Your Questions

Q: Dr. Eppley, I wanted to ask a rhinoplasty question. Since my primary motivation for getting any work done is to improve my smile. In a rhinoplasty where you reduce the nasal spine as we discussed, would there be a possible side effect of lengthening the distance between the nose and mouth? In my imagination, by eliminating some of the protruding cartilage in that area, the tissue and skin that currently exists there would be pulled back into that void, thus pulling up the lip slightly. However, I’m not sure if that’s even how the anatomy works. Is the tissue anchored to that area and would it need to re-anchor itself or would it just drape down further, thus lengthening the lip?

A: Your question is a good one. Theoretically by removing the nasal spine, your assumption is most likely correct that the tissue should be pulled back up into the removed area potentially lifting the lip somewhat. In reality, probably very little lip lift actually occurs. There have been a few reported instances where lips have lengthened as a result but that is not something that I have ever seen. One would not, however, try to anchor the tissues to the removed nasal spine area as that may potentially cause a tethering/tightness when one smiles. It is much better to let the area heal naturally rather than try to treat a potential problem which may never occur…and in the process create a whole new one.

The way I view your rhinoplasty, and is the reverse of the the concern of upper lip lengthening, is that the rhinoplasty is potentially setting up a subnasal lip. So whatever happens to the lip length (particularly if there is some lengthening) does not matter because you likely moving on to a lip lift anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you do tummy tucks scheduled and coordinated with a hysterectomy. What the cost would be and how much of a cost savings would it be. I am not only looking into having them done at the same time for cost savings (insurance will pay for the hysterectomy but NOT the tummy tuck) but for combining recovery time as well. Can a lower body lift (instead of a tummy tuck) be combined with the hysterectomy? A little info on me.  I am a 40 year old female, about 20 months post op from bariatric surgery. I have lost about 160 to 165 lbs and now weigh about 167 and weight has pretty much stabilized the last 4 to 6 months. I am 5’3″ and happy at the weight I am at now, but the hanging excess skin is really bothering me, in the way, clothes don’t fit right, it gets sweaty under the fold, and it is very uncomfortable. Thank you for you any information you can provide me and for your time.

A: Congratulations on your successful weight loss! Either a tummy tuck or a circumferential body lift can be performed at the same time as a hysterectomy. This is an historically common combined abdominal procedure. Besides the obvious benefit of one single combined recovery, the only key question is how do the economics work out. Since you will be paying out of your pocket for either a tummy tuck or a body lift, the question is what is the OR and anesthesia cost if done in a hospital with the hysterectomy compared to it being done separately in an independent surgery center? (the plastic surgeon’s fee would be the same at either location) Many patients would assume they are similar but that is often mistaken. Either location of the surgery should be priced out so you can see the difference between your fees. If the difference is small, then one should have the body contouring procedure done at the same time as the hysterectomy. But if the difference in significant (thousands of dollars) that may give one pause as to whether it should be done separately. You may ponder as to why there would ever be a difference between the two locations (hospital vs surgery center), the answer is simple….overhead and efficiency.

I will have my assistant calculate those specific costs between the two locations for just one of the procedures (tummy tuck) so we can see how different or similar those costs would be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long chin that completely throws off the rest of my features. I live in Arizona and can’t seem to find a good MD in the California/Arizona area. I wanted to know if you could recommend someone for the procedure, or if not, suggest the feasibility of going out there for the procedure. What would be the downtime/ballpark costs for vertical reduction in the chin length? Thank you for your help.

A: Thank you for your inquiry. It sounds like you need a vertical reduction wedge chin osteotomy.  As a ballpark range, the cost of a chin osteotomy is around $6500. We have many patients that come in for surgery from all over the world so this is a common experience for us. You may also feel free to send me some pictures of your face for my assessment to determine your suitability for this procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about a year ago I received a blow to the head from the rear causing a depressed skull fracture. The fractured skull segments were removed and replaced with a titanium material.  But there is the emergence of the head of the screws now seen through the scalp. Are there other ways to patche skull defects without these materials?

