Your Questions

Q: Dr. Eppley, I had a minor rhinoplasty (for instance family and friends did not notice) three years ago.  I am happy with the result, but I cannot breathe at all out of the left nostril.  I believe it is nasal alar valve collapse.  I have to wear breathe right strips at night, and I have a product called Breathe With Eez – a small nasal expander that is a tiny stainless steel thing that I insert.  I have to use this constantly – needless to say, this is uncomfortable and inconvenient.  I cannot breathe well out of the right side either, but the left is much worse.  I do not want to alter the shape of my nose at all because I am very happy with the outcome aesthetically, but I need to be able to breathe.  When I told my surgeon, he told me that he could not believe I would complain because most people would just be happy to have such a nice looking result.  When I complained that he is an ENT and I can no longer breathe out of my nose correctly, he told me he could try and fix it but it would leave scars on my face (he would go through the undereye area)…he treated me like I was crazy to expect to be able to breathe right again, and I did not trust him, so I did not go back for this operation – he explained it in a manner that made it sound terrifying. I would like to discuss possibilities on how to remedy my poor breathing problem.

A: Nasal breathing difficulties after rhinoplasty are not historically rare, particularly when significant tip narrowing modifications are done. If not enough support is left to the lower alar cartilages, they can become weak and bow inward causing internal nasal valve collapse. This problem can be modified if there is also middle vault collapse from a profile reduction as well. While an examination would have to be done to be certain as to the exact reason for your breathing difficulty, there are some standard manuevers for secondary rhinoplasty improvement. These include alar batten grafts to stiffen up the bowed lower alar cartilage on the affected side as well as spreader grafts to the middle vault. These cartilage grafts may have some slight effect on your current aesthetic result but should be relatively minor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing about my chin implant that I had placed three years ago at the time of my facelift.  I did not even want a chin implant in the first place but my surgeon talked me into a small one.  After this, there was a huge downward bulge on the right side (wing area).  It was a flowers small implant inserted through the chin.  When I went back to complained, he told me I was imagining it.  I was so intimidated, I left  it in even though it was impossible to miss it and I could not believe he denied it.  Shortly thereafter, I got the courage to re-approach him.  He conceded that maybe he could fix it a little this time and it was an incredibly painful experience, the numbing injections were horrible.  He told me he was repositioning it but there was risk of nerve damage and that if I removed it completely (my first request) there was even more risk of nerve damage, so I was too scared to take it out completely.  Well, he fixed it…but it is still bothering me – it hurts on that side – aches, pains and also I can easily still feel the bulge of the uneven placement even after that “fix”.  I cannot lie down with that side of my face or it hurts quite a lot after a while.  I am afraid it is an infection that flares up from time to time.  Also, many of my teeth are showing cavities or rotting and I am wondering could this be bone erosion of some sort? I would like the chin implant removed, if possible – I am concerned about skin sagging, so I guess I would like the sub-mental tuck done too if you recommend that.  Do you think I have a high risk of skin sagging?

A: The simple solution is to just have the chin implant removed. This is an easy procedure since it is  a smooth silicone implant and has no risk of nerve damage or exacerbating one even if it already exists. Given that this is a small implant I doubt that there will be any risk of significant soft tissue chin ptosis. I would remove it through the original submental incision and do a slight tuckup of the chin soft tissues at the same time. Your chin implant is not the source of your teeth condition and there is no correlation whatsoever between it and your dental or medical health.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a rhinoplasty to change the shape of my nose. I am Hispanic and I don’t like my thick wide nose. I will try to the best of my ability to describe what my goals are. I would like my nose to be more narrower from the top to the bottom. I would also like the side of my nose to be smaller and also a smaller yet defined tip. Its hard for me to explain but in person I can explain better but over all this is the work I would like done on my nose. I have attached pictures from the front and side for you to see what my nose looks like.

