Your Questions

Q: Dr. Eppley, I have spent considerable amount of time in researching fat transfers believing it to be the most viable option when done correctly, especially for thin older women. The stem cell benefits of properly done fat grafting add tremendous benefits as well. I understand although fat grafting has been around for a number of years, the harvesting and injection procedures have changed, creating greater success in keeping the fat cells alive. What methods do you use to ensure the success rate of your fat transfers, and what is the success rate you are currently having?  One of the greatest difficulty for a patient, are the major disagreements in the medical field regarding the procedures used. Please understand I believe fat transfers to be one of the greatest positive changes in how we address aging skin, I want to have it done, but I am still very undecided due to the conflicting medical opinions out there. There is a very heated debate regarding the “dropplet” vs larger blocks, and the placement location.

A: The concise answer to your basic question is that fat grafting is in a state of evolution and development. It is far from a perfected science from the harvest to the injection methods. No matter what you read or is touted by any one surgeon, no one knows the best method to do fat grafting and just about everyone does it using the same basic principles. No matter what any surgeon claims, they do not have a magical method that works all the time and claims about how much fat survives, in many cases, are perceptions about fat graft take not actual measurements. How well fat graft takes can not yet be measured in any quantifiable way and is based largely on photographs and what the surgeons perceives has survived. Quite frankly as a surgeon I can tell that such perceptions are often skewed by what one wants to see and most claims of survival are likely overstated, some with good intent and others for pure marketing purposes.  What may work well in one patient and one face or body area may not work well in the next patient. Fat grafting by injection remains an imprecise art with the science lagging far behind as of yet.

The most straightforward and honest answer that I tell prospective patients about fat grafting take is…no one can predict it and it will likely end up somewhere between 10% to 90%. While the goal is to have have maximal take on one procedure, every fat grafting patient needs to be prepared that more than one procedure may be needed.

Most fat grafting is done by injection because it is the only practical way to either treat a large area or get the material without undue scarring. En bloc fat grafts, also known as dermal-fat grafts, actually work and take very well. But their uses are very limited because a donor site is required and the size of the recipient site must also be relatively small.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was interested in getting my hairline lowered as well as brow and frontal bone reduction. However I have a very thin hairline due to constant damage to my hair follicles. Any suggestions and how long after would I have to wait to get a separate surgery.

A: If I understand your question correctly, you would like hairline lowering/scalp advancement combined with frontal/brow bone reduction. The concern, which is both understandable and appropriate, is whether with a fine and thin hairline that you should have the procedure. The answer to that question would be based on what your frontal hairline looks like now (please send me a picture), how much scalp laxity you have and whether you were eventually planning on any hair transplantation along the hairline after the procedure. (as some people do for scar camouflage) The quality (hair density and pattern) of your frontal hairline determines how well the scar would do and its potential visibility. Your existing vertical forehead skin length and your natural scalp laxity determines how much scalp advancement/hairline lowering is possible and whether the result justifies the effort. Knowing that one may be considering the potential for hair transplantation later gives one more freedom to perform the procedure is someone with less than an ideal frontal hairline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would love to smooth out the under eye area- fill in the depressions created when I smile, and add an over-all fullness that I have lost, most recently in the last year as I have gone through menopause. I experienced a rapid and major estrogen deficiency that truly took a toll, especially in my face to appearing almost gaunt. (being a woman is quite a life-time adventure in of itself!) Looking at pictures just one year ago show a noticeable loss of facial volume even though I have experienced no overall weight loss or gain. Again, thank you for sharing your time and expert skill with me.

