Your Questions

Q: Dr. Eppley, I took a look at the computer imaging that you did for me for my jawline. I like what you did to the chin but don’t like the jaw angle result. I saw a case of a guy onlione who had custom made jaw angle implants done and he did not had that square look. Is that possible to be done to me like that as well?

A: Let me explain the purpose of facial computer imaging. Initially it is to create a dialogue or communication as to what the patient wants. No knowing what anyone really wants when they say a stronger jawline, I have to have a starting point for discussion. I made those angles square to see if this is the tyhe of jaw angle look you prefer. They do not reflect any particular implant selection as of yet. Therefore, looking at other jawline examples is helpful only for the standpoint of giving me guidance as to what look someone prefers…it means nothing about the implant style. So custom jaw angle implants are not what you need. Custom facial implants are usually used when the final look is more extreme or when stock off-the-shelf implants can achieve the desired look if they are intraoperatively modified. When going for less than a square or flared jaw angle look, stock jaw angle implants will work just fine…and they are far less expensive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I weighed around 95 pounds before I had ovarian cancer.  After my cancer treatments, I gained 130 pounds.  I ended up have gastric bypass surgery and now have lose skin that needs to be taken off. Had a tummy tuck in 2001 so, don’t have too much loose skin in the tummy area. I am interested in my butt, arms and legs…can you help me with this?

A: Thank you for your inquiry. I am going to assume that you need a traditional arm lift (brachioplasty) and an extended inner thigh lift, which would be standard for many extreme weight loss patients after gastric bypass surgery. While every patient is different, I will assume these issues as a starting point. Your butt concern is harder to figure as I am uncertain whether an upper buttock lift or a lower buttock tuck tuck needs to be done. I will assume for now that an upper buttock lift (lower back lift) need to be done as this would be most common in the bariatric surgery patient. It is also a way to finish off a circumferential lower body lift as a second stage procedure to your initial tummy tuck done previously.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the lipodissolve or liposmart for underneath my chin and abdomen area. I have excess skin and fat due to having a child. I am still a thin female, but have insecurity in these areas and feel these procedures would benefit me the most in regards to my weight and issues I am having. Please email me with more info and pricing estimates if possible.

A: The best way to get an accurate price quote is to come in for a consultation so I can see what you really need. or send me some pictures. The under the chin area (submental) fat is going to need to be treated by liposuction (Smartlpo) not lipodissolve for a variety of good reasons, mainly a much better result in a single treatment session.  The abdominal issue is less clear given that I have no idea what it looks like. When you use the words ‘excess skin and fat’, that may imply that liposuction may not be a good treatment approach because of the skin excess. No form of liposuction is going to shrink much loose skin, not even Smartlipo. If you have any stretch marks at all on this loose abdominal skin, there is no chance of shrinkage due to complete loss of elastic fibers/elasticity in the skin. Depending upon how much loose skin there is, this may put you more in need of some form of a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have concerns about my nose and I focus on it all the time. I think (know) my nose is too pointy at the tip and people confuse me as if I am Native American. I could see why. What can be done to make my nose less pointy?

A: In looking at your pictures, the pointiness  of your nose is the direct result of the alar cartilages which make up the tip. Your alar cartilages show rim retraction (an acute alar angle backwards) and a narrow dome area. Together this makes your nose tip come to a point. Since the overlying skin just follows the underlying cartilages, this gives you a sharp and pointy nose appearance. This could be improved through a tip rhinoplasty with cartilage grafting. In some cases of a pointy nose, the tip is both narrow and very long. This requires tip cartilage shortening. But your tip is not too long, it is just too narrow. Cartilage grafts would be harvested from your septum and used to augment the alar rims combined with a tip shield and dome spreading grafts. The objective is to change the shape of the dome and lower alar cartilages to make the tip more round and drop the rim of the nostrils down. This should help make a substantial change in the way the tip of your nose looks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to reshape my chin. My chin doesn’t stick out, it just looks boxed look especially when I started losing weight. Also my ears don’t stick out, I feel they look big as in length for my small head. What do you recommend? I have a front and side picture for you to see.

