Your Questions

Q: Dr. Eppley, I am primarily concerned with the lower third of my face. I think my chin is too long and pointy which contributes to the long, thin face look. Do you think a chin reduction combined with jaw implants or a pre jowls chin implant would do the trick? If so, do you perfom such procedures? Do you have any other suggestions as to how I could improve my facial features? Please do not be afraid to hurt my feelings!

A:Thank you for sending your pictures. Your long thin face is partly the result of a long sweeping jawline with a modestly steep mandibular plane angle.  This makes for a lower face that appears vertically long. This is magnified by the observation that your midface (cheek and paranasal areas) is relatively flat/recessed. That combination makes for what you see,, a face that has a greater vertical component than horizontal projection and width.

To address this concern, I would recommend a chin osteotomy which, based on the angle of the cut, allows the chin to become vertically shorter as it comes forward. You need both a mild amount of horizontal increase with an equal amount of vertical reduction. Only an osteotomy can make this bony chin movement possible. In addition,. I would place jaw angle implants that both widen and vertically drop the jaw angles downward. Between the chin and the jaw angle changes, the lower third of your face would become shorter and wider. That will help counter the long thin face look. I have attached some predictive imaging to illustrate these changes.

The other change that would be helpful is cheek augmentation. That would bring the midface more forward, again a manuever that counters the vertical and thin (horizontally deficient) facial appearance. I have attached an image that shows where this cheek augmentation would be. Your pictures are not of a good enough quality to really show what cheek augmentation can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 56 year-old man who has always had a weak chin. While I have always wanted to do something about it, I could just never get the nerve to go in and see a plastic surgeon. My girlfriend has given me the encouragement to now do and I am going to make the move to see what is possible. Could you give me some direction in what you think I need? I think the problem is more than just a short chin, my overall jaw just seems smaller. I don’t want to get a chin implant placed on the end of my jaw if it does not look right or natural. I have attached some photos of me from the front and side for your evaluation.

A: Having a weaker jaw/chin in an older male always raises questions about both bone and soft tissue management since there is some degree of sagging of the jowls and neck. While you would undoubtably be helped along the jawline with a facelift (neck-jowl lift), I am going to pass over that issue for now as dealing with the bony deficiency should always been done first. Since a lower facelift affects the posterior jawline and neck angle the most, it would have its greatest effect on the jaw angle area. Whether you would benefit by jaw angle augmentation or a total jawline procedure is unclear to me at present. (and also unlikely) Therefore for this discussion I am only going to focus on your chin deficiency and submental fullness which are your biggest facial imbalance issues.

What you need is a chin implant and neck liposuction/submentoplasty. The question is whether a preformed or off-the shelf chin implant will work or whether a custom implant is preferred. Both will make positive changes. It is just a matter of degree and how substantial that change is. You do have both horizontal, vertical, and transverse (width) chin deficiency which is common when the chin is very weak. The problem, as you have accurately pointed out, is really an overall jaw growth issue not just a simple short chin. This makes the entire lower face short in every dimension.

I have done some predictive imaging based on both off-the-shelf and custom implant approaches so you can get a feel for how the two type of chin implants differ. A custom chin implant will address all dimensional deficiences. and produce a more profound change..if one finds that look appealing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just had a old tragus piercing split. Is this something that can be stitched back together or will the skin grow back? Or does it require plastic surgery? If the latter, will it look normal after plastic surgery? Thanks.

A: While piercings are common on both the earlobe and the tragus of the ear, there is one anatomic difference between them. The earlobe is completely comprised of soft tissue, skin and fat only, and this is what holds the piercing in place. The tragus, however, has a central core of cartilage with skin on top. It is the cartilage which holds piercing in place and it is usually much more secure and resistant to stretching unlike the earlobe. When a tragal piercing splits, presumably by it being pulled on, the underlying cartilage may have split as well.