A: In interpreting your facial concerns they are two-fold: lower eyelid hollowness and a general mid-/lateral facial involution below the zygomatic body and arch bone levels. While both of these are caused by loss of fat, they may or may not be treated similarly. For the generalized facial wasting, the only effective treatment is fat injections. This is the only way to help restore larger facial surface areas that have no underlying bony support. (what I call the facial trampoline area) The lower eyelids are a bit different because the thin skin exposes the use of fat injections to risks of asymmetry and irregularities with so little interface of tissue between the lower eyelid skin and the underlying orbital bone. Other options include the use of orbital rim implants and dermal-fat grafts but those are not without their own issues. (more invasive, palpability, donor site harvest) Given these issues I would favor fat, whether it is of the injected or en bloc variety.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a chin implant put in and removed within a few months about 4 years ago. I have slight chin ptosis, and read about “routine” procedures to reattach/tighten/lift the chin pad, like what you discuss above, but when I google search, I find no one who does this . I have googled “raising the introral sulcus”, “correcting bottom tooth show”(no one seems to have any suggestions for this), “correcting chin ptosis”, “submental tuck up” (which you have also talked about) and get like 2 results. and those that do these procedures have like one photo on their website. I would also like projection higher up on my chin so that overhead light hits a small area on the chin, the rest in shadow. The implant I had before just extended the downward line of my jaw and increased the area that the overhead light would catch, making my chin look longer. I feel a feminine chin not only projects, but curves slightly upward at the end of the jaw. On your chin implant page, the 7th one down has a nice curve up, as do many of your patients, the 8th one down does not, nor does the one on the bottom of page 1–you just continued the downward direction of these jaws and I don’t think it looks right. How do you avoid that?? Thanks.

A: Correcting chin ptosis is anything but a routinue plastic surgery procedure. There is not much written about it because its correction is not easy and the results not always predictable. I have learned that the most predictable way to get sustained improvement is to do a lower periosteal/mentalis release, elevation of the chin pad by suture anchorage to a higher position on the bone, a V-Y lower lip mucosal advancement and a shortening vestibuloplasty. Combining all four maneuvers will always correct a some degree of a sustained chin pad repositioning and maybe some slight lower lip elevation.

Getting a chin pad that curves upward with implant augmentation depends on numerous factors including the presurgical shape of the chin pad, chin implant style and size (women usually do better with a central button style chin) and whether an intraoral or submental approach is used.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to get a new shape to my eye that is more narrow and uplifted. I have attached a picture of the kind of eye look that I would like. I was able to create that look by using elastic bands attached to tapes as was seen in a video on Youtube to create an instant ‘facelift’.

A: Thank you for sending your pictures. What you are illustrating I would consider an extreme lateral eye reshaping result which I am not sure can come completely from a lateral canthoplasty alone. I know you were using tapes that pulled the corner of the eye AND the skin around it so it made a very artificial and not surgically achieveable look without pulling the temporal skin back with it. That issue aside it does illustrate that a subtle change in the corner of the eye will not be enough for you. The entire lateral canthal tendon will have to be shortened and pulled way back onto (through) the lateral orbital bone to create that much change. While that is possible it is likely to create a skin fold at the corner of the eye that can only be eliminated by combining that with a temporal lift.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Please see the photos I have included regarding my interest for a breast lift and abdominal procedure. I am a fit individual in that I work out 5 days a week, and try to keep a balanced diet. Your advice and expertise would be appreciated.

A: Thank you for sending your pictures. From an abdominal standpoint, I agree that liposuction on the abdomen and around the waistline would be beneficial. Certainly no form of an excisional procedure (tummy tuck) is needed. For the breasts, however, that is a different story. As you have also mentioned, a breast lift is needed. There is simply too much skin for the amount of breast tissue you now have. The type of breast lift needed is most likely a blend of what I call a type III (vertical or lollipop lift) or a Type IV (anchor or inverted T lift) These names relate to the degree of lifting they achieve and the type of scar pattern that occurs as a trade-off. I think you could only get by with a Type III lift if you were doing a simultaneous implant for volume enhancement as well.

Both a breast lift and abdominal and flank liposuction can be done at the same time for your trunk makeover.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had two cheek implant surgeries. Initially I had 4mm malar shell implants which were barely noticeable. Then I switched to 6mms implants which are now too big. I have a question regarding projection size.  I’ve attached two photos showing my face with Conform Terino Malar Shell medium implants with 4mm projection.  As you can see, I didn’t feel that these 4mm implants gave me enough definition in my cheekbones or enough outward projection. Therefore, I just had these implants exchanged with Terino Malar Shell 6 mm, but I now feel that the 6mm projection sticks out way too much.  I’ve heard that a 1 mm difference in implant thickness (projection) is equivalent to about 1/2 inch difference in actual cheek shape.  So, looking at the attached photos (and now that I know through trial and error that 6 mm projection is too large), do you think the same implant with a 5mm projection would still look too large, so I should go with a 4.5mm implant when I exchange the implants next month?