A: Thank you for sending your excellent pictures. Your square chin can be contoured fairly simply through an intraoral approach where the square corners are removed (chin ostectomy) and the chin made more rounder as a result. The vertical height of your ears is a more challenging issue. It can be seen that what makes your ears long is that the upper half of the ear is big compared to the lower half.  While they can be reduced substantially in height, this necessitates a scar which would run across the outer helix in the upper ear area. I am not so sure this is a good aesthetic trade-off. There is an alternative approach for ear height reduction that is done from behind the ear, which leaves no scar on the outside, but it would only reduce the height of the ear a minor amount. So you can see neither approach is ideal, substantial reduction with a scar or minimal reduction with no scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about 4 years ago upon a surgeons recommendation, I got infraorbital implants. Shortly afterward, I noticed a “bulge” underneath my eyes. I am not sure if the implants need to be removed or if this is a case of my cheeks dropping and my own bones would have produced the same appearance. I believe the implants were placed close to the lower lid. (I have attached  a picture of where they are placed ) I am not sure exactly what they are made out of.  When I went to the web-site, it just said a porous material. I believe that they were placed from inside the mouth.

A: Based on that information, you have Medpor implants placed through the mouth. This means they are actually a combined infraorbital rim/malar type implant. The bulge to which you refer, given that it appeared shortly after surgery, is undoubtably that of the implant and not your natural bone. As the tissues eventually contract and shrink around the implants, their outline and placement become fully evident.

The good question now is what to do with them. The only way to get rid of the bulge is to remove the implants. The interesting question is what will happen to the soft tissues that have been expanded because of them. It may be that is largely a non-issue or it may be that it will cause some soft tissue sagging over the cheek afterwards. It is hard for me to tell the likelihood of either just based on one single photo. However, knowing their location, size (bulge) and that they are a Medpor material (which means they will be harder to remove), that all suggests that there may be some additional cheek sagging afterwards. An alternative approach to removal is to feather the edges of the implant so that a bulge no longer is seen, but keeping the implant volume in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to place the wing of a chin implant separately from the front part of the implant by cutting it loose? On one side of the jawline my implant wing crosses the bone and sticks out. My jawline is asymmetric and is higher on one side. On the higher side the wing sticks out. My doctor told me the implant wing can’t be placed upward and inserted on line with the jawline because the shape of the implant doesnt allow it. The wings on the implant don’t have the right angle to match my higher jawline. Placing it on line with the jawline would stress the implant and eventually lead to malposition. Is it possible to cut the wing loose from the implant and place it separately from the rest of the implant on line with the jawline?

A: The simple answer to your question is yes. You are referring to a chin implant revision due to a wing malposition. Although the malposition in your case is a direct result of your own anatomy which is not symmetric. During your revision, the wing can be separated from front or main bofy of the implant. But that alone will not make the wing move into the desired position. The implant pocket must be modified as well to accommodate the desired position of the implant wing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift about six weeks ago. This was a very traumatic experience for me. While my jowls and neck got better, my nasal folds and turned down corners of the mouth did not. They initially looked good while I was still swollen but that has now all gone away. This is very disappointing since this was one of the main reasons I had the operation. I feel like a wasted my money as my jowls and neck were not that bad.

A: This is a common misconception and occurs either as a result of inadequate education during the consultation or a failure to understand what a facelift does best on your part. Because the tissue pull of a facelift occurs from around the ears, it has the least effect on anything far away. The mouth area is the furtherest point from the ears on the face, thus deep nasolabial folds or a downturned corner of the mouth will ultimately remain unchanged. It is just biomechanically impossible to substantially change the center of the face from back in the hairline. This is an issue that has frustrated facelift surgeons for years and many techniques have been tried, few with much success. This is why adjunctive techniques are often done with facelift that address the mouth area directly, like fat injections and a corner of the mouth lift. These can be at the time of a facelift or afterwards as may be desired in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have deep nasolabial folds and a mouth whose corners turn down. I have read about a way to improve them by using your own tissue through grafting. I had a facelift already which got rid of my jowls and helped my neck but didn’t do a thing for the area around my mouth. I don’t want to treat them with injectable fillers because that will only be temporary. Are you familiar with this tissue grafting technique?