A: It is very common when scalp swelling goes down over time that the metal mesh and screwheads become apparent through the skin on skull reconstructive surgery. This is particularly evident in the forehead although it can be seen all over the scalp. In some cases, just the screws can be removed and leave the titanium mesh behind. But if one wants to remove all metal material, the titanium can be removed and replaced with a skull reshaping bone cement that will leave a smooth surface and no risk of visibility through the scalp.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how large of breast implants can I get? I know that most women don’t want to look like they have had breast implants but I do. I want a very round and very full look to them. I have a good breast shape 34C with no sagging but they look very small. I don’t know what extreme breast augmentation means but I think that is what I mean. I have had several consultations and I have tried on various sizers. (Mentor sizing system) The plastic surgeons I saw said they would not put in more than 500cc but I like the 650ccs the best. Is this too much for me? if I like the look why won’t they do it?

A: The size of breast implants is, of course, a very personal choice and no one can tell you what you should like. That is up to you. But it is important to remember that it is a medical device and there are risks and potential complications with them. These potential adverse effects can become more apparent or likely when the implant ‘exceeds the tissues to support them.’  Thus size can make a difference in these risks. Exceeding the limits of breast tissue support can be simplistically thought of as violating the breast base diameter, the existing perimeter of your natural breast skin mound. This can be measured in centimeters as well as can the base width of an implant. (as implants get bigger so does it’s base width) If the implant base width stays within your natural breast base width, the implant will be well supported by the tissue attachments and have little risk of bottoming out (dropping) over time. When an implant’s width exceeds that of your natural breast base width, the tissue attachments are stretched and the risk of the implants dropping, going to the side excessively or otherwise losening their retention up on the chest wall will likely occur over time. This can be a difficult problem to fix later.

What your plastic surgeons are telling you, and some plastic surgeons absolutely will not violate this guideline, is that your size request is exceeding what is believed your breast tissues can support. This is likely what they mean by being ‘too big’. I tend not to be so rigid about this concept and will let patients choose the breast implant size they want. But I do advise them, like much of life, the choices we make today will always have future ramifications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The right side of my head (just above my ear when looking at me face on) buldges out about 5mm more than the left side. The left side looks perfect compared to the right. Would it be possible to reduce this ‘buldge’ and would the scar be noticeable? Thank you.

A: The simple answer to your questions is yes…and no. A 5 to 7mm reduction is what usually can be achieved in side of the head (temporo-parietal reduction). While most people think the reduction in this area of the skull is bony in nature, it is actually largely a muscular reduction. By releasing and shortening the posterior extension of the very large temporalis muscle, this will reduce the bulge on the side of head. (head reshaping) It is done through a fine line vertical incision over the thickest part of the bulge that is not longer than 4 to 4.5 cms in length. Usually this scar heals very well because the scalp incision is not under any tension. The noticeability of the scar would also depend on how one cuts their hair. If you shave your head I can not guarantee that the very fine line will not be seen.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’ve been calling around Indianapolis trying to find a doctor that does Intradermal botox. It’s for oily skin and large pores. I think it is a newer procedure because a lot of places I called had never heard of it. Can you please give me some feedback on this? I really feel like this would help my skin very much. Thank you for your time.

A:  What you are talking about is the use of Botox to help control acne and/or oily skin. This is not new or anything magical about it. The concept was introduced years ago. It is simply putting Botox into the skin (intradermal) as opposed to under it. This is actually how Botox is used for armpit sweating, putting the injections into the skin where the sweat glands run through. The question is not whether it can be done but how effective it is in controlling oil gland production. In theory it sounds good but the requests to have it done are so few that I can’t tell you how effective it is most of the time. It is not a skin problem for which Botox is FDA-approved or ever been subjected to rigorous clinical trials. So in doing it one has to know it is uncharted territory for Botox use. (i.e., it might not work) When it comes to reducing pore size, I would say that Botox is not likely to be effective for that particular skin problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face needs a vertical augmentation about 8mm and a horizontal one about 5mm or so. Yesterday I met a doctor in our area, he told me that with an Osteotomy surgery he can give it a nearly 2 to 3mm of vertical projection and about 3 to 4mm of horizontal projection, and above that level is impossible. He described that they cut a piece of my chin from its below, with a triangle section (kinda similar to a wedge I guess) and slide it forward and downward. I wanted to get your advice about how the surgery could be more efficient for me and how I can reach my desirable face.