A: It is not true that 1mm of cheek augmentation equals a half inch difference in how the cheek looks. What I can tell you is that it can be striking how a few millimeters in the cheek area can make a big difference. So I think the statement that a little augmentation goes a long way in the cheek area. You case illustrates that in particular. If 4mms is too small and 6mms is too big, one would logically assume that 5mms would be the right size for you. Be aware, however, that in any cheek implant style and size that not just the thickness changes but overall size of the implant (height and width) as well. It is unfortunate that you will have had to go through three surgeries to finally get the right size implant. But there remains no quantitative way before surgery to determine how any amount of cheek implant augmentation will look

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, two months ago I got 6 mm silicone malar shell implants put in. I have flat cheekbones and full cheeks so the goal was to achieve higher, chiseled cheekbones (without placing them too laterally because I didn’t want the overall width of my face to look wider). To be clear, I do not have a combined malar/submalar implant because I did not want to augment my submalar region. Is the malar shell the implant you would have used or would the Medpor RZ malar implant work better to achieve prominent, high cheekbones? Thanks so much.

A: Quite frankly I would have used neither. All silicone malar shell implant styles are fairly wide which are going to give a round look to the cheek more than a high angular look. The medpor RZ implant is a lower projecting cheek implant style that will not give a high lateral look either. In reality, there is no really one good cheek implants style that will give that highly placed chiseled look in many patients. The best cheek implant that I have found is to either cut the silicone malar shell implants in half so that only the highest part stays or to use a so-called anatomical (style 1) implant that only imparts fullness to the high malar region.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have got a knife scar on my face since I was 5 years old. It is about one and half inch long, is not very deep by any means. I can really see it from 3 feet away. However, it still bothers me sometimes. Is there a way to make it disappear? Thanks a lot.
A: Scar ‘disappearing’ is not likely in any scar. Its further reduction in appearance may be possible, but there is no such thing as scar elimination. The involved skin can never be made completely normal. Scars can be made more narrow, more smooth and have a more normal color, but they can never be completely eliminated or made to completely disappear. Whether any of these techniques or changes will be beneficial to your scar,  I would have to see pictures of the scar to provide a more specific scar revision recommendation.
Dr. Barry Eppley
Indianapolis, Indiana

 Q: Dr. Eppley, I saw a doctor for a genioplasty consultation and he is supposedly a guru in the field. I have Class II, deep v shaped labiomental fold and my lower lip is behind my upper and my chin height is short and retruded back. He said a sliding genioplasty to horizontally and vertically lengthen my chin will work, but he also said he wanted to inject some kind of new stem cell bone material on my chin underneath the fold which will create new bone and fill in the valley on my chin, which would push out the soft tissue of the fold. I’ve never heard of this. He said bone augmentation was superior to soft tissue implants or fillers, and that this technique is very new.

A: What you are referring to is the simultaneous management of a deep labiomental fold during a genioplasty. Even though vertically lengthening the bony chin with the horizontal advancement will not deepen the fold any further, it is also unlikely to make it more shallow either. Filling in the bone gap of the osteotomy, while often thought as helping push out the labiomental fold area, does not. It is below the level of the labiomental fold. Thus a soft tissue approach is needed to help fill out the deep labiomental fold. That can be done by a variety of methods from injectable fillers, fat injections, allogeneic dermal grafts, and even silicone rubber (Permalip) implants. So-called stem cell injections (usually just concentrated fat injections) is a hot topic for injectable soft tissue augmentation. It is certainly a safe technique to do but its effectiveness is far from established.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, why are tear trough implants such a rare procedure? Can the implants pop out of place? What are some bad things that could happen with tear through implants? I am very young with very dark eye circles and I look terrible and need to do something about it.