A: Thank you for sending your pictures. In looking at your nose and your reshaping goals, I think much of that is achieveable. To achieve an overall nose thinning, I would use an open approach with the following steps; radix cartilage augmentation (build up the nasal root), low lateral osteotomies (upper nasal bone narrowing), tip refining through lower lateral cartilage trimming, suture plication and a columellar strut graft, and alar wedge reduction. (nostril narrowing. It is important to realize that the amount of overall nasal slimming that can be achieved is controlled by the thickness of one’s nasal skin and how much it will contract. Given your ethnicity and thicker nasal skin, there are limits as to how much thinning can occur. I have attached some computer imaging to show what I think is a realistic outcome. Most of the benefits of this proposed rhinoplasty procedure will be seen in the front view and not so much in the side view since no dorsal profile change is being done (with the exception of radix augmentation and the tip is not undergoing any projection changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a particular head which is pointed at the top and flattened behind. I have already had several consultations of which opinions are different. Thus I am confused. One opinion was to fill the flat areas by a material without touching the  pointed top. Others proposed a craniotomy to cut the bone and reposition it so that the lump is found in the back and the flattening will be  up at the top. Since I know you have great experience in craniofacial surgery and am familiar with many ways to change the shape of the skull, what are your thoughts between these two skull reshaping options?

A: While I have not seen a picture of you, I can only make some general comments. The preferred and more practical treatment to your skull concerns would be to do an external  skull reshaping technique. This would be to burr down the ridge/high spots as much as possible and build up the flat areas with a cranioplasty material. The converse approach would be a craniotomy in which the bone is completely removed and reshaped. This would be a very aggressive approach to a cosmetic problem which is fraught with potential problems when attempted to be done in the very thick and vascular bone of  an adult.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how many injections and where do you give it and what dose of Botox in treating muscle hypertrophy of the jaw? How many visits and what is the cost?

A: Botox injections can be very beneficial in the treatment of bruxism, masseteric muscle pain and large masseter muscle size. The injections take but a few minutes and are done in the office. A good starting dose is 25 to 35 units per side or each masseter muscle. The injections are placed in the bulk of the muscle near the jaw angle. It is not a good idea to place the injections above a line drawn from the corner of the mouth to the top of the earlobe. Injecting above this line runs the risk of paralyzing one or more of the buccal branches of the facial nerve, resulting in upper lip paralysis for the duration of the Botox effect. Masseter muscle size starts to shrink down even after the first injection session. How many injection sessions it takes to cause a permanent reduction in muscle size, if that can really be achieved, is controversial. Some report three Botox injection sessions spaced four to six months apart as the protocol. Dramatic reduction in masseter muscle size can certainly be achieved with three sessions. Whether that creates a permanent result varies in each patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently got a fat transfer done to give my pecs more definition but I have noticed that as the swelling has gone down, my pecs have gotten smaller. I called the clinic up to ask them why this has happened but they said that this is normal and that the fat is volumizing.

A: Fat grafting for pectoral augmentation is an uncommon procedure but is part of the burgeoning expansion of injectable fat grafting use throughout the body. Unlike pectoral implants which produce an immediate volume that only goes through a swelling resolution phase, fat grafting is a more dynamic process that is associated with a triphasic recovery on the way to the result. There is phase one which is the immediate effect of the fat injections which are associated with the visible change in volume right surgery. As the fluid and some of the fat cells die and are resorbed in the first few weeks after surgery, the volume then goes down. (phase 2) If the fat cells take and multiple through preadipocyte conversion (stem cells) then the result will expand again in volume. (phase 3) This is what has been referred to as ‘volumizing’.  This is the unpredictable phase of fat grafting and how effectively that occurs will not be known for months. Usually the result will be evident by three months after surgery but may take as long as six months. Certainly what you see by six months after surgery is the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking into a chin reduction for quite a few years now, but I have never gone through with it because I’ve always been afraid that the results would be terrifying. I read through your case studies on chin surgeries, and I must say it’s a relief to see someone with as much experience on the subject of chin surgery. Perhaps other doctors have just as much experience or more, but it’s relieving to be able to read about it instead of them briefly talking about it. I’m a man who has a larger than average chin (or at least I think so). My main reason for wanting a chin reduction is because I feel that I look weird when I smile, and it was not always that way. When I was a child I thought I had a great smile, nowadays I’m sad to say that I smile much less simply because I feel self-conscious. The other goal is to ensure that the chin surgery doesn’t make me LOOK like I’ve had surgery (this may be an obvious goal, but this is the one reason why I’ve been so reluctant on getting surgery in the first place). If a random stranger would introduce themselves to me, I don’t want there first thought to be “that man’s had work done’.

