Your Questions

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

One of the most common reasons men appear for facial plastic surgery revolves around one issue…they are tired of looking tired. Even though they get 7 or 8 hours of sleep, every morning someone eventually asks if they had slept well. Most men over age 50 can relate. They want their face to look as good as they feel and can be frustrating when it is not.

The classic story that I often tell is one of the differences between being younger and older. In college you pull an all-nighter and the next day, looking like you had, proudly proclaim your accomplishment when asked. When you are older you get 8 hours of sleep, go into work and the first thing someone asks is…did you pull an all-nighter?

Eyelid lifts, or blepharoplasties, can clean up that tired look  by removing extra skin and fat from around the eyes that has developed over the years. But blepharoplasty is just one of the growing number of cosmetic procedures that more men are having. Facelifts, hair transplants and stomach and love handle liposuction make up most of the age-fighting operations.

While men were once just a minute fraction of any plastic surgeon’s practice, those numbers have grown to represent 15% to 20% today. Men of all ages are growing more comfortable with the idea of getting help for their looks. It is simply more acceptable today, another example of the rapidly changing social attitudes sweeping our society. Most men are interested in improving their appearances but without taking too much time from work. It also doesn’t hurt that plastic surgery reality shows (do men really watch these?) and affordable financing have also promoted interest.

Another galvanizing drive for man having plastic surgery is job insecurity and staying competitive. While looking good and appearing energetic has always been important, in a tough job market it is important to look as best as one can. I just had a man come in last week who was between jobs and wanted to look good for interviews. The competitive nature of men can make them willing to try something they believe will give them an edge in an interview or a potential business transaction. The practical economics of men also has them saying such changes are an investment in their future.

The internet has also fueled this male cosmetic surgery interest, specifically internet dating. I have had more than one man who has told me he can’t post a current picture online of the way he looks now. One patient even told me a woman embarrassed him by commenting in an e-mail exchange about his eye bags. (he reposted his picture after his eyelid lifts)

Men fear more than women that undergoing plastic surgery will make them look too drastically changed or have a ‘surgical look’. While there are certainly some male celebrities and actors that have that look, they are the exception. In reality, getting rid of those sagging jowls and droopy eyelids can definitely make one look less tired and more alert but the change is almost always subtle and natural.

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

Q: I want a stronger chin and jawline. I currently have a 7 mm winged chin implant in now (with rhinoplasty last year), but feel the asymmetry lies more in the vertical dimension. I also feel that my mandible does not have enough lateral dimension or width. It seems that my lower face is somewhat deficient in multiple planes and I’m unsure which would be better for me, a chin osteotomy with vertical and horizontal augmentation combined with a widening of chin, or a custom wrap around implant. It might be helpful to see the predicted outcomes of both. And, of course, I would love to hear what you think might be best based on the picturesI have attached. Any other suggestions you might have would be appreciated also.

A: I think factoring in all considerations and looking at some imaging predictions, I would opt for the chin osteotomy. The recovery time is actually shorter with the implant but the photographic projections shows what an osteotomy can do and that seems to be the bulk of where the change needs to be to get your face more balanced. Given your 7mm implant that is already in place, your osteotomy needs to come forward 11mms and down at least 7mms. This will require plate fixation and hydroxyapatite block grafts.

Also I have noted that you could benefit from nostril widening. That parft seems to have been overlooked in your original rhinoplasty as well as some additional tip refinement. I would also consider adding in buccal fat removal for submalar narrowing and this would add nothing to the recovery time.

Dr. Barry Eppley

Indianapolis Indiana

Q: I want to make my forehead appear a bit broader. Is it possible to remove some hairs permanently? This I think would help give me more forehead/scalp skin.

A: I assume you mean that to make the forehead broader, you want to move back your temporal hairline. This is an uncommon request as most people have trouble with their hairlines being too recessed or too far back. But can the temporal hairline be repositioned through hair removal? Yes, this could be done through laser hair treatments. Scalp hair is difficult to remove by any method, including laser hair treatments, but it is possible. Because the scalp is thick and the hair follicles lie quite deep with an extensive blood supply, their eradication is not easy and multiple treatments will be needed.

