Your Questions

Q:  Dr. Eppley, does zerona help with belly fat and gynecomastia. Not sure why it wouldn’t help gynecomastia if it’s all adipose tissue.

A: The first thing to realize about fat is that it is not all the same throughout the body. It is both structurally and biochemically different as it actually serves different physiologic roles depending upon its anatomic location. It is present in our bodies for very functional purposes other than being a source of annoying collections of unwanted bulges. It also has some differences between males and females as well. This is illustrated in your question about male gynecomastia and belly fat. Male breast enlargement is composed of fibrofatty tissue. Some of this is fat but it also has a significant component of gritty fibrous tissue. This makes it unresponsive to an external treatment like Zerona. Gynecomastia can only really be effectively treated by liposuction, particularly Smartlipo, or open excision. Belly fat is distributed differently in men than women. Most of belly fat in women is external to the abdominal muscles (subcutaneous) and can be reached by Zerona (up to 5 cms. penetration) or liposuction. Male belly fat has a greater percent hat lies underneath the abdominal muscles (intraperitoneal) and does not respond as well to such fat treatments.

That being said, Zerona is not a good treatment for Gynecomastia and tends to be less effective for some men than women for the reduction of belly fat.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in forehead augmentation to make the slope of my forehead less so and longer. I was hoping to retain my brow ridge prominence somewhat as that is a family trait…and in fact I’d like to keep the forehead looking sloped and straight as opposed to rounded and convex….keep it similar to how it is now, except for perhaps slightly raising the hair-line and moving it out a bit, while making the slope of the forehead greater, but certainly no where near convex.  In other words, just as the brow ridges end moving toward the hair line, all of that forehead area I was hoping to making steeper, but still straight and non convex, and at the very top where the hair line is i was hoping to making higher and more in line with the rest of the forehead.  Is that not possible? I don’t know how these surgeries work… in other words, I don’t know what the limitations are for the shape of the molds and their complexity…but I certainly didn’t want a drastic change in the forehead. How “complex” can the moulds be made that fit into the forehead region?  What is the potential for tweaking certain aspects? 

A: Forehead augmentation is not done by a preformed implant or a mold. It is done by cranioplasty onlay materials. These are mixed together at the time of surgery and applied like plaster of paris. It is then shaped by hand until the desired form is obtained and then allowed to set or cure. The average working time is about 10 minutes for this process. It is a very artistic technique which is why one has to have a very good idea what type of forehead shape the patient wants. You have been quite explicit as to your forehead shape desires which is good. Given the volume of material needed (at least 40 grams), PMMA (acrylic) is best for you because of the cost issue with that volume of material. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Would Acell Matrsitem be helpful in forehead reshaping to minimize the scalp scar in the hairline? I have a crooked forehead as a result of the way I slept as a child and I know surgeons are generally reluctant to perform this procedure in maklkes due to the scalp scar in the hairline showing as it recedes.

Also, I was wondering of you have ever heard of or used Resobone (custom fit degradable implants to correct bone defects and what are your thoughts on this technology?

A: I think when it comes to optimizing a scalp scar in any patient, but particularly a male, anything that may help would be useful. In that regard, Acell Matristem may provide some healing advantage and it is certainly easy to apply into the wound during closure. While it is not magical and can not make it heal without any scar, anything benefit it can provide to making the scar as narrow and inconspicuous as possible is a bonus.

Resobone is a mixture of two resorbable materials, poly-lactic acid polymers and tricalcium phosphatre. Its intent is to act as a matrix to encourage bone to heal a defect. For bone reconstruction of bone defects, it is an option although I do not see a big advantage over many of the hydroxyapatite cements that exist today or even a computer-generated custom HTR-PMI implant. It does have one disadvantage and that is it is resorbable, so if bone doesn’t replace it the reconstruction will be gone. It should not be used, however, as an onlay or building up material. Since bone will never grow into and replace that of an onlayed resorbable scaffold no matter what its composition. If your thoughts are to use Resobone as a forehead cranioplasty implant it will eventually resorb away and be left with very little if any augmented result.

Dr. Barry Eppley

Indianapolis Indiana

Q: I was recently burned on my chin and left with pitted scars.  I am interested in ACell to repair and restore the skin.  I believe it can facilitate new skin to grow if the scar tissue is removed.  If you believe this too can you help me.  I am a 34 year old mother of three.

