Your Questions

Q: I am a transgender person with HIV. I am healthy and on medication. I am really having a hard time finding a cosmetic surgeon that is willing to do surgery on me, perhaps because they feel uncomfortable about my HIV or are unsure if I am more prone to infection afterwards. I have read that you have performed plastic surgery uneventfully with people who have HIV. I hope you can help me with my questions:

1. Any advice with the anesthesia ( I read a few stories that it could interfere with medication and that could lead to coma). I am on a medication called Atripla.

2. What is the best CD4 count I would be reasonable to continue with surgery?

3. Any suggestions with antibiotics and anti inflammatory medication to avoid infection and promote good healing?

Dr, your advice and help would be much more appreciated. I hope to hear from you very soon.

A: There is a growing body of evidence that HIV patients are not at increased risk for infection or wound healing problems from surgery in general and plastic surgery in particular. Recent published studies in plastic surgery dispel this myth, provided that the patient has good CD4 counts and is not an immunosuppressive medication. One study has shown that there may be an increased risk when plastic surgery is done through the mouth as opposed to the skin. But it can also be said that such may apply to the general population as well. In my Indianapolis plastic surgery experience, I have not seen any increased problems operating on HIV patients for either cosmetic or reconstructive plastic surgery. To answer your specific questions:

1) Atripla is a multiclass retroviral drug commonly used in the treatment of HIV. It has no known adverse effects on wound healing which is the most important consideration in surgical outcome. From an anesthesia standpoint, there is a drug interaction with Versed, a common drug in the anesthesiologist’s pharmaceutical cornucopia. This drug is mainly used to treat anxiety immediately before surgery done on an intravenous basis. It is not absolutely necessary to use it for general anesthesia as other drug options exist.

2) Patients with CD4 counts greater than 200 and low viral loads have surgical risks that are similar to the general population. There is no evidence to support the historic contention that they have poor or compromised wound healing. Increased surgical risks are in those patients whose CD4 counts are less than 200 or have viral loads greater than 10,000.

3) The usual use of antibiotics and pain medications, as is usually done on any other patient, is all that is needed. No extra dosing of antibiotics or prolonged duration of antibiotic use has any proven benefit on reduced infection risk.

Dr. Barry Eppley
Indianapolis Indiana

Q: I am a 30 year old African-American female.  I have had three breast augmentations and the scar from the first augmentation was too high leaving me with visible scars. My last augmentation left me with even longer and more hypertrophic scars. I have tried laser in the past and I am considering deep resurfacing and then using the ACell micronized particles (Matristem powder) as this may help smooth the skin out. What do you think?  The alternative will be to open the scars and redo them but that would not help as I have done 3 boob jobs and still scarred. I would like to give the laser a go and use the particles as I believe that if it can heal a finger without scars it should at least prevent the skin fromover healing and it will heal to a more even tone. Please email me your thoughts.

A: Hypertrophic scars from breast augmentation, even in an African-American female, is not common. But when it does occur, as yours obviously has, it can be a real problem to improve. Searching for another solution than what you tried (scar excision and re-closure) is understandable.

Matristem collagen particles, derived from porcine bladder, is a new wound healing agent that is certainly touted as having regenerative properties. But do not confuse how a fingertip will heal with that of hypertrophic breast scars. Those are two completely different types of wounds and they do not translate in terms of results. Lasering your scars is probably the worst thing that you could do. It would result not only in loss of skin pigment but creates a secondary healing event that is more prone to scar hypertrophy than your prior scar excisions. I doubt that the ‘magic’ of Matristem particles will overcome your body’s robust healing response in that setting.

I would be more enthused about re-doing your scar revision using Matristem particles placed into and between the wound edges at closure. They are then better placed to exert their beneficial effects at the site of where the active wound healing process is occurring.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a few questions on creating the male model look which I have read about in a number of forums.  This will involve a number of procedures including cheek, chin, and jaw implants, facial liposuction, rhinoplasty, lipadvancement, and possibly a forehead and brow augmentation.  First, is it recommended to have all these procedures performed at the same time?  Second, is there a discount on the per procedure cost for having multiple procedures performed at the same time?

A: The male model look is about having a well defined or well chiseled look to the face. This specifically relates to facial features where the bony highlights of the face are prominent and ‘strong’. What it would take for any man’s face to achieve that look, or whether it is even possible, depends a lot on the anatomy and look of their face to start with. No everyone is going to need all the procedures that you have described. Some may just benefit from just a few of them in facial areas where they are deficient. Others may require a more complete number of available facial contouring procedures to get a better result. Each man’s face must be assessed on its own merits and must have a custom treatment plan. Some may just require a rhinoplasty and chin implant, others may require those as well as cheek and jaw angle implants and buccal fat extraction.

That being said, in the spirit of getting the best change possible, whatever procedures are deemed best should be done at the same time if possible. That is not only more efficient from a facial change and recovery standpoint but is more economically efficient as well. The main reason to ever stage such facial procedures is because of the cost or if one is uncertain as to whether a procedure(s) may be beneficial.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to ask if you do use fillers for augmentation in the temple zone, where I have sufffered fat loss. If it is possible, what filers would you use? I look forward to hearing from you.

A: Temporal hollowing is a result of fat loss which occurs for a variety of reasons. Some people have it at birth, some develop it with aging, and others develop it from certain medications and surgical procedures. Either way, it is a deflation of the temporal muscle as the fat is lost underneath and around it. While synthetic injectable fillers can be used  to fill it, it is not my first preference. This is because it takes a lot of filler to augment the area and, given that they are not permanent, is not a good value in the long run.