A: Tear trough implants are very uncommon because other simpler alternatives exist such as the use of temporary injectable fillers or fat injections. These are far more appealing to many patients, and in the appropriately selected lower eyelid defect, they can be a good and effective choice. At the least, an injection approach is a good trial to see if this more non-surgical approach can be effective. For a defnitive permanent solution to the lower eyelid tear trough/infraorbital rim deficiency, a bony-based implant can be an effective choice. Tear trough implants are placed through a lower eyelid incision. They are attached to the bone by small screws so there is no chance of them ever moving out of place. The only issues that I have ever seen with tear trough implants is that you may be able to feel them through the very thin lower eyelid skin. In addition, carving and shaping them down so they have a natural flow into the surrounding bone is important so that there are no unnatural step-offs is an important aesthetic contouring step.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting liposuction to reduce the size of my waist and hips. Attached are some pictures of my waist and hips. I am after achieving very specific circumferential measurements in these areas. I have a measurement of 34 inches on my waist, and 46 inches on the widest part of my hips/ buttocks. I am 5 foot 8 inches in height. I need to be at least a 32 inches in my waist and 40 inches in the widest part of my hips/ buttocks. I am also interested in getting my thighs done. Is this possible.

A: Thank you for sending your pictures. On a realistic basis, I do think it is possible that your waist could go from a 34 inch down to a 32 inch waistline. However in the hip/buttock area a 6 inch reduction is simply not realistic. This is an area whose diameter is highly influenced by the hip and pelvic bones as well as the thickness of the attached muscles. Fat plays a role in its shape but not the level of a 6 inch reduction. A more realistic goal would be 1 to 2 inches, and maybe even 3, but I am not sure with your body shape how realistic a 3 inch reduction would be. My concern for any patient that comes in for any form of liposuction body contouring that is going to use a quantitative measurement as a determination of the success of a procedure is that they may end up disappointed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Oh dear, my pictures show how bad my neck really is. It looks worse in pictures than in real life! How you are going to fix it I don’t know. But I suppose you’ll be able to figure it out. The horizontal necklines I’ve had all my life. I recall a closeup when I was 20 that showed them clearly. But the sag is relatively recent. In the last 5 to 7 years I started to notice sagging. The wrinkly skin aspect is newer and that’s what I really hate! If I tighten my chin it doesn’t show, but I can’t go around looking as if I’m spoiling for a fight! Thank you.

A: Thank you for sending your pictures. I can see your neck skin concerns. This is due to the traditional sagging of skin that occurs with time and gravity. Your long-standing horizontal neck lines act like clothesline across the neck and the sagging skin now hangs between them. That is why your neck looks like it has multiple rolls.The fact that you can stick your chin out and it makes the neck skin smooth supports that a necklift (lower facelift) will be the definitive answer…and then you won’t need to constantly stick your chin out to have a good looking neck.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in jaw angle reduction surgery but I am worried about the risk of asymmetries. In most before and after pictures that I have seen, I do notice asymmetries… one side of the jaw is thinner than the other. Why is that happening since X rays are being taken before surgery? Is it difficult to see where to shave during surgery? Is that a common risk? I also have seen some patients complaining about bumps and dips on the jawline (bony irregularities), why does that happen? Is that a common risk? Thank you so much.

A: As you have observed with excisional jaw angle reduction surgery, symmetry can be difficult to achieve. Having an x-ray before surgery is not helpful in executing the actual procedure. Doing the procedure inside the tight confines inside the mouth is quite different than making drawings on an x-ray. It may help estimate how much bone one wants to remove, but during surgery there is no way to see both sides simultaneously and no way to know if one side matches the other. In essence, excisional jaw angle reduction surgery is a guess on each side of the angle of the bone cut and how much bone is being removed. This problem can be magnified if the patient already has some existing asymmetry in the shape of the jaw angles. Converselly, burring or shaving the jaw angle is different. Because you are keeping the existing outline of the jaw angle bone and merely making it thinner, the risk of irregularities/asymmetries is dramatically reduced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can jaw angle implants be custom made out of Porex? I had Porex jaw angle implants placed to restore my jaw bone deformity after jaw reduction surgery. but I am not happy with the result. I realized off- the self implants do not suffice in my case. I am considering my implant removed and replaced with custom made ones. All I have seen of custom made implants is to be made of silicone. Is it difficult to make a custom made implant out of Porex or too much expensive?

