then becomes softer cartilage as it extends to join the sternum. (ribs 10 through 12, also known as the ‘free floaters’ do not extend to the sternum…which turns out to be a very important point in this discussion) If the rib is osteotomized (cut) at the bone-cartilage junction, the cartilaginous end would be more bendable and theoretically could be molded inward as it heals for a more narrow waistline with after surgery binding. This would only apply to the free floating ribs which do not have an attached end. It would not work for any higher ribs because they have a complete arc around the body with a fixed point to the sternum.

The advantages to rib reshaping is that it would be less invasive since the ribs are not being removed, would have an easier recovery, may be able to be be done with a smaller incision on each side and would preserve the ribs. The disadvantages is that it is not really clear if it would really work and could be a source of chronic pain if the separated rib area do not heal. (osteochondritis)

Dr. Barry Eppley

Indianapolis, Indiana