A: What you are talking about is an old plastic surgery technique, dermal-fat grafts, that has been applied to a cosmetic problem. A dermal-fat graft is a piece or strip of skin that has a thin layer of fat on its underside. The overlying epithelium or skin layer is removed, leaving just the dermal skin layer with the attached fat. Provided that the graft size is not too big, it survives quite well as the blood vessels of the recipient site attach quickly to the vessel ends in the dermis. This allows a quick return of blood flow to the fat thus enabling it to survive.

For use in the face for nasolabial folds,  it must be taken from the lower buttock crease or any other large scar site and must be at least 6 to 7 cms in length for each nasolabial fold. From inside the nose, a tunnel is made under the nasolabial fold curving down to the corner of the mouth. The dermal-fat graft (dermis side up) is then placed through tunnel and fixed to the corner of the mouth through a small incision from inside the corner. It is then lifted and tightened from inside the nose and the excess graft trimmed and closed. The graft simultaneously augments the nasolabial fold and lifts the corner of the mouth. I have done this procedure numerous times and it does have its merits. But the issue is that it requires a harvest site and the buttock crease is almost always the best choice because of the thicker dermis. The discarded skin from a pretrichial browlift can be used as well. There are also other simpler ways to achieve both of these facial objectives. Fat graft injections combined with a corner of the mouth lift is another approach. But for the right patient who does not mind a buttock scar, the dermal-fat graft approach can be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I’m a 19 year old male. I recently cut my hair short and to my surprise, I have a very Neanderthal-esque brow ridge. It doesn’t stick out as far as some people from pictures I’ve seen, just a couple of millimeters probably. I was wondering if there was any alternatives to plastic surgery for this? Can small amounts of pressure be applied to the area over an amount of time to reduce the appearance, or anything similar? Obviously at such a young age I don’t want to resort to plastic surgery, but I dislike the appearance that my brow ridge gives my face. Thanks in advance.

A: The pneumatization or expansion of the frontal sinus cavity creates the prominence of the brow bones. This is not bone growth but bone stretching due to underlying air expansion. This is why the brow bones, the bigger they are, are very thin often only being a few millimeters in thickness. The development of a brow bone prominence or bossing is genetic and can not be modified once established by any external pressure or molding. If it is too aesthetically excessive, it requires surgery for brow bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 32 year old and about six months ago an ENT specialist diagnosed me with having a deviated septum. I have not had good sleep in about 15 years, because I have extremely restricted breathing. I do have insurance to cover the surgery but would prefer a plastic surgeon to perform the procedure, so that I may also correct a very large bump on my nose that I have extreme insecurities about. Do you know if your services would be covered by the insurance company? Also, is this a procedure that can be done if I am in my first trimester of pregnancy?

A: Your inquiry has two fundamental misconceptions. First, no elective surgery or procedure is ever performed on any patient who is pregnant. Pregnancy is an absolute exclusion for surgery and anesthesia because unknown and potentially deleterious effects on the developing fetus. Secondly, insurance does not pay for any external change to the nose such as removing a large nasal hump. That is cosmetic surgery and must be paid for as an out of pocket fee. Insurance will usually cover septoplasty and other functional nasal airway surgery but not for any rhinoplasty procedure. The two most certainly, and commonly, are done together but you will have to pay additional surgeon, OR and anesthesia fees for the cosmetic portion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a mastopexy/abdominoplasty (mommy makeover) in future years. So that I have an idea about cost, I would love to know the extend of the incisions that I would need, i.e., anchor incision and full vs crescent incision with partial tummy tuck. I am 5 pounds from my ideal weight and still carry quite a bit of weight in my torso. My ptosis is moderate to severe in my mind, but would love an expert’s opinion. Thanks!