A: Quite simply, the manufacturer of Porex implants  is not willing to make custom jaw angle implants. This is undoubtably because the Porex material has to be machined (milled) to create the implants which is both time-consuming and expensive. Conversely, silicone implants are poured into a mold which is far easier to manufacture and more economical. It sounds like you had jaw angle reduction surgery (amputation of angles) and then had them restored by jaw angle implants. I have seen this scenario numerous times. It may be that only custom implants are an appropriate solution for your problem or it could be that the implants you have in place have either not been the right style or not well placed. Medpor (porex) jaw angle implants are notoriously difficult to properly position. So unless your surgeon has tremendous experience in doing jaw angle implants the problem may be in the implant selected or how it was positioned. Unless you have a 3-D CT scan of your face/jaw done it would be hard to know what the real problem is.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, At the age of 23, I am in the Navy, and I have always had a tough time with the tape measuring. I was doing some research for liposuction reduction on my butt, thighs, and waist, so I wouldn’t have to worry about the measuring around my hips and waist. And I came across your website. I live in Florida, but I can get time off to complete a liposuction surgery. I was just wondering how much the procedure would cost? Thank you for your time and please reply.

A: I am very familiar with the tape measuring that is done to pass a fitness test as that is the number one reason most people in the service have liposuction in my practice. So your request is not a rare one. How effective that would be in your case, how much fat could be removed and what that would cost would depend on what your areas look like. In other words, what do I have to work with and how big are they? If you can send me a few pictures of the areas in question that would be very helpful. In the interim, I will have my assistant send you an estimated cost based on what I would envision the areas to look like. That may or may not change based on a review of any pictures you would send.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am possibly interested in a limited facelift. I am generally taken for younger than my 64 years and have been told by physicians that I have very good skin. But my neck, to me, is hideous. There are some other signs of aging about my face, but in general I can live with those–it’s the neck that upsets me in my mirror view. I assume you do consultations? Are there brochures you could send or websites to recommend? Thank you.

A: While the entire face ages in everyone, many people are most concerned about the changes in their neck as they get older. The neck angle opens up and drops as skin sags, fat accumulation develops and platysmal muscle separation occurs. In women in particular they will often develop wrinkled or creepy skin as well. At age 64 the only good and effective solution is going to come from a lower facelift, often called a necklift or a neck-jowl lift.  This procedure lifts up and redrapes all of the neck skin back up over the jawline and around the ear. In essence, putting the tissues back up from where they came and turning back the clock on how the neck looked 10 to 15 years earlier.

The best way to a consultation with me is to send me some pictures and we can initially talk by phone or Skype. You never have to leave your home to get all the information you need to know!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have very little earlobes. Can I increase their size and shape using dermal fillers??

A: The size of your earlobe can be increased (expanded) by the use of either injectable fillers, fat injections or even a small dermal-fat graft placed from an incision on the backside of the earlobe. Which technique is better for you depends on the current size of your earlobes and the amount of earlobe skin that you have. You may feel free to send me pictures of your earlobes for a more definitive recommendation. But as a general rule, the first step to do is to use temporary injectable fillers to see of you like the change they make. If so then you may consider a more permanent solution with one of the fat grafting options.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently 30 years old and after a long career of modeling I see that I’m not longer as popular as when I was younger. Since I have seen good plastic surgery turn people 5 to 10 years younger, I was wondering if the same thing could be done for me. Could implants help me to retrieve a more youthful look. I’m not expecting to look any younger then 25, I am realistic about the possibilities. What would you suggest? What would help me the most to fight the “aging”. Even though I’m still young, it is important to me to know what my options are. From what I have understood. Elasticity of the skin declines and the cheeks start to sag, so will an implant help with that? I also have a bit hollowness under my eyes. What could be done against that? People have advised me to get some kind of fillers, or fat transfer to create that younger look again. But what is your opinion? Is it surgically possible to make even a fairly young person look younger? Thanks.

A: Most likely at your age the initial changes that you see are best treated by some skin rejuvenation techniques and fat injections. The quality of your skin can be improved, at any age, by such techniques as light fractional laser resurfacing. Loss of some facial volume, particularly over the cheeks, is very amenable to improvement by fat injections as is the infraorbital hollowing. Depending upon your natural skeletal anatomy of the infraorbital-malar area, the concept of cheek implants is also an option. But I would have to see pictures of your face for further assessment as to the benefits of fat injections vs cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had lumbar spondylolisthesis from birth. I had gastric bypass to help with weight on my lower back. I didn’t lose the 100lbs requested to get tummy tuck but the lumbar pain is still horrible every day and night. Can insurance cover a tummy tuck as medically necessary ?