Like the earlobe, a tragal split will heal on its own due to the excellent blood supply. Whether it will heal with a notch or cleft in it is impossible to say. I would allow it to heal on its own and see what it looks like later. Scar revision can always be performed of the contour of the tragus is not perfectly smooth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar from a tummy tuck in 2007. I also have scarring under my breasts from a lift and augmentation at the same time. While the mommy makeover boosted my confidence by not having sagging skin it also left me with these horrible scars. While I can cover them up in a bikini when I couldn’t cover up the sagging skin, it still leaves me very shy and not confident when I have no clothes on. It doesn’t seem fair that I spent so much money in 2007 for a mommy makeover to be left with such embarrassing scars. I don’t know if you can help me but I would appreciate your advice. Thanks so much.

A: While the combination of a tummy tuck and breast implants with a lift can remake the female torso altered by pregnancies, there is always the tradeoff of scars. While these breast and abdominal scars are usually quite acceptable, there is always the risk that they may not be so. When the scars are not aesthetically pleasing it is almost always because they are widened or hypertrophic. Improvement in these scars can be achieved by revision consisting of excision and re-closure. The scar outcome is likely to be improved because the tension or tightness on them will be much less now than the original procedure where much more tissue was removed. While the scars can not be removed or significantly repositioned, they can be narrowed such scar revision surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, While searching the internet I found a program that allows one to change things on their face. I have always been interested in having a nosejob so I went ahead and did my own picture. I really like how it turned out as I have always wanted a thinner looking nose. My question is whether you think I could get such a result from actual surgery. The skin on my nose is thick so I don’t know how realistic this program is?

A: Morphing or imaging programs are very valuable is aesthetic facial surgery, particularly in rhinoplasty surgery. Their accuracy in predicting achieveable results, however, is primarily determined by whom is doing the imaging. The computer software is just a tool and has no ability on its own to predict how body tissues will respond to surgical manipulations and healing. Only the user of the computer tools who is a rhinoplasty surgeon can use them to demonstrate results that may actually occur.

 What you have demonstrated by doing your imaging is what you would like. While I agree the change is very favorable, it is not realistic. One of the most difficult problems in rhinoplasty is the male with thick nasal skin. While the cartilage underneath the skin can be changed and reduced, the thick nasal skin often dampens what is seen on the outside. Realistically, you can achieve the amount of nasal thinning that is about half of what you have imaged.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 57 years old and have just discovered that my hidden penis condition can be treated and improved. I have suffered through my teenage years and adulthood with the taunts  in gym and the odd looks of women when I could of had something done about it! Doctors told me that I was OK and said that some men have an inee and others have an outee. I knew that something wasn”t right. My folks and the doctors back then could circumsize me, but they couldn’t fix this! While most of my sex life has passed me by at this point, I’d still like to look normal before I die.

A:  While having either an inner or an outie may be normal for the appearance of the bellybutton, it definitely is not normal for penile exposure. The buried and hidden penis is often a developmental condition that can become apparent early as a child or in the teenager years. It is caused by a tethered or retracted penis that is often accompanied by a larger surrounding suprapubic mound. This combination can frequently result in partial or complete coverage of the penis. While a majority of buried penis cases do occur  in males that are overweight, it is not exclusively so. This penile problem can be improved by a combination urologic and plastic surgery approach. The buried penis needs to be released while the suprapubic fat mound needs to be reduced by liposuction with or without a suprapubic lift. While there are some cases where suprapubic mound reduction alone is sufficient, most long-standing cases in adults benefits by dealing with both anatomic issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead contouring surgery. My forehead is kind of rounded and I would like to have it more like square-shaped. When looking at a profile view my forehead sticks out where my brows are and my eyes look deep in the face. I also have attached a picture of a gentleman that his forehead looks more like square and that is exactly what I’m looking for or something close that will reduce my forehead. Thank You

A: Thank you for sending your pictures. Your forehead shape is a combination of brow bone protrusion and an upper forehead that slopes backward. Together this gives your forehead a 50 to 55 degree backward slant in a profile view. The desired forehead shape that you have shown is almost completely vertical. While that is not completely possible from the forehead shape that you have now, you can make significant improvement in your current shape. To change the slant of your forehead, you need to address the two components of the problem, brow bone protrusion and upper forehead retrusion. This is done through a combination of brow bone protrusion and forehead augmentation above the brow bone area. Neither brow bone reduction or forehead augmentation alone will make this improved shape. It takes this combination ‘ying and yang’ approach to create the substabtial forehead shape change that you desire. I have attached an imaged result of what I can think can be achieved by this approach. This would be done through an open coronal incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year-old female who has been considering breast enlargement for a long time. My right breast is significantly smaller than my left breast and I have never been comfortable with them being so lopsided. I am pretty sure that I want this procedure done but I am a bit nervous about how they will be made more even. I don’t want to larger breasts that are just as lopsided. How would you go about making my breasts more even?