A: There are four basic types of breast lifts that vary based on much lifting is needed and the scars that they produce. Without seeing pictures of your breasts, it is impossible for me to say what exact breast lift operation you need. But since you used the term ‘moderate to severe’ ptosis, and patients almost always underestimate what they really need, I will assume that you need a full breast lift. (anchor scars) Also know that few women actually ever have just a breast lift alone unless they already have substantial volume. Breast lifts in general do not create persistent upper pole fullness which most women want when undergoing any breast enhancement procedure. This is why most breast lifts also incorporate the use of an implant at the same time. (augmentation mastopexy) Even if it is a small implant, it provides that retained upper pole fullness that merely lifting up and resuspending the breast tissue on the chest wall that does not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year-female with a chin issue. My chin doesn’t look too bad when I’m not smiling because I have a large nose so it is somewhat in balance.  However when I smile, I have excess soft tissue that almost looks like cellulite on my chin and it then sticks out more.  It is an appearance that is very similar to what I understand is witch’s chin deformity or chin ptosis.  I would like to know what you recommend for this problem and what the cost would be.  From reading your blog, I would presume that you would suggest some chin burring using the underneath the chin approach and soft tissue excision.  My concern of course is the length and visibility of the scar and I wondered what your experience with that has been. What is the average size of the scar? Is it visible from a frontal view and does it fade significantly over time? Also, do you think you can effect significant improvement in my problem or would the change be only minor?

A: In looking at your pictures, I suspect most of your chin issue is a soft tissue problem with a small bone component to it. That makes the submental approach the most effective treatment. The submental chin reduction scar is about 4 cm long and is curved to match the border of the lower jawline. Quite frankly, the effectiveness of the procedure is a balance of how much soft tissue tightening/removal can be done vs keeping the scar as short as possible. The scar is not visible from the front view and the redness of the scar does fade with time. I suspect the final result would be somewhere between a minor change vs a significant improvement. That is probably the best way to think about it. It is going to change, it is just a question of how much.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a healthy 65 year-old women with a large turkey-like hanging directly under my chin as well a bit of jowls. When I pull the skin back at the jaw angle/ear area, I see a great change and I look like myself again…like I did 20 years ago. What type of necklift is this? I do not feel like a need a facelift but just a necklift.

A: The turkeyneck is a common problem and there are many people who have this pessky aging issues but are happy with the rest of the face…or at least it does not look as bad as the neck and jowl area. This hanging neck skin must be treated by moving it up and backward to hidden incisions around your ears where it can be removed and invisible scars left in its wake. Your perception of a facelift is common with the belief that it is a top of the scalp down to the neck procedure, which it is not. A true isolated facelift only treats the lower 1/3 of the face, exactly where your concerns are. As a result, it is a much simpler and easier procedure to go through than most patients envision. Your proof that this is the correct procedure is evident by the presurgical facelift ‘test’, pulling up and back around the ears and jaw angles creates the desired neck and jowl changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have my buffalo hump liposuction along with my neck done at the same time. As I have gotten older the buffalo hump and bad posture have made my spine curve a bit. The hump is really visible when I straighten my back and when you feel it you can feel tissue but you can also feel my bone. My concern is does this put me at a risk for injury to my spine? is it possible to hit my bone while performing the liposuction and paralyze or injury my spinal cord in any way?

A: The buffalo hump is a collection of fat that appears above the fascial covering of the muscle. It is a subcutaneous collection that is far away from the deeply located spinal cord which is under the muscle. Also remember that the spinal cord is encased by protective bony vertebrae besides being deep to the muscle. Therefore, there is no chance of vertebral or spinal cord injury with liposuction surgery to the buffalo hump fatty deformity. The type of fat that is in the buffalo hump is also a more firm or fibrofatty tissue that can be more difficult to extract than softer fat like that in the stomach. For this reason, the use of advanced technology, like Smartlipo, may be more effective in the loosening or melting of the fat prior to suction extraction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 45 year-old female and I have concerns about my jaw line. I have attached some pictures and we would like to have your opinion on what would be some treatment options. I would like to have a return of firmness to my jawline.

