Your Questions

Q: Dr. Eppley, I was wanting to find out information about breast augmentation surgery. I used to be a DD and then I have lost weight and gained weight off and on and my breasts have gotten smaller and they sag very bad. I would like to find out how much you charge and if you do any type of financing. Could you please let me know because I really need to figure out how I can get this done because I have such a complex about my body now. It is very bad and I want to try to get this done if at all possible. Thank you.

A: The first thing that I can tell you is that breast implants alone are not the complete solution to your breast concerns. Knowing how big your breasts were at one point (DD cup) and then having lost weight, you undoubtably have a lot of breast sagging. You have described your breasts as so yourself. Contrary to common perception, implants will not lift up sagging breast tissue. This will require some form of a breast lift if implants are done to get a satisfying result. Sending me a few pictures of your breasts will show what type of breast lift you will need with your implants and what the cost of that procedure would be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old male and I am interested in facial cosmetic surgery. My previous history of cosmetic surgery is otoplasty, rhinoplasty and a chin implant. I would like a more balanced face and more of an oval/square shape. 

Frontal/anterior view:

-Is it possible to augment more on the weaker side (jaw and cheeks) to balance asymmetry?

-On the cheekbone I would like to augment both the temporal process and the zygomatic bone, augmenting both the sides and front of the cheek bone (particular more augmentation on the right side to balance the weakness)

-On the mandible, i would like the Ramus more laterally augmented (a more square jaw) (also particularly more augmentation to balance the weakness on the right side)

-On the nose, a narrower and more defined tip

Left and right profile views:

-augmentation of the cheekbone (both the temporal process and the zygomatic bone)

-more square mandible angle

-slight de-projection of the nasal tip, lower and upper cartilage*

*Tip projection is more pronounced in the photos of the oblique smiling views. 

I am sending pictures of anterior view and right oblique smiling view. If you could please send me altered photos with your expected results explaining the procedures you have added and why you feel so.

Thank you for your time and consideration

A: Thank you for your inquiry. Unfortunately the images you have sent me are inadequate for imaging. Only the front view is useful. A NON-SMILING oblique and side views are needed to get a more complete analysis.

Other issues:

1) It is not clear if the images are flipped or not. As I see them, the left side of your face is the smaller or weaker side.

2) The concept of oval and a square face are contradictory. As a male I will assume you mean more of a square facial shape is what you desire.

3) While the temporal hollows can be augmented, the bony zygomatic arch and its temporal process  which lies below it can not.

4) Correction of facial asymmetries is difficult even using differently sized implants for each side. Improvement may be obtained but do not expect perfect symmetry as that will not happen.

5) Since you have already have a rhinoplasty, what was done to the tip of the nose initially? What tip changes ere already done and didn’t achieve your goals? It is now a scarred tip and a review of the previous operative note would be helpful to know what now lies underneath and whether cartilage grafts were harvested from your septum. You also have a right middle vault collapse, a step-off at the osteocartilaginous junction, significant nasal deviation and nostril retraction/asymmetry. These and the desire for tip de-projection are going to require cartilage grafts.

All this being said, I have done some imaging based on the one useful frontal view that you have provided with jaw angle, cheek and temporal implants as well as revisional rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get breast augmentation and mastoplexy. What do you charge usually? And what type of lifts do you preform?

A: In trying to determine cost of a combined breast implant-lift procedure, there are several variables in that combination that affect cost. One is what type of implant (saline vs silicone) and the other is what type of lift is needed. These two issues significantly affect cost due to a material issue (implant) and the time it takes to perform the procedure. (lift) Thus there are a wide range of price differences (thousands of dollars difference) when these two issues are factored into the cost equation. I would really need to know what type of implant you want and would need to see pictures of your breasts to determine the degree of sagging you have and the type of lift that is needed to improve its shape. There are four basic types of breast lifts which differ based on how much lift they create and how much scar results from doing it. So it is not a question of what type of lift I perform (you have to be able to perform them all) but what type of breast lift you need.

But for the sake of information, I will have my assistant pass along the costs of a combined silicone breast implant and vertical (lollipop) breast lift which is the most common need/request that most women have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been insecure about my body ever since I was in first grade and was made fun of for my build, weight, and lack of breasts. I want a surgery done involving chin tuck, tummy tuck, possible liposuction and rib removal; for I have too short of a torso to have curves and it bothers me. Another struggle is I am covered by Medicaid because my family can’t afford regular insurance or hospital visits. Is there anything that can be done, or anyone I can be referred to?