A: You are referring to a sliding genioplasty procedure. The dimensional movements to which you have been told are far below what is possible. While I don’t know what your chin looks like, I would see no reason why you couldn’t have an 8mm vertical elongation and a 5 to 6mms horizontal advancement. Such movements are possible because of the use of specially designed chin plates that can be adjusted for a wide variety of chin movements to hold the bone in the desired position. I have no idea why you have been given those small chin movements as being what is possible. But to say that 8mm of length and 5 to 6mms of horizontal increase are impossible is not accurate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a 22 years old male and am interested in the orbital reshaping/brow bone reduction process. I had a procedure done a year ago, it was a frontal sinus reduction. This procedure didn’t really accomplish much. I didn’t stress to the doctor the type of results I was after. I guess looking back, I have myself to blame. I have attached pictures which show most of what I’m unhappy with… the somewhat uneven/large orbital rim. I would like to smooth that down to create a simple and more attractive looking eye area.

A: Thank you for sending your pictures. Knowing that you went through a major frontal sinus reduction procedure, there must have been some miscommunication as to your outcomes. While I don’t know what you looked like before, my assumption is that what was achieved was some high frontal sinus/brow setback. But you were as much interested in the lower frontal and lateral setback as well. In your previous procedure, do you know how it was done? Was the bone taken off and put back with small plates and screws, wires etc?? That may have an impact on how well further reduction can be by hardware being in the way, scar tissue, etc. There is also the issue of how much bone along the orbital rim can be reduced without entering the frontal sinus. This is the value of the frontal sinus osteotomy technique which overcomes this limitation. Orbital rim reshaping/brow bone reduction is more of a burring technique although some features of an osteotomy technique can be incorporated into it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been getting injectable fillers placed in the bridge of my nose to hide a small nasal bump that I have. It works quite well but doesn’t last as long as I would like. I am thinking that injecting fat may be better since it can be permanent. Has this ever been done before?

A: To no surprise, injecting fat into the nose is not new or novel. Like synthetic injectable fillers, fat grafting can be an option to change the shape of the nose for those that do not want to undergo surgery…in very carefully selected patients. As has been proven with the use of synthetic fillers, injections are for adding volume in nasal deformities that benefit from augmentation. This is primarily useful in deficient areas in the upper nose where a hump or pseudohump deformity may exist. It can also be useful for those that want a higher radix area for the same reason. (camouflage a small hump) There are also selective tip or bridge depressions which may also be helped by the injection of small amounts of fat droplets.

While fat can be injected into the nose, it is important to realize that it behaves differently than a cartilage graft or an implant. Because it is soft, it is prone to recoil pressure from the tight overlying skin. Thus it is more prone to resorption, distortion and migration from the injected site.  It is best injected into a tight pocket as exists in a pure injection technique rather than as part of an open rhinoplasty.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been looking at your web site for over a week now and I believe I have finally found a perfect plastic surgeon for my problem with my forehead. I’m 58 years old in fairly good health. I’ve had car accident long time ago when I was about 20 years old, which left a scar running vertically in the middle of my forehead. It looks like a thick vein coming down in the middle of my forehead. Also due to scarring (swelling like) there are 2 shallow bulging just above both of my eye brows. What do you think needs to be done to make for a smoother and level forehead?

A: It certainly sounds like you have a depressed scar that runs down the middle of the forehead, which is not surprising with long scars that run perpendicular to the relaxed skin tension lines in the forehead. The smaller two bulges to which you refer could be either your native brow ridges (which have become more prominent due to the depressed scar/bone) or they may be extra bone formations. (periosteal reactions to the original injury) I would have to see photographs to answer that part of your forehead issue better. But let us assume this is what the forehead issues are. In this case, a scar revision of the entire forehead length can be done and the bony prominences reduced through this open exposure. It may also be necessary to do a little buildup of the bone underneath the scar will a little bone cement to help make the bony part of the forehead smooth across the original injury area.  (forehead contouring) But this would await what is found during surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a lower elliptical buttock lift in late December.  It looks similar to the procedure that is shown on your website.  Is it normal to still have swelling around and below the incisions 3 months later?  My PS says yes, but I would like a second opinion.  The ‘swelling’ is significant to the point that it looks like a ‘banana roll’ on the back of my thigh, below the incision and buttock crease.  Can you comment?  Any information would be appreciated.  Thanks.