A: Congenital or developmental breast asymmetry is one of the most challenging problems in breast augmentation. This is because the two breasts are not different in just mound size but also in the amount of overlying skin and in the position and size of the nipple-areolar complex. While implants are an integral part of this ‘reconstructive’breast augmentation, consideration must be given to adjustment of the nipple position as well as a possible staged approach using  a tissue expander if the asymmetry is severe enough.

The key phrase here is ‘making your breasts more even’ or decreasing the magnitude of the breast asymmetry. Perfect breast symmetry is not possible in these cases and one has to be prepared for a higher risk of the need for revisional surgery to try and achieve the best result. Breast implants alone, while making the breasts bigger, often unmask or reveal the many differences between the two sides in breast asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a zygomatic surgery four weeks ago. My right cheekbone was broken.  The swelling has not completely gone down yet, but I can not understand the asymmetry in my face. My question is when these swellings will go away completely?  I feel very anxious about if my cheekbones will  have good symmetry again. It seems like I still have a collapse in my cheek bone even though there still is swelling present.

A: There is no question that zygomatic fracture repair can be associated with a large amount of eye and cheek swelling, particularly if it required a combined intraoral and eyelid incisional approach. Less swelling occurs from a more simple intraoral reduction. Since I don’t know the classification and magnitude of your cheekbone fracture and how it was treated, I can not say with any certainty about when most of the swelling will subside. But six weeks is a good time period to judge the results even though it may take until three months for all swelling and tissue contraction to occur.

However if in the face of swelling a cheek bone fracture repair shows persistent asymmetry, it may well be that the fracture repair was inadequate or not stabilized ideally. If this is the case, it is still possible at six to twelve weeks after surgery to do a revisional fracture repair with an improved outcome. (secondary facial fracture repair) Very delayed zygomatic fracture repairs may require camouflage procedures such as a cheek implant and/or combined with an orbital floor implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I gave birth to twins over three years ago and since then I now have an abdominal hernia and umbilical hernia due to my abs splitting from being pregnant with twins. I also just have extra skin that exercise will not help with. I currently have surgery scheduled for next month with a general surgeon to fix my hernias. He is doing it laproscopic. I was curious if you would be able to fix my hernias by repairing my abdomen muscles and removing my excess skin. Or if you could do the tummy tuck the same time as my surgery with the general surgeon so that would reduce my anesthesia cost and then my insurance would cover some costs. Please let me know your thoughts.

A: Your questions are good ones and fairly routinue inquiries in regards to combining tummy tucks with hernia repairs. Let me discuss the aspects of such a combination from both a medical and financial standpoint.

Most hernias from childbirth are going to be in the midline between the rectus muscles and around the umbilicus. This would be the standard location for a woman who has been considerably stretched from having twins. In a tummy tuck procedure an umbilical hernia would be encountered, reduced and repaired with the midline rectus muscle fascial plication that is almost routinue in most tummy tucks. I have done this many times and there is good logic in combining these procedures in terms of operative efficiency and recovery. If an open tummy tuck is being done then there would be no need to do a laparoscopic approach to a hernia repair.

The issue of doing the two together through insurance is the intriguing twist to this combination. Contrary to popular perception, there is no financial benefit to putting these procedures together. Many years ago there was but those days have long passed. The hospital is fully aware that a tummy tuck is being done and will charge a full rate for the tummy tuck procedure including OR and anesthesia charges. There is no such thing anymore as the insurance covering the OR and anesthesia charges for a cosmetic procedure when done with an insurance covered operation. Both the hospital and the insurance company consider that fraud so there are extremely vigilant about that issue. Interestingly, doing a cosmetic procedure with a covered insurance procedure in a hospital could very well end up costing you more, a lot more, than having a tummy tuck and the hernia repair being done in a surgery center on a purely cosmetic basis. These are the realities of today’s hospital and insurance economics.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had a bone cement for 10 months on my forehead and this was done by my neurosurgeon. He had to elevate the depression on my forehead and on my frontal sinuses due to an accident 10 years ago. I am planning to learn mixed martial arts in a few months but I am worried that my bone cement will get hit and break. Is my bone cement as strong as the rest of my skull? Thank you very much!