Dr. Barry Eppley

Indianapolis Indiana

Q: I`m considering having some plastic surgery and that`s the reason I`m writing to you. I am 28 years old and I`ve got a very rounded face with lot of babyfat and I want to make it more sharp/angled and more masculine looking. I have had a rhinoplasty done on my nose when I was 18 and it looks great from the profile, the only thing is that from up front one of the sides is indented and I was thinking that either an injectable filler to build up that side up or a silicone implant to make that side more fuller and match the other side. I don`t need a major or new nose job, just to fill up one side of my nose. I`ve got a double chin and even when I was thinner I still didn`t have a 90 degree angel between my neck and chin. So I want a liposuction and tightening of the neck muscles. I think this will also help to make my jawline stand up a bit more. I have a very round and big chin. It`s not too big but it`s very round so I was thinking that the liposuction of the double chin and platysmaplasty will also help to give my chin more angles but I`d also like to have a small dimple there. This will give me that masculine clefted chin look. I`d also like to have liposuction of my lower face (removal of buccal fat) to give it more angles and make it less rounded and more masculine. I think some cheek implants will give my face more bone structure. I want to remove the bags under my eyes. I`d like the procedure where the incision is from the inside of my eyelid. My upper lip is a bit uneven. One side is more rounded than the other, so I`d like to correct and get more symmetry to my lips. It`ll be nice to get them a bit bigger too. I have attached some photographs for you to review and await your comments/recommendations.

A: In reviewing your photographs and your concerns, I can make the following suggestions/recommendations:

1) Nose. Your nose is asymmetric because you have left upper cartilage/middle vault collapse. That is why it appears deviated due to the inward turning of the dorsal line. This is the result of your prior rhinoplasty. That is best corrected not by an implant or an injectable filler, but by cartilage grafting. The use of a left spreader graft and a crushed cartilage onlay graft over the indented area is the treatment of choice.

2) Lips. Fat injection grafting would be best. Although a vermilion advancement would perfectly correct the left upper lip asymmetry (lack of vertical height), that fine line scar in a male would be unacceptable.

3) Lower Eyelids. The lower eyelid bags could be removed by a transconjunctival lower blepharoplasty with fat removal only.

4) Cheeks. Cheek implants would be a good choice for your malar-infraorbital hypoplasia. I would also add fat injections above the cheek implants along the infraorbital rims.

5) Cheeks. Buccal lipectomies are needed to get rid of the fullness below the cheek bones which are going to be highlighted with the implants.

6)  Chin. A square-shaped chin implant is needed with the placement of a central dimple or cleft, whichever is your preference. The chin implant would have minimal forward projection but is more to create fullness on each side.

7) Neck. it could be improved by some liposuction  and a corset muscle plication (platysmaplasty ) to maximize the cervicofacial angle.

Lastly the Jaw Angle. A would do some liposuction around the jaw angle area to try and make it a little more distinct although the result would be fairly subtle.

Most of these procedures you had already surmised but here is what can be realistically done in an effort to achieve more of a sculpted masculine facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a botched chin and jaw implant procedures from an inexperienced surgeon who had never done the procedures before and things didn’t turn out well. I have had both the chin implant and the jaw implant taken out. That was about a year ago. Now there is significant scar tissue and also sagging along the jaw implant lines (but not so much on the chin). Could I send photos to you? Could you be able to fix my problem and me go back to the normal chin and jaw I had before? I have read much of your material on the web and would be very grateful if you could deal with my problem and fix it to the best of your abilities.

A: Facial implants expand the contours of the implanted bone site at the expense of soft tissue stretching as well. When implants are removed, the overlying soft tissue may or may not shrink back down to its former position. The larger and bigger the implant, the less likely the soft tissue will have any recoil. This is also affected by how long the implants have been in place.

In the jaw, chin implants typically pose the greatest problem with ptosis or soft tissue sagging after removal. Jaw angle implants usually cause less of a problem because most are of the lateral augmentation design and don’t disrupt the attachment of the pteryomasseteric muscle sling at the inferior border of the jaw. This is more of a potential concern in inferolateral augmentation jaw angle implant styles.