My choices would be either injectable fat, a synthetic implant, or a dermal graft implant. Any of these are surgically placed beneath the deep temporal fascia on top of or underneath the muscle. I have used them all and find that for most cosmetic augmentations (not caused by a craniotomy or temporal muscle detachment) the use of a subfascial dermal graft woks well. It is simple to do, is  a natural collagen material that is soft and flexible, and appears to have good long-term retention. Some would argue that fat injections are best, and I do like them, but their volume retention is not as assured. Through a very small vertical temporal incision, sheets of dermal graft can be placed which fill out the hollowing very nicely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want to investigate the use of botox to help with my jaw clenching and teeth grinding. I currently wear an appliance to help protect my teeth, but still clench and have jaw pain.

A: Clenching and the sequelae from it, pain and excessive tooth wear, is the result of overactive masseter muscles. (and sometimes the temporalis muscle as well) No one knows why this muscle hyperactivity occurs although it is blamed on personality types and stress. The exact reason why, however, is unknown. The traditional treatment of clenching uses non-muscular therapies such as dental appliances and anti-inflammatory or anti-spasm drugs. The purpose of a dental appliance (i.e., splint or mouthguard) is primarily to protect the teeth from excessive wear. It does an excellent job of that and there is no better substitute. The other objective of some dental appliances is to break the cycle of muscle spasm through jaw opening (increasing the interdental space and stretching the muscle out) and changing how one’s teeth interdigitate. (bite or occlusion) Their effectiveness in this regard is quite variable. Great claims are made by some as to how beneficial they are. But, in the end, they will work well for some and not for others.

Botox takes a different strategy to the muscle problem in clenching. By directly injecting the muscle into the most spastic and painful areas, these zones of paralysis or muscle weakening that Botox causes can very effectively reduce the muscle spasm and pain. For some patients, it can be a near miracle. For others the relief is still significant. I have yet to see any clenching patient who does not get noticeable relief. Sometimes additional or supplemental injections are needed to get the right dose of Botox after the initial treatment. The relief will last as long as the Botox works, for 3 to 4 months.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have one ear that sticks out further than the other. I think the good ear, the one that doesn’t stick out as far as the other, looks pretty good and may be normal. But my bad ear on the other side is definitely different. The bottom part where the earlobe is ok, it is the upper part of the ear that sticks out. My question is…can you just fix only one ear? And can you just fix a part of one ear only? Thanks and look forward to hearing back from you.

A: Otoplasty, or ear reshaping surgery, can be done on just one ear or just a part of one ear. In fact, in my Indianapolis plastic surgery practice, about half of the otoplasties I do are on just one ear or some part of it. Otoplasty, like rhinoplasty or nose reshaping, is not an all or none procedure. The ear is composed of a number of different cartilage convolutions and indentations which can be selectively shaped.

Cartilage shaping in otoplasty is done through either suture shaping or bending combined with weakening the cartilage at specific points through cartilage cuts or actual cartilage removal. It does take a bit of artistic sense and experience to know how to cut and suture the ear cartilages to get just the right shape.

While otoplasties on both ears is usually done under general anesthesia, single ear otoplasties can often be done under local anesthesia in the office in adults. This is particularly true if the only a simple stitch or two for cartilage bending needs to be done to get the right shape.

Dr. Barry Eppley

Indianapolis Indiana

Q: Who is the best Indianapolis plastic surgeon?

A: This is not an uncommon question as there  seems to be many purported ‘bests’ of about anything. However, there is no such thing as Indianapolis’ Best Plastic Surgeon. While magazine and websites may create these ratings, and doctors may so anoit themselves as such, there is no real rating method to make this determination. There is not one single plastic surgeon in Indianapolis who is the best….many are quite good…..but not one that is the best at everything…and maybe not even the best at even one single procedure. I can tell you that there are many fine plastic surgeons in Indianapolis who do excellent work. It is your task to find the plastic surgeon that is the best suited for you and your concerns!

But let me give you a few pointers to help you find your Best Indianapolis Plastic Surgeon.

One of the first questions that patients should ask is about  board-certification. Despite knowing to ask this question, most patients have no idea what it means or what to do with the answer. If the answer is no, keep moving on to another doctor. But if the answer is yes, don’t just stop there. That answer needs some qualifying…are they board- certified in plastic surgery. And you don’t even have to ask that question to the doctor directly…. go to their practice website and get that answer. But it may be misleading and here are some signs that it might be. Stating that one is board-certified, but not specifically saying in what specialty. Being board-certified in Dermatology or Family Practice, for example, is obviously not the same as being board-certified in Plastic Surgery. A weekend course or seminar does confer the same experience and skill set as years of actual training. Stating that one is board-certified in Cosmetic Surgery. This is the one that is the most misleading because it conveys equivalency. Being board-certified in cosmetic surgery is not the same as being board-certified in Plastic Surgery. Plastic Surgery is one of the 22 recognized medical specialties by the American Board of Medical Specialties and has been training plastic surgeons through organized medicine and its own recognized board (American Board of Plastic Surgery) since 1937. The American Board of Cosmetic Surgery is not a recognized specialty by the American Board of Medical Specialities. Rather it is a more recent invention created by physicians and dentists from many other medical and dental specialties to provide a forum for education as well as a method to bestow some level of qualification. It is not a certificate that indicates that a residency training program was done by the individual in plastic surgery. Most doctors certified by the Cosmetic Surgery Board have their residencies in other disciplines such as Ob-Gyn, Dermatology, and Oral Surgery. This statement is not to imply that board-certified Cosmetic Surgeons perform less quality work than that of board-certified Plastic Surgeons…just that their training is substantially different. One does not equal the other.