A: The treatment of acute burns versus the chronic scarring that it creates after it has healed is different. During the healing of a partial-thickness burn, the application of Acell particles may well have an accelerated healing effect that may result in less scarring than would otherwise occur with its healing on its own. Once the burn wound has healed and scar is formed, however, there is no role for any form of topical therapy. Removing the old burn scar and then reapplying Acell would be unlikely to create a better scar result in my opinion. This is because you are no longer working with a fresh wound that does not yet have a lot of scar tissue formed. In a healed wound, substantial scar tissue exists and removing the topical layer alone is not sufficient to change the final scar appearance. To have its best effect, Acell would have to be applied close to the time of the original injury to work with the wounded tissues before a lot of scar (unnatural tissue) has already been formed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m 46 years old. I have a spare tire around my middle. I don’t want to lose weight because I end up losing my breast and butt. What procedure do you recommend?

A: When someone has a ‘spare tire’ around their middle, they could be referring to two basic types of waistline problems. The first would be fat only. They have thickness around the middle and waistline due to a fat collection but there is no loose or overhanging skin. The other problem is one in which there is both too much fat but with excess skin as well. Each requires a different solution. The fat only problem is treated by liposuction of which Smartlipo (laser liposuction) is my current choice. For a fat and skin problem, a tummy tuck or an abdominoplasty is needed. Often liposuction must be added to the tummy tuck to get those muffin tops which wrap around the sides of the waistline into the back.

You are correct in assuming that some surgical intervention is needed if you are not willing to try some weight loss efforts. Such ’spot’ body contouring changes require surgical treatrment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am 22 years old and am currently on my journey to lose at least 80 lbs which would put me at 5’4 and 115 lbs. That being said I realize mine is an ambitious goal and I also know that a lot of skin will be leftover when I get there. So i am interested in abdominoplasty, mini or full depending on what is decided at consultation and also breast implants and butt implants might be of interest too. But we’ll talk about that particular idea when I get where I am going. I have a couple questions:
* how much will a high profile gel, hopefully via armpit run me?
* do you accept payment through www.myfreeimplants.com
* would there be a small discount because i will at least be combining the breast and abdomnial surgeries,
* how much is abdominoplasty,
* and finally, if I added up all three abdominoplasty, breast augmentation and gluteal implants, what about would be my total?

A: I applaud you setting an ambitious but achieveable weight loss goal. Going from near 200 lbs down to 115 lbs would be a good achievement and, as you have predicted, will result in some significant loose extra skin from the arms down to the thighs. While it is impossible to accurately predict what you may need, there are some relative certainties. Your abdominoplasty would not be a mini- but would be a full. A breast lift will likely be needed in addition to getting breast implants. An implant alone will not lift a breast. Butt implants are not a solution for a sagging butt anymore than a breast implant alone solves a sagging breast.

In your search for plastic surgery costs, look for some general pricing from plastic surgeon’s websites for a full or complete abdominoplasty ($6500 to $8500) and breast lifts with implants. ($ 7,000 to $ 9,000) This will help you think about setting some financial goals as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m 25 years old and I just had my 4th daughter in February of this year. I am still breastfeeding and I am going to stop breastfeeding in two more weeks. How soon can I do my breast augmentation after I stop breastfeeding?

A: This is a common question as many women want to quickly improve the size and shape of their breasts after childbirthing. Obviously breast enhancement can not be done while actively breastfeeding so how soon after?  Breast augmentation, because it involves the placement of a synthetic implant, needs to be done as sterile as possible to avoid infection. Milk actively coming from a nipple with breast manipulation during surgery does pose an increased infection risk. You also want to be sure that the breast is adequately deflated and is still not engorged so one is working with a stable breast size that is not subject to further tissue changes after surgery. Most plastic surgeons would  recommend waiting at least 3 months after you have finished breast feeding before undergoing surgery. I would also recommend getting a consultation once you have finished breastfeeding to begin the consideration of implant options. It is also likely that after having four children that breast augmentation alone is not the only solution to better breasts. If there is any sagging (nipples at or below the lower breast crease), then a breast lift will need to be done at the same time as the implant placements. (mastopexy-augmentation)

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if an intraoral chin reduction could be successful if I don’t have much soft tissue. I know if the mentalis muscle is disturbed it can cause sagging but if it is properly tightened back together could this still happen? What is the likelihood?