A: All I can say is that this has not been my experience with the lower buttock lift. From what I have observed there usually is very little swelling with this procedure and a quick recovery. The only long term issue is how well does the scar do and the stability of its location. I would suspect that this is more related to the amount of tissue removed rather than swelling at this point.  The very act of sitting on it and the lack of any tissue undermining done in a lower buttock lift limits how much swelling can occur and how long it persists. But this comment is made without seeing pictures of what you look like so this is just speculation for now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 21 year old guy with a big jaw and a long chin. Also my jaw line is low which gives me a long face. What’s the best and the safest thing for me to do? Should I go for a jaw line reduction surgery and a chin reduction surgery as well? Are they safe? I have attached some pictures of my jaw from different angles.

A: Thank you for sending your pictures. You do have a most unusual pattern of jaw hypertrophy that I have ever seen with excessive horizontal chin projection and jaw angle protrusion. It would be very help to see some x-rays (even a panorex would be useful) to confirm that the bulges at the jaw angles are primarily bone and not masseteric muscle hypertrophy. But let us assume that these are all bony protrusions, they could be reduced through intraoral approaches by burring reduction of the chin projection and an osteotomy/saw reduction of the lateral jaw angle protrusions. These are not only safe but the only jaw surgery options you have for their reduction. If the vertical length of the chin is felt to be too long, then a vertical reduction osteotomy could be performed by the horizontal burring reduction. But it would be important to manage the then excessive chin soft tissues that would result from the reduction of the bony support. I would performed suture suspension of the soft tissues to the reduced chin size.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had a lap band for about 5 years and I have lost about 90 pounds and basically kept it off give or take an occasional 5 to 8 pounds. I would very much like to get rid of the remaining skin and fat in my stomach and upper torso area. I am searching for a surgeon who has quite a bit of experience with these procedures. I was planning on a local plastic surgeon do it but he is moving out of state and is booked solid. I only know of one other Dr. in this area who has extensive experience in this procedure on drastic weight loss, however, I do not choose to have him do this for me. I have consulted and been examined by my initial plastic surgeon about one year ago and he approved me for the surgery. I just was not quite ready at the time. I am now.  I am 66 years old. I am very active and always have been and am in very good health.
I would like to know if you are accepting patients from central Illinois, and if this is something that we can talk about the possibilities and the possible concerns of my not living in your area. I will likely have to self-pay, since my insurance company was approached as to if I would be covered for this procedure, and I was denied. They feel that it is cosmetic and not a necessity. Therefore I would also like to be informed of the cost involved. I would also like to have my breasts lifted and was wondering if it is possible to do both surgeries at the same time and the cost of that procedure as well. I think you in advance for your time and consideration.

A: Congratulations are your weight loss and, equally importantly, the ability to have maintained it. With a near 100 lb weight, you undoubtably have many of the typical findings that one would expect with  a resultant abdominal pannus and significant breast sagging. While I would ultimately need to see some pictures  of you to confirm your exact surgical needs, having done a lot of extreme weight loss patients (bariatric plastic surgery) over the years I can envision with some certainty as to your needs… an extended tummy tuck and full (type 4) breast lifts. It is very common to do both of those procedures together and it is safe to do so.

I have patients that come from all over the world for a variety of procedures so we are very familiar with how to handle patients from afar and can accurately foresee their needs and how they must be accomodated from afar. Doing a tummy tuck and a breast lift in a 66 year-old from afar would need to be done as an overnight procedure in our facility. The extent of the procedure (it is surprisingly not that painful) and your age mandates overnight observation for your medical safety. Whether you would then go directly home the next morning or stay just one more night in a local hotel is an issue to be discussed and also based on how you feel. You would go home with abdominal drains (you would have breast drains but those would be removed the next day) and those would need to stay in for 10 days at which time you would come back to have them removed. We follow all of our patients carefully using e-mail, photographs and texting, available 24/7, to handle any questions or needs. Thus you may be far away but are electronically just a click of a button close. All incision are taped so you have to provide no care to them and can shower with 48 hours, getting all tapes wet without any concerns about doing so.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 21 year-old transsexual male. (female to male) I have been on hormones for a year and a half and my face has changed in sufficient ways. However, I still lack much masculinity in my facial features, and the bones don’t face drastic changes at my age. I also know that I have a bulbous tip to my nose and a weak chin. I have been considering plastic surgery not only for aesthetic reasons, but for the more masculine appearance I could gain from it. My goal isn’t to correct the flaws in my facial balance as much as it is to “masculinize” it. A strong chin, a strong straighter tipped nose would be my goals. I am wondering if you think you could achieve what I am asking of you. I can send pictures and you could give me your input. I will send them from different angles, completely neutral appearing. Thank you for your help in this matter.

