Your Questions

Q: Hi  Do you do premaxillary augmentation? I had a lip lift and I lost the subnasale curve so that now the subnasal is pushed in and sits a little behind the pink lip. The curve was removed from the subnasal area which I would like this procedure to put the curve there I would like to augment the area with something other than an implant. I came across this article on premaxillary augmentation and wondered if you can do it this way? Thanks.

A: Premaxillary and/or paranasal augmentation is one of the least implanted of all facial areas. Its ‘need’ is based on some degree of maxillary or low level midface deficiency. It is more common in certain ethnic groups where the maxillary profile is concave to flat rather than convex. Premaxillary augmentation specifically refers an anterior nasal base and anterior nasal spine deficiency. It is the smallest of all facial implants and is made as an off-the-shelf implant by very few manufacturers. Its implant position is unique in that it has a vertical placement at the base of the nose, which makes it more prone to shifting, and the soft tissue coverage between it and the linings of the mouth and nose is thin.

Mersilene mesh is an implant material that has been around for a long time. It is a traditional preformed implant but rather sheets of non-resorbable mesh material (intended for hernia) that it rolled and made into an implant by the surgeon. It finds its greatest use if chin augmentation. Its drawback as a facial implant is that it has no form of its own and must be rolled and cut into a crude-looking implant. However, in the small area of the paranasal/premaxillary region with no complexity to its needed shape, it will work quite well. It does have an advantage in this area as scar tissue will quickly grow into it holding it into place. Mersilene mesh is a very acceptable material for premaxillary augmentation is my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in learning more about abdominal etching. I am into bodybuilding and and love to sculpt my body. However, even when I diet down my love handles take away the full V-taper appearance. Also, my abs are never really etched like I want them to be. Right now I am actually pretty lean and do not have a lot of fat around my mid-section. It seems like from various pictures on the web, most after images are not really that great. Granted they were not in the best shape to begin with, but I would feel better seeing more pictures of a better after-shot. I was wondering if you had a computer program or are able to manipulate a photo to show what the end result could look like after the surgery?

A: Contrary to whatever pictures you may have seen, I have found that abdominal etching gives very good results. The key is proper patient selection. Not everyone is an ideal candidate as the most lean patients are those who benefit the most. The results are also affected by how aggressive one is with the technique and what expectations the patient has. Etching is basically linear liposuction done with the intent to remove almost all fat between the skin and the underlying abdominal  fascia. (this is not what you normally do in liposuction) There is always a central vertical line and at least 3 horizontal lines at select levels. Occasionally additional vertical rows are put in out laterally. It is a very simple recovery since this is really liposculpture and not volume liposuction removal. I find the use of the Smartlipo probe to be very helpful in performing this procedure.

I would need to see a picture of your abdominal area to see if you are a candidate. Computer simulations I do not find helpfulfor this procedure for patients as anything can be done with Photoshop, that does not mean it will turn out that way from actual surgery. Marking the lines on the photo, however, can be educational for the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in tumescent liposuction. I’m in the Army stationed overseas.  I have a permanently damaged leg from being in Afghanistan and I’ve gained a lot of weight due to my workout limitations.  I’ve lost 20 pounds but can’t seem to lose anymore. I will be visiting family in your area this year and I am researching doctors that may help me shed some fat in the abdomen area.

A: Sometimes people do need some help surgically with their weight issue. Liposuction can be beneficial when one has ‘hit the wall’ in their weight loss despite their best efforts, when they need a jumpstart to get them motivated to make or continue with their lifestyle changes, and to help those that simply can not work out due to physical limitations. While liposuction is not the long-term solution to troublesome body areas with excess fat, it can be a successful part of one’s weight loss efforts if properly understood.

When it comes to liposuction, there is nothing special or new about using the tumescent concept. Perhaps 20 years ago, tumescent liposuction was an advanced technique. But today, every liposuction method uses tumescence or the infiltration of fluid prior to the actual extraction of fat. This fluid is essential, not only for numbing the tissues, but to help control bleeding from the trauma to the tissues. Whether it be Smartlipo (laser liposuction), Vaser, or ultrasound methods, tumescent fluid infiltration is a part of all of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Does fat from flaps (such as TUG, DIEP for breast reconstruction) have as high of a concentrated stem cell as fat from liposuction (fat grafting alone to rebuild the breast ie with or without BRAVA)?