A: Unlike chin augmentation, chin reduction surgery is much more difficult and technically precarious. In plastic surgery, it is usually much easier to make something bigger than it is too make it smaller. Chin reductions are done either removing bone by an osteotomy or burring or reducing the soft tissue envelope. In many cases, both bone and soft tissue need to be reduced to get a good result. Most male chin reductions are a function of too much bone and leaving them with a smaller but still strong chin is acceptable. As you have stated, some improvement is better than too much change that would look unnatural. That is a good approach for any type of male facial plastic surgery in general. In looking at your pictures, I can see that a vertical chin reduction by wedge osteotomy would be a good approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severely chapped lips. I have tried everything for years, been to over ten doctors, and tried every lip balm and salve that exists. It gets so chapped that it is painful and a source of constant embarrassment. I have read that chapped lips can be improved by a procedure known as a vermilionectomy. What does it look like after surgery? Will there be a bruising and will the vermillonectimes heal quickly. I have been researching the internet about the procedure. The closest thing I can find about the lip procedure is for people that  have lip cancer . I don’t have lip cancer but it does give me an idea about the procedure. I have not found articles  for people that  severe chapped lips.

A: A vermillionectomy is used for a variety of lip procedures such as cancer excision as well as cosmetic lip reductions. It is nothing more removing a strip of vermilion with the posterior edge at the wet-dry line and the anterior edge as far forward as needed to removed the desired amount of aberrant vermilion. The excision is widest in the middle and tapers to a feather edge as it comes to the corners of the mouth. It is closed by a combination of the outer lip rolling in (vermilion) and the inner lip (mucosa) rolling out. Dissolveable sutures are used for closure. Any lip surgery does tend to swell considerably but there usually is not much if any bruising. For chapped lips, which occur exclusively on the dry vermilion, the amount of improvement obtained depends on how much of the involved vermilion lies within the excisional area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, does cheek bone augmentation work?

A: On the surface this seems like an unusual question. Cheek bone augmentation with implants has been around for nearly thirty years. Next to chin implants, cheek implants are the most common facial implant performed. (this has a lot to do with that there are two cheeks but one chin) It is a very straightforward procedure to do because they are placed through a small incision high up under the lip. There is very little muscle and tissues to dissect through and there are no important structures, such as nerves, that are in the path of implant placement up across the zygomatic prominence and onto the zygomatic arch. . From that standpoint, it is a very successful facial augmentation procedure. But cheek implants are prone to complications, most of which are aesthetic in nature. Getting the right style and size of cheek implant can be challenging and their symmetrical placement is not always easy or assured. This can lead to the need for cheek implant revision…which could lead one to believe that they don’t ‘work well’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, four months ago I had two moles removed on my cheeks.  The plastic surgeon removed them by circular excision to achieve a short scar.  She didn’t mention the dreaded dog ear deformities that I have now been left with.  I now have four white hardish protuding lumps at either end of where my moles were.  So I have no moles but four lumps instead.  Was this a bad method of mole removal?  The plastic surgeon is still hoping that they will flatten in time but my cheeks are quite fat and I am seeing no improvement or flattening out so far.  How long shall I wait to hope that they will dissapear or do you think four months without any improvement means that they won’t.  Would much appreciate your advice as I really don’t know what to do for the best result.  I have very little in the way of scar where the mole was but if I now have to have the lumps excised what can I expect in the way of scarring?

A: Removing the smallest amount of normal skin when removing a skin lesion, particularly on the face, is a desired approach. In many ways, you have had a ‘punch excision’ but without using that specific instrument. The trade-off for a circular excision is that there may residual skin (dog ears) as you now have. After four months, most likely what you see if what you will have. Improvement will only come from a scar revision (elliptical excision) now. While there are scar concerns, your recent experience shows that you seem to scar fairly well in this facial area. You will have to decide whether a flatter scar or these bumps are better aesthetically. That is as much as I can say without seeing pictures of these areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am confused about the distinction between different doctors who perform cosmetic surgery/medicine. I know plastic surgeons have historically performed cosmetic surgery but today it seems many different types of doctors do it. How is it legal that so many doctors do it even though their training and specialties are obviously different. This same situation doesn’t exist, for example, in heart surgery so why is it so for cosmetic surgery?