A: As a general statement about facial gender transformation, it is usually easier to make a face appear more masculine than more feminine. This is because augmentation of the facial bones, usually by implants, can produce a more noticeable change than trying to reduce the size of any facial bone. This, of course, depends on the facial bone structure that one has to work with but augmentation by millimeters will always be greater than what bone reduction in millimeters can be achieved.

In making a face more masculine the jawline is always of great importance. Whether it is just chin augmentation or a more complete jawline enhancement including jaw angle implants, one of the defining male features is a strong jawline. While the nose is not as important a male feature as the jawline, a nose and a rhinoplasty that creates a high dorsal line and a well defined tip goes along with a good jawline that makes a very masculine statement in profile. Computer imaging will show how much of a difference these changes can make in the appearance of your face.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a cheek dimple on one side that I would like deepened. I don’t know if this is possible. I have attached a few pictures of where it is located.

A: Thank you for sending your pictures. You have a very lowly positioned cheek dimple which is below the horizontal level of the corner of the mouth. As you may know, many cheek dimples are posiitoned higher on the face than yours. While such cheek dimples represent a split or bifurcation of the zygomaticus muscle, yours involves some defect in the buccinator muscle. The good news is that it is located in a very favorable position as it lies below the level of where the buccal branches of the facial nerve run through the face. (below a line drawn from the tragus of the ear to the corner of the mouth) Efforts at deepening your cheek dimple involves an incision inside the mouth right opposite where your cheek dimple is. Fat is removed from beneath the cheek dimple and a resorbable suture is placed through the skin and sewn down to the buccinator muscle to pull it inward further. This is done under local anesthesia and does involve some cheek swelling afterward. It would take up to 4 to 6 weeks to see how much dimple deepening may be obtained.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  It is getting closer to my surgery date in June. I have a few questions.  If I were to get abdominoplasty prior to getting my facial surgeries, (paranasal, premaxillary, chin tuck up and labiomental implant).  How long would I have to wait after I got my abdominoplasty before I could get my facial surgeries.  I went back to my old tummy tuck doctor from ten years ago and had him have a close look.  He said he wouldn’t tighten the muscle, he would only remove skin during a mini tuck.  I thought about trying to travel all the way to you and back with the seriousness, healing, and limitations of a tummy tuck and I am a little concerned about the travel distance. Would I have to wait a long time in between the two surgeries?

A:  I would agree with your old doctor, only skin should be removed. That is all you can do which is common after someone has had a tummy tuck previously. That is a much different postoperative experience than the first time because it is much more limited. There is a reason it is called a mini- because it is so much smaller in magnitude. The incision makes you think it is the same but it is far different.

But if you were going to space multiple facial implants and a mini-tummy tuck apart it is just an issue of recovery/travel between the two. I wouldn’t think more than a few weeks would be necessary either way.

When you have good lips like you do to start with (adequate vermilion) implants work really well. I am not sure how to answer how that would look without the submental tuck-up because I don’t think one really affects the other that much. I would say it would not look strange.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got combined medpor orbital/cheek rim implant(with midface lift) and canthoplasty last year. The orbital rim and canthoplasty was supposed to fix my scleral show and negative vector. I still have the scleral show. I am not sure why. I am not sure if I still have negative vector. I like to get scleral show fixed. Can you tell me if you can fix the scleral show and what do you propose?

A: While there was aesthetic benefit to the concept of infra-orbital rim/cheek implants, they alone are not sufficient to ‘ drive up’ the horizontal level of the eyelid. To do so they would have to be extremely large and highly disproportionate to your face. It is a flawed concept that you can push from below and think that the lower eyelid will be pushed up. Such implants are protective but not curative of a lower eyelid problem. Given your natural state of a low horizontal eyelid with scleral show, I would not have expected a canthoplasty to produce significant elevation either. In theory one would think that the combination of the two would be effective but they usually aren’t for several reasons. First the problem in the lax natural lower eyelid with scleral show is that there is a vertical tissue deficiency in the eyelid. When this exists there is no amount of pushing and pulling that is going to overcome it and have a sustained result. Secondly, the need to make a subciliary (lower eyelid) incision and lower eyelid dissection for implant placement and the midface lift creates a lot of scar. This will have a natural tendency to pull the eyelid downs as it heals. Lastly, the space occupied by the implants actually fights against the midface lift often creating a zero sum gain…as your result indicates.