The American Board of Plastic Surgery is the most prestigous distinction that any plastic surgeon can achieve in the world. To be certified, one has to complete a two to three year residency training program in plastic surgery after completing prerequisite training in another surgical discipline, most commonly general surgery. After training is completed, a combination of written and oral examinations are required to attain the status of board-certification in plastic surgery. Every ten years one must re-certify by taking a repeat examination, assuring that one has maintained an adequate knowledge base in the areas of plastic surgery that one primarily practices.

It is easy to find out if your doctor is board-certified in plastic surgery. Simply go to the website of the American Board of Plastic Surgery and see if you doctor is listed as a member.

Once beyond assessing qualifications, education and board-certification, only an actual consultation can provide the following important insights.  The consultation is really about finding out if the surgeon you are seeing is right for you. It is as much about a personality match and an emotional connection than anything else. Yes, getting good and accurate information is important. Hopefully, every plastic surgery consultation provides that transference of information. But the feel of the consult will tell you about your level of comfort and connectivity with the plastic surgeon. Ask yourself these questions afterwards. Did the consultation feel like an educational experience or a sales presentation? Where treatment options presented and reviewed…or was only one treatment approach offered? Did you understand why the surgery proposed was right for you? Was time given to answer all your questions….and a way to answer questions that may arise after? Did the plastic surgeon provide you with a way to see before and after photographs, either during the consult or a referral to a website? Do they have a website where more than one before and after photo set of the procedure is shown? Was talking to actual patients whom have had the procedures offered as an option? Were these patients who have had surgery in the past three months? (recent experiences are better than someone from a long time ago) Finally, once home, did the plastic surgeon and his office feel right? Did the consultation make you feel more comfortable and secure in your decision?

In the end, The Best Indianapolis Plastic Surgeon is the one that has the training, education and experience to effectively treat your problem…and the one right demeanor and personality that makes you feel comfortable.

Good luck on your search for…..Your Best Indianapolis Plastic Surgeon!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Just had a question about the pubic lift…Can I still have children after the surgery is done or is it something that needs to be done after having children? Thank you so much for your time.

A: The pubic lift is a modified form of a tummy tuck or abdominoplasty. It is very much like the reverse of a mini-tummy tuck or an upside down mini-tummy tuck. During the procedure, the suprapubic area is first thinned out or reduced by liposuction since there is usually a lot of fat within it. (which is one reason it is so puffy) Then skin is removed and the pubic area is lifted up to a predetermined line. The combination of the two creates the pubic lift.

Pubic lifts are often done concurrently at the time of an abdominal panniculectomy or a large tummy tuck as large pubic mounds are usually present in patients that need these procediures. More often, however, a pubic lift is done as a secondary procedure after a large tummy tuck or panniculectomy as they are hard to optimally treat at the same time. The pubic lift is then done using the scar line from the first stage tummy tuck or panniculectomy.

There is no problem having children after any pubic procedure, albeit pubic liposuction or a formal pubic lift. Pregnancy, however, will not help the result and from an aesthetic standpoint one could argue that it is best to wait until one has a more  stable abdominal area before investing in that  effort.

Dr. Barry Eppley

Indianapolis Indiana

Q: Is it possible to reduce the size of my forehead? I do not mean lowering the hairline, because my hairline is already low. My forehead is vertical and almost seems as if I do not even have a forehead to begin with. The shape of my head is very strange. As most people’s head is round or square. My head is like the roof of a house, being pointed at the top making a sort of 60 degree angle. I can feel and hear my head always cracking as if its not stable or solid. I am also not sure it bone can be molded or change shape but I have been able to compress my head through pressure. Very very painful but I was desperate. With a 30 minute span however, it would return back to its original shape. I most know if there is some way to mold my cranium to a rounded shape?

A: First of all, you should now that it is not possible to reshape your skull bone by any form of external pressure, except in newborns where the skull plates are not yet fused. All you are doing by external compression is squeezing the fluid out of your soft tissues overlying the bone. Once released, the fluid returns and your ‘skull’ reverts back to its original shape. I can assure you that your skull is solid and is not ‘cracking’.

It is possible to do some forehead reshaping through an open scalp approach. The bone can be reduced and shaped by about 5 to 6mms, maybe more, in some patients depending upon the thickness of their outer cortical table. This may be enough of a change for some patients to notice a visible difference.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr Eppley I have two deep scars (they are red and has slight dent) )on my legs due to an accident three months ago. I know scar revision can remove the redness, but can it treat the dent too? How long will it take and how much will it cost( just give myself some mental preparation)? Thank you.

A: Contrary to your perception, scar revision can do exactly the opposite of what you think. Scar revision can improve the indentation of the scars by removing the depressed portion and bringing skin in from the sides to make it more level. The redness of scars is not something that traditional  scar revision will help. Redness of scars fades mainly a a function of time. As the scar matures, the blood vessels in it recede as the nutrients are no longer needed to heal. That makes the scar redness go away.

The more significant question is the timing of your scar revision…when is  a good time to undergo scar revision? That will depend on the appearance and location of your leg scars. Each scar must be assessed on its own qualities. Scars on the legs are particularly difficult to improve due to the tightness of the leg skin and the pressure and stresses to which the leg is exposed. I would have to see pictures of your scars to determine the best approach as well as timing and the costs. Relaxation of the surrounding skin is particularly important. So being only three months after your injury is undoubtably too soon.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi, I’m interested in getting a buttocks lift with the fat injection procedure. I am currently a student and therefore do not have a lot of money, I’ d like to know if you offer payment plan options and, if so, what would be an approximate monthly payment. Thank you.

