Your Questions

Q: Dr. Eppley I am interested in revisional surgery. Over a year ago I had a rhinoplasty done. While there have been some improvements, there are numerous features about it of which I am not happy. I would like tip size reduced/refined to reduce the overall size. I might be intereted in some more narrowing of the bridge depending on upon complexity and down-time. I have attached some pictures for you to review of where I am now.

A: Thank you for sending your pictures. I can tell by the appearance of your nose and your description that you have had prior rhinoplasty surgery. Based on your desires, I see an upper third (bridge area) which can be further narrowed by osteotomies, an indentation of the right osteo-cartilaginous junction between the right nasal bone and right upper lateral cartilage, and a tip that is a little too wide and with a slight amount of over-projection. The nose has a fairly good dorsal profile and tip rotation. (nasolabial angle) These are features that you don’t want to change. For a revisional rhinoplasty, I would do low lateral narrowing osteotomies for the bridge small cartilage graft for the right upper middle vault indentation, and tip shortening and narrowing. This would be done through an open rhinoplasty which I assume is how your first rhinoplasty was done. I have attached come projected imaging. Since it has been over a year since your first rhinoplasty it is reasonable to critique the result and consider any revisional rhinoplasty at this time.

Dr. Barry Eppley

Indianapolis Indiana

Q: What is the cost of tummy liposuction?

A:  This seemingly simple question is actually more complex that it appears. When people request liposuction of their stomachs, and its associated fees, they often are under a false perception that this is what will work for them. About half of the patients that I see for tummy liposuction do not need or do not get that procedure. Many actually need a tummy tuck due to their excess and loose tummy skin. But assuming that liposuction of the stomach is the right procedure, there are other variables that will affect the time and cost of performing the procedure. Does the whole stomach need to be done or just the lower half? Does the flanks or muffin tops along the waistline need to be done in addition to the stomach to get a better overall result? All of these affects both the results and cost of the liposuction procedure. This makes for a cost range of between $4000 to $5500 depending upon how much work needs to be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in doing a ” Brow ridge reduction “, at least that is what I think it is. Also I would like a chin reduction. So my questions are; Are these types of surgeriess even possible? How far in advance do I have to schedule them? Have you ever done similar work to this? I have attached some pictures for you to see what I mean. Sorry as they are not the best quality.

A:  Thank you for sending your pictures. Your requests for brow bone and chin reduction surgery is not uncommon and these are established procedures. I am very familiar with doing them and get requests for them all the time. Brow bone reduction (technically frontal sinus reduction since the brow bones are largely sinus cavities not solid bone) is done through a scalp incision. The outer table of the frontal sinus is removed and set back which makes the brow bone less prominent. It is a very effective surgery and the only significant issue in men (which are by far those who request the procedure) is the need for a scalp incision and the resultant fine line scar in the scalp to access the forehead and brow areas. Chin reduction surgery is done different ways based on which dimension of the chin one wants to shorten. If it is a vertical chin shortening that is done by an intraoral osteotomy and bony wedge resection. If both a horizontal and a vertical chin reduction is needed that is usually done by a submental (under the chin) incisional approach and the bone is burred down and the soft tissues shortened and tightened to the smaller bone.

This will give you a general overview of your requests. Both surgeries are possible and are part of cosmetic craniofacial reshaping surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I have one very prominent ear that is a big source of embarrassment for me. I am fifteen and this is a huge deal for me. I would love to get this fixed but I am worried about cost.

A:  First, it is important to know that I, nor any plastic surgeon, can communicate or have any medical discussion with a minor. It is critical that all minors have parental consent before any discussion can be done even by e-mail. An e-mail communication is no different than an office visit when it comes to providing medical advice to any patient. This can be done by having your parents fill out a form and return it to us so that we have confirmation of their knowledge of any future medical communications between  my office and you. This issue would eventually be crossed at some point if surgery ever becomes a reality, not only for consent for the operation but for payment as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, we talked about1 month ago about forehead reduction. Subsequently I have gone to a hair transplant specialist where I live and he told me that he thought that I would not lose anymore hair in my life. Now this was of course only his assumption. Anyway, I’m really struggling with my forehead problem and it’s limiting my days and is taking a toll on my mind. I would like to know if it’s strictly not done on men or if this operation is only done on men at a certain age. And if I would actually lose my hair in the front in a couple of years, how big is the scar and is it very noticeable? Because I’m thinking about this operation all the time knowing that there is something that can be done. Thank you for your time.