A: Your confusion is understandable and the rise of some many different doctors with widely discrepant cosmetic procedure training is fueled by many factors. The most significant contributing element is its fee for service basis, making it lie outside the boundaries of insurance-reimbursed medicine where the controls are much more rigid due to hospital and federal regulations. While cosmetic surgery is not new, the number of available treatment options has exploded in the past two decades and the law has yet to catch up with these medical procedures that continue to rapidly evolve and expand. That being said, future changes may be in the offing. I have just read that Puerto Rico last year passed a law that restricted the practice of  cosmetic procedures to those doctors who are board-certified in either plastic surgery or dermatology. This precedent law was based on the desire for improved patient safety. In essence, base training in the rudiments of the medical procedures should make for better outcomes and lower complication rates. While such a law may be easier to pass and enforce on an island with a small population, it is not clear what impact this will have if any on any other state. Hopefully someday we will have better definition as to what constitutes adequate training to perform the various cosmetic procedures. Unfortunately, this will undoubtably be created by the law and not by any group of doctors or medical governing body 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have previously had liposuction and a breast augmentation from which I am very happy. I am now looking to inquire on a cellulite treatment. I am seeing that the most recommended is Mesotherapy. If you could please forward information, such as costs & before & after pics I would appreciate it. Thanks!

A: The best thing that I can tell you about cellulite treatment is that there is no really effective method that produces consistent improvement, no matter what you hear and have read. Many methods from external suction and massage, innumerable topical creams, mesotherapy injections to energy-based devices have been done. Almost all of the success from these efforts are anectodal in reports with few prospective clinical trials done that show satisfactory improvement in more than a handful of patients. This is not to say that some of them don’t offer mild improvement, just usually not enough to satisfy most of the patients whom I know when the cost of them is factored in to an overall satisfaction survey. The only promising current method that states it can provides long-term improvement with a single treatment is that of the Cellulaze laser method. This is more of an invasive method that is a spin-off of the Smartlipo or laser liposuction method. The amount of improvement with Cellulaze is very visible and two year results show sustained results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got Medpor cheek implants that where placed high and lateral extending towards the ears one month ago.While I am very pleased with the result, the surgery caused damage to the facial nerve. Immediately after surgery I couldn´t move my right eyebrow and when I tried to close my right eye, my eye was half open. About 6 hours after surgery I could move my right eyebrow again and my right upper eyelid closed almost completely. Ten days after surgery I noticed that I got water in my right eye when I washed my face, but I didn´t had any problems with dry eyes or any sleeping problems. A friend of mine told me that my right eye is about 2 mm open when I close it and the movement of the right upper eyelid is slightly delayed. I also noticed that while the lower eyelid of the “healthy” left eye touches the iris, the lower eyelid of the right eye is 1 mm below the iris. Fortunately 3 weeks after surgery my eyelid situation improved. The right lower eyelid almost touches the iris, the gap between my closed eyelids is almost not visible (1 mm or less) and I feel the muscle movement of my right upper eyelid growth stronger and stronger. The movement of the right upper eyelid is still slightly delayed. I also have to mention that the whole eyelid problem on my right side is gone in the morning and towards evening it becomes worse. How bad do you think is this kind of nerve damage that I got from surgery and what do you think happened to the facial nerve? Do you think that in my case there is any chance of a complete nerve regeneration or should I learn to live with it? Is there anything I can do to promote nerve regeneration, for example by taking high dosage of B vitamines and exercising the movement of my eyelids or is there anything I should avoid?

A: Your description is classic for a nerve traction or stretch injury after surgery. What was affected was the frontal branch of the facial nerve. This crosses over the zygomatic arch and obviously was affected by the very lateral placement of your cheek implants. I have never seen such a nerve injury after cheek implants but then the very lateral placement of your cheek implants is also uncommon. The goods news is that such a rapid improvement of nerve function after surgery bodes well for complete recovery. I suspect by three months after surgery this will no longer be an issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had my forehead and brow bone augmentation for correction of a frontal sinus and forehead depression from an old injury done three weeks ago. I have a few question about my result. The stitches on my eye seems to have a permanent crease. Is it gonna get straight and flatten out later? Also the operated side of my head is more elevated. You informed me that it would nearly perfect before we started this operation. I’ve waited nearly 10 year before I had the funds to do this operation and I really want it to be perfect.

A: Good to hear from you and thanks for the followup. Before answering your specific questions, let me refresh your memory as to our preoperative discussion. If we wanted the perfect result and the most assured way to achieve that, the operation would have been done from a large scalp incision from above where everything can be seen from the normal side to the depressed side. We chose not to pursue that option for the obvious negative tradeoff of a large unaesthetic scalp scar. In choosing to go through the eyelid with more limited visibility, which is the right choice and one I would repeat, the contour may be less than perfect and the potential risk of revisional surgery is higher. That is the potential aesthetic trade-off for that approach.