A: Fat injections are one of the two options for buttock augmentation. Often referred to as a buttock lift or the Brazilian buttock lift, it ‘lifts’ the buttocks by adding volume and expanding the buttock skin. Probably calling it a lift is a bit of an exaggeration. It is really a buttock augmentation, any lifting is purely coincidental.

As for financing of any cosmetic procedure, there are few if any plastic surgeon’s and their practices that would directly do the financing. Many patient’s ask about whether we finance and it is an understandable question. But plastic surgeon’s are not experts in banking or lending and therefore do not do it directly. It is also not prudent to provide a non-returnable service upfront and then hope to be paid until completion later. For this reason, plastic surgeons use outside financing companies to which they refer their cosmetic patients. There are numerous ones and each plastic surgery practice has one or two that they have had good experience using. In my Indianapolis plastic surgery practice, we have used many over the years and currently use Care Credit. Once patients have the quote for surgery, they can go online and see if they qualify. They have many different financing options which allows patients to choose the length of the loan and their monthly payment.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Hello,  I am 58 years old and  I had a full hysterectomy in May and then another surgery a few weeks later when all my stitches ripped out and I totally opened up.  My son is in Afganistan (fourth time) as well as my daughter in law.  I also served in the Navy years ago.  Anyway, as I cannot afford the smart lipo on my abdomen (upper and lower) presently, I was wondering how much of a discount the patriot plan saves on this procedure and how long will this promotion go on?  Also, does the skin actually tighten up and not sag?  This email is just a question about the future possibilities and any information you can give me would be appreciated.   I really want to get rid of my stomach and maybe next year I would be able to afford it.  Thanks for your time – I appreciate it.

A: Thank you for your inquiry. The general discount in the Patriot program averages around 25% off the full procedure and the program continues without any deadline. What type of procedure is best for your stomach area, however, remains unclear based on your description. My concern is that the description of your problem sounds more like some form of a tummy tuck than that of Smartlipo. If there is any substantial skin excess, then no form of stomach liposuction is the way to go. One of the great misconceptions about Smartlipo is that it is a great skin tightening method. It is not and is highly overpromoted that way.  While it does have some skin tightening ability, it will tighten inches of loose abdominal skin which many people that come in for it have. Between a hysterectomy and its after surgery problem, multiple pregnancies and your age, I suspect that the skin issue is beyond what Smartlipo can improve. A tummy tuck in some form is likely more appropriate for your problem.

Feel free to send me a picture of your stomach and I can answer that question very quickly.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello. Does Dr. Eppley do cosmetic hip implant surgery? I saw this on the website, but I couldn’t find the surgery listed on the drop down menu.

A:I have performed implant procedures all over the body including the rarely done hip implant. It is very infrequently requested (you are only the second inquiry that I have ever had) and I have only performed the procedure one time, on one side, for a traumatic injury problem to get better hip symmetry and provide a ‘ledge’ to hold up their pants better on that side.

Hip implants are almost exclusively done for cosmetic augmentation and, in rare cases as described above, for reconstructive purposes. For those women who feel that their hips are too narrow and want more of an hourglass figure, hip implants can give them more curvature.

Hip augmentation can be done through either an implant placement or fat injections. each has their advantages and disadvantages. Hip implants require an incision to be placed and are a foreign material in a very palpable and prominent area. They are placed down on top of the fascia or aponeurosis covering the iliac crest. They are not placed directly on the bone surface as this requires stripping of attachments off of the crest which is painful. (like an iliac bone graft harvest) Fat injections use your own tissue (which gets a cosmetic benefit also from the harvest site) and are soft with little risk of infection. But their reliability in terms of volume retention is not always assured.

Dr. Barry Eppley

Indianapolis Indiana

Q: I’m a male in my thirties and I would like to have surgery to give my orbital rim and forehead a more masculine (protruding) appearance. I had a craniotomy 3 years ago which has left a dent on my forehead which I would like to eliminate. I understand that solid HA is more porous than the moldeable putty type which would allow tissue growth and ossification. I would like to know answers to the following questions. 1) In order to make my forehead more prominent would it be possible to use 3-D CT scan technology to customize a solid HA implant instead of using moldable HA paste? 2) Could the customized HA implant be made with an interior mesh to make it less brittle? 3) Would a customized HA implant in solid form be easier to work with than HA in paste? 4) Could using a solid HA implant present problems such as fluid accumulation, visible borders, migration or extrusion. I thank you for your time.

A: Thank you for your excellent and thoughtful cranioplasty questions. I can answer of your HA cranioplasty questions by saying that I really don’t use the HA pastes anymore. In their day they were state of the art and they were wonderfully moldeable, but they are brittle. This is no different that HA blocks or HA custom implants which actually are just as brittle and much harder to work with. The newest and more improved cranioplasty material is Kryptonite Bone Cement. It offers easy molding and shaping into the defect, sets up and gets just as hard as bone, and is truly porous (unlike most HAs which are not except the blocks) which allows tissue ingrowth. This is clearly the superior cranioplasty material and eliminates all of your stated concerns and questions.