A: The only way to know whether insurance will cover any plastic surgery procedure is to send in a pre-determination letter with photos and wait to receive a written response. The size of your abdominal overhang must meet very specific physical criteria and documented medical symptoms to qualify for medical coverage. As a general rule, I would not be optimistic. Most insurances turn down every request for any form of an abdominoplasty no matter how big it is or what symptoms that it is associated with it.. Send me some pictures of your abdominal area and I’ll tell you what I think your chances are based on my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My 19 year old daughter has some facial deformity and atrophy secondary to scleroderma. Although we are still in the early stages of diagnosis and treatment we are beginning to look for an experienced cosmetic surgeon that has dealt with this unfortunate condition. She has one side of her chin that is considerably smaller than the other. She also has some thinning of the upper lip unilaterally and a small amount of wasting to the same side cheek area. Again, we are still in the early stages but this appears to be a limited scleroderma with morphea traits. I would expect a chin implant would give her the best results but I would be very concerned to have any foreign substance placed in her at this time with the possibility of reactivating the condition. So I would expect “fat injections” to be the next best option?? Thanks for any insight you may be able to give.

A: Your daughter’s case sounds very classic in my experience and fortunately fairly ‘limited’. (I am certain she does not feel that way) You are correct in your assumption that fat injections are one good treatment option as that is the tissue that is largely missing/absorbed.  Concentrated fat injections have one significant advantages, the introduction of stem cells with the fat that may help soft tissue rejuvenation. Often I will use PRP (platelet-rich plasma) with the fat injections to get optimal fat cell survival and perhaps stem cell stimulation. Although depending upon the degree of soft tissue indentation and its location I would not exclude the possibility of bone augmentation with an implant or even a dermal-fat graft. The best facial recontouring results come from using any of these available techniques based on the size and location of the defects. There is no evidence that treating this form of scleroderma reactivates or exacerbates the condition no matter what treatment is done. While it’s etiology is very poorly understood, it is believed to be of neural origin and of an automimmune nature.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgery to improve my skull shape, I would just like to clarify some things first. You mentioned 60 grams of PMMA to obtain the predictive image results which would indeed be quite good for me. However I’m wondering if this quantity would be enough to make this aesthetic difference. Indeed I’ve read that PMMA has a density around 1.2 g/cm3, thus 60g of PMMA would have a volume around 50cm3, which seems to be quite small (I checked with 50g of water).As you’re quite experienced with skull aesthetics, do you think this would be enough in my case, and are you positive that the predictive image is obtainable? Maybe it would be preferable for me to have a first stage to stretch the skin, then have a bigger implant inserted? Please excuse my uncertainty, I’m trying to find the best option I have. I have seen one of your skull reshaping surgeries on your blog of a 42y old man with a flat spot much like mine. Do you remember what kind of surgery he had? Thank you for your help and advice.

A: I can certainly appreciate your volumetric computations of the biomaterial mass. But one aspect of that assessment that is missing is how any implanted volume of material translates into a change in external appearance. One thing I have learned over the years is that small volumes can usually make a much bigger change that one would think in many cases. In other words, one can easily be fooled in seeing how something looks in your hand than when it is implanted in the human body. The use of 60grams of PMMA in skull augmentation is usually the upper limit of how much the scalp can stretch over a skull augmentation without undue tension.  With longer or more full coronal incisions, one may be able to get up to 90 grams of material implanted as the scalp flaps are more fully mobilized. In your case, I would much rather take this approach as I do think that somewhere in the 60 to 90 gram material range should be more than adequate to achieve the predicted result. The patient to which you refer in the blog had 25 grams of PMMA implanted for that unilateral occipital skull augmentation result.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my mother has a grade 5 abdominal pannus that covers her knees and below and 2 years ago developed a lymphedematous mass and hernia through the abdominal wall. It drains fluid off and on chronically and she has been taking antibiotics chronically off and on for years. She is on Medicare and they have denied coverage for the panniculectomy portion of the surgery, stating they will only do the hernia repair and not the panniculectomy which is coming out to 7000 dollars. Is there any advice you can give to help us appeal this? She has been on South Beach diet for 2.5 years, lost 44 pounds on the diet, and been at a stable weight for many years. She can no longer walk due to the herniated pannus. She has atrial fibrillation and a pacemaker and diabetes (although well controlled on oral hypoglycemics) I believe that leaving the pannus in place poses a significant risk to her to develop infection and a clot or other dangerous complications. I would appreciate any advice you can give. We need to fix the hernia and also want the panniculectomy so she can walk again and continue her diet and exercise program as weight loss may also help her atrial fibrillation problem as well. I cannot believe the insurance company considers this cosmetic in a 74 yr old woman. 🙁

