Your Questions

Q: Dr. Eppley I am just wondering how I am able to fix the dent in my forehead above my brow bone? I want a more smoother look. How much would the procedure cost?

A: You are referring to the area above the brow ridges where you would like it to be more smooth and confluent as it goes upward into the upper forehead. That is a common request amongst females that I get. This involves adding material above the brow bone so that it creates a flatter, or even a convex shape, to the forehesad area. This has to be done through an open scalp (coronal incision) That cost for this type of frontal cranioplasty procedure is in the range of $8500. Several features influence the cost of the procedure including the type of material used for the cranioplasty procedure. (hydroxyapatite vs. kryptonite vs acrylic) This is an outpatient procedure that usually takes about 2 hours to complete. There would be some swelling of the eyes afterward as gravity pulls swelling downward. The trade-off for this forehead improvement is a permanent fine line scar in the hairline and some slight permanent numbness of the scalp near the incision line.

You may feel free to send me some pictures of your forehead for my assessment and your suitability for this procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am requesting male masculinization including cheek and jaw implants. I want a  “wrap around” jaw implant with a very good cleft in the chin portion.. I would like a widened, elongated and very distinctive jawline angle and very shapely square chin, preferably the most square chin implant. I would also like that fine line of distinction between the lower part of the jaw implant and the chin implant. A line that is located on the sides of the mouth maybe about an inch from the corners giving the jaw and chin a very strong look when implants are placed together. I’m hoping this can be accomplished by using a “wrap around” implant without too many additional implants.  Can this be done and with what type of implants? I have attached some photos for you to see my jawline.

A: When it comes to your jaw, I understand what you want to achieve as far as jawline enhancement is concerned. While your jawline and chin is by no means weak, it appears you want it to be more pronounced. When it comes to doing a complete jawline enhancement or ‘wrap-around’ augmentation, there are two fundamental implant approaches. The first is to use three or a triple implant approach. This would be a chin and two jaw angle implants. The weakness or flaw to this approach is that the union of the wings of the chin implant and those of the  front edges of the jaw angle implants is a weak contour area. It is never filled in as well as the chin and jaw angle prominences, particularly when the chin is more square in design and the jaw angle are more pronounced. The other approach is to make a custom jaw implant as a one-piece unit. (even though it may be put in as two separate halfs and combined in situ) This avoids the body of the mandible contour defect from the triple implant approach. Its one drawback is that this is a more expensive method as the custom implant has to be made off of a 3-D mandibular model prior to surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in getting a revisional rhinoplasty but honestly this is a difficult decision. Overall I’m not eager to go through the whole process again.  I’m trying to determine if my gain in appearance is worth putting myself through it again.   I’m 43 years old now and somewhat concerned about my body healing as quickly or as well. As a side note, I am in good physical condition for my age as I do lots of exercise.  I figure if I’m going to do anything more with respect to my appearance, now is the time.  I may be having a bit of a mid-life crisis I suspect. I do have an appointment to see about Botox/filler/collagen and/or fraxel laser treatment in attempt to back-off the aging process which is now in full-swing.

A: It is always a difficult decision as to whether to revise a rhinoplasty or not. Having experienced the recovery once gives one pause to really assess the the benefit:risk ratio for round two. Given the fact that your rhinoplasty result may be very reasonable (no major complications or deformity) and you are shooting for a more advanced aesthetic outcome also makes one ponder it carefully. In the end, the appeal of the potential benefits has to outweigh the understandable disdain for the process to get there.

One potential advantage of a revisional rhinoplasty, besides that of the nose, is whether there are any other facial procedures that could be combined with it. These might include fat injections for fillers or any type of laser skin resurfacing. This is what I call an opportunity factor given that being in the operating room under anesthesia is a very rare occurrence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting liposuction. I thought I would never even consider this but times have changed. My main concern is my hips.  I’ve tried for years to lose this area. I am really having a problem finding clothes to fit me due to this problem.  I usually have to buy a size bigger to accommodate my hips, which in turn causes the rest to not fit properly.  So, my need is my hips.  As most women go, I’m sure I could find other areas that I’d like done, but this is what I really need and I emphasize the need to get my hips done.  This is just my personal desire and goal for myself. How well does liposuction work for hip reduction?

A: Usually when patients are referring to the hips, they means an area between the upper waistline and down to the outer thighs. (saddle bags) Whether this is just a small hip roll or a much larger area depends on whom is asking and their body type.That is an area that responds pretty well to liposuction and significant improvement can usually be obtained. Depending upon the size of the hip area, one can usually drop a clothes size which would work out well for you given how you have to buy your clothes now to accomodate your larger hips. The only real complication to hip or thigh liposuction is the potential for contour irregularities or dimpling. As this area often has some degree of cellulite in many women, making it perfectly smooth after surgery may not always be possible.