Therefore, based on these working properties of Kryptonite,  HA is no longer used and a 3-D CT scan model is not necessary beforehand since there is no advantage to making a pre-formed implant. (which is now a disadvantage and very costly)

I see no problems at all doing forehead and orbital rim augmentation and any contouring of a forehead indentation with Kryptonite Bone Cement through your existing scalp scar and open approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: My ears have always stuck out. One definitely sticks out further than the other. Growing up I have been always self-conscious about them and I have never worn my hair in a ponytail as a result of how my ears look. It was awful when I went swimming because with my hair wet my ears stuck out even further. I have finally decided to do something about it with otoplasty surgery. My question is at age 43 am I too old to get a good result? Are the ear cartilages too stiff (too old) at this point to be changed? Also, will changing the shape of my ears affect my hearing?

A: External ear reshaping, known as otoplasty, can be done at any age. While it is true that cartilage does stiffen with age throughout the body due to loss of water content and even calcification, this cartilage ‘aging’ does not affect the ear cartilages very much. I have done otoplasty in patients in their 60s and 70s (rare as they are at this age) without any noticeable change in the ability to reshape the cartilages.

A change in your ear shape will not affect your hearing. Although the ear’s folds and convolutions do serve to concentrate and localize sound waves, pinning back or reshaping the outer aspect of the ears will not produce a noticeable change in your hearing. The inner bowl of the ear (concha) is what does most of the gathering of sound waves and this is not changed significantly in otoplasty surgery. 

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi Dr. Eppley I want to get your opinion on what to do with scars after surgery. Specifically, in regards to the use of a taping method. I know there are a lot of creams out there but the use of tape just makes more sense to me. I have read about two different taping materials, silicone sheeting or strips and something called micropore tape. Which one do you think is better?

A:  Yours is not the first such question that I have ever heard about the use of different taping methods. Specifically, can micropore tape or any other similar adhesive tape be just as effective as silicone sheets or tapes in helping scars look better? From a proven standpoint, I should say that  silicone scar sheets are the only FDA-approved methods for the treatment of scars. This means that enough evidence and documentation has been provided by certain manufacturers that has clinically shown that it works. Silicone has a long clinical history of success in the management of surgery scars The molecular composition of silicone has a parallel position as one of the most inert biological materials known to man. This allows it to have minimal irritation to the skin with long-term use. As silicone also has a semi-occlusive  property, it allows for scar hydration which has been shown to be helpful in minimizing undesired collagen production.

Micropore tape is appealing, however, because it is an easy taping that may be less expensive and more convenient. Manufactures of silicone-based tapes would no doubt tell you that there is no proven effectiveness of micropore tape and that it may, in fact, lead to skin reactions because it is too constrictive and does not permit hydration of the skin. The lack of FDA-approval is true but I have yet to have a patient that has developed a skin reaction problem with micropore tape, which is my preferred method of scar taping.

 The debate between these two taping methods may continue but doing some form of scar management, if possible, is probably better than no method in many cases. In select cases, it could be beneficial to avoid the need for a later scar revision and is very helpful as a postoperative scar revision topical treatment.

Dr. Barry Eppley

Indianapolis Indiana

Q: Does Dr. Eppley have experience with lip reduction procedures (making lips smaller instead of fuller? How is the surgery done and how successful is it?

A: The number of requests for lip augmentations exceeds the number for lip reductions by about 1000:1. Every request that I have ever had for a lip reduction is almost always in an ethnic patient, most commonly African-Americans although not exclusively so. I usually perform about six or eight cosmetic lip reductions per year, if you are counting lips and not patients. Lip reduction is done by removing a wedge of lip tissue at the junction of what is known as the wet-dry vermilion. This is a very distinct line of demarcation between your dry vermilion (pink part of the lip that is seen on the outside) and where the wet mucosa begins on the inside of your lip. That area is easy to see when you roll your lip outward. The dry vs wet part of the lip is quote obvious. This is where the incision line is placed most of the time. The actual part of the lip that is reduced is the dry vermilion. Usually about 5 to 7mms is removed in the central area of the lip and then it tapers outward towards the corner of the mouth. (commissure) The lip is then rolled back and closed so that the visible part is reduced and the scar remains behind in a more inconspicuous area. The key in lip reduction is not to overdo it or remove too much. There is no way to put back lip tissue. One can always remove more later if quite not enough has been removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have just read a few artcles from Dr Eppley and I would value his opinion on my scars. I had fractional laser treatment for three scars on my right cheek. Afterwards,  unfortunately, I developed an infection as my skin would not heal and there was bleeding underneath. I could not get the area to heal so I ended up contacting a specialist out of the country who diagnosed it s fungal. I was treated with antifungal medications and it healed within a few weeks. While it healed, it developed a lumpy shiny texture. I then underwent intense pulsed light therapy and topical steroids to help the skin recover. This did help. After a while I was recommended to have more fractional laser treatment for further improvement. Despite having good results so far, I thought I could get even better. Unfortunately the settings may have been too strong and things became ten times worse.  My right cheek has every imaginable scar and the texture is horrible, just like a burn. I am now having PDL and smoothbeam for one year with very mimimal improvement and I more recently had a PDT treatment which I am not sure if it helped as I am still very red. I seem to have exhausted everything and am now without any hope of looking normal again. Do you have any suggestions.