A: That is a most interesting question. The simple answer is that no one knows that with any certainty. At this point, it is not even clear whether stem cell concentrations differ in various fat compartments throughout the body although it seems logical that it should. But the decision to use flaps that contain fat vs. injectable fat grafting has so many other considerations that rank much higher on the decision tree than their stem cell count. Thus making that issue an academic one but clinically irrelevant. Injectable fat grafting has a very limited role in breast reconstruction, relegated to being used in primary reconstruction of lumpectomy defects and more commonly used as a secondary contouring method to breast reconstructions done by flap method first.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a lip lift performed several months ago. I have attached some before and after pictures. As you can see the incision isn’t on the borderline and its now indented and puckers. I’m really so unhappy and paranoid with the scar and am now so desperate for revision. I was so impressed with your website you actually used 48 stutures on the womens top lip,  I did count 🙂 In my surgery the surgeon only used 8 stiches.  as you can see in the pics. In you lip lift proceedure do you actually cut right through all the skin lares? Only when I had my lip lift surgery the surgeon did numb my upper lip with a dental block, but the pain was still horrendous.  Also as I wasn’t having my bottom lip operated on it wasn’t numbed, therefore I actually felt my actual top lip resting (flipped over) onto my bottom lip.  Is this normal procedure to actually sever top lip so completely that it is able to flap over like that? What I’m asking really is do you cut so deep and if so do you place internal stiching of any kind? Its all a bit complex for me but I really need to know the whole procedure. Thank you in advance and looking forward to your reply.

A: Thank you for sending your pictures. Technically, what you had done is known as a lip advancement or vermilion advancement. A true lip lift is done with an incision under the nose. I prpare patients with a dental block first and then inject directly into the upper lip once one is numb. It should be a virtually painless procedure to go through after the dental blocks and local infiltration. During the procedure, only full-thickness skin is removed and no underlying muscle. There is a two -layer closure with some deeper sutures for the dermis and fine sutures for the skin closure.

Your scar is a bit wide and indented compared to a typical result lip advancement result in my experience. That could easily be improved and a little more skin removed and more of a cupid’s bow made to get a better result.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a few dents on the right side of my head. I have a nice sized depression on the top right side of my head. I have a noticeable depression that runs all the way along the top right side of my forehead down to my eyebrow. I also have a small depression underneath my temporalis muscle on the right side of my head. I have done a significant amount of research and I have seen that Kryptonite bone paste can either be injected externally or you can open the flaps of skin and insert the kryptonite internally. Basically, I wish to have this type of operation done some day. What I really want to know is what is the price range of this type of operation for the three areas I described above?

A: The cost of this type of skull reshaping/dent restoration can be highly influenced by the type of cranioplasty material that is used. Also knowing why these dents are there, from prior surgery, injury, or just natural development, is important to know. If these are there from just natural development, then only an injectable Kryptonite technique would be used because new scars from incisions may be unacceptable. Assuming that about 10 grams of material would be needed the total cost is in the range of about $9500. If there are existing scars or incisions, then some form of an open technique can be used. In this case, a less expensive material like hydroxyapatite cements or acrylic (PMMA) could be used. This would lower the cost about $1,000 to $1,500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am in need of an abdominal panniculectomy but my insurance has denied me saying it is cosmetic. They denied me saying it is not medically necessary because it is not preventing me from being functional. I have plenty of documentation with all my medical care providers in support of this need. What can I do?

A: The request for abdominal panniculectomies , or an amputation of overhanging abdominal skin and fat, from insurance companies is very common. As a result, they have a very specific set of criteria to be eligible for coverage. These typically include the following; a pannus that hangs down onto the thighs (photographs are required), a documented history of recurrent skin infections underneath the pannus that requires topical medications, and a six month history of these recurring skin infections that has failed non-surgical treatments.

If a proper predetermination has been done and the insurance company has denied it, then there is nothing you can do. You are legally entitled to an appeal of which they tell you how to do it on their denial paperwork. But once an appeal has been denied then that debate is over. The insurance company controls what they will pay for or won’t pay for. Their determination is based on their policy requirements and the determination of their medical director. They obviously have determined, no matter how unfair you think it may be, that your abdominal pannus does not qualify. Your only option is to have the procedure done on a cosmetic fee basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, I am a 24 year old male. I wanted to ask a question concerning forehead recontouring. I dislike my big forehead as it sticks out. I want to make my forehead smaller and flatter. I see you perform surgeries such as burring the forehead bone down. My problem is the slope of my forehead above the eyebrow area. I have attached a picture for you to get a better opinion. Do you think this surgery is possible for me? Please and thank you.