A: It certainly sounds like your mother would benefit greatly by a combined abdominal panniculectomy and hernia repair. But I believe you may have a misconception about how Medicare works. Medicare, a federal program, does not preauthorize or preapprove any surgical procedure. They never have. A surgeon must do the procedure and then wait and see if Medicare will actually approve (pay) for the procedure. When it comes to an abdominal panniculectomy, no matter how medically indicated it might be (and your mother certainly fulfills that criteria), Medicare will almost certainly deny it after it is done. This leaves the patient with the benefit but the doctor will rarely ever get paid and if they do it is pennies on the dollar. An abdominal panniculectomy is a lot of work, risk and after care for little if any reimbursement. A patient may say that this is not their problem but the doctor’s…but it influences the options for many  prospective patients. This is because very few plastic surgeons are willing anymore to do such procedures under Medicare. Thus the origin of the $7,000 fee to which you refer must be a cosmetic fee quote to do the procedure, allowing Medicare to pay for the hospital, operating room and anesthesia fess which they are obligated to do. Short of doing it under this fee for service basis, you will have to seek a plastic surgeon who accepts Medicare coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is there a procedure to reposition the lateral canthal area into an uptited eye or narrow eye? If so what is the price range? Thank you.

A: Such an eye reshaping as you have described is one in which the outer corner of the eye is more narrow and slightly longer to the side. This can be achieved by an eyelid procedure known as a lateral canthoplasty. This is a change in the position of the lateral canthal tendon in its attachment to the inside of the lateral wall/rim of the orbital bone. The lateral canthal is usually detached and moved up slightly higher and tighter on the inside of the bone. This will then pull the corner of the eye more laterally, making it more narrow and with a slight upward tilt. This is done an outpatient procedure under anesthesia which takes about an hour to do. My assistant Camille will pass along the cost of the surgery to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, will ObamaCare affect the cost of any of your services? I know it impacts in some ways the cost of general medical care but I assume that in cosmetic surgery and cosmetic services that it will be unaffected since these are cash and not insurance-reimbursed procedures.

A: Unfortunately, your assumption is incorrect. ObamaCare impacts all medical services including that of surgical and nonsurgical cosmetic services. The Affordable Health Care Act, passed into law in 2010, has imposed a few changes on the way we conduct business. One of those changes became effective in January 2013 – the new Federal Excise Tax of 2.3% on all medical devices. This tax affects any cosmetic procedure in which a device is implanted. This includes surgical devices like breast implants, facial implants, metal plates and screws and various mesh support and fixation devices. This also affects the very popular injectable fillers such as Juvaderm, Radiesse, and Restylane which are classified as medical devices and are thus included in the new federal excise tax. Interestingly Botox is not classified as a medical device but as a drug so it is excluded from being taxed.  In order to maintain the fiscal health of my practice, the price of all medical devices will be increased to absorb this new tax.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going through back problems at the moment but didn’t know if it was still ok to get breast enlargement and a tummy tuck. I am already on all kinds of medicines and have back pain but I think I am getting to the end of this, finally. I had worked out and walked four miles a day to loose weight and quit smoking then my back started acting up the tummy tuck and breast enlargement is something I have wanted since I had my three kids which I love dearly but ruined my body. I would like to know how long I should wait, I also have a hernia that they said unless it didn’t hurt all the time then don’t come back until it did . I’m sorry but I just feel like my life is on a complete hold while still wanting to look better and feel better about myself. I have to be at the mercy of all of these other problems before I can have my life back and have these things done to make me feel better about myself. Please reply with an honest answer all of what I am going through now is very heartbreaking so a reply soon would be greatly appreciated. Thank you.