The problem that you have now is that the lower eyelid is scarred and is not easily going to be mobilized without the issue if postoperative scar contracture. What I would recommend is to first have some fat injections done to make the lower eyelid more supple and help replace scar tissue with more vascularized tissue. Then after three months you could have an eyelid procedure that would introduce an interpositional palatal or alloderm graft to the inner lamellar of the lower eyelid and an osseous-based canthoplasty that is more effective than just a simple tendon tightening.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am confused about all the different types of facelifts. I reading on the internet I have come up with over a dozen types and names of facelifts, some of which seem similar and others very different. Can you help me figure out what is what is facelift surgery?

A: Admittedly, the marketing and promotion of facelift surgery can be very confusing. While there are many naunces/details within a facelift that does differ by plastic surgeon, there are some fundamental concepts that they have in the basic execution of a facelift and in what each individual patient needs. In my practice, I look at three basic types of facelifts and this is how I both allocate time and the charges to do them. It is important to also understand what a facelift is…which is a lower facial procedure that focuses on the neck and jawline.

Level 1 Facelift = Jowl Tuck-up, a true short scar facelift, no neckwork is done (liposuction or otherwise) This is for jowl problems only and would usually be done in someone under 50 years of age.  SMAS imbrication by suture is done. Drains are never used.  This is the facelift procedure that if one was truly motivated really could be done under local or IV sedation. It would be very similar to the well known Lifestyle Lift . May be called JOWl TUCKUP. It usually takes about 1.5 hrs to perform.

Level 2 Facelift = Semi-full facelift that includes postauricular incisions that usually do not go into the occipital scalp. Neck liposuction is usually done. SMSAS imbrication or flap elevation is done. Drains may or may not be used but are usually not. This is the type of facelift for jowlings and minor neck sagging issues. May be called FACELIFT.  It usually takes about 2 hrs to perform.

Level 3 Facelift = Full facelift, extended postauricular and occipital scalp incisions are used with open neck work. There is a full connection of skin flaps between neck and face. Full SMAS flap elevation is always done. Drains are always needed. This is for those who have a major neck problem or concerns. Anyone over 60 or 65 years of age will always need this type of facelift. May be called FULL OR EXTENDED FACELIFT.  It usually takes 3 hours to perform.

I hope these basic facelift concepts are helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I  am sending you pictures of my face and how I want to look like at the end of surgery. The first 3 is me, the last 2 is how I want to look like.  I believe we will need a nose job, mouth reduction, and some facial bones work. 

A: Thank you for sending your pictures and demonstrating your objectives. First, let me make some general statements about your facial enhancement objectives. If your goal is to look very close to the pictures you have shown, that is not a realistic goal. Besides some similarities in skin color (actually his skin is much lighter than yours) he has a completely different facial bone structure and soft tissue makeup. Your facial structures are radically different. Thus there is no way with any surgical procedures that you are going to look remotely like him. It is simply not possible. You can not be made to look like someone else. You can be a better facially balanced and proportioned you but you can not be him. While I understand why his face and those objectives are appealing, you will have to focus on what you do within the limits of change in your own face.

What I see on your face that can be improved is the following.

1) Your facial bone structure is known as bimaxillary protrusion where the jaws and the teeth stick out. That can not be changed but your chin is comparatively very short. A sliding genioplasty to move the chin forward would improve your facial proportions.

2) Your nose is very classic being low and broad. Building up the nose with a rib graft rhinoplasty and narrowing the nose will create more of a narrow and slimmer looking nose. Your thick nasal skin prevents your nose from ever being very refined but this will help.

3) You have a tremendous amount of lip tissue, particularly in the size of the exposed vermilion. (pink tissue) An upper and lower lip reduction will help although there is a limit as to how much lip reduction can be achieved.

I have done some imaging which is attached so you can see how these proposed changes may help in a realistic facial enhancement effort.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a forehead cranioplasty but I have an unusual request for it. I also want to add width to the sides to make my forehead wider. What would be the safest method and how would you do the augmentation (implants or cement)?