A: Thank you for sending the pictures. I can see exactly your forehead concerns. There is a bulge that starts above the brow area and extends upward, stopping short of your frontal hairline. There ius no question that can be made more flat by burring. Probably at least 5mms to 7mms can be reduced down into the diploic space to remove this bulge and make your forehead more flat rather than bulged. The only issue is one of the incisional access to do the forehead contouring procedure. It is no more complicated than a traditional open browlift procedure. That means there would be a fine line scar inside your hairline from the incision needed to turn down the scalp flap. You have good hair density presently it is just unknown, like any male, what the future may hold for your hairline. The scalp scar would be the trade-off for a flatter forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi there, I have researched a tremendous amount on the internet to find what I think I need. Although I am from the UK I am willing to travel to you for good results as you are the only surgeon that has a wide range of procedures I feel I need for my long face. I have had prior surgery to my face including chin reduction and fat transfer to my cheeks. However it’s my facial skeleton I feel that just still does not look right. My eyebrows are hooked which I see you do brow reduction which you may recommend but its the whole chin jaw nose balance I am looking for improvement. I constantly am compared to the actress Sarah Jessica Parker which I hate! So you can sort of understand my facial faults. I am looking for improvement in my facial structure and to achieve better looking eyes. Many Thanks and looking forward to hearing from you.

A: While I will obviously need to see some pictures of your face, the long face look is not uncommon. There are certain features to it that create that look besides the fact that the vertical length of the face is measurably long. Often the face is thin and skeletonized with a prominent chin and a long and narrow nose. This is undoubtably why you have had a chin reduction and cheek augmentation to try and create a counteracting effect. While this has probably been somewhat helpful, those procedures alone may not create enough of an effect. Additional procedures to consider would be rhinoplasty, brow bone reduction, jaw angle augmentation and possibly further efforts at chin reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: How is cheek shaving done and what effect does it have on the face?

A: Cheekbone reduction is done to either reduce a prominent anterior zygomatic prominence or to help narrow the width of the face in the cheek area. It can be done through either a cheek shaving technique or cheek (zygomatic) osteotomies. Cheek shaving is best used to reduce an isolated anterior zygomatic prominence. While it will result in some narrowing of the front part of the cheek, it is not a good procedure to make a big difference in the width of the face which is composed of the body of the zygoma and the entire length of the zygomatic arch. Cheek shaving is done from an intraoral incision and a burr is used to take down the projection of the zygomatic buttress from the lower lateral edge of the orbital rim down to the lower edge of the zygomatic buttress where the masseteric tendon attaches. Conversely, cheek osteotomies are more extensive and use a ‘front to back’ approach. Bone cuts (osteotomies) are made through the zygomatic buttress anteriorly and the attachment of the back end of the zygomatic arch to the temporal bone. This requires a small incision in the temporal scalp as well as from inside the mouth. This allows the whole length of the zygomatic bone to move inward, thus creating a narrowing effect in the width of the face. These two cheek procedures use different surgical techniques that result in degrees of cheekbone reduction. The selection of either technique is based on the anatomy of the patient and what their specific midface goals are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Have you ever done rigid hip implants to make the iliac crest appear wider/bigger?

A: Let me offer you my opinion and experience on this currently rare plastic surgery procedure. The placement of an implant over the iliac crests, known as hip implants, is both possible and I have done one case previously. It is done through a small incision placed over the anterior superior iliac spine. The implant is placed in a soft tissue pocket directly on top of the ridge of the iliac crest. It does not go back as far as the posterior iliac spine. While the placement of the implant is not difficult, there are several potential problems with the procedure. First, there is no preformed or off-the-shelf hip implant that is available. To make a hip implant, a buttock implant is used and carved to shape during surgery. The implant material should not be rigid like the iliac crest but needs to be soft. Therefore, flexible silicone elastomer implant material is used. Secondly, it is not possible to rigidly secure the implant to the iliac crest without making numerous incisions along its course which would be aesthetically undesireable. Lastly, the concept of having a soft moveable implant over a rigid underlying rim of bone may pose issues of feeling the implant or discomfort when wearing clothes that ride up against them. This last issue is more theoretical than proven given that so few hip implants have ever been performed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I recently had an otoplasty done and I like the way my ears are set back. They have a nice shape and position to the side of my head. I just have a problem with my ear lobes and was wondering what could be done to make them look better.