A: While I can empathize with your body concerns, the reality is that cosmetic surgery is not covered by any form of insurance, Medicaid or otherwise. There are no justifiable medical reasons for your body change requests, regardless of the psychological or physical symptoms that they may create. Also there are no referral places for free or substantially reduced costs for cosmetic surgery procedures even at a local University or large medical center. Plastic surgeons have costs no matter where they are located, some of which they have no control over (operating room, anesthesia) and significant liability exposures. Thus the hard reality is that the barrier for you having cosmetic surgery is an economic one.

On a more instructive note, the one suggestion that I do have is that you pick one procedure (since you can’t afford them all) and the one that is the most important to you. In other words, if you could only have one plastic surgery procedure ever in your lifetime, what would it be? Then with that one procedure in mind, reach out to plastic surgeons and see if you can find someone who will do the procedure for you at a negotiated rate that you can afford. Most plastic surgeons are extremely compassionate and have done a lot of ‘community work’ in their practices over the years. If you approach your desire for cosmetic surgery this way, you are likely to be far more successful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Bodyjet lipo. It seems to offer the best result with the quickest recovery. What are your thoughts on it?

A:Bodyjet lipo is just another method to perform liposuction. It is no better or worse than any other available method.  Instead of an energy like laser, it uses water under pressure to evacuate the fat. The key to a successful liposuction outcome is not so much the technology, contrary to the manufacturer’s marketing, but the skill and experience of who is holding and driving the technology. Using the best liposuction technology available in unskilled and inexperienced hands will still lead to a poor outcome. Old-style liposuction techniques in skilled and experienced hands can still lead to a great outcome. One thing touted by all new technologies, and I have used most of them, is that the recovery will be quicker and easier. This is simply not true since no matter how liposuction is done it involves the same trauma to the tissues over a broad surface area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering butt augmentation with fat injections. I am 25 years old, 5’5″ and 185lbs. Am I a good candidate? I have read various things about recovery times and costs, what are yours?

A: The main qualifications for buttock augmentation by fat injections (aka Brazilian Butt Lift) is whether one has enough fat to harvest to make the procedure worthwhile. While I obviously don’t know what you look like, your listed height and weight strongly suggests that you do. Recovery times for the procedure are going to be similar for everyone, no matter who does it. The recovery is largely related to the liposuction harvest and is like any other liposuction procedure where fat is taken from the abdomen, flanks and back. Depending upon what kind of work you do will determine how long your recovery is…a sitdown job will be 10 to 14 days whereas a very physical job may be up to three weeks. Understand that recovering for work is different than a complete recovery from the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the difference between a stage one and two skull augmentation? What is the most you can expand? And how does the expanding procedure work? (ie what is used? Is it painful? How long does it take? Do I need to stay inIndianapolis during this time? Is it noticeable? Etc) I want to assume that I will expand a lot and I want to expand on the back and top of the head.

A: In ‘extreme’ or significant skull augmentation, it requires the initial use of a tissue expander to gain the necessary amount of scalp expansion for coverage over the volume of cranioplasty material. The first stage is the insertion of the scalp tissue expander which is similar to a balloon. It is inserted in a one hour procedure and is placed flat. (unexpanded) It is inflated on a weekly basis over the next 3 to 6 weeks based on how fast one wants to expand and other issues such as their geographic location. Depending upon the amount of expansion needed and one’s hair style, the tissue expander changes may be slightly or very obvious. Scalp tissue expansion is associated with minimal discomfort. The second stage where the cranioplasty material is applied to the skull can occur anywhere from 3 weeks to 3 months after expansion is started based on their schedule and the amount of expansion needed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, the left side of my face is different from the right side. It seems to be missing jaw bone. Is it possible to even up my face with the jaw implants? I have attached a picture.

A: Thank you for sending your picture. It is not the best picture (from an angle standpoint) but it does show that you do have significant facial asymmetry which appears to affect the jawline the most. It would be optimal if I had some different picture angles of your face that had your chin more upward and not pointing down. But to provide some basic answers, some form of a jawline implant is needed. Whether this could be a done with a stock preformed implant or would be best done with a custom implant would require a little more in-depth information with some x-rays. At the minimum a panorex x-ray is needed, more ideally a 3D CT scan is best. That information will answer what type of implant is needed and how it would be done. Also, fat injections to fill out the overlying soft tissues is always needed as well as the facial asymmetry is caused by more than just a bone deficiency. Think of improving your facial asymmetry from the bony foundation underneath outward to the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a nineteen year old female and since I was 16 I have had saggy breasts. When I was 16 I was a bit overweight. I weighed 180 at 5.5″. By the time I was 18 I had gotten my weight down to 120. I did this by working out and eating healthier. My breast still looked the same however. They are so saggy for my age. I have a small chest too. I’m a 34 B so I’m not sure if I have a medical condition or just bad luck but I want to know if my best option is a breast lift and or going up to a size C with implants.