A: In regards to early onset jowling/laxity, there are two basic options depending upon how one wants to approach the problem. From a non-surgical standpoint, there is a slew of energy-based devices out there that do create some degree of skin tightening/fat reduction for minor degrees of jowling. Devices such as Exilis, Ulthera and Thermage all drive energy into the dermis of the skin to heat it up creating some new collagen production and a tightening effect. Given Melinda’s good skin thickness and minor amount of jowl softening, you could argue that she is an ideal candidate for this non-surgical device approach. Its negatives are that it requires a series of treatments to get the desired effect, usually four separated by a week or two between them, and it is indeterminate how much improvement can be obtained. While I find these devices effective, it is best to view these treatments as a delaying manuever or bridging step to an eventual  surgical treatment. For some patients, it may put off the ‘inevitable’ for years. Remember that you don’t cure aging, you just temporarily improve it. As a surgical approach, a very simple and easy jowl tuck-up can provide an immediate improvement that will surpass what any device can do. This one-hour tuck-up with less than a week social (appearance) recovery is a common facial rejuvenation procedure today as people seek earlier treatment for their jowls and neck issues than ever before. It is really just a miniature or microform version of a lower facelift.

In conclusion, either jowl tightening approach is perfectly valid and the choice depends on what result someone wants and what they want to do to get it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had fracture of my cheekbone and eyesocket and four plates with eight screw were implant in my face…………..I want to ask can I remove these plates once if my fracture got healed??……Will there be any problem of refracture or any another problem after plate removal??

A: It sounds like you have a very typical zygomatico-orbital complex fracture which required three/four point fixation for anatomic realignment.There should be no problem with removing your fixation hardware 6 to 12 months after your original facial fracture repair. Facial bones generally heal completely by 6 months after surgery so removing them should not be a problem. Barring any future facial trauma, removing your plates and screws will cause the bones to collapse or refracture. Given the re-entry operative trauma to remove your hardware, there should be compelling reasons to do so such as uncomfortable palpability, cold temperature transmission or plate and screw loosening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Has you ever successfully micropigmented a donor strip scar from a hair transplant?

A: In my experience, it is virtually impossible to match skin colors with micropigmentation tattoos. There is always going to be some color mismatch. But your specific situation in the scalp is unique. There are two approaches you could use, all based on the concept of if you don’t like it you can also just excise the micropigmented area and be right back where you started or maybe even with a better looking scar. You could try and match the skin colors by micropigmenting the skin. Or you could place micropigmented dots to represent hair shafts.  Which approach may be better would require me to see some pictures of your scalp scar. But I would imagine that trying to create ‘shaved’ hair dots would be more a more effective camouflage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 27 year-old Asian female who would like to change the shape of my nose. I have a low nasal bridge and a flat tip of my nose with low projection. I would like to get my nose more Westernized with a higher bridge and more tip projection. I have read that this takes cartilages grafts that either come from my nose or from my rib. I definitely do not want a rib graft done so I am considering implants instead. I know about the implant used to build up the bridge but how does the tip get more projection as well? Is cartilage used to do that or can implants be used for it?

A: In changing the tip and columella of the Asian nose, a septal extension graft as well as a columellar strut graft is used. The septal extension graft is placed along the caudal edge of the septum and out onto the anterior nasal spine. This graft not only helps tip projection but also improves a retracted columella and opens up the nasolabial angle. When combined with a columellar strut, these two tip grafts together give more tip support for the weaker lower alar cartilages and is a standard technique in my practice. It is entirely possible, and very likely, that the septum of the nose may not provide an adequate donor source for the amount of grafts needed. If the septum is inadequate, one can use synthetic implants instead. The best choice of implants would be Medpor or porous polyethylene sheeting from which to fabricate these grafts. Usually a combination can be used, using the septum or the columellar strut and Medpor for the septal extension graft for an Asian rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read this article on bone erosion from chin implants and wanted to make sure I understood it. I am a 28 year old male and have been debating getting a chin implant for awhile now. What I got out of the article is that the bone structure in the chin is going to change with age no matter what and when it does the chin implant has no choice but to settle into the bone because of the muscle behind it is going to press to the bone causing resorption. Is it only until it settles back again? I’ve been debating this for awhile and it is the one thing that keeps me from going thru with the procedure. Also is it something that most people won’t notice you had done? I wouldn’t want anyone to know I had the procedure.