A: Otoplasty is largely a cartilaginous procedure. This means that the effects of the procedure is caused by the bending of the cartilage structure and giving it a new shape with suture stabilization. The earlobe, however, has no cartilage in it and is not affected by whatever method of cartilage manipulation is done. This can make for the upper two-thirds of the ear having a nice new position but the earlobe may still stick out afterwards.

An important aesthetic goal of otoplasty is to have a smooth and uninterrupted line of the ear’s outer helix as it goes from the top of the ear down to the earlobe. This is why I almost always reposition the earlobe back as well during an otoplasty through a concomitantly performed fishtail excision of skin on the back of the earlobe.

Secondary earlobe reshaping after an otoplasty can be done as a simple office procedure under local anesthesia. The fishtail skin excision can still be done on the back of the ear and the finishing touches to the otoplasty  can be done.    

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a single mom and have a daughter who will soon be 12 years old. She is suffering from a lot of teasing because her ears really that stick out. I think they are adorable but she has become very self-conscious and is dreading going to middle school in the fall because of her ears. I am writing to inquire of how much ear pinning would cost. Not sure if I can afford it at all as I am a single mom and have another daughter in college. So my question is how much is it and is there a possibility of payments? Thank you.

A: When the ears excessively protrude or stick out, it is not rare that a child or teenager receives a lot of unwarranted criticism because of it. While parents have been with their children since birth, they often can fail to see how bothersome their ear position or shape can be. Children frequently will not say anything to their parents about it.  Fortunately you have perceived her distress and recognize that otoplasty surgery can make a dramatic difference. Otoplasty is a fairly simple procedure that reshapes the cartilages of the ear from an incision on their backside. In a one hour operation, the ears can be dramatically reshaped so they blend in naturally and inconspicuously to the side of the head. The average costs of an otoplasty is generally in the $4,500 to $5,000 range, all costs included. You may be able to work out a discounted fee with a plastic surgeon and I would not be afraid to have that discussion with their office. Perhaps you will be able to work a ‘single mom’s’ fee reduction for your daughter’s otoplasty surgery.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a SMAS facelift earlier this year in February. I also had my eyelids done as well. I have several problems from this surgery. My eye opening is smaller than before and one of my lower eyelids is hanging down. In addition, you can not tell that I have had a facelift. It doesn’t look different or improved at all. The Dr. said he will not redo it. Will I have to get a complete facelift again? Do you do redos?

A: Anytime there is an outcome that does not meet a patient’s expectations, it is important  to determine why. There are only two fundamental reasons; there has been a complication that mars an otherwise acceptable result or there has been a fundamental miscommunication between the doctor and the patient as to what to expect afterwards. Having one lower eyelid than hangs down or is pulled away from the eyeball after surgery is known as ectropion. That is a postoperative complication that can occur after a lower blepharoplasty. If it is a small amount of ectropion and it is not that far out from surgery, then time and patience are acceptable for now. But since it is four months after surgery and there is still some noticeable lower eyelid malposition compared to the other side, revisional lower eyelid surgery may be needed. Why you see no result from your facelift is another matter. That would be an unusual outcome given the nature of how a facelift is performed. I think you need to go back and discuss your results with your original plastic surgeon. Most likely what he said was that he would not revise or redo your surgery at just 4 months after surgery. A different answer may be forthcoming with more time and if your lower eyelid ectropion persists. Only after you have given the original surgeon ample opportunity to come to a mutually acceptable decision should you pursue an outside opinion for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am going to get a breast augmentation next month. I am 23 years old. My plastic surgeon never mentioned or suggested about getting a mammogram before surgery. I have read that some plastic surgeons require it while others do not. What is your recommendation?