A: While I have not seen pictures of your breasts, I can make several general statements. Whatever degree of breast shape/sagging you have, it is due to your genetics and the natural way that they developed. Their current shape is not due to a medical condition. While the concept of sagging is a relative one, when someone who is very young like you describes that they have saggy breasts they most likely really do have ptosis (sagging), it is just a matter of the degree of it. But when you combine the issue of a 60 lb weight loss, one can be assured that this is real breast sagging. (low nipple position relative to the lower breast fold) Thus some form of a breast lift is probably needed. Whether an implant is done at the same time to increase breast size as well is an option open for further discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted information about getting breast implants for my wife. How much do they cost and what are the payment options? What size is better for her? How long does it take to do the procedure?

A: The first question about breast implants is what type does your wife want. That is an important decision for various reasons and one of them is cost. Saline breast implants will cost less than silicone breast implants. The size of breast implant any woman wants is a personal one and I can not tell any woman what size breast implant she should have. I can guide her with her decision but she will have to provide some input. The best way to do that is to look at before and after breast augmentation results and show me some of the results that she likes. Otherwise, breast implant surgery is done under general anesthesia and takes one hour to perform.

The typical full cost of breast augmnetation is $4700 for saline implants and $5800 for silicone implants. The most favorable and convenient formk of financing is through Care Credit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  it’s been exactly 2 months since my cheek implants were inserted and I cannot move my upper right lip & have numbness in the lower cheek area. My upper lip movement has SLIGHTLY increased since the surgery but I’m very concerned that I have permanent nerve damage or lip upper paralysis. In your experience, have you seen any cases where patients get permanent lip/facial paralysis as a result of cheek implant surgery?

A: The intraoral insertion of cheek implants is a subperiosteal pathway to the zygomatic body that lies way below where the buccal branches of the facial nerve lie in the more superficial overlying muscles. The dissection does expose the large  infraorbital nerve (2^nd division of the trigeminal nerve) which is a sensory nerve that exits the bone below the infraorbital rim and usually transects the small zygomatico-orbital nerve branch (sensory nerve branch) as the dissection crosses the zygomatic body.  Thus it is very common to have some temporary numbness to the cheek area and even the upper lip which can take several months to resolve. It is very difficult to get motor weakness/paralysis of the buccal facial nerve branches which supply movement to the upper lip given where the nerve lies and where the deeper dissection is done. If weakness is present, it is likely due to a traction injury rather than nerve branch transection. In addition, there are numerous branches of the buccal nerve which have some cross-innervation. This means that eventual return of full lip function is assured. The return of nerve function may be slow and the fact that you are seeing some upper lip movement indicates that the recovery process is ongoing. It may take up to six months or more for complete function to return.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a breast enlargement when I was 20 years old and I was suppose to get a 36 full c and I got a 36 DD and I have never been happy with it and Im 44 years old now and I want them to be smaller. It makes me look like a bigger person and I want to be able to look smaller and wear tops that are smaller can you help me please. It has me in a bad depression and I have a complex now and I don’t even like to look in the mirror anymore. Thank you so much.

A: Exchanging breast implants to a smaller size is very straightforward and much easier on you than the original surgery since there is an established breast pocket. It would be helpful to know what type (saline or silicone) and size (cc volume) your current breast implants are. To go from a DD to a C would need at least a 150cc volume reduction if not more depending upon your body and chest wall size. The key question in your breast implant revision (downsizing breast implants) is what will the enveloping breast skin do. In most cases, significant downsizing of breast implants may require the need for some form of a breast lift or skin tightening. This, of course, depends on what the breast tissue was like before surgery and how much elasticity remains in your breast skin currently.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m hearing a lot about micro cannulas and wonder if this would eliminate the damage done by needlesticks, such as scarring and divots in the skin from the needle’s being entered over and over in or near the same spot.  Isn’t the cannula bigger and could it actually cause more damage? Can you explain the process? Thank you.