A: It is not that it forehead reduction/contouring is never done in men because that is not true. It is just that one has to think about it much more carefully than a woman because of the hair issue. The forehead problem is men has to be more ‘significant’, in terms of either its shape or its psychological impact on the patient, to justify the effort and the scar risk. Scalp scars generally heal fairly well actually and usually end up as just a fine white line in most cases. Scars in hair tend to heal well provided the hair follicles are not damaged during the making or closing of the scalp incision.

Dr. Barry Eppley

Indianapolis Indiana

Q: My upper arms are huge and flabby. I can’t get rid of it. My arms hurt to move. I’ve had rotator cuff surgery on both shoulders and bicep reattachment on my right shoulder. I have Medicare and Tricare insurances. My shoulders and arms hurt terribly. What can I do?

A: Based on your description of your problem, you appear to have the intent or belief that one’s medical insurance will cover you upper arm surgery. What you really need is an arm lift or brachioplasty. This is where all the loose skin on the back of the arm is removed with the trade-off of a long scar. While you have shoulder and arm symptoms, no insurance company is going to cover this type of cosmetic surgery. While an armlift can make a dramatic difference in the appearance of your arms, there is no medical evidence that it will improve shoulder pain or the function of the arm. That is not my medical opinion but the written stance of every insurance company. Your only option is to consult with a board-certified plastic surgeon and get a fee quote for this type of surgery. It can be done as an outpatient in a 90 minute to two hour operation. Arm lifts generally do not cause a lot of discomfort after surgery and recovery is fairly quick. While it does result in a long arm scar, it makes an immediate and dramatic change to the arms… that might even make your shoulders feel better. Dr. Barry Eppley Indianapolis, Indiana

Q: I am interested in SmartLipo on the upper arms. I have lost over 100 pounds with lap band surgery and would still like to lose some additional weight. I was wondering about the effectiveness of having the liposuction while still planning and needing to lose weight. I may want to have additional procedures in the future but would like to get my arms now if that is feasible.

A: When it comes to losing a lot of weight, the arms in women will always show the result of that effort…with sagging ‘bat wings’ in many patients. The use of liposuction for the treatment of saggy upper arms (back of the arms or triceps area) is not the right treatment approach. Liposuction only removes fat and not skin. The problem in the weight loss arm problems is about 85% to 90% skin. Therefore, what you really need is an arm lift or brachioplasty. This is where all the loose skin on the back of the arm is removed with the trade-off of a long scar. What undoubtably drew you to Smartlipo for your arms is the perception that it can tighten skin. This is a frequently touted property of laser liposuction. While Smartlipo can tighten skin, it does so as measured in millimeters. Patients, however, want and need centimeters of skin tightening. Simply put Smartlipo can not tighten the skin on the back of arms, it needs to be cut off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can you please advise of any plastic surgeon that does breast lift/augmentation at a discounted rate? I have a birth defect that has hindered my ability to become intimate for years. I am ashamed/embarrassed to have anyone see/feel my breast. I am 40 yrs old & desperately want to be normal for once in my life, I just want the chance to have what other women have in their lives. I cannot express enough how very important this is to me. I would like to have the opportunity to love/be loved in my life. Please, if you know of any surgeons, it would be greatly appreciated. Thank you for your time.

A: The desire to try and get cosmetic plastic surgery procedures at the best price, or even for free, is a common one. It is an understandable request and I get many of them each week. As a general rule, one will find few if any plastic surgeons that will provide their services for free or significantly discounted for cosmetic surgery procedures. Quite frankly, there are several reasons why this is so. First, there are many other expenses incurred during surgery besides the plastic surgeon’s time. Operating room supplies and anesthesia fees are two of the most prominent. These have to be paid and are out of the control of the plastic surgeon. Secondly and of equal importance are the medico-legal risks that a plastic surgeon is exposed to from any surgery and patient, regardless of what fees are or are not paid. There is simply more to the cost of providing a surgery other than just the plastic surgeon’s time. This is why you will not find a plastic surgeon that will provide breast augmentation at a fee rate that most patients who like it discounted to.     

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have two surgical pitted crater-like scars on the side of my nose which are really annoying. I have previously tried erbium laser, two courses , nine months apart, and punch excision surgery, but neither treatment helped me. I noticed that your Doc had some impressive photographs of before and after scarring online and would like to know if I can be treated by way of any suggestion the Doc can make. I can send a photograph if you like.