A: While I have not seen what your cheek looks like, it would be fair to say that the numerous laser and light treatments have ended up making the skin area act more like a scar than normal skin. All of these therapies, laser or light, produce a thermal insult on the skin. And just like burn skin, it will be more sensitive to just about anything you do. Unless…you give the skin area an adequate time to recover without doing anything including topical steroids. An adequate time is at least a year with leaving it alone. While that will understandably seem like an eternity, particularly when it is on your face, it is the best thing to do if ever you are going to do any more therapy that might ultimately be effective. Sometimes patients keep searching for the next light or laser treatment that will be the ‘magic’, when the real magic in some scars is time. I think it time to sit back and let the area fully recover and then re-evaluate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Do you use screw fixation for your silicone chin implants? I have a silicone chin implant that moved upward off the inferior part of my chin. I am looking to do a revision but I want some type of screw fixation this time.

A: If a chin implant has slide too far upward for optimal chin projection, it was likely placed through an intraoral (inside the mouth) incision. This is a common problem with this approach as the dissection and the pocket created allows the implant to slide up towards the incision after surgery…unless it is secured in a low position on the chin bone by a screw. This problem does not usually arise when the incisional approach is from a skin incision under the chin as the undisturbed mentalis muscle keeps a firm ‘roof’ over the implant.

In any type of chin implant revision, where the problem is shifting from the ideal position, some method of implant fixation is needed. The easiest and most economical approach is to use a single midline screw to the bone. If side-to-side shifting is the problem (rotation), then double screw fixation may be needed.

While screw fixation of chin implants can be very helpful, it is not always needed in a primary or initial surgery. Many chin implants can be secured in the midline with a simple resorbable suture to the periosteum covering of the bone.  But implants placed from inside the mouth or those that need to be kept positioned very low on the bone for optimizing vertical height need screw fixation.  

Dr. Barry Eppley

Indianapolis Indiana

Q: I went in for a rhinoplasty consultation and, during the course of discussion, the plastic surgeon brought up the idea of combining it with a premaxillary implant. I had never heard of that type of facial implant before. I can understand that it pushes out the base of the nose but I am concerned as to what it may due to my upper lip. Does a premaxillary implant change the appearance of the upper lip in any way?

A: The premaxillary implant is one of the uncommonly used of all the facial implants. The benefit of its use comes when one’s facial profile or midface is a little recessed or retruded. With this facial skeletal pattern, the nasolabial angle is usually too acute (less than 90 degrees) and contributes to a hanging or downturned nasal tip appearance. Bringing out the nasal base can be aesthetically helpful in midfacial hypoplasia whether one is having a rhinoplasty or not. The premaxillary implant builds out the paranasal and the anterior nasal spine area using an implant which spans across the entire lower pyriform aperture region. (nasal base) This will usually result in a very mild vertical lip lengthening although that will not occur in everyone based on their anatomy. At the least, it will cause the upper part of the lip to be more full/protrusive. This will also change the nasolabial angle, the angle between the columella of the nose and the upper lip, which is the primary objective of this type of facial implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr.Eppley, I am interested in having surgery to better my breathing through my nose. In my younger days I was hit in the nose several times and suffered much damage which makes it hard to breath through my nose. I have suffered with this for years and would like to do something soon.I do have several questions and would like to be very educated on the procedure. I was wondering how long you have been doing these types of operations and how much they would cost. Also what can I expect after the operation. As of now you can see my nose has caved in on the sides and it is extremely hard to breath through my right nostril. I look forward to hearing from you. Thank you.

A: Injury is a common cause of nasal breathing difficulties. External forces can displace both the nasal bones and the septum, causing obstruction through one’s nasal passages. While septal deviation is the most common sequelae of traumatic injury, changes in the external skeleton through nasal bone fractures and upper and lower cartilage derangements (middle vault collapse) can also be sources of the breathing problem. Such changes are also a source for visible nasal asymmetries and crookedness of the nose. Traumatic nasal injuries almost always require a full septorhinoplasty to get a complete correction. This sounds like what you need by your description. If you could send me some pictures, I can take a look at them and do some computer imaging as well if needed.

Typically, insurance will cover some of the costs of a septorhinoplasty but may not cover everything depending upon what is needed and done. This would have to be initially pre-determined through the insurance company with a letter and photos to get an answer from them in regards to coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I have two babies born via c-sections. Is it safe to have a Brazilian butt lift even though I have had these c-sections? My youngest baby is 5 months old and I am still breastfeeding. Should I  I stop breastfeeding before surgery? How long in advance should I stop my breastfeeding before having the surgery? Thank you.

A: The Brazilian Butt Lift, a bit of a misnomer but this is how the procedure has been branded, is buttock augmentation with fat injections. It has gotten this branded name because it was developed and popularized in South America where the aesthetics of the buttocks is highly regarded. It ‘lifts’ the buttocks per se by adding fat volume, not by cutting and lifting tissues in the traditional sense. Having c-sections on the abdomen does not in any way interfere with having this buttock procedure and one does not affect the other. Fat may be taken from the stomach area to be transferred to the buttocks but a c-section does not interfere with that process.