A: Whether a mammogram is needed before breast augmentation has no uniform answer. Every plastic surgeon has a different perspective on this issue.  My practice is to not get a mammogram under the age of 35 unless there is a family history of breast cancer or a history of breast problems such as cysts or fibromas. While breast cancer does rarely occur in younger patients, the statistical likelihood of a young patient having it is so low that I do not feel that the extra expense and radiation exposure justifies the effort. After age 35, I follow the recommendations of the American Cancer Society in regards to a baseline mammogram and subsequent studies. Some plastic surgeons routinuely get mammograms regardless of age before breast augmentation and this is a perfectly valid approach as well. You need to discuss this issue with your plastic surgeon and reach a mutually acceptable approach to the need for this presurgical breast screening study.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want a bigger butt and am interested in silicone injection buttock augmentation. How much does it cost?

A: As you may not be aware, the use of silicone injections is poor medical practice (if not illegal) in the United States..not to mention that it is a terrible procedure associated with a lot of complications. It seems to be performed only by the most nefarious of practitioners some of whom are not even physicians. I would advise you to stay well clear of this approach to buttock augmentation. Fat injections to the buttock, however, are a different matter and are an accepted method of natural buttock enhancement. This is the injectable procedure you should be considering. It has the advantage of not only being safe but gives one the secondary benefit of liposuction done elsewhere, usually on the stomach, waistline and back. Its one drawback is that how well the fat survives and takes is not always assured and only so much fat volume can be done at a single time. But that is a much better ‘problem’ and easier to recover from than infection, granulomas and skin pigmentation changes that are not infrequent problems with silicone injections into the buttocks. Not to mention that the silicone can never be removed no matter what problems it may be causing,

Dr. Barry Eppley

Indianapolis Indiana

Q: My nose is fatty from the tip area. When I smile it becomes even more broad. Should I get just the tip changed or should I go for whole nose plasty. I have attached some photos for you te see what my nose looks like.

A: When considering rhinoplasty, it is important to first look at the whole nose. While it may be that just the tip area seems to bother you, the problems with the tip may extend up into the upper two-thirds of the nose as well. This would be very common in the broad or wide nose. ln reviewing your pictures, you have a rather classic ethnic nose. (Indian) The nose skin is thick, the tip is broad, the nostrils are slightly flared, there is a hump that extends up into the upper third of the nose and the nasal bridge (bone) area is wide. In essense, your broad nose is not just limited to the tip area. Rather it is an aesthetic issue that extends throughout the entire nose. Doing just a tip rhinoplasty alone may likely leave you unsatisfied with the final result. I would recommend a complete rhinoplasty in which the hump can be removed, the bones narrowed, the tip reshaped to be less broad with increased tip rotation and the nostrils narrowed. I think you will be far more satisfied with this rhinoplasty result. The differences between a tip and full rhinoplasty can be easily illustrated with computer imaging before surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q: I desire a larger more prominent but one that is more sculpted. Can you do the a cleft chin implant with the y fissure? Or a chin dimple? I am looking for a square chin implant with the y fissure. I have a implant now but it is not squared and not exactly what wanted.

A: Chin implants today come in a vareity of styles and sizes. Some of those styles from different manufacturers include square chin implants and chin implants that have a central vertical groove or cleft in them. I find the square chin implants very effective for those men that need more transverse chin width. The cleft chin implants, however, look good on drawings and would theoretically appear to create an often desired chin cleft. In reality, however, the external appearance of the cleft may not always appear due to the effect of the overlying thickness of the soft tissues of the chin. That is why I also create a vertical groove in the muscle and sew the tissues into the clefted chin implant to be sure that an external effect is seen. Chin clefts in implants can be done with either a dimple or a vertical fissure or groove. When trying to place one in conjunction with a chin implant, it is more reliable to have a vertical groove or notch whether the implant has that shape or not. You can always take a squate style chin implant and cut a cleft or vertical groove in it at the time of surgery. That is a simple intraoperative manuever to do during chin implant augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested to find out if you could help me to reduce my facial assymetry. What would you actually perform as I am not able to even guess that, but it seems that my halves are different in jaw and forehead shape. I want to make my face more symmetrical and I want to reduce and minimize the difference of my jaw and forehead. Please advise what kind of procedure do you recommend and what would be the estimated cost. Attached is the photo so you can see and assess the treatment.