A: The use of microcannula delivery is a major advance in the delivery of injectable fillers. It makes it easier and a much more pleasant for both the patient and the injector alike. Being blunt-tipped rather than having a razor’s edge like a needle, it passes through the tissue with causing pain or bruising. Because the microcannula does not cut, a needlestick is still needed to make a small puncture in the skin

for the microcannula to enter. But this is trivial compared to the multiple needlesticks needed for a traditional injectable filler treatment. It has no chance to cause scarring or divots at the entrance site, no matter how many times the treatments are done in the same area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lipomas which make me very self conscious.  I saw a video on you tube about Dr.Eppleys lipo-dissolve injections and I was so thrilled.I always thought the only way to get rid of them was surgery. The idea of a bunch of scars frightened me. I live about 2 hours away so I was wondering if I would be able to talk to Dr.Eppley over the phone answer some questions and to explain the procedure. Thank you in advance.

A: A phone consultation can certainly be arranged. The key to understanding the use of lipodissolve injections for lipomas is that, unlike surgery,  it may or may not work. It is not an assured treatment. It may get rid of some of them completely, it may reduce the size of some of the lipomas, or it may have no effect at all on them. Only surgery is a guaranteed treatment of removing lipomas. Lipodissolve injections are a safe and minimally invasive treatment for lipomas and are a reasonable option to try before surgery. But they should not be thought of as a surgical substitute for the treatment for lipomas.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 20 year old female. I used to weight 105 lbs and gained a lot of weight after going on the Depo shot. I currently weight 145 lbs. My height is 5’0 so I believe it is a lot of fat for my size. I have fat on my arms and back and a lot on my belly area, also my legs are very thick. I would like to know an estimate on having the fat removed from those areas and having it place on my butt and breast. I am a B cup and would like a little more in that area but don’t want to go for implants at all. Maybe around a 36C. I have a little fat on my butt but I would like it to be round and firm with a little more extra fat. I wear a size 7 going on 8 pants, I can also fit a size 9 already. A lot of my fat is on my thighs. I’ve been interested in having this procedure done for a while but I’m not sure on the price and would like to know how much you would charge for the procedure. I have looked at your reviews online and I was very impressed. So if I do decide to get the procedure I would definitely like to go to you. Can you give me an estimate on the procedure for both breast and butt together and an estimate for butt only? Thank you very much for your time. I’m looking forward to hearing back from you.

A: Thank you for sharing your body description and your goals. With these in mind let me provide with some clarifications.

1)      While liposuction can effectively remove fat, it cannot do it equally well everywhere on the body. The thigh is a particularly challenging area because circumferential thigh liposuction can not be done. It can not effectively reduce large thighs. The outer thighs (saddle bags) and the knees can be treated but only some areas of the contours of the thigh can be changed.

2)      Transferring fat from liposuction to the buttocks is commonly done and is known as the Brazilian Butt Lift. Provided one has enough fat to harvest, the shape and and firmness of the buttocks can be improved.

3)      Fat grafting to the breasts, however, is not so simple for an augmentation effect. While fat can be injected directly into the buttocks without stimulation, it can not be done so in the breasts. The breasts must be pre-treated by an external suction device (Brava) for weeks before the procedure, have the injections, and then have the suction device used for several weeks after. Fat injections into the breasts are a lot like planting seeds to grow. The ‘garden’ must first be prepared and fertilized to receive them. Also it is highly that you would have enough (after processing and concentrating it) to inject both the buttocks and the breasts at the same time. You would have to pick either the breasts or the buttocks for fat injections, you can not do both.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been on your website which is quite impressive….I had jaw implants/small chin implant and a little lipo on the neck/jaw area. It’s been 8 weeks exactly and although a major amount of swelling has subsided, it still seems too large and one side is quite noticeably larger than the other…..not symmetrical….my surgeon is a notable surgeon so I have faith in him but just feeling a little down that at 8 weeks I’m still a little looking like a super hero and I’m a relatively small woman with a “small” profile so to speak….also my smile is still effected as my lower lip does not lower to show the same amount of lower teeth….is this all normal…..the swelling, asymmetry and these feelings of despair…..thanks for your advice.

A: All I can say about your present surgical situation is what I have seen in my own practice. If the jaw angle implants are too large at this point in your recovery, particularly for a woman, then they are simply too large for your face/aesthetic desires. If there is jaw angle asymmetry at 8 weeks after surgery, even though some subtle amounts of swelling may still go down, is indicative of asymmetry of the jaw angle implant positions. Jaw angle implants are very difficult to place perfectly symmetric and it is not rare to have a malposition of one which will appear like a ‘lump’ on that side of the jaw angle. Putting these two together would indicate to me that you are headed towards a revision, downsizing the implants and adjusting at least one of their positions. It is not a question of if…but when. Your plastic surgeon will tell you to wait longer because of ‘swelling’ but the final outcome will not change. If the jaw angle implants are silicone then there no harm in waiting as they are easy to remove and replace. If the jaw angle implants are made of Medpor, then sooner is better than later due to tissue ingrowth.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a two time kidney transplant recipient, both from cadaver donors.