Breastfeeding, however, is a different matter. There is no reason to be having elective plastic surgery while one is still breastfeeding. There is a very remote chance of drugs from surgery passing through to the infant through the breast milk. Once none of these drugs are likely harmful to the infant, why take any chance even as remote as that possibility is. One should stop breastfeeding at least one month prior to any elective surgery. In addition, you really want your body totally focused on healing from the surgery and not having its energies split between healing and producing breast milk.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am considering having my septoplasty and rhinoplasty done at the same time. It does seem like it would be cheaper and more practical to have both done at the same time and only pay one anesthesia bill, surgery room cost, etc. If the septoplasty is medically necessary and you have to have it anyway, it should be substantially cheaper to go ahead and have the nose reshaped at that time as well. I recommend finding a Dr. that will work with you on this. There is a big variation on prices out there. I heard from a friend that needed upper eyelid surgery (blepharoplasty) for excess eyelid skin. The plastic surgeon she first went to see just assummed insurance would not pay it and did not even let me get tested to see. Then she went to an Opthalmologist, and in less than one week, had insurance approve the procedure. I am a healthy person in my thirties, who never gets sick, and don’t feel like when I do need a procedure, insurance should try to get out of paying. (Which they did not, but the first MD assumed they would not)

A: While on the surface this basic insurance coverage question seems reasonable, it reflects a deeper misunderstanding and a general societal feeling about health insurance companies. (not that I have any great compassion for them either) The issue is one of justifiable coverage and insurance fraud. Trying to get a cosmetic procedure covered under insurance, is quite frankly, fraudulent. That is not what health insurance is designed to cover and their policy guidelines make this quite clear. While some physicians will code certain diagnoses and procedures so that they appear medically necessary, so the patient doesn’t have to pay and they can bill for the procedure, this is ethically wrong and illegal. While it may be common practice, that does not make it right or justifiable. There are many plastic surgeons who will not exhibit such unethical behavior and this may make the patient feel that they are being unreasonable. In reality, they are being quite honest and forthright. And what reasonable patient would ask a plastic surgeon to risk his license or practice for something that their insurance company is not obligated to pay?

This is not to be confused with the benefits of performing a cosmetic procedure with a medically necessary one, such as a rhinoplasty and a septoplasty. Many believe that the benefit is that the insurance company will pay for the operating room and anesthesia costs of the rhinoplasty as just part of the septoplasty. Again that is fraudulent behavior that the hospital or surgery center will no longer allow. The patient is obligated to pay for all additional costs related to the rhinoplasty once the septoplasty is completed, including operating room and anesthesia costs. The combined benefit is that the additional time to complete the cosmetic portion is less than if the cosmetic procedure was performed alone, thus reducing one’s out-of-pocket expenses. In addition, many plastic surgeons may discount their professional fee for the cosmetic procedure as a courtesy for doing both at once. That is the ethical and legal approach to getting a financial benefit for the patient from combining such procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Ii am 22 years old and would like to undergo a rhinoplasty procedure with you since I have read some very good things about you. I am aware about the rhinoplasty surgery and I don’t need further information on that procedure. But I was wondering if you can fix another facial problem. The distance between the mouth and the nose is very good. But when I close my mouth its like fat or muscles pile up and that makes the area between my mouth and the nose look big, even though it is not. In addition,  the corners of the mouth droop down and give me a sad face appearance. Is there any surgical techniques to fix these problems?  

A: The upper lip fullness to which you refer seems like a natural phenomenon . If you open your mouth, the upper lip thins as the nose moves upward and the upper lip stretches downward over the teeth. When you close your mouth, the ‘accordion’ shortens and the upper lip gets fuller again. This seems to be a normal tissue reaction and there is certainly nothing that can be done to surgically change the thickness of the upper lip at rest.

The downturning of the corners of the mouth, however, is a different issue. That can be changed through a simple procedure known as a corner of the mouth lift. A small triangle of skin is removed just above the downturned corner to bring it back to a more horizontal lip level.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello, I recently had a consultation with a plastic surgeon in Indianapolis for rhinoplasty and breast augmentation. The doctor told me that I could have both procedures for a low price as long as I did not finance it. I felt the Doctor was not personable. I have looked at your before & after photos and wanted to know if you would discount the procedures if I paid without financing.

A: Financing of elective cosmetic surgery procedures today is extremely common. While once accounting for about 5% of cosmetic surgeries in the United States in 2000, that number is approximating near 40% in 2010 based on my practice experience. While financing has been a boon to plastic surgeons in general, there is a surcharge from the financing company to do it and some of that comes out of the plastic surgeon’s fee. A similar issue applies to credit cards which extracts about a 3% surcharge.

For these reasons, there is always a financial benefit in most plastic surgeon’s offices if a patient can handle paying for their cosmetic surgery without financing. That would be true for just about any other business as well so this not unique to plastic surgery.

When combined cosmetic procedures are done, it is also common practice to provide some discount over what those procedures would be if they were done separately. For this reason, it is always best to combine as many procedures as you desire in a single surgery. This is not only more efficient from a  recovery standpoint but financially as well.   

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have 5 lipomas in my stomach area and would love to have their size reduced, if not completely gone. I’ve been looking into having them treated by deoxycholate injections. What has been your success in getting rid of them (all of them are less than 4 cm in diameter) and how many injections sessions does it usually take? 

A:  The traditional method for lipoma removal is excision. These are encapsulated benign fat tumors that actually pop out of small incisions made directly over them fairly easily with a little pressure. But in an effort to avoid surgery, the use of fat-dissolving injections has been done for them as well. Known chemically as deoxycholate or phosphatidylcholine deoxycholate (often called Lipodissolve), this solution has been well described for the cosmetic reduction of small body fat collections. Working through an inflammatory process, this solution is known to break down the cell walls of fat allowing their fatty acid content to be released. It is less well described and known for fatty tumors (lipomas) treatment but it works through a similar inflammatory process. The fat in a lipoma is more densely packed and , in theory, is a little more resistant.

I have treated a series of lipoma patients with these Lipodissolve injections in my Indianapolis plastic surgery practice and do find it to be effective. It does take more than one injection session to get maximal reduction in most patients. How many injections sessions that would be depends on the size of the lipoma. As a general rule, expect about a 50% reduction with each injection session. 