A: Your question is a very good one. Normally I would use an acrylic or hydroxyapatite bone cement for a frontal cranioplasty but yours is not the standard frontal cranioplasty. Adding width to a forehead requires going past the anterior temporal line of the forehead into the temporal muscle area. Thus one has to decide whether the augmentation should be done on top of or under the temporalis muscles to add the width. There are arguments to be made for either approach. If the material is placed on top of the muscle, it has to have a very feathered edge and edge demarcation or visibility of the implant-muscle transition will occur. This would be much more possible with a preformed silicone implant than an intraoperatively formed bone cement augmentation. Conversely, raising the temporalis mucle and putting the width augmentation under it requires reattachment of the muscle over it and that is frequently associated with some muscle atrophy and resultant overlying indentation/contour. With bone to bone contact throughout, a bone cement would be preferable.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in Asian rhinoplasty. May I know what charges and how much time will be spend on it. And what is best option for Asian rhinoplasty, cartilage graft or something else.

A: Thank you for your inquiry. The first place to start is to see some pictures of you and see what your goals are. Even though I likely know what they are, I would like to hear your nasal goals. Secondly, since almost every Asian rhinoplasty involves either dorsal or dorso-columelar augmentation, one has to decide whether one wants it done by cartilage grafting or a synthetic implant. There are advantages and disadvantages with both approaches and that choice significantly affects the time of surgery, cost and recovery. Although an implant rhinoplasty is relatively easy  to go, has a lower cost and a very short recovery, the use of an implant in the nose has a significant incidence of long-term complications including infection, thinning of the overlying skin and implant extrusion. A rib graft in the nose requires more skill to perform, involves a donor site, costs more and has a longer recovery. But once healed, rib grafts become a permanent and natural part of the nose. From my perspective a rib cartilage graft rhinoplasty is always better in the long run but it is involves a bigger commitment up front.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 34 y.o. male who has suffered with gynacomastia since puberty. I have not taken my shirt off in public since I was a boy – not for the pool, the beach, or even to get a suntan. I am ashamed to take my shirt off at home except to get into the shower. I’ve worn multiple layers of clothes to hide it, even when the weather is stifling hot. I’ve tried wearing super tight under shirts, Spanks and wrap-around girdle (which helps only slightly); and I’ve even tried wrapping tape around my chest but that only created bulges on my back. I have always been interested in surgery, but I have a couple of concerns that I was hoping you could address. First, most of the “after” photos I’ve seen on the net are horrendous. It’s as if either the surgeon has never seen a normal male chest before, or he’s so repulsed by the male body that he couldn’t care less how ugly he leaves it. Secondly – and this the most important issue – I have always had very sensitive nipples; they are a major erogenous zone for me and a very important part of my sexual experience. I’ve heard that there are some guys out there who have no erotic sensation in the nipples and I really feel horrible for them. My biggest concern about gynecomastia surgery is the loss of nipple sensation. I know that no guarantee can be made for perfect success in any surgery, but is their any gynecomastic procedure that can be done that doesn’t harm the extremely sensitive nerves? It would seem to me that liposuction involves an inserted wand that is moved willy-nilly about like a bull in a china shop. I don’t want to suffer from this condition any more; it’s been a daily humiliation. But to lose nipple sensation from surgery would be as horrific to me as being castrated. Thank you for any advice you can offer.

A: Thank you for your inquiry and I am certainly empathetic to how you feel.  The first question is what is the anatomic form of your gynecomastia and what technique is needed to address it? While it would ultimately be beneficial to see some photos of your chest, my experience has been that most cases of gynecomastia require some form of open excision…with or without liposuction. Using this approach does raise some concerns about what could happen to your nipple sensation. That is an unpredictable risk. On the one hand, I have never had a male complaint about loss of nipple sensation. But that may be because most men had little to no significant nipple sensation…so no complaints does not mean that it does not occur. Given your level of focus in this area, I do have reservations about any gynecomastia procedure with your nipple sensation concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have seen that you offer skull reshaping. You said that the maximum that can be reduced is 5 to 7 mm. My question is, will that be enough to make a difference in someone who has a big head? I mean, a visual difference. Would it make a difference also when buying hats and sunglasses? I don’t expect a huge reduction, but I am just figuring out how much of a visual improvement I could expect. Lastly, if you take out the outer table of the skull, doesn’t it make it more susceptible to fractures? I would be scared to bump my head and injure my brain. Thanks

A: It many cases it can be surprising how much of a difference 5 to 7mms in skull reduction creates when done on a near circumferential manner. Given that the skull thickness ranges anywhere from 12 to 20mms depending upon the location, there is no danger of increased susceptibility to skull fracture after a burring reduction.

Dr. Barry Eppley

Indianapolis, Indiana

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