In specific answer to your questions:

1) The eyelid incision/scar, particularly in Asian skin, takes a long time to settle down and mature. Asian skin is particularly  prone to early scar hypertrophy and hyperpigmentation. It will take at least 6 months before you will see what the final scar outcome will be.

2) The final shape of the forehead and brow augmentation will take at least three months for all swelling to go away and an additional 3 months for the scalp tissues to shrink down and contract around the implant. This will be particularly true in your case because of the hematoma and second operation you sustained. At just one month after surgery, it is simply too early to say what the final result will be. I would much rather see a contour that is too big at this point as it has the potential to go down…rather than too small of a result which has no chance to improve with time.

In conclusion, it is too early to judge the result. Patience is the key and a more useful assessment will be at three months after surgery. No consideration will be given for any form of revisional surgery (not that I am antipating or hoping for it) until six months after the original procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m a skinny guy with puffy areolar tissue. I’ve had it my entire life. It is not steroid induced. Considering surgery, I am a student covered under Anthem Blue Shield insurance. I am not sure if it will be covered. I hunch my posture to conceal the protrusion in shirts, and it has lead to a lot of neck and back pain. I do not have a picture of it, but my build and areolar shape look exactly like the case study on your website for gynecomastia reduction for athletes/body builders.

A: The amount of gynecomastia the patient to which you refer had is the most type that I see. It is a harder type of gynecomastia that causes the puffy nipple appearance due to its mass effect. The amount of breast tissue present is much more significant that it looks on the outside. It must be removed through an open approach using a lower areolar incision. This smaller type of gynecomastia is not covered by insurance in my experience and is considered a cosmetic procedure. The overall cost of an open gynecomastia reduction procedure done under general anesthesia taking one and a half hours of operative time is in the range of $4500 to $5000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have HIV and my cdf is about 350 and i am non-detectable. I have developed a small hump in my back and large fat sacks on my legs in certain areas and excess fat in my stomach. I am always unconfortable from the extra weight. I cannot not afford to have this procedure done. I had a price for about eight thousand. I don’t unsterstand why insurance will not cover this.  Do you know of anyone who might put extra effort in to help you getting it covered by insurance.I i have medicare. M y knees hurt terribly from the extra weight. The weight is not from my eating habits. I just can’t get these areas down in spite of all the diets I try. It can be very depressing at times as I have so many people ask if i am pregnant because of the weight gain. Can you help?

A: The fat collections or lipodystrophy that you describe are  classic areas of collection due to the medications used to treat HIV.  They are not going to be removed by diet and exercise although doing both of those is always good. The reason that fat grows in thsese areas is due to a specific hormonal stimulation effect of the medications, not due to excess calories or food intake.  When it comes to insurance coverage for liposuction, the simple answer is that it is never going to be covered as it is considered a cosmetic issue regardless of what caused the fat to appear. Much of your stomach fat is actually not treatable by liposuction anyway since it is in an intraperitoneal location (around the organs) and not between the skin and the abdominal wall (subcutaneous layer) which liposuction can reach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some areas on my stomach and thighs that have a little extra fat and some loose skin. I do not want to undergo surgery however to make them better, that is just too much for me. I know that there are a lot of different non-invasive body contouring treatments out there that claim effectiveness. The one that has me intrigued the most is Exilis based on my research. How does Exilis work and what has been your experience with these treatments?

A: Exilis produces its effect through the use of highly controlled radiofrequency waves. It delivers high energy levels down to an inch under the skin. Its delivery technology allows that energy to be delivered without injury to the skin through a synchronized pulse delivery and cooling method. Thie keeps the treatments comfortable without risk of skin injury. (burns)  It effects fat by breaking down their cell walls so the lipid contents are released and absorbed. It help tighten skin through a process known as neocollagenesis, which is the unraveling of the collagen fibers by the energy and the subsequent stimulation of fibroblasts to produce new collagen resulting in dermal thickening and increased skin density.

The transducer delivery system allows 17 different body areas to be treated from the eyelids down to the hands and everything in between. Our experience has been extremely favorable in properly selected patients who have been educated about achieveable results without surgery. Incremental, lasting and measureable results  can be obtained in four treatment sessions or less of Exilis for many patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants and am confused about what type of implants to get. I have seen two doctors and one uses Mentor implants while the other uses Natrelle implants. I don’t understand the differences between these two company’s implants and I realize that choice is best determined by the doctor. I read recently that there is now another company offering breast implants known as Sientra. What are the benefits to these implants if any?