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi I was wondering what you think of Bioplasty or have you ever heard of  it. Doctors in Brazil does the whole face with pmma called Newplastique,  injecting it into the jaw, cheeks, chin, eyes, brow anywhere.  I saw a doctor in Mexico who uses this new plastic pmma and he quoted me $2400 for jaw jawline cheeks chin and said second touch up treatment would be half the price. What do you think?

A: What you are referring to are ‘permanent’ injectable fillers for facial fillers and volume enhancement. They are permanent based on that they contain a percent of non-resorbable particles (usually about 30% or less in volume) mixed in with fluids which allow them to be injectable. (flow through a relatively small needle) The percent of particles in any given size syringe is always less than the amount of fluid otherwise they would clog up the needle and not be injectable. There are a variety of these type injectable fillers that exist in the world using different plastic particles and different fluids. The concept, however, is the same and the potential complications are similarly the same.

Quite frankly, I am not a proponent of these type of injectable fillers for widespread facial use. I would be concerned about the potential for long-term problems from the particles such as granulomas and lumpiness. They would be difficult to remove and may have to be cut out should these types of problems arise. Advocates of their use feel that these problems can be minimized by good injection technique, which I am sure is true, but how do you know who does it well and who does it poorly? Around the world, where the medico-legal implications are not as severe, these fillers are more widely used. In the United States, however, their use and many of these type of fillers are not widely done and are not even FDA-approved for use. Nonetheless, It is not an injectable procedure that I feel comfortable doing to patients. That doesn’t make it wrong, just that I have a different practice philosophy.

I feel more comfortable doing enhanced fat injections for facial volume and reshaping. While their permanency is variable, they also are not associated with any long-term complications since it is the patients own tissues. While it is more effort and expense, and may have to be repeated sometimes as well, safety is more important than a lower cost.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello,  I have several questions regarding cosmetic surgery. First off I want to say I am a single mom of four wonderful children but they have destroyed my once nice looking tummy. But I HATE how I look. I have suffered an eating disorder since my first child being born, to the point I was approx. 90 lbs and I am 5′ 5″. I still do not eat right as I am petrified that I am going to gain weight and make my stomach even bigger. I am also a full time student so I know I cannot afford surgery. There is simply no way. Is there ANYTHING I can do? I hate the way I look, I hate to take showers, I hate to be seen by my fiance naked!!! I literally HATE my body. I currently weigh 135 lbs. So I have done very well maintaining weight. I am at a loss as to how can I rid myself of this awful belly? Please help!!

A: Unfortunately, the short answer is that only surgery can offer any help. After multiple pregnancies, your abdominal wall has been irreversibly changed. The abdominal muscles are no doubt separated along the midline and are lax which accounts for the protruding appearance of your belly despite being at a good body weight. In addition, the overlying skin has been stretched beyond its elastic limit as evidenced by stretch marks. All you can do with your weight is keep the fat layer thin but that will not change your skin and muscle of the abdominal wall. Perhaps one day you will be able to have the tummy tuck surgery that can provide the solution that you are looking for.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I feel like I am ready for a facelift and want to get the best result that I can. In doing my research on the internet, I have come across several recent articles on a procedure called the Stem Cell Facelift. In reading them, they make it seem like it is the best way to go with the best results. But I don’t understand what stem cells have to do with a facelift. Do they help lift the droopy skin or do they make what is already there better. I would like to go to a doctor that does them but I am also worried about whether this is so new that maybe it doesn’t really work that well or it is just some sort of a scam. What is your opinion?

A: The concept of the Stem Cell Facelift is based on two simultaneous techniques, a traditional facelift to lift and tighten loose neck and jowl skin and fat/stem cell injections to add facial volume. The injections are not responsible for any type of skin lifting. They add volume to areas of fat absorption that have happened with age and are purported to help make the skin look better. (which remains far from proven) They may be done together but the fat and the stem cells they contain can not make for any tightening effect on the skin

Is this facelift concept hype or hope. At this point, a little of both in my opinion. The concept is very appealing and the technique uses all natural products from each patient, thus there are no risks involved in doing it. Conversely, whether this facelift approach is better than the traditional proven methods has yet to be adequately studied over the long-term. It may well prove to be an improved method with better results but at this point the promotion of it is ahead of the actual science.

Dr. Barry Eppley
Indianapolis, Indiana

Q:  There seems to be a multitude of people out there with chin/lip problems arising from intraoral surgery who don’t know where to turn or what to rely on to remedy their situation. Mostly their problems are attributed to mentalis detachment/loosening and scar tissue, particularly in the labiomental fold region. Chin/lip deformity poses a significant quality of life issues and must be taken seriously. A case study of scar revision in this instance, with before and after photos and details of the surgery, would be of great assistance. Mentalis resuspension seems straight forward enough if its loosened or detached from its origins. The question in my mind with regards to scar tissue excision, is how much mentalis muscle in the labiomental fold or chin pad region, can be safely excised before the mentalis can no longer function properly?

A:  Ptosis, or sagging, of the soft tissues of the chin can occur after any form of chin surgery done through an intraoral (inside the mouth) approach. When it occurs, one surgical method to put the soft tissues back onto the chin bone is mentalis resuspension. This is fairly way to do and the most important technique for the procedure is how the muscle is secured back to the bone.

Generally speaking, the only scar tissue that ever needs to be removed during any chin revisional surgery is the scar capsule around an existing chin implant. (if the implant is being removed) This needs to be removed because it will not allow the overlying muscle to heal back onto the bone.

Dr. Barry Eppley

Indianapolis Indiana