A: The term ‘bone cements’ refers to a family of synthetic materials that can be used for cranioplasty purposes. Historically, this used to refer to the material PMMA or acrylic which has been used for over fifty years in cranioplasty surgery. This is still a very common material that is used by many neurosurgeons in particular. It is mixed together and creates a very strong composition similar to what most people known as plexiglass. This would resist any type of trauma much like normal skull bone would do. In the past decade new cranioplasty materials composed  of various forms of hydroxyapatite have emerged which are also known as hydroxyapatite cements (HAC) or bone cements. These are not nearly as strong and are much more brittle. These are more likely to fracture if exposed to trauma.

Your cranioplasty was an onlay or augmentative one in which whatever material was used was placed on top of existing but depressed skull bone. This is much more supportive of the cranioplasty material than if it was used to replace a full-thickness cranial defect so impact resistance is greater regardless of the material used.

If you had a PMMA cranioplasty I would have no concerns whatsoever about sustained implacts. If this was a HAC cranioplasty, however, I would be more cautious.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Many years ago I had an absessed septum in my nose and had to have emergency surgery. The doctor wanted to do plastic surgery after the procedure due to the excessive loss of cartilage in the nose, but because of the trauma of the initial surgery, I did not want it. After many years, I wish I had done the corrective surgery. Is there a chance that insurance might cover some of a corrective nose surgery for me after so long?

A: Loss of portions of the septum due to infection or hematomas creates, sooner or later, collapse of the overlying nose. This creates what is known as a saddle nose deformity with collapse or inward deviation of the dorsal line of the nose. With the sinking in of the middle vault, the tip of the nose will turn upward with excessive nostril show. With loss of portions of the septum there may also be a hole or perforation of varying sizes between the two sides of the nasal airway inside.

 Reconstruction of a saddle nose almost always requires a rib graft to rebuild the dorsal line of the nose. The septum usually is not and cannot be rebuilt due to loss of lining nor would it have any influence on the appearance of the outer nose. Such rhinoplasty procedures would most certainly have some coverage under one’s health insurance due to the medical basis (infection, loss of septum) for the cause of the problem. This would be ascertained before surgery through an insurance predetermination process.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation last year and was advised before surgery that I needed a breast lift also to get the look that I wanted. I have had two children and had a bit of breast sagging. But I didn’t want the scars or the extra expense at that time. Now I have come to realize that the doctor was right and feel now that the scars would be better than the way the breasts look now. The implants have actually made my breasts look worse even though they are bigger. Can I still get a breast lift now even though I already have implants in place?

A: For those women who have some minor amounts of breast sagging that present for breast augmentation, the idea that they need a lift as well is often a bit much. Due to concerns about scarring and the extra expense from a simultaneous lift, they may defer and let the results ‘prove’ that a lift is beneficial or not. While in hindsight you may have regretted this decision, the possibility of avoiding scars and saving some money was not an unreasonable one. Now that you have the implants in place you can certainly go on to a have lift as a ‘two-stage’ approach to your breast enhancement. The good news is also that you might get a better breast lift result because of working with an established breast mound underneath from the previously placed implant. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very petite frame and am 5’1”and weight 108 lbs. But despite this small size I have a little area of stubborn belly fat that won’t go away. My weight doesn’t fluctuate that much and runs anywhere from 105 to 110 lbs. If I get this fat removed by liposuction what are the chances that it will come back? Since my weight fluctuates a little while this cause it to return?