A: While all silicone breast implants contain silicone gel material, there are different formulations of that silicone used by each company. These formulations are proprietary and are given different names by each company. What is becoming most important in gel formulations is how cohesive they are, also known as form stable. The more form stable implants have become known in urban terms as ‘gummy bear’ breast implants.  Sientra offers only silicone breast implants that are composed of what they call ‘high strength’ silicone gel, which is their version of the so-called gummy bear implant. What I like about the Sientra implants that they may be form stable but are also very soft. If cut in half, the gel material does not extrude or break down and remains intact. You can actually take the implant and twist it 360 degrees and the implant shell/material will not fracture or break. This is a very important feature to decrease the effects of shell stress on insertion and lower long term implant rupture rates.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have gotten lip injections using fillers for the past five years. While my lips are not really that small, I like the plump up that fillers give them. But after five years and over a dozen injection treatments, I am tired of the expense and the hassle (pain!) of the lip injections twice a year. I have read that there are permanent materials for lip augmentation. This is of interest to me now as I need to really explore how to end injections by a single operation if possible. What can you tell about permanant lip implants?

A: The concept of lip implants has been around for a long time. Despite their existence for over fifteen years in the plastic surgery world, they have never garnered much traction as an everyday procedure. Part of that is because of problems in implant design and materials and partly because of a general fear of having an ‘implant’ in the lip. I have used every developed permanent lip implant available and have seen many of their benefits and potential problems. I have had good success over the past ten years with the use of Advanta implants but for a variety of reasons they are not as available as they have been in the past. But the newest lip implant, called PermaLip, is the best design and material that I have seen to date. It is made from a very soft and flexible silicone elastomer. Based on how it feels, it could easily be called the ‘Gummy Bear Lip Implant’. It has well designed tapering edges, which is very important, and has sizes up to 5mms in thickness. Based on my experience, this is a good safe size for the soft tissue tolerance of  the lip tissues. They are placed in the office under local anesthesia with some swelling and occasional bruising which is largely resolved in a week after the procedure. The real test of the success of any permanent lip implant is the ‘kissing test’  in which the patient has no concern that they or the recipient may be able to feel the implant…and Permalip passes that test!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to achieve a male-model look. I think that I have rather feminine facial features and I would like to look masculine. I was thinking about a square and a big jaw to match my high and curved forehead, a Rhinoplasty, Dimples, and high cheek bones implants. Do you think I will need anything else? I want to look handsome, a 1010 by most women scale. I don’t have a precise male model look that I thought of, but I guess I will choose the one that would naturally suit my face the most. What do you think, can we achieve it? Do I need all of the procedures I listed? Do I need any other procedures?

A: Thank you for your inquiry and sending your pictures. Let me first start off by making some general comments about structural facial surgery, particularly in men. The use of the term, ‘male model look’, really refers to creating some angularity and definition in the facial bone highlights  and overall better facial balance and harmony of the features. This does not mean that one will ever look like a male model or may even be considered strikingly more handsome after such features. All plastic surgery can do is help a patient have better facial features and improve the facial foundation and the face that nature has given them. Therefore, while I understand quite clearly your objective and improvements can be made, I do not like young male face patients to have goals such as ‘male model’ or ‘I’ll be a 10’ after surgery. This is a setup for disappointment.

That being said, I will work on some computer imaging and show you what may be achieveable with a variety of procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking at the tummy tuck pictures and was interested. I looked again the next day and I was able to get a closer look and the scars are very big. I have decided I’m going to try and go to a center for weight loss and see how that works first. Approximately, how much does a tummy tuck with flank liposuction cost?

A: While a full tummy tuck will solve the problem in a manner otherwise not achievable, the ‘price’ to be paid for it is the trade-off of the a long horizontal scar. While very effective, you have to be certain that this aesthetic trade-off is worth it to you. That is why I could not agree more that you pursue every non-surgical option first and only consider surgery when you have become convinced that all other methods are not achieving what you want. Much of plastic surgery is about trading one problem for another, you just have to be certain that the other ‘problem’ is more acceptable that what you have now. In the case of a full tummy tuck that aesthetic trade-off is the scar. The approximate total cost of a full tummy tuck with flank liposuction, which is what you ideally need, is around $8500 all costs included.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Since you are experienced in migraine surgery, would you mind answering a few questions? 1) How does surgery for migraines work? 2) How many people undergo the surgery? 3) How often does it work? 4) What are the costs? 5) Is it covered by insurance? 6) What should people try before undergoing the surgery? 7) Why are you the only doctor in Indiana who performs this surgery?