A: When the chin bone is shortened from inside the mouth, the muscle is not only detached but now an excess amount of soft tissue results. In other words, there is too much soft tissue for the amount of bone left. That is what creates a chin soft tissue sag or witch’s chin. While tightening up the muscle back to the bone is effective for very small chin reductions (that aren’t noticeable), such muscle tightening will not work for more visible chin bone reductions. The extra amount of soft tissue must be shortened (removed) as well as tightened. So the answer to your question is that intraoral chin reduction is usually a bad idea no matter how well the muscle is retightened. Only a submental (under the chin) approach can adequately remove and tighten the loose soft tissue that is created from chin bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the chance of any type of nerve damage from chin, jaw and cheek augmentations. Also, what is the rate of infection from facial implants? Mostly though I am concerned about nerve damage from these facial implants.

A:  When considering nerve damage from chin, cheek or jaw angle implants, you must separate the two types of facial nerves which are motor (risk of muscle paralysis) and sensory. (risk of numbness) There is no risk of facial paralysis from any of these facial implants. Where they are inserted from, which is usually from inside the mouth (with the exception of a chin implant), does not come near any branch of the facial nerve. Risk of some numbness, temporary or permanent, is the more common nerve risk of facial implant surgery. Branches of the trigeminal nerve at risk are the mental (chin implants), infraorbital (cheek implants) and the long buccal nerve. (jaw angle implants) It is rare that permanent numbness would result from these surgeries.

Infection is always a risk from the placement of any type of synthetic material into the face. While the face is exceedingly well-vascularized, it is still possible for infection to occur from bacterial contamination during their placement. The infection risk is about 1% to 3% and is slightly higher when the implants are placed from inside the mouth vs. through the outside of the skin. A chin implant is most commonly placed through an incision under the chin through the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am concerned about the way my face has started to look. I am only 45 years old but I look much older. I don’t think there is anything in my medical history that could explain this change in my appearance. I’m otherwise quite healthy; I eat well, exercise regularly, and have not had any recent weight loss or gain. I had a hormone panel done and they are all normal. The only other possibility I can come up with–although I highly doubt medical data could back-up my hypothesis–is that over the past few years I lost both of my parents. I feel that perhaps stress and anxiety have taken their toll on my face. I have attached pictures so you can see what I mean. I also have an indentation below my left cheek that has appeared without any explanation. I wonder if a submalar implant would work to build out that area. Otherwise, I would welcome any other suggestions you would have for my aging face.

A: Thank you for your inquiry and sending your pictures. Based on a review of your pictures, I can make the following comments.

 1) The area of left facial indentation/depression is not over a bony prominence or the submalar area. It is actually over the concave portion of the underlying maxilla and is in the area of the infraorbital nerve exit/distribution into the tissues. I do not know why it has selectively become that way.

2) You also have more generalized facial lipoatrophy which is apparent when looking at your younger facial photographs. While you have no sagging skin that would require something like a facelift, your face has undergone more deflation or loss of volume.

3) A submalar or any other type of synthetic or bone-based implant is not what will work for the soft tissue indentation.

4) I think that concentrated fat injections, not only into the left maxillary indentation, but through your cheeks, orbital and lateral facial areas would be a good treatment for you. You need restoration of facial volume through injectable fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley I’ve been suffering with TMJ pain for a long time. And I’d like to know how well does Botox work for TMJ and also do you use Xeomin as well for TMJ?

A:  Thank you for your inquiry. Botox is an anti-muscle spasm/pain injectable drug so it is good for masseteric muscle pain and hypertrophy but not specifically true TMJ dysfunction. Although many people think that they have ‘TMJ’, they actually do not have a true intracapsular joint problem which is a dysfunction between their condylar head and the moveable meniscus. (disc) Rather most ‘TMJ’ patients actually have myofascial pain (muscle pain) which may or may not be responsive to Botox. I would need to know more about your ‘TMJ history’ to determine if this is a treatment option for you. Knowing if you have specific trigger points for your pain would suggest that Botox injections could be beneficial.

Xeomin is the second competitive drug to Botox that has come out in the past two years. I do not currently use it as it does not offer any significant clinical advantages over Botox such as longer duration of action or a stronger effect. It works identical to Botox other than how its units are measured. One has to be very careful in trying to compare Botox, Dysport and Xeomin as they all have different unit dosages. Their units are not comparable terms of strength and price. Usually the unit dosing is different but the cost works out to be about the same, or very similar, for all of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to know what you recommend to make my nose smaller and my upper lip bigger. I have attached some pictures of myself for you to see and do computer imaging as well as some pictures of my goals. I understand the results are not going to be identical. The pictures are just an “inspiration” of what i want to achieve. I’am very excited to see the computer imaging!