A: The retention of liposuction results is definitely influenced by one’s weight. I tell all my liposuction patients that the long-term reduction seen will only be as stable as one’s weight and it also depends on what body area has been treated. The abdomen and waistline for both men and women is the area at greatest risk for fat return after liposuction since it is a primary depot site for excess caloric intake. However given your small frame and the relatively minor weight fluctuation that you have, this should not be a significant concern since you are talking about a weight fluctuation that is around 5% of your  total body weight. Fat return is more likely when weight increases are in the range of 10% to 15% or greater.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard that some breast augmentations have resulted in a decrease in feeling or sensation in the breast, especially the nipple area. Is it true that a breast lift can be done in a way that will not result in the loss of feeling?

A: While the potential for loss of some or all of nipple sensation can occur with any breast operation, that risk differs based on what type of breast surgery is being done. Breast augmentations and breast lifts are both procedures done to enhance the look of the breasts. But they are completely different operations and should not be confused in their potential effect on nipple sensation. Breast augmentation involves the placing of any implant in a pocket either on top of or under the chest muscle. It is in essence an ‘internal’ breast procedure whose pocket dissection may place at risk nerves that are making their way to the nipple from the chest wall through the breast tissues. Breast lifts are done by removing skin, lifting the breast tissue which contains the attached nipple upwards and tightening the remaining skin around the elevated breast mound. It is thus largely an ‘external’ breast procedure and does not usually involve dissection near the nerves that supply sensation to the nipple. These differences make the risk of decreased nipple sensation greater in breast augmentation than in breast lifts. Often implants and lifts are combined which pose the greatest risk to nipple sensation.

There are different types of breast lifts and some have virtually no risk of changing one’s nipple sensation. These are the first three types of breast lifts (superior crescent, periareolar and vertical) which do not involve dissection around the base of the breast mound.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old African-American female who is in need of a serious tummy tuck. I have had three children, the last two by c-section. I have a large amount of lower stomach skin with a lot of stretch marks. It makes my belly button look odd and almost buried with the loose skin around it. If I get a tummy tuck will they be able use my c-section scar? I need a tummy tuck so bad that if I had to have a new scar above the c-section scar I could live with it. But I would like if possible to keep it low and just have a longer c-section scar.

A: This is a common question and concern and one I think about when doing a tummy tuck in every women that has a c-section scar. I always want to use the c-section scar whenever possible for two reasons. The first is the one which concerns you and that of the unsavory cosmetic issue of adding another scar to the one you already have. But a more important consideration, and the one that I am most concerned with, is the survival of the skin between the two scars if the c-section scar could not be used as part of the tummy tuck. The intervening skin between these two scars may not have a good blood supply and could either not heal well or actually die…which would obviously create a significant after surgery complication. For this reason every effort is made to use a c-section scar in a tummy tuck and if you have as much loose skin as you describe this would not be a problem to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am hoping to reduce the size of my bulging head and brow bone to get an even and a more natural look. Please take a look at my pictures and tell me what you think.

A: There is no question that you have a significant forehead bulge or protrusion. In looking carefully at your pictures you can see a narrowing behind the forehead bulge running down the sides of the skull exactly where the coronal sutures would be. This suggests the reason for your forehead bulging is some variant of coronal craniosynostosis, probably a partial craniosynostosis deformity. Whatever the reason does not change how you might approach forehead reduction. While the most effective procedure would be removal and reshaping of the entire forehead bone flap and the skull bones behind it, this type of craniofacial surgery can only be done in infants and not adults. This is due to the inability to mold bone in an adult skull. Therefore, the only option as an adult is whether external bone reduction by burring would make a significant difference. That question can be answered by plain lateral skull x-rays. This x-ray would allow a measurement to be made as to the thickness of the forehead bone and, more specifically, the thickness of the outer cranial table and underlying diploic space. If up to 5 to 7mms of forehead bone can be reduced over the entire forehead, this may make enough of a difference to justify this approach to forehead reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several keloid scars that need to be treated. I had a submental tuckup procedure done and at the same time had a mole on my chest removed. My submental tuckup procedure was done in an unconventional fashion as it included removing neck skin vertically and not just horizontally under the chin. I now have a wide and raised keloid scar on the vertical scar in the neck as well as the one on my chest. I have done some research and have read about the use of steroids with scar revision. Do you think this combined approach will work for me? I have attached some pictures of the scars in question.