A: In answer to your questions:

1) Migraine surgery works on the principle of sensory nerve decompression by removing the constructing muscles around the nerves, known as trigger points. I would recommend you go to www.eppleymigrainesurgery.com to learn more or go to www.exploreplasticsurgery.com and search under migraine surgery where the details of surgery are discussed in multiple blogs in detail.

2) Migraine surgery is for those patients who have very specific types of migraines that have been fully worked up and treated by a neurologist and have received either no or little relief. Surgical candidates are chosen either based on their response to Botox injections or by their migraine history.

3) The one and five year results show that over 70% of people experience significant and sustained relief. About 30% of patients are cured and subsequently experience no or few migraines again. About 10% of patients experience only temporary relief and long-term do not show significant improvement.

4) Costs are based on how many migraine trigger sites are released and the time to do the surgery. Costs could range from $3500 to $8,000.

5) It is usually not covered by insurance. Insurance companies, despite the overwheling evdience, feel that it is still ‘experimental surgery’.

6) As per #2 above.

7) Migraine surgery is usually done by plastic surgeons who express an interest to treat this medical condition. The surgical techniques used are common to board-certified plastic surgeons and come from procedures learned from cosmetic and craniofacial surgery, microsurgery and hand surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is it possible to lift the ears in a higher position, perhaps for about 10 mm. If it is possible, how is this procedure performed and is there any risk that the shape of the ear changes?

A: Lifting of the ear superiorly is ultimately limited by its cartilaginous attachment to the ear canal. Essentially you have to rotate the superior ear cartilage in an upward direction with either fascial suture plication to the temporalis fascia or using a micro-bone anchor to the posterior temporal bone. This will cause the ear position to elevate, it is just a matter of how much. It is possible that it may move as much as an entire centimeter although it may be less. This type of otoplasty does not generally change the shape of the ear although it could slightly decrease the aurico-cephalic angle somewhat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, first of all I want to say that your site is full of information and i have learned a lot of things. I want to do an osteotomy/genioplasty on my chin to achieve facial balance cause I have a receding chin. I also want to do this surgery to shorten and make my lower lip thinner. Will this surgery tighten the lip and chin musculature and will it cause my chin to look thinner? I am looking forward to hearing from you.

A:  In most cases of an osteoplastic genioplasty where the chin is advanced, it will make the width of the chin thinner. This is because a chin osteotomy is like advancing the front part of an upside U forward. It is elongating the U and makes it more narrow. Whether that effect is significant or not depends on how much advancement is being done. But anything over 5 to 7mms, the thinning effect will be seen. It does not usually make the lower lip any thinner however.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was all ready to go ahead with the chin implant, but I have read some disturbing stories and research papers about how “silastic implants” lead to bone erosion in chin implants only, and how they could be as deep as 1.5 to 4 mm in depth, and their close proximity to root apices. Also, I am wondering why some surgeons, such as yourself, use screws to secure the implant while others just insert and leave it in the created pocket. I never thought of this aspect of chin implants, the complication with bone erosion.

A: You are referring to an old phenomenon that is largely irrelevant today. If a chin implant is placed too high up off the chin point (which is not where it should go), there may be some settling of the implant over many years into the softer alveolar bone under which lie the tooth roots. Some refer to this an ‘erosion’ but it is not an active process but a passive one representing pressure release. (meaning it stops once the pressure of the push of the overlying soft tissues is released)  If properly placed on the basal bone of the chin, which is 10 – 15mm below the lowest level of the tooth roots, this is an issue which is not seen. If this is an unsuppressed concern, I can also use chin implants made of Medpor material which have little history of showing the same effect. The difference is that the cost of surgery will increase as these implants are more expensive.

The number one complication of any facial implant, chin implants included, is shifting of the implant causing implant malposition and asymmetry. The most assured way to avoid that problem is to secure it to the bone, a very simple and effective method using screw fixation. It makes me feel the most comfortable that there is no chance the implant will shift either after surgery or later in life for any reason.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thrilled about which intervention I have to have done to my lips. They are both thin and fillers give me a duck look. I can’t decide if a vermilion advancement or a V-Y plasty is the best for me. Thank you for taking the time to answer me!