A:  Thank you for sending your pictures. I have done somecomputer imaging on your nose and lips. The side view is not a good quality image but I did the best I could. The refinement in your nasal tip will be somewhat limited by the thickness of your nasal skin which is always the limiting factor in tip definition from a rhinoplasty. But the tip area can definitely be improved. I also did some cartilage buildup of the dorsal line and bridge area. This will help make the rest of the nose higher and slimmer which will also help the appearance of the tip.

From an upper lip standpoint, you have nice contours and definition but just need some more volume. I would recommend concentrated fat/stem cell injections into the upper lip. That could be done at the same time as the rhinoplasty. An alternative is a subnasal (bullhorn) lip lift but this can not be done at the same time as an open rhinoplasty. Therefore, I would do the fat injections at the time of the rhinoplasty and see how that turns out. The subnasal lip lift can always be done later as an office procedure under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 24 yr. old Asian female interested in augmenting my brow line.  I’ve attached a photo of myself and another person with a protruding brow line.  I don’t expect to look like the second photo after surgery but I’m using it to get my idea across. About a year ago, I had fat injections to my eyebrow area, but I saw little to no results after the procedure.  Now I am considering different options for more noticeable results.  The other options I am considering are – implants, bone graft, bone cement, or filler. I would like to know if you’ve performed these procedures and I have a few questions concerning them:

• Where will the incision be?
• What is the possibility of infection?
• Is there the risk of facial nerves being damaged during the procedure?

Thank you in advance,

A: I have performed brow and forehead augmentation/cranioplasty with numerous materials over the years. In answer to your questions regarding brow augmentation:

1) You can look like the picture if you want. It is all a matter of how much material is added. There is not much limit to what can be added.

2) A scalp or coronal incision is used for access to the brows.

3) Infection is always a possibility but rare in scalp procedures. So rare that I have not seen it in my practice career.

4) There is no risk of facial nerve injury.

Also, without question, cement is what you want to use for brow augmentation. Not implants or bone grafts. Cements can be molded and shaped to the bone and are permament.

I hope this is helpful. Let me know if you have any further questions.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I want to get liposuction done as soon as possible. My only problem is my stomach which is what I want to get rid of. I hope you can help me. I am getting married this coming July. Can I have it done before then?

A: Liposuction can be a very effective solution for a stomach area that has fat which has been refractory to diet and exercise efforts. Provided there is no significant extra skin, which may mean a tummy tuck is a better treatment, then liposuction alone is a good choice. Recovery after any trunk liposuction always take longer and is more difficult than most people think. It is not as simple as ‘in one to two weeks you will be just fine’. That doesn’t mean that one is bed-ridden or severely limited in physical activities, it is just that it is sore for a much longer time than one would predict. This is particularly true around the stomach where its center of body location exposes it to constant movement and stretching. Before an extremely important event like gettinmg married, you want to allow a good amount of time between the liposuction procedure and your wedding date. I tell my patients at least 6 weeks and preferably 8 weeks beforehand is even better. You want to feel 100% by the time the big day arrives.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Dr Eppley, I was also wondering about the possibility of injectable kryptonite cranioplasty for plagiocephaly. I live in Europe and had not heard of this procedure until coming across your website.  I am a 30 year old man, and my skull is flattened at the back, and a bit asymmetrical. I would be interested in the procedure, but as I understand it is fairly new. I was wondering about any other potential problems- for example, would there be much loss of sensation/feeling at the back of head? or risk of any possible future complications?

A: The injectable Kryptonite procedure is one I have been doing for the past 6 months or so. The material is not new but the method of delivery is one that I have developed specifically for onlay cranioplasty. It is a simple technique that does not permanently change the feeling in the skin of the scalp. The only potential complication has been that of smoothness of its contour, particularly at the edges where the material has to blend into the surrounding skull bone. I have seen that and also developed a relatively simple rasping remedy, which like the original injection method, uses a very small incision(s) for access. So the significant risk of the procedure may be the need for secondary or revisional smoothing if any irregularities develop.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like information regarding Rhinoplasty.  I am thinking about having it done and need some more specifics as well as the cost. Thank you.