A: The nose is one of the most difficult areas on the face for effective scar revision. The skin of the nose is tight, stretched over bone and cartilage and very thick. This leaves little skin laxity that can close easily after excisional scar revision and skin so thick that even deep laser resurfacing can not smooth out. In looking at your pictures, your two nasal scars are wide and very saucer-shaped. It is a wrong concept to try and bring the surrounding skin down to the level of the scar through any form of laser resurfacing. They are too deep.  It is also not possible to excise them as they are too large and the nose has no skin laxity. What you what to think about is building up the scars from underneath with either cartilage or dermis/dermal grafts. They could be placed underneath the scars through an incision inside the nose. Building up the base of your nose scars is the only approach that will likely make them less noticeable by making their concave contour less so. Your nose scar revision is augmentative in nature.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, several months ago I had a lip surgery involving the removal of a fairly large mucocoele. Before the surgery there was a soft but noticable bumb just on the inside of my lower lip. After the surgery, however, I now have a huge knot of scar tissue that makes my lip protrude. Not only is it hard and gets in the way when rubbing my lips together, its very noticable when I smile and even when my lips are relaxed. We asked the surgeon about a steriod injection but were told that this doesnt always minimize scar tissue but can even have the opposite effect. Is it possible to remove or soften up the knot without making it bigger? Or will it go away in time? What is your advice?

A:  Mucocoeles are common lip growths that are usually seen on the inside of the lower lip. While they are easy to excise, it is not uncommon  that they are incompletely done resulting in a residual lump or bump. which could end up just as big or bigger than the original one. It would not be common to have excessive scar tissue from a mucocoele excision that made it look bigger than when you started. I would think more about an incompletely excised mucocoele. There is nothing wrong with injecting steroids as it will not make it worse (I have never heard of that happening), it is just a question of whether it will make it better. If you are less than 3 months from surgery, I would try steroids. If you are more tan 3 months from surgery, then a re-excision (lip revision) procedure is in order.

Dr. Barry Eppley

Indianapolis Indiana

Q: I want to achieve a completely caucasian look, I am Asian. Do you have any recommendations for my forehead? I am doing a hairline lowering procedure soon, should that be done before or after a forehead/browbone augmentation? Since there will be a scar from the forehead procedure right? I have attached some pictures for you to see me.

A: Thank you for sending our pictures. It is not clear to me what type of hairline lowering procedure you are doing. If it is being with a frontal hairline incision (scalp advancement), then the forehead augmentation should be done at the same time. If the hairline lowering is being done by hair transplants, then the forehead augmentation should be done first so the scalp scar will lie behind the grafted area. Improving the convexity of the forehead is what many women want to achieve, particularly those of Asian ethnicity.

As for other facial recommendations, it is not possible for you to have a ‘completely caucasian look’. Some facial areas may be tweaked but you can’t change the basic foundational look of your face. Tell me what you think would make the greatest difference in your face. In other words, what facial areas do you think would make you look less ethnic? In looking at your pictures, I do not see major areas of change but options do include the creation of an upper eyelid crease, buccal lipectomies, rhinoplasty, chin augmentation and jaw angle reduction.

Dr. Barry Eppley

Indianapolis Indiana

Q: So I wrote to you a few weeks ago. I had an implant placed and then removed after 4 weeks. The doctor said he didn’t remove bone structure but he did. My chin bone is round now instead of the two points (square) I had before, which I loved. He said he wasn’t removing bone structure, I can’t believe he did for a silicone implant. I wish he told me he was doing that and the side effects, I wouldn’t have done it. I liked the shape before. The implant was a huge mistake and I have stippling now after 4 weeks of removal. Can you fix that? Is there anything that can be done permanently to repair the orange peel/stippling? I was mostly scared of getting hanging skin, but this is way worse. 

A: There would be no reason to remove bone structure when putting in an implant. What you are seeing is the remaining capsule/scar tissue that surrounds an implant after its removal. That combined with the extra or stretched soft tissues that has been created will make for a rounder chin appearance. It will not return exactly like it was before. Some of these effects, including stippling, will get better with time (months) as the tissues settle and much of the capsule eventually goes away since it has no reason to be there. But it is unlikey your chin will ever return 100% to the way it was. It will get a lot better with time as scar tissue softens but there is no magic to do now to help the problem..short of putting back some form of a chin implant. 

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis Indiana

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

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

Dr. Barry Eppley

Indianapolis Indiana

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

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

Dr. Barry Eppley

Indianapolis Indiana