A: Usually the vermilion advancement  or lip advancement works best in very thin lips because they lack adequate vermilion height for exposure. The V-Y advancement is an internal mucosal roll procedure that primarily creates greater central lip pout and increased vertical lip length, in essence a greater effect on mucosa than the vermilion. They actually are quite different procedures on their effect on creating lip size and shape. The vermilion advancement is also much more versatile in shaping the cupid’s bow area of the central upper lip which the V-Y advancement can not do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some non-invasive body contouring. (stomach and flanks)  I have read about the Exilis device and it seem very promising. I know it uses radiofrequency energy to do its work. But there are other devices out there that all use the same type of energy. Why would Exilis be any better than these other ones?

A: There are many new radiofrequency devices on the market and a lot of them are claiming that they have a similar or superior technology to that of Exilis.  Regardless of what their product is called, almost all of them use bipolar radiofrequency.  Bipolar radiofrequencies only have the capability to penetrate fairly superficially, generally no further than the deep dermis. Thus they are good for skin tightening but can not reach the fat layer nor reduce it effectively or consistently.

Exilis is different in that it uses monopolar radiofrequency. This allows it to penetrate more deeply generally up to inch (2.5 cms) below the skin. This does reach the fat layer. The cooling component on the Exilis allows it to bypass the dermis to effectively place the energy into the desired tissue (fat) and maintain penetration depth, all while keeping the skin cooled and uninjured. There is also an energy flow control on Exilis that allows the target tissue to quickly reach the desired treatment temperature. The combination of these two technologies allows Exilis to have effective fat reduction and skin tightening capabilities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in 1) reduction of large occipital bone by burring and 2) forehead augmentation. Due to a narrow and recessed forehead above the brow bones, this needs to be built up with implant material. Can the scar follow the hairline if it naturally angles back laterally from the most center front couple of inches of the horizontal hairline?

A: Let me answer your two areas of concern with some general statements.

1) Reduction of a large occipital bone is always a question of how much be removed. In other words, is it worth it or not. That is best determined by getting a lateral skull film so measurements can be made to determine how much the bone can be reduced. It definitely can be burred down. The question is…is it enough to make a visible difference.

2) Forehead augmentation does require a scalp incision. generally, it is placed way back in the hairline…more than just an inch or two behind one’s existing frontal hairline. That would be particularly good if one is desiring some occipital reduction as well.

That being said, the first place to start is for you to send me some pictures of yourself for my assessment and then we can have a phone or Skype consultation for further discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I went to see a dermatologist for the first time due to dark marks on my hips and buttocks. I have been getting “boils” for the last 10 years…on and off, but recently it seems to be under control since I have been exfoliating and applying topical creams. My dermatologist tells me that I have “post-inflammatory hyperpigmentation” from folliculitis. He has prescribed a 4% hydroquinone cream which is to bleach these darker spots and will take approx. 6 months. When I asked him about any other method of treatment, he had no suggestions. I noticed on your website that you also offer laser treatments for skin problems. I’m wondering if there is anything more effective that can be done for my hyperpigmentation? I had read about certain types of lasers specific for the treatment of hyperpigmentation online but unsure how effective it would be. Being Asian, I’m not sure if these other treatments would be suitable for me. Could you please advise on the treatment for my case?

A: As you may know being Asian, hyperpigmentation is a common problem and a difficult one. Bleaching creams are the standard approach and, while they don’t pose any risks with use, are slow to work and often not that effective.

One technique that can be effective with a more rapid response is pulsed light therapy, often known as IPL or BBL. While often perceived as a laser, it is different being high intensity pulsed light not focused beam light. With selectivhe filters it can reduce the hyperpigmentation in a single treatment by selectively targeting the brown pigment for elimination. This in combination with hydroquinone can help reduce hyperpigmentation fairly quickly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can one have a facelift without any visible scars in front of the ear? I have darker skin and like to wear my hair back. I am worried that someone may be able to see the scars running down in front of my ears. I need a mini-facelift but many results I have seen show the scar in front of the ear. I like to pull my hair back & up!

A: It depends on how you define a scar in front of the ear. All effective facelifts require some type of incision in front of the ear. Most plastic surgeons place this incision behind the tragus of the front part of the ear so that final healed scar is virtually undetectable. A few others, particularly those trained only a mini-facelift technique, still place the incision in front of the tragus so the scar can be potentially detected no matter how well healed it becomes. Why they do this is unclear to me other than it is simpler and makes the operation faster. It clearly does not lend itself to a better scar result. So all facelifts create incisions on the front part of the ear but where they are placed determines whether it is ‘scarless’ or not.

Dr. Barry Eppley

Indianapolis, Indiana