A: Thank you for your inquiry. I get lots of requests that are just like yours, requesting general  information. Such questions, while well intended, are too vague and not very meaningful. There is a tremendpus amount of information aboout rhinoplasty on my website and blogs. To be most helpful, however,  I would need to know what specific information you seek. What you really want is not general information on the procedure but how it specifically relates to you and your nose concerns. The most helpful information would be what type of rhinoplasty do you need and how might it look on you if it were done. If you send me some pictures (a front and side view of your face on a clean background such as a door or wall) I can do an assessment and some computer imaging for you. That would be the most meaningful place to start in your search for rhinoplasty information. Once the nose problem is seen and imaged, some more specific cost information can be provided.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello. My hairline is kind of far back. I would say it is about 2 cm too far and it is really making me look odd.  I have attached a video which captured it pretty good as well as some photographs. Here are my thoughts. Every cm. down would be a great thing for me, but as you can see, I also have some natural receded hair in the corners of each side. Could this look weird or odd in case of bringing the hairline down a bit or will they also be brought down? Also, I don’t mind the ehighht of my forehead. It is just that the hairline sits so far back.

A: When doing a hairline advancement, the entire frontal hairline is moved although the greatest movement is in the middle. Your issue for a forehead reduction is that you are a male and young. Since you can not possibly predict how stable your frontal hairline will be for the rest of your life, the fine line scar from the procedure along your existing hairline may not always be at the very edge of your hairline.  This raises the very high probability for most men that the scar one day, sooner or later, may be visible in front of one’s hairline. This is why hairline advancements (forehead reductions) are rarely, if ever, done in men

Dr. Barry Eppley

Indianapolis Indiana

Q: My wife have stated to me that she would like to have breast augmentation. My question, is any type of plastic surgery covered under health insurance plans. I not sure if we could afford something like this. What are my options for plastic surgery procedures. Thank you.

A: It is not rare that I get a request from a prospective patient inquiring about whether a breast augmentation would be covered by their health insurance. This question points to a fundamental misunderstanding of what one’s health insurance is for and the differences between cosmetic and reconstructive plastic surgery. Health insurance is intended to pay for preventative and treatment care for medically necessary conditions. When it comes to the breast such medically necessary surgery would include breast biopsies, lumpectomies, mastectomies and any form of breast reconstruction that these procedures have caused. Breast conditions caused by underdevelopment (small breasts) or breast shape changes due to pregnancy or aging (breast sagging) are not medically necessary conditions. Therefore, rebuilding a damaged or partial or completely removed breast would be breast reconstruction and is medically necessary and paid for by health insurance. Increasing the size of the breast with implants or changing its shape by lift procedures are cosmetic changes and are never covered under one’s health insurance.

While it is understandable that one wants to have their insurance cover breast augmentation, that remains wishful thinking. At best, insurance will never pre-approve a breast augmentation. At worst, trying to do breast augmentation under insurance would be considered fraudulent.

Dr. Barry Eppley

Indianapolis Indiana

Q: My daughter is 14 years old and is bothered tremendously by her ears that stick out. While we are used to them and think she is beautiful, she clearly has a different opinion. She never wears her hair back and always has it so that her hair covers her ears. While we are not keen on her having to undergo plastic surgery, I think this is the only solution that will make her less self-conscious. What is a good age age for her to have ear pinning surgery?

A: Ear pinning, also known as otoplasty, is actually the number one teenage plastic surgery performed. It is a highly successful operation that can make a dramatic difference in the shape of the ears, changing it from one in which the ears are the most noticeable feature of one’s face to not noticing them at all. (which is how your ears should be) When evaluating teenagers for cosmetic plastic surgery, I always consider three factors; their physical maturity, their emotional maturity and their expectations. When it comes to ears, otoplasty can really be performed safely anytime after 2 years of age. It has been shown that the operation does not affect ear growth beyond that age. From an emotional maturity standpoint, the problem that otoplasty treats is very obvious as well as why it would bother someone so this is never an issue.  I think almost any patient, teenagers not withstanding, have reasonable expectations with the goal of an ear that does not stick out as far. As long as the operation does not create the reverse problem (ear plastered against the side of the head), most patients are going to be very happy with the results. In conclusion, I think your daughter can have otoplasty at anytime and the sooner it is done the better she is going to feel about herself.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in facial feminization surgery. I will be starting hormone replacement therapy in the next few months and as part of this I would like to know which surgical procedures I can benefit from. f you could list them in priority would be greatly appreciated. I need to prioritize my surgeries based on finances and benefit. Thank you so very much for providing this service, it will be such a stress reliever and I am looking forward to your recommendations. I have attached a front and side view picture of me to review.

A:  Thank you for sending your pictures. In looking at your pictures, I would recommend the following facial feminization surgery procedures and would place them in the following order of importance and value.