A: While breast and abdominal reshaping can make some dramatic changes in any women who has been through three pregnancies, I have numerous concerns in your case if this is appropriate. Your history and ongoing back pain are concerns as well as what medications you are on. Breast augmentation and a tummy tuck are not a cure/treatment for back pain and may well make it worse in the short-term after surgery. I would imagine that some of the medications you are on are for pain relief, which would make any narcotics needed after a breast augmentation and a tummy tuck less effective. A detailed medical and medication history would have to be assessed to see if such body contouring would be advised. In addition, your hernia repair history is also significant for consideration for tummy tuck surgery. Your surgical records for this procedure(s) would need to be reviewed to determine what type of hernia repair was done and if there is any synthetic mesh in your abdominal wall.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 25 and have one child, I would like to have breast implants but I’m afraid the cost and recovery time is too long. Can you give me any advice and info on the payment plans and the recovery times. Thank you.

A:  Cost and recovery are always the biggest issues when any women is considering getting breast implants. So every potential patient has to contend with these issues so let me discuss the facts on both of them. The recovery from breast augmentation is really a physical therapy one since the implant is placed under the muscle. (in reality, partially under the pectoralis muscle) So how does one recovery from a muscular injury…use it! I place all patients on arm range of motion exercises the night of surgery and no physical restrictions thereafter. The more you use your arms (within reason) the quicker you will recover. With there be discomfort after surgery…absolutely, but most patients do not find it severe enough to be very limiting for very long. I would have to know what type of work you do to better answer how many days you would need to return to it. From a cost standpoint, the issues are the type of implant where does one get financing to do it. Saline breast implants are the most economical and we have all of our patients use Care Credit for financing. They are a national company that we have found to be the best to work with and has the greatest option of repayment plans.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can the pubic lift affect the nerve supply to the penis or interfere with erection in any way?

A: This is actually a common sexual function question whether it is liposuction or a lift in the pubic region. Men are concerned that it will affect erection while women are concerned that it may interfere with having an orgasm. While the pubic region is near the sexual organs of either gender, neither a pubic lift or pubic liposuction will interfere with their function. The nerves to the penis lie deep and way below the tissue planes for either procedure. While the female clitoris is just below the pubic fat pad, liposuction does not traumatize it even though there is the possibility of some temporary labial or clitoral swelling and bruising as gravity pulls down any blood released during the procedures. Conversely in a handful of cases, I have had reports that a pubic lift in women has enhanced orgasmic sensations which may be due to changing the exposure of the pubic area. For men, pubic reduction may improve penile exposure and length.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am sending you some pictures of my lower eyes so please let me know what you think. I have bags and many wrinkles under my eyes even though I am only 29 years old! It’s so much worse when I smile because the wrinkles show much more!! I’m really excited to do something about it but scared of surgery!!

A: Thank you for sending your pictures. What I see is not really much infraorbital fat herniation. Rather I see some infraorbital rim hollowing and a lot of skin wrinkles when you smile. The infraorbital hollowing could be treated by fat injections and perhaps a little lower eyelid skin removal. But many of those lower eyelid wrinkles are impossible to treat surgically because they mainly appear when you smile, thus they are dynamic wrinkles. Much of your lower eyelid wrinkling needs to be treated by Botox injections to stop the muscle action.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am an active lady just turned 80 and I have a small amount of normal puffiness under my eyes.  My concern is that I have puffiness in the corner of my eyes between my eyelid and nose bridge.  It looks like a lump or a swollen gland and is puffy.  Is there anything I could apply that would reduce that puffiness cosmetically or is this a surgical issue?  Would cold or hot compresses reduce the size of this area of the eye?  Could the fat behind the eyeball be causing this area to swell?  What works best? Thanks for any suggestions you might have for this problem.

A: Undoubtably the puffiness that you see between your nose and your eye is not swelling. That is actual tissue, a combination of skin and fat, that is causing the bulge. Your assumption is correct that it is bulging eye fat.  It will not be remedied by any type of external compression. Rather it is going to require surgical excision to remove the now protruding and excessive upper eyelid tissue. This can be done through an upper eyelid incision. (blepharoplasty)

Dr. Barry Eppley

Indianapolis, Indiana