Due to both surgeries, my abdomen healed fine, it’s just that it healed in the shape of the letter V so to speak, and I have this big pouch that looks like a giant lip at my lower abdomen, no matter how much exercise I do, it is not going anywhere. I have considered cosmetic surgery for years, but was not aware that I could have it due to my transplants. I did gain weight, but I managed to lose 45 lbs. but I still have problem areas, that I feel I need to have corrected to help my appearance more. I am comfortable with myself, I just want to look as good as I feel.

A: Thank you for your inquiry and glad to hear that you are doing so well. A kidney transplant patient can have an operation like a tummy tuck safely and effectively. This would require that you have clearance from your nephrologist, have good blood counts (e.g., normal white blood cell count as an indicator of immunocompetence) and that the tummy tuck be modified to eliminate muscle plication and simply remove the skin and fat overhang. I would be happy to review any pictures that you may care to send to see if this would be a good option for you. It would also be helpful to know the location of the cadaveric kidney which usually in a subcutaneous abdominal location.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had breast implants placed, 500cc silicone gel implants placed under the muscle, four months ago. After surgery my right implant was seen to be lower right after surgery and it stayed that way. Then three weeks ago, I had the implant revised and tucked up higher. I am concerned now as it doesn’t look right. The bottom part of the revised breast looks square like a straight line across the bottom. It does not look like the other side. Attached are some pictures of my breasts before and after. What do you think?

A: Let me share with you some general

thoughts about the type of breast implant revision that you had. Unfortunately breast implant asymmetry is not rare, averaging around 5% to 7% in most practices. It can be caused by the patient’s own pre-existing breast asymmetry (often unrecognized), over dissection of the implant pocket, disruption of the IMF (inframammary fold) ligamentous attachments or stretching of the pocket due to the weight of the implant. Regardless of the cause, bottoming out of a breast implant is more of a challenge in which to have a successful revision than when the implant is too high. This is because a new IMF must be established and then it must stay stable as it heals. Inevitably when the revision is done, the bottom pole of the breast and its new fold level is rarely going to match perfectly with the other side. Some plastic surgeons prefer to set the new IMF at the horizontal level of the other side, others choose to make it higher with the expectation that there will be some rounding of the lower pole of the breast as it heals and settles. Either way, the new fold will often look like a straight line rather than a rounded curve like the other side. This shape is often unavoidable. Whether it will round out somewhat or stay the same is impossible to say at this early point. It is going to take up to 3 months to see how its shape evolves. What matters most at this point is that the horizontal level of the implants are fairly even. If that stays that way then it would be best to leave it alone. While that may not be the ideal shape you want, further efforts at manipulation may cause other problems (longer scar, infection) that may not be worth the risks and trade-offs.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have an asymmetric face, jaw, and bite and looking to even things out. The left side of my face is bigger. I’m seeking to make my jaw and cheekbone on the left side smaller to match the right. Also, my right eyelid and eyebrow are lower than the left.

A: I have taken a look at your frontal facial photo and looked at making changes that would provide the best benefit. These would include a left cheek narrowing vertical osteotomy, a left jawline/angle narrowing ostectomy and a right endoscopic browlift. I don’t know your age and you mentioned a bite that is off so there is the possibility of orthodontics and orthognathic surgery as well which would always need to be done first. If you have never had an orthodontic workup this would be a good evaluation to do so you at least know your options.

Facial asymmetry is usually very difficult to get the best symmetry when only one side is done. This is why there remains the option of a

small high right cheek implant or even a small right jaw angle implant…as the bigger left side can never be made quite as small as the opposite smaller right side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a non-invasive procedure for fat reduction basically at thigh and abdomen. I would like to know what you recommend and what do you think about CoolSculpting. I have had 3 c-sections, no other medical conditions. Thanks.

A: Let me make some general comments about the differences between non-invasive vs. surgical treatments for body contouring. (fat reduction and skin tightening) First, when it comes to considering non-invasives (e.g., CoolSculpting, Exilis etc) the patient never has anything to lose…other than money. There are no medical risks or downtime. The only risk is in how well it will work. Thus if someone is dead set against surgery then go ahead and do the non-invasive approach. It will either produce a satisfying result or it will not. Second, understand that no non-invasive therapy will ever produce a surgical looking result. I don’t care what is said about it or how good some before and after pictures look. The role of noninvasive treatments for many patients is a bridging therapy…I don’t want surgery but I want some improvement. ..and I will accept that it will likely do less than I ideally want. Lastly, no patient wants to waste their money and effort on a treatment that never had a good chance to work for them. Thus it is important to get a qualified answer beforehand as to what your chances are for success with any non-invasive treatment.