A:  In looking at your frontal view photograph, I see four isses that are making your face asymmetrical. The first is the difference in the sdie of the jaw angles between the two sides. The right is bigger than the left. That could be addressed by either a right jaw angle reduction or left jaw angle augmentation depending upon which side you like better. Secondly, there also appears to be left cheek deficiency which is less prominent than the right. That would be compatible with the left side of your face being smaller than the right. That could be improved by a left cheek implant. Thirdly, the right upper eyelid has more skin which hangs down onto the lashline. That could be removed by an upper eyelid blepharoplasty. Lastly, your nose is deviated towards the left side  with a broader tip. That could be improved by a rhinoplasty. I think the combination of these four procedures would go a long way to improving your facial asymmetry.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a subnasal lip lift as my upper lip is way too long and is getting worse as I age. I have several concerns about the procedure, hwoever, and wonder what could be done if undesired results happen. I had a previous rhinoplasty dne through an open rhinoplasty several years ago that I am quite happy with. Since the subnasal lip lift puts an incision at the base of the columella could that stretch or distort the space between my nose and lips and make it appear freakishly short? I know initially it may look a little short and that it does relax and stretch out somewhat later, but what if it doesn’t. Can any secondary correction be done if things didn’t resolve on their own? Thanks for your opinion.

A:  Your concerns about overcorrection in a subnasal lip lift, also known as the bullhorn lip lift, are very valid and it is something I think about every time I do this procedure. This is because of it is overcorrected, too much lip skin removed, there is no recovery from it. There is no aesthetic method of putting skin back once too much is removed. It is for this reason that it is always better to be more conservative than aggressive with this procedure. My rule of thumb on subnasal lip lifts is too never remove more than 1/3 of the vertical distance of skin as measured from the based on the columella down to the height of the cupid’s bow along the philtral column. Sometimes I may only remove 1/4 of that distance. Yes it is too true that it may relax and be undercorrected in some cases later. But it is always easy to repeat the procedure, it is impossible to reverse it if too much is removed.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am trying to make my face symmetrical. My jaw is not aligned, making my mouth and smile crooked and my nose is wide with a pronounced bump. I have attached some pictures for you to evaluate, image, and give me recommendations as to what to do. Thanks!

A: An analysis of your pictures shows that you do have a deviated nose with a hump and a wide tip. But in addition, you have left facial hypertrophy. This is the origin of why you feel that your jaw and smile is crooked. The left side of your face, from the orbit down to the jaw angle is bigger and wider. This creates your facial imbalance/crookedness. I have done some imaging of your rhinoplasty, with and with adjustment of the left facial enlargement. In facial asymmetry it is always a question as to whether to build up the smaller side or reduce the bigger side. In your case, I think it is better to try and make the larger side smaller through cheekbone and jaw angle reduction. This is shown in your rhinoplasty front view imaging, both with and without it being done. From a side view, I have also added a small chin augmentation as your profile shows some mild horizontal chin deficiency.

I think the combination of rhinoplasty, cheekbone and jaw angle reduction and chin augmentation can make for a more symmetrical and balanced face. This will not change the asymmetry in your smile as that is soft tissue-based and can not be adjusted like the underlying harder facial structures.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have lipoatrophy and would like to perhaps have my face lifted and cheeks implants placed in order to achieve a fuller, rounder appearance so I am able to appear the age that I am which is age18. I sent in earlier pictures and I was smiling in them and was told they were unusable so I sent these.

A: Thank you for sending your additional pctures. You probably have the most severe case of facial lipoatrophy that I have ever seen in someone your age. Facial lipoatrophy is classified on a scale of 1 to 5 based on its severity. You are clearly at least a 4 if not a 5. You face is completely skeletonized with essentially no fat, thus resulting in hollowing of the temporal, submalar, maxillary and lateral facial areas. This problem is not treated by any form of facelifting. Rather it requires volume addition, most of whcih must be fat not implant. Submalar implants would be helpful in the cheek area but most of the volume addition must come from fat injections due to the size and location of the hollowed areas. The important question is….do you have enough fat to harvest and transfer? Most medically-sound people with severe facial lipoatrophy are also thin in their bodies, thus having little fat to harvest for the procedure. At a minimum, you need about 30 to 35 cc of concentrated fat per facial side (in addition to the submalar implants), which means that 150cc to 200cc needs to be harvested from somewhere, usually the abdomen or thighs. While that is not much and easy to get from most people, your body may be a different matter.