Correction of soft tissue problems as you describe may require muscle repair back to the bone or it may be improved by overlying soft tissue suspension. I would need to see some pictures of your issues and what type of implants were initially placed.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if you had any experience using Acell Matristem tissue regeneration products? It is the stuff that was used to regrow finger tips, for scar revision/removal, and now in hair transplants. The reason I ask is because I have a medpor jaw implant and was considering having it removed but I understand that one of the difficulties with this is soft tissue damage. I’m under the assumption that the Matristem product would make this a non-issue but I wanted to know what your thoughts and possible experience has been with it.

A: I have used Acell Matristem and am very familiar with its working properties and its results. I have also revised and/or removed many Medpor facial implants and do not their removal as problematic as many suggest. They are not difficult to remove and do not leave behind significant soft tissue damage or tissue loss. They are only ‘difficult’ when you compare them to silicone facial implants which slide right out. So that assessment is a comparative one.

Your consideration of Acell particle implantation at the time of facial implant removal I assume is to repair the soft tissue damage left behind. That can certainly be done and may or may not be of benefit. If your intent is to implant Acell in the hope that it can replace the volume lost by removing the implant would not be a reasonable expectation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a weak jaw in terms of width and projection, coupled with a long and narrow face. I don’t wish to get any implants into my face as this idea scares me. I believe my only option now to add width to my jaw would be dermal fillers. How many mm can dermal fillers like Radiesse and others add to the jaw. I believe I am 10-15 mm deficient in terms of the jaw. What is the maximum the best dermal filler can give in terms of width? What is the name of this filler?

A: I am afraid that the very thing that scares you is the only good option to do. While Radiesse injectable filler can be added to any area along the jawline, it would take a lot of material to create 10 to 15mms of bony augmentation. That cost alone would well exceed $10,000 to $15,000 for a result that would last at best 1 year. That cost is comparable to surgically implanting multiple jaw implants which would be permanent and last a lifetime, provided they suffered no initial complications.

Injectable fillers for bone augmentation is to provide some subtle highlights that do not justify surgery or as a trial to see if implants might be a good choice. Facial implants are for significant volume and contour change that require broad surface areas of material. Your jaw problem is better suited to the latter. Injectable fillers are not a good option for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I saw a tummy operation on a TV show the other day that got me reallly excited. It was a new operation called the Smooth Tuck.  It was a impler way of doing a tummy tuck because no muscle repair is done and it uses a much smaller scar above the bikini line. The recovery is only one week. This sounds great! I was scheduled to have a full tummy tuck and I was dreading it. This sounds so much better. Do you think I should have this tummy procedure done instead? Is it too good to be true?

A: While I have no idea what your tummy problem is or looks like, I can make a predictive statement that it is too good to be true. The Smooth Tuck is nothing more than a mini-tummy tuck wrapped up with a slick sounding name. Whether the smooth refers to how your tummy will look after or what it is like to go through and recover from is unknown to me. And I am not saying that it is a bad operation. The key question is whether this is an operation for you. Does the solution it can provide match the size of your problem? If you are better suited to a full tummy tuck, then this lesser operation will leave you disappointed no matter how smooth it sounds. There are some tummy tuck patients who are ideally suited for this approach but it is usually only a minority of them. You understandably are interested in something that sounds easier than the traditional tummy tuck approach. Just be certain that the real limitations of this marketed operation do not leave you with the opposite of your desired result…an unsmooth tummy that should have had a different tummy tuck technique done.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr Eppley, I just read a reply you wrote to a patient inquiring about forehead and orbital rim with either implants or hydroxyapatite paste to which you reply that Kryptonite Bone Cement would be a better option. I want to get your opinion on which material is the best choice for filling out the outer brow bone area(just very slightly). I’m asian, I have eyelids and round shaped eyes but my brow bone looks very weak, which makes me look tired unless i wear eye shadows/shading which I think have lead to my eyelid skin aging prematurely. My eyelids have started looking a bit saggy and I’m only in my late 20s. I want to have the appearance of having more developed brow bones (which looks normal on an asian person) i think this should also help keep my lids from sagging. I want to know if Kryptonite Bone Cement would be a good option for the browbone in my case? Or should i try something else? I’m also considering fat grafts. Please get back to me and let me know what you think is best. Thanks very much.