A: In looking at your pictures what you have on your chest and neck are not keloids. Those are known as hypertrophic scars which are quite different biologically from a keloid which is a true pathologic derangement of scar formation. Hypertrophic scars often result in very predictable areas, such as the chest and vertically in the neck, due to the tension that is placed on the scar line. Treatment of hypertrophic scars is excision and reclosure, not steroids. Steroids will likely result in a recurrently wide but depressed scar as it interferes with collagen formation and wound healing. Steroids should only be used in true keloids that are recurrent and not hypertrophic scars. The location of your two scars in question places them in jeopardy for hypertrophic scar formation, even with scar revision consisting of repeat excision and closure. But this is still a worthwhile effort to do and improvement in the appearance of the scars is likely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting some information on breast augmentation, particularly about the costs involved. Also if a lift is needed does that effect the cost and by how much? Thanks.

A:  The cost of breast augmentation is fairly standard and only differs by whether one uses a saline ($4700) or silicone implant ($5800), all costs included. If a lift is needed, there are additional costs. What those costs would be would depend on what type of breast lift is needed. There are four different types of breast lifts that differ based on how much and where the scars are located, the amount of the lifting effect that is created and the time it takes to do it. The complexities of the need for a breast lift and what type is best can only be determined by an actual physical examination and discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get breast implants but I am concerned about them since I work out a lot. Am I at increased risks for problems if I run a lot and lift weights? Also should I have them placed above or below the muscle?  I don’t want them to look and move unnaturally. I also don’t want them to be too big so what size do you think I should get? Thanks!

A:  The debate about whether one should have their breast implants above or below the muscle is largely an historic one for most women. The benefits of being under the muscle, or a dual-plane approach, are significantly superior in the long-term. This would be particularly true in an athletic woman who often has little breast tissue to interface between the skin and the implant. Breast implants placed partially under the muscle tend to have fewer problems with visible rippling, long-term encapsulation, and interference with mammograms.  These advantages outweigh the potential for implant movement that can occur with pectoralis muscle flexion.

When it comes to implant size, this consideration would be of particularly significant in an athletic woman. You don’t want the implant size to interfere with any exercise activity. This basically refers to getting the implants too far to the side so it gets in the way of any arm swing. The best way to avoid this potential problem is to not get an implant whose base diameter is bigger than one’s own natural breast base diameter. This simple linear measurement will always avoid having a breast implant that looks too big as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need some type of implant to correct my severe case of temporal hollowing. I have looked at some of the available temporal implants that are available but they don’t seem thick enough to me. What type of temporal implants do you use? Do you use the silicone ones or the Medpor ones? What is the most thickness that I can get in a temporal implant?

A: Silicone temporal implants are but one type that I use. The largest commercially available temporal implant, in terms of thickness, is the silicone temporal implant. The largest silicone temporal implants measure 6cms x 4cms with 10mm thickness at one end. That would be more than adequate for the vast majority of patients. It can be quite surprising how ‘small’ an implant may look when holding it your hand and then how much change it actually makes when put in place. I have been surprised many times and have learned with many forms of facial implants that changes can be much more dramatic in place than one thinks, no matter who well one has measured and thought about the defect beforehand.

If one really needs a thicker temporal implant, it can be made through a custom fabrication process. But it is important to remember that subfascial temporal implants can only be so thick or they will be very difficult to fit into the tight space. Much thicker temporal implants need to be placed in a submuscular location which requires a more extensive scalp incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very severe case of dark circles under my eyes. I am 30 years old and am of Indian ethnicity. I know this is a common problem in people of my heritage. I have tried numerous topical crèmes for dark circles but none of them have done anything. I am sending you some pictures for your assessment. Do you think there is anything you can do to help me?

 A: Thank you for sending all of your pictures. There is no question that you have is a fairly severe case of dark circles. Much of it is actual skin hyperpigmentation rather than a hollowing effect.  And the zone of skin hyperpigmentation extends fairly far outward from the eyelid area. I don’t think on seeing this extensive collection of photos that you have a really significant tear trough or hollowing problem. There is some mild hollowing but that is not the true cause of the problem, the hyperpigmentation of the skin is.