While I have no idea what you look like, the fact that you have had three pregnancies/c-sections give me cause for concern about the success of any non-invasive treatment approach for your abdomen. Your abdominal skin is stretched out and probably has poor elasticity…that would be inevitable after three pregnancies. If you have any stretch marks at all, there is next to no elasticity. That skin has a very limited ability to shrink back down on its own no matter what energy treatment is applied to it. So even if you can shrink some fat what will happen to the skin? Without skin shrinkage with fat reduction the change in the abdominal contour will likely not be an aesthetically significant improvement. On your abdomen after three c-sections the real question is whether anything will really work short of a tummy tuck.

The thigh area is always different because the skin always has better quality. The issue here is the debate of something like CoolSculpting vs liposuction. I think that answer lies in how much reduction is needed and what does your abdomen really need. If a tummy tuck is the only answer to your abdominal concerns, then you might as well have liposuction done on the thighs at the same time.

I would be happy to review of any pictures of your abdomen and thighs to give you a more definitive answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had an upper blepharoplasty where a lot of skin was removed. This caused my eyebrows to lower ( about 5 or more mm). I want to restore my eyebrow position but I don’t want my eyes to appear any more wide open than they are and for too much  of my upper eyelid to show. Is it possible to perform an upper eyelid skin graft to assist in my situation?

A: The first question is how long has it been since the initial blepharoplasty procedure? If it was 6 months or more afterward then it is reasonable to consider some management strategy.

If it is less than six months there is still some possibility of upper eyelid skin stretch that may lessen the overresection effect.

A skin graft can certainly be done to the upper for an over-resected blepharoplasty problem and it will take very well. It is the definitive answer to your present concerns. But there are some trade-offs. First a skin graft will often appear as a small patch because it will be virtually impossible to have a perfect skin color and thickness match. Secondly there has to be a donor site for the graft and it needs to skin that is very thin and with as little pigment as possible. This usually means it has to come from the back of the ear. In older patients it could come from the lower eyelids but this opportunity is very rare.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had a breast enlargement in September under the muscle. Three weeks ago I had to have revision surgery as my right breast dropped and now my breast still does not look right as he has tucked it up so tight the breast looks square. I would really appreciate if I can send you the photos and you can give me some advice and tell me what your thoughts are. Many thanks.

A: Unfortunately breast asymmetry after augmentation surgery is not rare. While one implant can be too high or too low, the more challenging revision is when the implant is lower than desired. It is always easier and more predictable to drop an implant down than it is to raise it. This is because the new lower breast fold is held together with sutures and it is not always known how stable the new fold position will be with time. Ideally I prefer to position the new breast fold in the desired position and use enough permanent sutures that it does not drop or settle later. Other plastic surgeons prefer to overcorrect with their experience that some dropping of the implant will occur as it heals.

Based on your present description of a square-shaped implant, that would suggest that the new breast fold is higher than the other side. Given that it is only three weeks after your breast implant revision, it is too early to say what will happen in the next few months. You need to give this revision time to heal and settle for at least 3 months if not longer. Any attempt at further revision now would be ill-advised.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr.Eppley, I am interested in skull augmentation.  I have heard of Osteobond being used overseas.  Is an expander needed? I have a normal shape, just want to make it larger.  What is the estimated cost? Thank you, I appreciate your time.

A: Whether an expander is needed for skull augmentation depends on how much skull expansion is desired and where that expansion on the skull is needed. Please send me some pictures so I can do imaging to get a feel if yours is a one-stage or two-stage skull augmentation. Knowing that and the material used plays a major role in the cost of the procedure.

Osteobond is not an FDA-approved cranioplasty material in theU.S. The approved options here are polymethylmethacrylate (PMMA, Cranioplast) and hydroxyapatite (HA, Mimix and others).

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have gynecomastia reduction but my puffy nipples persist which was the problem in the first place. My surgery was in October 2012 and it was liposuction via the armpit area. I am a 31 year-old in good shape and this has been a problem in my life since I can remember. I can’t tell you how excited I was to have the surgery FINALLY after all these years. The end result, however, was a leaner chest (one side a little more than the other) and still puffy nipples. When I read some of your comments online I figured I’d look for a second opinion, as my first surgeon has offered a second surgery to correct my problem.