A:  You are somewhat correct in your assessment of the unique phenomenon of chin implant settling. Note that I do not call it erosion which would indicate an active process caused by inflammation…which is not the case for a chin implant. This settling phenomenon is more likely to be seen with larger chin implants that are under more pressure from a tighter chin pad in front of it. In many chin implants, this settling is not seen at all. Also, implant settling is more likely to occur when the implant rides high on the chin bone where the cortical bone is much thinner. When a chin implant is placed in the ideal l position on the low end of the symphysis, where it is more dense cortical bone, settling is either not seen or is very limited. (1 to 2mms)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young man with a skull that is flat at the back. It has caused me a lot of grief as a teenager and to this day and I think it’s time I did something about it so I can stop being so extremely subconscious about it. I have attached pictures which show how flat the back of my head is when the hair is parted in such a way or id wet. The flatness is pretty much only isolated to the back of my head. At  the very top of the head near the crown there is a noticeable ‘bump’ then the skull goes in a drastic decline. The forehead, and front sides of the head appear and feel normal/symmetrical it just the back which is causing the aesthetic issues for me.

From my research you appear to be the most qualified to do such an operation as you’ve had a great number of patients with the same issue as me therefore I would fully feel comfortable with you doing this procedure because of your extensive experience. This brings me to my next question, can you help me? From the pictures provided do you think you could give me the normal male skull I desire? There is nothing more I want than being able to shave my head really short. I understand there are different methods of operation some more intrusive than others. I am actually not concerned with the scars the operation will leave so long as it gives me the normal shape I have always desired, a skull that appears normal and wouldn’t get a second look from passers by because it’s normal. I would only want one operation to fix this issue and would like to avoid having to come back to do revisions to the operation. Now, having that in mind what type of procedure would you recommend for me?

A: Thank you for your inquiry and sending your pictures. I can clearly see that your degree of occipital flattening is significant. It is probably one of the more flat back of the head cases that I have seen. When it comes to correction, I think you have two options. First, using a standard open technique a cranioplasty can be done to build out the flat area somewhat. Stretching of the scalp is the limiting factor and you could get about a 10 to 15mm build-up. That I feel would be a mild improvement but I think is inadequate for a significant improvement. It would be better but not ideal. The second and more ideal option is a two-stage approach using a first-stage tissue expander followed by a secondary cranioplasty build-up. This could get upt to 25 to 30mm of skull expansion which ideally is what you need. The tissue expansion provides the necessary creation of additional scalp tissue to cover the size of the build-up tension-free. Computer imaging will show the differences in the result between the two approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to lift the eyebrows of the forehead area and reduce the protrusion of the forehead bone but I don’t want a coronal incision to do it. I need minimal incisions as I am a male.

A:  Browlift surgery in a male is a challenge due to the hair issue or lack thereof. Male browlift surgery can be performed either through an endoscopic technique with an epicranial shift or through the eyelids (transpalpebral) with or without an endotine device. The frontal hairline and density will determine which option is best.  When it comes to brow bone reduction, however, there are no other options that a coronal approach. The male brow bone is really frontal sinus expansion and must be reduced through an osteotomy approach. Even if the brows could be reduced by simple burring, good access is needed and an endoscopic approach can not be used. For most men, the coronal incision is an understandable objection and brow bone reduction is not possible.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a single cardio bypass done last fall. My doctors failed to notice that my sternum was not healing together. The doctor who performed the surgery knew ahead of time that I have EDS with sublexes of all joints, discs and sternum. Because of the surgery I am still being told I can only move as if the surgery was just done, that the sterna wires were holding me together. The sternum has shifted and even if it does mend together eventually it is still causing more dislocations of the collar bones. I have problems with collapsing lungs from the inflammation because of the movement all the time. What are my options for repair? Living like this I am unable to breathe or move without pain. This is not my idea of living. Please respond as I am getting very depressed.