I don’t know how much improvement can actually be obtain in such a severe case  of dark circles but some effort is certainly justified given the magnitude of the problem. I would approach your dark circles with a combination procedure of fat injections to fill out some mild hollowing, a pinch lower blepharoplasty to remove some excess skin (you do have some despite your young age) and a 25% TCA peel to try and remove some of the superficial hyperpigmentation. 

How effective this combined approach would be is undetermined and I would never assume it to be a complete cure or solution…as there is no such thing with such severe dark circles. The goal is to see what degree of improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been working out for about three months now, and the first thing that always goes first are my breasts. I am currently a 34B, and I would like to be one cup size bigger. I looked at your before and after photos, and they look very good. I know I want them, but the cost is a big factor. Would I have to schedule a consultation with you in order to know how much it would cost? Thanks so much.

 A: Your description of the desire for breast augmentation is a common one. Whether it be from weight loss, exercise or pregnancy, breast tissue shrinkage or involution is one of the most common reasons for why women want breast implants. Their desire is to either return to a breast size that they once had or just get some more volume to fill out deflated and saggy breast skin. When it comes to determining cost of breast augmentation, an actual consultation is not necessary. The pricing of breast augmentation is one procedure in most plastic surgery practices which is fairly ‘standard’ and usually published. In my practice it would be around $4700 for saline breast augmentation and $5800 for silicone breast augmentation, all costs included. This pricing assumes that no other procedures are required such as any form of a breast lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are the various mini- or limited types of facelifts effective and how long will it last?

A: The numerous type of franchised forms of quick recovery facial tuck-ups are well known versions of limited facelifts or a jowl tuck-up procedures. There is nothing magical or unique about this operation or approach. It is a scaled down version of a more complete facelift or a neck-jowl lift. It can be very effective if done well and will get years of sustained improvement which will vary by a patient’s skin type and genetics. It could be anywhere from 5 to 10 years depending upon where one starts and how well one ages. The more relevant question, however, is whether this type of facelift approach is right for you. The vast majority of unhappiness with these franchised named ‘mini-facelift’ is that the patient wasn’t a good candidate. Their facial aging issues were more advanced and they should have had a fuller facelift to get the kind of result that they were expecting. Patients understandably are tempted to choose a facelift operation based on how it would be done (local or IV sedation), a short recovery and/or a low cost rather than choosing a facelift operation that better fits their actual needs. This is the real issue you should be thinking about.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I been looking for a expert on lip reduction for a very long time. About five years ago I had silicone injected into my upper lip and I have regreted it everyday since,  its ruining my life. I would really appreciate it if you could just give me a honest answer as to what be done about it. I want my four front teeth to show again and make the upper lip smaller than my bottom lip. I have attached some pictures of my lip including what it looks like underneath.

 A: Based on your pictures I can see that there are many bumps on the underside of your upper lip on the mucosal surface. This would likely be the location of much of the silicone material, either being pooled collections of the oil or silicone granulomas. While it is probably impossible to ever completely get rid of all of the injected silicone material, the good news is that much of it appears to lie in the tissue zone of excision where an upper lip reduction would be performed. A lip reduction typically removes mucosa from the inside of the lip from the junction at the wet-dry vermilion. This allows the upper lip to roll in and become vertically shortened. Where this tissue is removed is also where most of your bumps are so you would get a dual benefit of a less full upper lip and some of the silicone material removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How could I get any lifts or tucks via my insurance which is Medicare. I know alot of it would be seen as cosmetic. However,  I can assure you  that all I want is to look normal and able to wear real clothes and not tents. I’m 45 and need my life back.

 A: While all plastic surgeons are emphatic to your plight, the reality is that Medicare will simply not provide coverage for any type of so-called ‘lift or tuck’ procedures such as tummy tucks, pubic lifts and thigh lifts. Medicare is unique amongst insurances in that it will provide no predetermination before surgery to validate whether it will or will not pay for such procedures. Having provided a lot of these services in the past only to learn later that Medicare will not pay, many plastic surgeons will no longer  perform such procedures for Medicare patients. They are viewed as cosmetic procedures to be done as a fee-for-service basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck last year but it did not fully correct my sagging mons. I would like now to have that fixed as well. Where are the incisions for a monsplasty placed? Can they be placed in the groin crease to avoid a visible scar? I don’t want any more scars than the long tummy tuck one that I have now. Is it better to have a monsplasty lift or monsplasty by liposuction?