 1) Forehead Contouring/Brow Reduction and Brow Lift – This is almost always one of the most important areas as you have a classic male forehead and appearance with a low horizontal brow shape, mildly prominent brow bones and a dip in the forehead shape. A more feminine appearance comes from smoothing donw the brow bones with a lateral wing effect, cranioplasty to make the forehead more convex, and a browlift to create an arch to the eyerows with a lateral swoop. This can dramatically change the way the eye and forehead area looks, creating a very softening effect. Because this has to be done through an open scalp incision, you will need to consider potential hair transplantation later. But this may have been on your list anyway at some point.

 You would also benefit from an upper blepharoplasty to get rid of the extra skin and create a better eyelid shape to go with the forehead/brow reshaping.

 2) Rhinoplasty – The thick skin and shape of your nose needs substantial refinement. That is a challenge with your thick nasal skin and underlying cartilages but significant improvement can still be obtained.

3) Chin Contouring – Tapering the chin bone to make it less square would provide a softening effect.

 4) Necklift – Tucking up the loose neck skin would help the chin and the neck angle to be more defined.

 As outlined above, the Forehead, Brow and Nose are really important in our case and would be the first set of procedures you should do. I have attached some rough computer imaging which gives a general idea but would probably look better in real life as there are limits to what moving image pixels around can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in correcting some asymmetry in my face and creating more harmony to the lower third of my face. The back of my lower jaw area (masseter muscle) is bigger on my right side. There is also some soft tissue asymmetry with the right side being fuller in my mid cheek area, and my chin is off center. I have been to different cosmetic surgeons but have not come across anyone who has a real solution for this. Orthognatic surgery was recommended, however I believe there is a way to correct this without such invasive surgery. I have had trouble locating a doctor in my town that does jaw implants, that’s why I was happy to find your site because it seems jaw angle implants and dealing with facial asymmetry and the jaw area in general is something you have extensive experience. I have done some research, and the solution I came up with would be jaw angle implants, with the one on the right side being bigger to account for the asymmetry. However, even without the asymmetry I would still be considering jaw implants, just because I feel that my jawline is more narrow/less defined than I would like. For the soft tissue asymmetry I would like to do removal of the buccal fat pad/or facial liposuction to thin out the lower cheek area of my face and make that area more defined. Please let me know what you think. I look forward to hearing from you and getting an idea of what you think is best from the imaging. Thanks!

A:  Thank you for your inquiry and sending your photos. As you have astutely pointed out, you have overall lower facial asymmetry marked by a very high left mandibular angle (steep mandibular plane) compared to the right side and chin bone asymmetry. This could be improved by jaw angle implants (3mm lateral style on right and 3mm inferolateral style on left) and chin bony contouring. (right chin tubercle reduction) For the midface, I would look at not only buccal lipectomies but the addition of small cheek implants as well. When you have a long face that is flatter in profile (malar hypoplasia), some anterior projection of the cheeks is helpful. Otherwise, buccal lipectomies alone may just make you look a little more sallow or gaunt and not provide the facial highlighting that you desire. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 38 years old and I need some changes to my face. It is a very round face without much definition or highlights. From a side view, I think my profile would be much improved with chin augmentation and fat removed from under my chin.. I do not know if my chin augmentation would benefit more from an implant or osteotomy. From a frontal view, I would like the distance between my upper lip and nose shortened. It is too long and I have a thin upper lip as well. I am attaching some picture for you to image to show me what could be done with plastic surgery.

A:  Thank you for sending your photos. I have done some computer imaging based on your desired changes.  I think you are correct in predicting that chin augmentation (implant not an osteotomy) with submental liposuction would make a nice change. The combination of the two can completely change the profile of your lower face. From a lip standpoint, your upper lip is very long and a subnasal lip lift would help shorten that distance. I have also added a buccal lipectomy to help slim your cheeks which would provide a good thinning complement to the proposed fat reduction in your neck.

 The combination of all four of these changes would help make your face more proportioned and balanced. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 40 years old and I have a mound around my penis area. When fully erect I have 4 1/2 inchs but when I press down on the mound my penis measures about ¾ inch more. I have lost some weight and consider myself in good shape. But understandably I am a little embarrassed about my penis size. Plus my scrotal skin is high up on my penis making it smaller than it otherwise would be. Do you think liposuctioning of this mound would help? How long would the recovery be if I had the procedure?

A:  Fullness of the suprapubic mound can definitely cause some concealment of the penis. There is no doubt that liposuction of the suprapubic mound can help with penile exposure but it is a question of how much. There are numerous factors that can contribute to camouflaging penile length besides a surrounding fat collection including scrotal skin position, overhanging suprapubic and lower abdominal skin and ligamentous attachments to the penile shaft. Whether liposuction alone would be beneficial or whether it should be combined with other penile lengthening procedures should be discussed with a Urologist.