A: Your result does not surprise me with that approach. While liposuction can make the chest leaner, it will not in and of itself take away the puffy nipple. That is going to require an open areolar incision to directly remove the firm breast tissue that lies right under the nipple. This tissue is just too firm and gritty in many cases to be removed by liposuction. If there is one thing I have learned about the puffy nipple in young males is that they want it completely flat and that is only going to be most assuredly achieved by direct areolar excision. The liposuction is helpful for general chest contouring but rarely removes the puffy nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, first I appreciate your answers to the questions that I asked you about custom made facial implants. Recently I read of computer or CAD/CAM designed implants. What is the difference between them? The CAD/CAM designed implants would work well for the reconstruction. While custom made implants designs are made by hand, computer designed implants models could be created by using computer soft ware. If it is such, I think that the CAD/CAM designed implants would be more suitable for my case to restore the exact defects. Could you design and manufacture jaw angle implants through CAD/CAM system?

A: Custom made facial implants is a general term that relates to several methods of manufacture. Handmade custom implants are done using a prefabricated skeletal model (made off of a 3D CT scan) where either a technician or the surgeon makes the desired shape of the implants which is then transferred into a final implant design. CAD/CAM designed implants is done digitally by a technician using a 3D

CT scan of the patient. There are advantages and disadvantages to either approach. When there is a very specific facial bone defect and a normal side to compare it to, the CAD/CAM approach is a good one because the computer has a definitive target from which to shape the implant. When one is after general aesthetic augmentation of any facial skeletal area, there is no specific or predictable target. Whether it is done by hand or the computer, the exact implant design is still a guessing game so to speak in terms of what will create the desired aesthetic effect.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Firstly, I would like to take the opportunity to thank you endlessly for the abundance of information you have on your website regarding cranioplasty. You seem to be the only person that has posted information about it, which has in turn reassured

me throughout my own medical process.
The reason for my email is to find out the best proposed solution you can present to me for my current cosmetic concern.
I have noted in some of the answers you have provided prospective patients with, you recommend using Kryptonite Bone Cement. My enquiries all relate to the use of Kryptonite Bone Cement to amend some defects I have from a past cranioplasty. I would really like to avoid having to shave off my hair where possible as it is almost as devastating as the defects themselves.
Last year in June 2012 I had a titanium plate inserted to cover the bifrontal (top front part of my head) due to replacing bone from a decompressive craniotomy after sustaining Traumatic Brain Injury. After the swelling had subsided from the insertion of the plate, I have been left with a visible line (indentation) where my plate goes across my forehead. I have also been left with a decent sized dent in the side of my face in the temple area, there also seems to be a smaller dent on the other side too. I have attached photographs so you can see the extent of my concerns.
What I would like to know is:
1. Will Kryptonite Bone Cement be suitable to use with my titanium plate? It seems to be an ideal solution to conceal the indentation along my forehead (where the plate meets my forehead) and fill in the gaps around my temple area and being injectable reduced the shaving and scarring as I would imagine.
2. If Kryptonite is not suitable, please tell me what the other options are that you would suggest.
3. Are there any side effects that I would need to be aware of?
4. Are there any long term studies on Kryptonite or proposed solutions that are available?
Many thanks in advance for your assistance, I eagerly anticipate your response.

A: In looking at your pictures and the accompanying commentary, let me answer your questions in the order that you presented them.

1)      Kryptonite bone cement is no longer commercially available for reasons that are unknown to us as surgeons. But even if it were, it would not be appropriate for your case. Any injectable cranioplasty technique requires an unscarred scalp/skull area, no indwelling hardware and a defect surface area that is not unduly large. With your craniotomy history, presumably large titanium plate and the extent of the cosmetic deformity (bitemporal crossing the forehead), it is going to require an open cranioplasty approach to adequately correct. It should be approached no other way. While this is not the approach you would like to hear, the good news is that the procedure can be done without shaving any hair. I never shave any hair for an extracranial crcanioplasty procedure.

2)      The only issue with an open cranioplasty is what material to use. It could be either hydroxyapatite (HA) or standard acrylic cranioplasty. (PMMA) There are some minor advantages and disadvantages with either material. I would have to see some x-rays of the extent of the plate location to answer that questions better.

3)      The only real risks of this procedure are aesthetic in nature. Can a seamless transition be done in building up all the areas from the temples across the forehead. The front of head looks very much like a ‘vice’ across it so more volume is needed to build out these areas in your cranioplasty than one would think.