A: With significant amounts of pubic sagging or fullness, a tummy tuck may not ideally reshape the mons area. If recognized before surgery, modifications can be made in the tummy tuck incisional design or through the combined use of liposuction to get a good mons correction as well. When done secondarily, a direct mons lift is done using the central part of the tummy tuck scar so no new incisional locations are needed. Ususlly liposuction is done with a mons lift in most cases as the combination approach produces the greatest amount pubic reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 36 yrs old , weigh 132 lbs and work out three to four times a week. Despite these good numbers, I have big saddlebags that definitely don’t fit the rest of my body. I have had them my entire life ever since I was a teen. They make my bottom half completely mismatched to my small and toned upper half. I have read that after liposuction fat can reappear and in different places. I would not want to ruin my upper half at the expense of improvement in my lower half. Is this something that I should be concerned with?

A: Liposuction of your saddlebags will provide great improvement and patients like yourself are exactly what liposuction was designed for and is best at…spot fat removal. There are many fallacies and inaccuracies about what happens  to fat after liposuction. When it comes to potential future weight gain, the saddlebags unlike the stomach and waistline is not an area that fat will reaccumulate. It is not a metabolic depository site for extra calories. But other body areas are and it is certainly possible that fat can appear in other body areas with weight gain. The concept that you are really referring to is known as ‘fat equilibrium’, the  belief that everyone has a certain amount of fat that they are genetically predisposed to have. And by removing one area of fat, the body in an effort to maintain a fat balance will just have it accumulate elsewhere. This fat concept, while often talked about as if fact, has never been scientifically proven. A recent small study in plastic surgery did show that abdominal and thigh liposuction patients one year after surgery did have some measurable increase in thickness in the arms and upper back. But it was not something that the patients noticed. I would not be concerned that your saddlebag liposuction by Smartlipo will change your upper body shape to any noticeable degree if at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very weak jawline and some fullness to my cheeks and face. My face is sort of round and not very distinct. I went to one plastic surgeon and he said that a chin implant would change  my facial shape. But I have read that many chin implants also have liposuction under the chin as well. This seems to make sense to me but I still don’t see how that will improve my chubby cheeks. What would be your recommendations? I have attached some pictures of me from the side.

 A: I think there is no question that you have a short chin and a rounder fuller face. A chin implant will definitely over good improvement of your profile. But to really ‘deround’ a fuller face it is going to take other adjustments. These would include some fat removal as well. Liposuction under the chin would also be a definite plus and, with the chin implant, can dramatically change the jawline. But the cheek area needs thinning by a partial buccal lipectomy with perioral liposuction. Buccal fat removal only affects the upper cheek area below the cheek bone. Perioral liposuction is needed to remove fat from the lower cheek area at the level of the corners of the mouth. The combination of chin augmentation and fat removal from the neck and cheeks can very effectively make a round face have a much more defined shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline breast augmentation in 2005. Over the past year or so they see, to have gotten smaller. I know they are not broken or deflated but they definitely don’t seem to be as big or firm as they initially were. Is there a way to make the, bigger without having to pay for new implants? My original ones were put in through the armpit.

A: There are two reasons why many women find that their breast implants seem to be smaller years later. The first is a psychological one, the novelty over times passes and they just seem to be smaller. This is what I call cosmetic accommodation and it happens with many cosmetic procedures. The second is a real physical one. The breast tissue between the implant and the skin may actually become thinner due to pressure resorption over time. When combined with natural skin relaxation, there can be a definite looser and smaller feel to the breasts in some women. This is also why in saline implants there may be the feel of implant rippling over time.

A more firm feel and slightly larger implant size can be obtained in saline implants without having to replace them. More saline can be added to them through a very simple procedure of reattaching a filler tube. This can not be done through the old armpit scars, however, and requires a nipple incision for direct access to the fill valve area.

Dr. Barry Eppley

Indianapolis, Indiana