A: While this is an issue for your cardiothoracic surgeon to determine, it appears that your primary problem may be a sternal non-union and instability. If the sternum has not healed and become stable at more than nine months after surgery, then it is not going to be. While wires are a common method of sternal fixation, they may not be sufficient in some cases. One option to consider is that of sternal plate rigid fixation. Removal of the wires, interpositional allogeneic bone grafting with PRP (platelet-rich plasma) and compression and fixation of the sternal edges by plates and screws designed exactly for this use is the only treatment option at this point. Its use depends on how good the remaining sternal bone is, of which only your cardiac surgeon knows. It may well be that he chose wires exactly because the bone quality was inadequate. There is also the issue of whether having EDS (Ehlers Danlos Syndrome) leads to impaired bony healing and non-unions given the underlying genetic disorder of connective tissue and collagen formation. Your sternal non-union may have been unavoidable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 31 year-old male interested in chest reshaping. I have large man boob and pointy tits. I am specifically interested in the SmartLipo or VaserLipo male breast reduction. How many surgeries have been performed? Do you offer a consultation by video chat? It’s a pretty long drive to come into the office for a simple consultation.

A: I routinuely do Skype consultations for far away patients, or even patients locally, to make talking to a plastic surgeon as asy as from your own home. I will have my assistant contact you to schedule a convenient time for a Skype consultation. It would be helpful to have you send me some pictures of your chest so I can determine what the best option may be. Smartlipo my be it but that is not an assured treatment if you have ‘pointy tits’ and large man boobs, which suggests that there may be a significant glandular component to your gynecomastia. It may need to be combined with open excision as well. Gynecomastia is a surgery that I regularly perform for men who range with gynecomastia problems from the puffy nipple to actual large breasts. There is no one single treatment method that works for every gynecomastia problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t know what they call this defect but my ears are too far back like Paul McCartneys. They don’t stick out, just too far back, the whole canal. Is there a surgery to move everything or just cover the ears?

A: There is no surgery to move the ear forward. The ear canal is the fixed point of the ear which stakes it to its position of the side of the head. No significant movement away from this point can the ear be moved other than a very limited amount of rotation around the canal. The cartilage of ears can be reshaped through various otoplasty maneuvers but the entire ear can not be picked up and moved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to reduce the size of a skull/head when it is too big? My head has a circumference of 23.6 inch/60cm. I have attached pictures of where I would reduce the skull to give it a better shape.

A: Thank you for sending the computer imaging showing the areas of your skull you would like reduced. These images make it very clear your areas of concern and I will define these as three skull areas. First, on the low back of the head is the prominence known as the nuchal line. This is a naturally raised area in many people because it serves as the attachment of the neck musculature to the back of the skull. This is why it is thicker and raised. Second, there is a prominence in the bi-occipital width as seen in the front view. Lastly, there is a midline ridge on the top of the skull known as the sagittal line that is prominent giving your skull a bit of a peaked appearance.

Based on these locations and the amount of skull reduction you have shown in the images, I think that is a very achieveable aesthetic change with burring reduction in all areas. The key question is the need for an incision to get there to do it. Given that you are a male with a close shaven head, this is a serious aesthetic consideration. There are two fundamental approaches. A limited posterior scalp incision that will good access to the back of head for nuchal line and bi-occipital width reduction but a more limited reduction of the midline ridge due to the curved surface of the skull and how far the ridge goes frontally. Good access could be obtained to all areas with a full bicoronal incision but that is less desirous in a man with a shaved head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Medpor chin implant placed 3 years ago and now there is an exposure of the right corner of my implant. I know I have to remove it but my concern how I will look afterwards if it is removed. I like my look with the chin implant but now that I have to lose it I am afraid of looking like an old woman. I actually did this implant to help make my jaw bone stronger and correct the small skin sagging on my two side of my jaw bones. Tomorrow I have appointment with a facial plastic surgeon. Do you believe I am too concerned? Thank so much for understanding.