Dr. Barry Eppley

Indianapolis, Indiana

While women have always made up the majority of plastic surgery patients, the percentage of men is steadily increasing. More men today acknowledge what women have known all along…appearance does matter regardless of age.

While the goals are always the same, to look as good as one can, a man’s age influences why it matters. Younger men are motivated by optimal attractiveness or to correct features that they consider embarrassing. Older men are motivated by divorce, job competitiveness and countering the effects of time. The common procedures that men choose, not surprisingly, are also influenced by age.  Droopy eyelid skin and neck wattles are the concerns of older men while the removal of excessive body fat and reshaping noses, ears and chins captivate younger men.

While age may make a difference in what plastic surgery procedures men desire, there is one characteristic that they all share. Men are less patient than women, particularly when it comes to appearance issues. This means that cosmetic treatments that require regular maintenance, like Botox and injectable fillers, are not that appealing. Men prefer more of an immediate fix like what surgery does. And men do not want a lot of recovery or downtime after surgery if possible. Discretion is paramount in male cosmetic surgery. While everyone knows that men having plastic surgery is not rare, the male patient does not really want to broadcast it.

One observation that has reverberated amongst plastic surgeons for decades is that men can be difficult to please and are less satisfied than women after surgery. They also are more prone to want revisional surgery. That has not been my experience…with the exception of the younger male patient. Facelifts and eyelid surgery in the middle to older-aged male gets good results and satisfaction is just as good as women. When it comes to structural changes in the face or body contouring surgery in the younger male patient, there is some definite truth to that belief. Younger men today grow up today playing with action figures, looking at men’s magazines and seeing great emphasis placed on exercise and sports which exposes them to more pressure to have a very masculine face and body. This makes managing the expectations from surgery in younger men extremely important.

One male quality that seems to be true…and most women will probably second it as well… is that many men are not very tolerant of pain. They are less comfortable with after surgery discomfort and that is to be expected as men have never endured pregnancy and child delivery. That gives women a decisive advantage in the early after effects of many plastic surgery procedures. This is not to say that men are not tough, just not as tough as women when it comes to appearance alteration.

Last year over one million men underwent some form of cosmetic alteration in the U.S. The stigma of men paying more attention to their appearance and grooming habits has changed alot in the past ten years. The beauty gap between men and women is closing to some degree as an increase in the desire of men to use their improved looks to remain competitive professionally and personally is on the rise.

Dr. Barry Eppley

Indianapolis, Indiana

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

A common question that some women face today is…are they for real? With more women than ever undergoing breast augmentation, this is not a far-fetched question. It may be inappropriate to ask but the statistical reality is one may be more right than wrong many of the times. According to statistics from the American Society of Plastic Surgeons, the number of women who have had breast augmentation had risen nearly 40% over the past decade. In 2010, nearly 300,000 American women received cosmetic breast enhancement.

One other trend in breast augmentation is a noticeable size difference. Many plastic surgeons have commented that women are asking for bigger breasts than they were a decade ago. Historically women would usually ask to go a cup size bigger. Today it is not uncommon for a women to want two or three cups bigger, particularly the younger they are. Women state they want to get a good value for their investment and they want to make a noticeable difference in their clothed appearance.

What accounts for these trends in breast augmentation? By far I would say that it is simply more accepted than ever before. As we enter the upcoming decade of 2010 to 2020, this is the beginning of the third generation of women who have had access to breast implants for cosmetic enlargement. It is a normal part of society now and younger women’s mothers and soon grandmothers will have had the procedure.

Breast augmentation has a track history of safety as well as effectiveness. Despite the hullaboo of what transpired in the early 1990s, the procedure has been proven to cause no medical problems or makes people systemically sick.. While it is far from a perfect procedure, because after all it is an implant in the body, its complications are local in nature and often aesthetic in significance.

The social trends of today play a major role in its popularity as well. Just go through the checkout counter at the local grocery store and the magazines are full of articles about celebrities who have had or are assumed to have had some form of plastic surgery. Many of these are women actors and performers who have enhanced their top half. The influence of these magazine, TV shows and now the internet have made it seem that having breast enhancement is now the new norm.

There are more choices in breast implants today than ever before. Since 2006, both saline and silicone implants are available in not only differing sizes but projection and styles as well. With the potential for gummy bear breast implants to be available perhaps later this year, increasing implant options appeal to an even broader spectrum of women. Just like the many aisles in a drugstore, multiple options for a single product line result in more sales.

The rise in breast augmentation is a result of greater societal acceptance, safety of the devices, influence of famous people, and a wide variety of implant options. I suspect the upcoming decade will see the number of implanted women continue to rise.

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