The pictures you sent are not easy to show the results of volume addition, which is virtually impossible to image from the side view. The front view imaging is not great but it demonstrates what happens when your facial hollows are filled in or expanded. Just think of your concave facial regions becoming more even with the surrounding bone structure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have been researching how to make my cheek area look better as it seems to be kind of flat and has no cheek highlights, plus my face is a little round. It seems I have two choices, cheek implants, buccal fat removal or some combination. In my research I have reading that cheek augmentation would be better than the buccal fat removal as far as years down the road as I may not like it and it may look like I am older than I really am. Just doing some research on this subject. What is your opinion? Thanks for your help.

A: Both cheek implants and biccal lipectomies do impact on the appearance of the midface. While they are in close proximity, they create different midface effects. Buccal fat removal decreases the fullness below the cheekbone area. If the complete buccal fat pad is removed then a gaunt look may eventually appear is some patients. The key is subtotal reduction, particularly in someone who does not have a ‘fat’ or round face. Cheek implants create a different effect as it brings out the prominence of the bone above the buccal fat area. These can be not so subtle differences and you have to look and play with your own face to see whether more cheek or less fullness below it is better. They are not necessarily interchangeable procedures. Whether one is better than the other, or whether a combination of both is best, is determined by one’s facial shape and must be decided on an individual basis

Dr. Barry Eppley

Indianapolis Indiana

Q: I had cheek and jaw angle implants last year. While I think I look better, I still feel my face does not have enough definition and is still a little too round. What do you recommend that will help my facial aesthetics? I have attached some before and after pictures from my previous surgery.

A: Thank you for sending your pictures. I think you have achieved some facial highlights from your previous procedures but implants also add width and volume. In certain faces this can make one’s face look a little ‘fatter’ or fuller and not always provide the definition that one wants. This can be particularly true with jaw angle and cheek implants. To create some further facial refinement, I would recommend buccal lipectomies to slightly narrow the area below the cheek implants, a chin implant with a prejowl extension to smooth out the jawline better (your chin is slightly deficient and there is a notch in the jawline at the prejowl area) and possible a jowl tuck-up to remove some skin along the jawline an give it better highlights and a possible thinning rhinoplasty. The goal now is to create more definition in your face and help better highlight the facial features that you now have.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I need to do something with my stomach to make me feel better about myself. I have had two children and the last one really did my stomach in. I didn’t have any stretch marks or loose skin after my first child. But I gained 45 lbs with my second and obviously my skin didn’t like that and now I am left with some loose skin and stretch marks particularly around my belly button. I did have a plastic surgery consult about six months ago and was told that I needed a mini-tummy tuck with a ‘free floating umbilicus’. I didn’t understand what that was and I was worried that my belly button would move around so I never had the surgery. Can you tell me what that is and should I be concerned about it?

A: The fundamental difference between a full or complete tummy tuck and a mini-tummy tuck is in how much skin and fat is cut out and where this occurs. In a mini-tummy tuck this tissue removal is done below the belly button as opposed to a full tummy tuck where it is done above and includes the skin around the belly button. Thus in a mini-tummy tuck, the underlying attachment of the belly button to the abdominal muscles (technically the fascia covering of the muscles) must be released so the upper abdominal skin can stretch down and close to the lower abdominal incision. Before closure the base of the bellybutton is reattached in a new lower position, usually about an inch or so lower than where it was originally. It is only ‘free floating’ for a very short period of time during surgery and is not an issue after surgery. The term free floating is both an historic and poor name which is why it is better known as umbilical transposition or relocation.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am 62 years old and I am thinking about getting breast augmentation. I got divorced recently after 35 years of marriage and want to start dating again. I think breast implants will make me feel and look better, not to mention more appealing. My breasts have shrunk and have gotten quite floppy over the years. Do you think I am nuts for considering this cosmetic procedure at my age?

A: I don’t think there is an upper age for breast augmentation or any other cosmetic procedure. If one is healthy and in good physical condition, then there should be no problem with undergoing this surgery. The more important question is whether breast implants alone will create the result you want. With advancing age, the breasts not only lose volume but develop more sagging or ptosis. If the nipple is pointed south or hangs at or below the lower breast crease, then some form of a breast lift will definitely be needed in addition to an implant.  If the nipple sits above the lower breast crease then breast implants alone will create the look you want.