When liposuction to the suprapubic mound is done, there is an immediate result that is apparent intraoperatively. However, because of swelling and gravity these early results can quickly be obscured. While compression after surgery with a garment is always provided, the low position of the suprapubic mound makes it difficult for any compression garment to be ideally effective. Therefore, one should anticipate a fairly long period of swelling and firmness around the penis. It may take as long as 6 to 8 weeks after before the results of the liposuction procedure can be fully seen.    

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want a fuller face with full cheeks. I have a very thin face that looks gaunt and sunken. It seems to be getting worse as I age. I think I need either cheek implants or fat injections but am not sure which is best. I have attached some pictures of my face for you to see and do some computer imaging to see what the possible changes would be. Thank you for your time.

A:  Thank you for sending your photos. To do accurate imaging, however, a front and side view photo is needed in which one is not smiling. Your photos can not be used for any imaging as the smile obscures the whole process.

 Otherwise, you have a type IV facial lipoatrophy condition with near complete loss of the buccal fat pads and most of the subcutaneous fat tissue. This gives you that sunken facial appearance.  You would ideally benefit from a combination of submalar cheek implants combined with concentrated fat injections to the upper and lower submalar area as well as back along the side of the face. Given your thin face, it may well be that your body is equally thin so whether you have enough donor fat remains to be determined. With fat concentration techniques, one needs to harvest as least twice as much fat as the face requires. I would estimate that you need about 20cc of fat for each side of the face so it would take about 100cc of liposuctioned fat to do the job.

Dr. Barry Eppley

Indianapolis, Indiana

Q: My son was born premature and needed a tracheostomy. He was unable to be decannulated and then had a tracheolaryngoplasty performed at three years of age. This has left a large ‘hole’ in his neck. He is now 11.  We have seen a plastic surgeon who seemed to think that it couldn’t be made better and he should wait until he is fifteen years old. Do you have any experience with this type of neck scar problem? He is quite small for his age, has a very husky voice and the scar is not good for his self-esteem.

A: Having done numerous tracheostomy scar revisions over the years, I have observed that they come in numerous scar orientations (vertical vs horizontal) and depths. (smooth vs indented) The most difficult tracheostomy scars are those that are significantly indented such as the one your son appears to have. They are difficult because the problem is more than just a wide scar but that there is a significant soft tissue deficiency between the skin and the underlying trachea. The pressure of the tracheostomy tube has caused subcutaneous fat atrophy which is why it is indented. This tissue deficiency must be replaced to get a satisfactory outcome. In these cases, I usually use a dermal-fat graft to fill in the defect after the scar edges are released and undermined. Then the skin portion of the scar is closed over it. Because the skin closure is usually under considerable tension, a second scar revision on the skin may needed a year later if it widens to any degree.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting a rhinoplasty done. I want a more streamlined look to my nose. It needs to be straighter with less of a downward slope or dip in the bridge area. I think the dip is the result of a barbell bar that I dropped on my nose when I was about 12 yrs old. I have attached some pictures of my nose for you to see. What are your rhinoplasty recommendations?

A:  Your pictures and your history show a classic saddle nose deformity. Your nasal bones and middle vault (upper and middle third of your nose) are collapsed and your internal septum is underdeveloped. This also results in a low and broad nasal tip, short columella and flared nostrils. The key to a successful result in the saddle nose deformity is building up of the entire dorsal line from the bridge down to the nasal tip. Without question the best material for this is your own cartilage. Your septum, however, would not provide adequate donor material. Ideally a rib graft should be used. This provides the best amount and shape that this buildup requires. One could use a synthetic implant, which is easier, but there is a definite risk of long-term problems with foreign materials in the nose. Otherwise, your rhinoplasty would be done through an open approach with dorsal graft and columellar grafting, nasal tip refinement and nostril narrowing. This would provide a more streamlined and straighter look to your nose as the attached computer imaging illustrates.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 24 years old and have familial multiple lipomatosis as my father has it. I have multiple lipomas (relatively small) in arms, trunk and thighs and some of them cause me pain. Looking for excision of the lipomas which number about a dozen. I don’t know who exactly to go to or what to do. I’d appreciate it.