4)      There are no long-term studies of Kryptonite that have ever been published. But this is irrevelant now since it is no longer available for clinical use.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 37 year old male. I have been feminizing my face for the last few years. I’ve already had my brows shaved and my hairline brought down. I wonder if you can help with 2 other areas that trouble me.
(1) I used to have a narrow, pointed chin. Unfortunately I had it shaved flat. Then I had a shaved medpor medium sized anatomical implant inserted. But my chin still looks wide, rounded (not pointed) and too long.
I have read a lot about you. I understand that you can use a smaller implant and shave the wings off to make it more narrow, and shave the point of the implant to be more pointed and shorter.
I have enclosed a photo of how it used to look, which I liked, and how it looks now which I don’t like.
(2) I also had high and narrow cheek implants inserted. Unfortunately the left implant became displaced after a car accident

and then removed. So now I only have the right implant in.
I wondered if you could place feminine implants in to replace the cheek implant i already have.

A: In looking at your chin and cheeks and your accompanying commentary, I can offer the following recommendations:

1)      Your chin is now broader and more masculine than it was because of the use of an anatomical chin implant design. The Medpor chin implants have very broad wings that add fullness to the side of the chin making it wider. That could be changed by either altering the implant you have in place (difficult to do because of the material) or remove and replace it with a more central button implant style which will return the chin to more or of a triangular shape. The length of the chin may just be a function of the size and location of the indwelling implant. But if some real vertical chin shortening is needed, the lower edge of the chin bone will need to be reduced.

2)      The cheek implants you have in place produce a more sculpted male look being high and lateral. A more feminine cheek appearance requires a rounded more anterior cheek look. That could be achieved by replacing the cheek implants you have in now with those that are better shaped for that look.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I believe I need a pubic lift. I have lost 100 lbs and am still over weight by a lot. But I had an abscess removed from one side of the upper pubic area and I’m also uneven on both sides. If you type in pubic lift blog on yahoo and under images there is pictures I believe of one you did that is quite large like mine little different I presume. My question is cost and what would be the steps and healing?

A: When

one has lost 100lbs, I would have no doubt that a pubic lift is needed. But I am suspicious that you may need much more than that. Usually such weight loss causes a lot of abdominal tissue overhang which is most commonly called a pannus or apron. This is a hip to hip removal of the abdominal overhang that would include a pubic lift. It is possible that an isolated pubic lift may suffice, or be partially helpful, but I would have to see pictures of your abdominal area to make a visual evaluation. There is a big difference in the cost and recovery of a pubic lift vs. abdominal panniculectomy so knowing what you look like is essential to answer your questions with any accuracy.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, have a little crater on the outsite skin on the top of my nose. I tried filler, excision, laser and dermabrasion. Nothing helps. The crater is 2/3 millimeter deep. Now a doctor in Switzerland want to put a little piece of cartilage under the skin to lift the crater. But I have no confidence because they all have no experience in this case. Can you help me? It’s no problem for me to visit you because I love your country….

A: It is hard to comment on such a nasal defect without seeing a picture of it and knowing where in the nose it is located. The key question is whether this defect is located to just within the skin (dermal indentation) or whether it is located in the subcutaneous tissues between the skin and the underlying bone/cartilage. Only a subcutaneous defect will be positively affected by any implant placed

underneath the skin as this will push out the overly skin indentation. If, however, the indentation is a result of dermal thinning (which I suspect may be the case) then no implant under the skin will help as it will just make a bump appear with the skin indentation merely pushed outward….actually making it look worse. Dermal skin indentations, which are common in the nose, are virtually impossible to improve as you can’t smooth down the surrounding skin and there is no way to make the dermis thicker. In rare cases, it may be possible to place an allogeneic dermal graft directly on the underside of the dermis but even this approach does not assure elimination of the skin crater. This type of nasal scar is very difficult to improve regardless of the method of scar revision that is tried.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I

Am 73 years old. Is blepharoplasty an answer to my swollen, puffy under eye condition? If they can be removed, will they come back?

A: Lower eye bags are caused by the progression herniation of fat that comes out from under the eyeball. Many people will eventually get them as they age although some people will actually have the opposite effect…loss of fat and deep set eyes with hollowing as they age. A lower blepharoplasty procedure will remove the protruding fat, a little bit of lower eyelid skin and tighten the corners to reduce the risk of a drooping lower eyelid after surgery. Age is not an issue when it comes to having this eyelid procedure only one’s health is. Most lower blepharoplasty procedures need to be done under anesthesia as it is very difficult to keep the eyelid still when you can see what is happening right in front of your field of vision.

Dr. Barry Eppley

Indianapolis,Indiana