Today’s 60 is yesteryear’s 45 or 50 so your request, while not common, is both reasonable and medically safe.  The oldest breast augmentation patient I have performed was 64. It is also important to remember that breast reconstruction is regularly done on patients your age. So the desire to look normal and or even be enhanced is not limited by age.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in getting breast augmentation but am confused about what size of implant I should get. I am 5’ 4’ and weight 115 lbs with a small A cup and I mean really small. I wear a 32A bra. I want to be a small to medium C cup but don’t want to look like I obviously have breast implants or a look like some entertainer. What is the best way to go about selecting the size of the breast implant that looks best on me?

A: For any woman undergoing breast augmentation, size is the number one issue they understandably think the most about. Plastic surgeons have numerous methods of how they size patients and there is no uniform method for doing so. The ‘safest’ method of breast implant sizing is matching the base diameter of one’s breast to the base diameter of an implant. Each size of breast implant has an increasing base diameter as the size or volume of the implant gets bigger. With this approach there is no fear of the implant being too far to the side (in the way of the swing of the arm) as it is matched to one’s natural breast dimensions. There is also no fear that the implant will ever be too big. Conversely it is more likely that for some women the final result may not be big enough with width dimension alone so it shouldn’t be the only criteria used. But it is the one that can  be specifically measured and is unique to each patient.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have 3/4 inch gauges in my earlobes which were taken out 6 months ago. I would like the holes sewn up so I have normal looking earlobes again. I want this done asap, please contact me soon. Thanx!

A: Thank you for your inquiry. Please send me a picture of your ears so I can see how big the residual holes are. The good news is that gauged earlobes create an excess amount of lobe tissue, making a good reconstruction possible albeit with a few fine line scars. This procedure is very common for me so all arrangements can be made to do the repair as an office procedure under local anesthesia in advance to save you a separate consultation trip.

The earlobe reconstruction takes about an hour to do for both ears. Sutures are placed on both the front and back of the earlobe. Only those on the front of the earlobe need to be removed 7 to 10 days later. (if one is from out of town dissolveable sutures are used on both sides of the earlobe so removal is not necessary) There is no dressing applied and no special wound care other than to apply a little antibiotic ointment. You may shower and wash your hair the very next day. There are no after surgery activity restrictions. Within a few months the earlobe scars fade to a near indiscernible appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to know if there is any procedure that can be done to reshape or reduce the muscle on the tip of my chin. I had a sliding genioplasty in 2005 but I still have this round fleshy muscle on the end. I know the muscle is functional but can it be reduced at all or reshaped? I can send pictures if you would like. Thanks so much.

A: What you are referring to is the size or thickness of the mentalis muscle. That certainly makes up some of the chin thickness but there is also some contribution by fat also. Some debulking of the mentalis muscle can be done but you have to be careful not to take too much. That can cause  scar tissue and lead to irregulrities and muscular fasciculations when the chin moves. But it may benefit by some debulking and repositioning on the chin bone since you have had a prior sliding genioplasty. I would have to see some pictures to have a better idea as to whether that is a reasonable option.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Dr Eppley, I had chin implant taken out before the doctor tried to sew the intraoral incision under the lower lip 3 times to fix numbness and droppy lower lip before taking the medium silicone chin implant out which was put intraorally. Now after 6 months the pain and numbness is gone but the chin is droppy due to all these surgeries. Do you think a sliding genioplasty will make the chin look less droopy and, if it is possible, to also slide it forward and bit upward? Where I live the surgeons are not advanced as you Dr Eppley. I tried to call the manufacturer who supplies dissolvable bone anchors but they did not know anything about this treatment. Please advice me something as I have lost all hope.

A: The concept to grasp about the placement of a chin implant is that it stretches or expands the existing chin tissues. In essence, it creates more soft tissue than was originally present. This combined with disruption of the mentalis muscles off of the bone over a  projecting prominence make for a potential problem if the implant is ever removed. Without implant support, the chin soft tissues will sag or become ptotic. There are multiple strategies to deal with this chin problem but a sliding genioplasty can be a very effective solution. As the chin bone is advanced, it not only increases chin prominence but adds underlying volume to support the sagging expanded soft tissues. While I would have to see pictures of you to be sure, this sounds llike an excellent solution to your chin problem.

Dr. Barry Eppley

Indianapolis Indiana