A: While many people have single or isolated lipomas, a few patients will have many more than one and lipomas that continue to occur over their lifetime. This is a condition known as familial lipomatosis. No one understands why it occurs or what causes it. Since there is no definitive cure for this recurrent problem, it is usually best to wait until there are enough symptomatic (painful) ones that justify surgical removal. There is an injectable treatment which is best reserved for those that are smaller and not near any important structures such as nerves. Injecting can help suppress their growth and may for some small lipomas be curative of them. Otherwise, intermittant excision will be needed as their numbers and size dictate.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I was wanting to know if you guys do laser stretch mark removal? If so I’d like to kow more about it and maybe get a consultation to see what it would cost.

A: Stretch marks remain a cosmetic problem that defies any effective treatment. If there was one really good treatment that consistently worked, we would all know about it as there are millions of women that siffer from this aesthetic concern. While there have been and are many types of treatments that promise the elimination of stretch marks, none have ever been shown to really work well. Therefore, there is no effective treatment strategy known as laser stretch mark removal. That is not a realistic expectation of what lasers can do or any type of stretch mark treatment.

Why do stretch marks elude treatment success? Because a stretch mark is not a superficial skin problem. It may appear that way when looking and feeling them from the outside, but a stretch mark represents a full-thickness skin problem. The dermis of the skin is damaged and permanently thinned. A stretch mark is really a scar with loss of pigment, although they can appear red rather than white. The skin has been stretched to the point where it is partially torn on the underside. This is why no outer or topical treatment will really make them less visible.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello Dr. Eppley, I was wanting to know if you do fat transfers to the arms? I had liposuction done to my arms over a year ago that left me with a lot of dents and irregularities. It has improved a lot over the past year and now there is just some loose skin that bothers me. I think these arm areas could could benefit from some filler. I wanted to get some fat removed from my stomach which has always been a problem area for me. Thank you for your time.

A: Arm liposuction is very prone to irregularities given its thinner skin and that the liposuction technique can not really use a cross-tunneling method, which is really useful to prevent large irregularities in fat removal. It is good that you have waited until the arm sites have matured and all the tissues have settled. Many arm liposuction irregularities will improve with time although they rarely go completely away. For small remaining areas, injected fat would be the only good treatment option. Only a small amount of fat would be needed so your stomach sounds like it would provide more than an adequate donor area. The fat that is harvested is washed and concentrated so that the highest percentage of viable fat  and stem cells gets transplanted. This should help fill in some irregularities and expand out some loose upper arm skin.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like my brow bones enhanced but I think I only need the outer 2/3rds of the browbone or even just the outer 1/3 (the area underneath the eyebrow) plus a little bit on the temple that’s connected to the brow. I want the area to look flat but padded up and not stuck out like a ridge. I don’t want to end up looking like a neanderthal. So I think only the outer brow bone needs enhancement but I do not know how it would look esthetically in practice. I’m not a plastic surgeon. Have you done many outer 2/3 of the browbone enhancement surgeries before? How do they look? Would you mind sending me some before and after pictures? I am thinking of getting juvederm to the area first to see how it would look with the permanent filler. Should i do that? I also have a low nose bridge which I want to enhance a little bit. If you don’t mind I’ll send pictures. What are the chances of scarring with the upper eyelid approach? Where is the incision going to be? In the eye crease? I think saw you mention to someone else the Q&A about preparing the periosteal, what does that mean? Why do you prefer the hydroxyapatite paste instead of kryptonite bone cement for this procedure? I’m sorry for asking too many questions Dr. Usually when you search about enhancing the brow bone on the web, only the stuff about silicone forehead implants come up, which seems rather drastic and scary to me. You’re the first Dr who have said the 2/3 browbone enhancement is a viable option.

A: For the area of brow bone that you want enhanced, an upper eyelid approach is the best way to go. It is much closer to the bone area to be augmented and is done through an upper eyelid crease incision. This is the same incision used for standard upper blepharoplasty procedures. The material of choice is hydroxyapatite cement. This material must be placed through an open incision, contours nicely, sets up quickly, and is less expensive than Kryptonite bone cement. Many people are enamored with the injection approach with Kryptonite but they misinterpret it like it is the same as injectable fillers for soft tissue. It still requires an open pocket dissection and then must be contoured from the outside by hand without actually seeing the bony contours. That may be fine for a large skull area but when it comes to working with very discrete contours this is not good and will very likely pose irregularities that will have to be revised later.

The tail of the brow can be either reduced or augmented (lateral brow bone augmentation) through the upper eyelid approach. I have done both very successfully. A scalp approaach is needed, however, when the entire brow needs to be modified.

Dr. Barry Eppley

Indianapolis Indiana