A: It sounds like to me that your chin implant was placed through the mouth (intraorally), which would be the only way the implant could be exposed at this point. Taking out the chin implant is going to have a negative impact on your chin and jawline appearance to be sure. It is likely that this implant is placed too high. You will likely have to have your current implant removed and allow it to heal for a few months. Then you can have a new implant placed through a submental skin incision form under the chin. It may be possible that a new implant can be placed at the same time as your exposed one is removed. But that would be impossible for me to say just based on your description alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several body problems that I would like to get rid off. I have lost 100 pounds and have kept it off for 11 years. First, my large batwings are causing strain on my shoulders  I exercise five  days a week but they will  not go away. Will insurance pay for this since I am having it done to decrease my pain and not for  cosmetic reasons. Also the loose shin around my inner thighs is increasing. I also have engorgement of  my varicose veins  I am currently looking to have surgery for these three problems. Will insurance pay for this two also.

A: After a 100 pound weight loss, most patients will suffer loose and redundant skin which can not be exercised off. Such loose skin in the arms and inner thighs is common and can be removed through arm lifts (brachioplasties) and inner thigh lift procedures. It is highly unlikely that either procedure would be covered by insurance. These are viewed as procedures that largely have cosmetic benefits not functional ones. But no plastic surgeon can tell you whether any procedure would be covered by insurance. There is a process known as insurance pre-determination in which the information would be submitted by the consulting plastic surgeon on which your insurance would make the final decision. My experience has never been favorable in that regard. Conversely, the varicose veins should be covered by insurance but you will need to be evaluated and treated by a vascular surgeon for that problem. Varicose vein surgery should not be performed at the same time as the body contouring surgery. It should be done first so that your risk of DVT (deep vein thrombosis) is lessened for the body procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a jaw angle implant for just one side. I have facial symmetry on my right side which is smaller. Not sure why. I’m saving up for that type of procedure now. Is there anyway you can give me a ball park estimate of how much something like that would cost and is any part of it ever covered by insurance? Also, is the surgery normally done when you are asleep or awake and if it’s asleep will I wake up with a tube down my throat? I know it sounds like a dumb question but the thought of it makes me nervous. And lastly, how much of an improvement would this make because I know it won’t make me look perfectly symmetrical and everyone’s results are different. I just want to make sure it’s the best thing I can do.

A: If your facial asymmetry is relegated primarily to the posterior face in the jaw angle area, then unilateral augmentation can be very helpful. You just have to make sure that the asymmetry is located down by the bulk of the masseter muscle area. The effectiveness of jaw angle implant augmentation depends on the size and shape of the implant. How much width and if any vertical lengthening is needed are critical question before surgery to select the proper implant. Because this surgery is for cosmetic enhancement (appearance), it is not ever covered by insurance. The surgery is done through an intraoral approach and involves lifting up the masseter muscle. Thus this is a procedure that requires general anesthesia with endotracheal intubation. The tube will be removed before you wake up so this is not a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting breast augmentation but need to know the cost. I am 48 years old and have always been small. My breasts are in good shape but I want them larger and lifted. What would be an average cost as I am shopping.

A: The specific answer to your cost question depends on what type of implant you desire (saline vs silicone) and whether any formal type of breast lift is simultaneously needed. These two issues have a major role in the cost of the procedure. Without seeing pictures of your breasts, the best I can do is give a range from the lowest cost procedure (saline breast implants only) to silicone gel breast implants with a superior crescent and/or vertical breast lift. All costs included would put that cost range from $ 4,800 to $ 8,450. So you can appreciate how not knowing exactly what you need makes an accurate price quote impossible. The key question in this price range is whether one needs a simutaneous lift or not.

Dr. Barry Eppley

Indianapolis, Indiana