A: When it comes to brow bone augmentation, it is my opinion that it is always better long-term to add to the bone with a material of similar hardness…provided that the trade-off to doing it (incisional approach) does not leave any significant scarring. Fat injection grafting is a reasonable option nd it does offer simplicity and ease to do with a natural material. (fat) But how volume will stay and what its shape will be is not always predictable.

You have said one key statement in your inquiry…‘filling out the outer brow bone area’. It is critically important to know what specific brow area one wants to augment. If it is just the outer two-thirds or tail of the brow, then that could be done through an upper eyelid approach and adding hydroxyapatite paste. That would by far be the best way to do it and is very straightforward. If one needs the entire brow augmented, then I would use an endoscopic approach with Kryptonite bone cement. By this approach,  it could be injected and then molded under endoscopic guidance.

Dr. Barry Eppley

Indianapolis Indiana

Q: My four year-old child had a surgery for repair of an elbow fracture. Screws were initially inserted to fix the upper arm bone where it attaches to the elbow. It went on to heal well and the screws were  removed three months later through the same incision. Now he has an ugly wide scar which lies on the outside of his elbow and is very visible. It is about 3 cms wide. We need it to be removed as soon as a possible.

A: Scars from orthopedic surgery, particularly around a joint area, can often end up less than ideal. This has to do with a variety of factors including the intent of the surgery (fix the bone fracture, the appearance of the scar is largely irrelevant), the pulling on the skin edges from the equipment used in bone repair, repeat surgery through the same incision, age of the patient, and the continous stretching on the scar from the motion of the joint. By far, the latter plays the major role in such scar widening and hypertrophy. While a scar revision will make an immediate improvement the question of whether some scar widening may still occur is relevant given that the elbow joint will be moving after surgery. So pulling and tension on the scar will not be eliminated. What degree of scar widening will occur after revision can not be predicted, but hopefully it would be minimal.

One concept about the treatment of scars that must be tempered is the concept of removal. There is no such thing as scar elimination or removal. Scar revision is all about how much improvement can be obtained. A complete scar ‘cure‘ or total eradication is not possible for any scar.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have recently consulted with a maxillofacial surgeon who has recommended performing a chin osteotomy procedure. He intends to remove a 3mm wedge (for vertical reduction) as well as a 3mm advancement, with the osteotomy performed at a slight upward angle. I seem to have the unique situation of anterior mandibular vertical excess with a very flat labiomental fold (which would be enhanced by the advancement) What are your thoughts on the success of this procedure?

A: Without looking at photos and x-rays, it would be impossible for me to comment on whether this is a good procedure for your concerns or not. That is a technically sound chin osteotomy procedur and is very straightforward to do. The only question I would raise about it is that these bony movements (3mms) are fairly small. Such small movements are unlikely to make much of an external visible change, albeit a very modest one. To take down the chin bone by osteotomy for this amount of bony movement seems like a ‘solution that is bigger than the problem’. For a horizontal advancement of 3mms, an implant would be far less invasive. For a vertical reduction of 3mms, there is no other solution than osteotomy and bone removal. This makes it a difficult decision in my mind as to whether the problem justifies this degree of surgical effort.  I would look at your chin concerns carefully and would reconsider carefully the potential benefits and risks of this type of chin surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I had an injury and got a little scar over my right eyebrow. Because of this I have slightly lees eyebrow hair over that eyebrow. Is this something you can fix? I only need to fix 5-10% of the eyebrow hair on the right side.

A: Lacerations that cross into and through the eyebrow will frequently result in a bald spot or a scar area that is missing hair. This is the result of either actual injury and loss of hair follicles, separation of the eyebrow hairs by scar, or both. Depending upon the size of the eyebrow defect, there are two approaches to restoring eyebrow hair continuity. In many cases, the scar can be excised and the eyebrow hair margins brought back together through simple scar revision realignment techniques. This works well for small eyebrow defects. In larger eyebrow defects, it may not be possible to bring the normal eyebrow margins together without shortening the horizontal  width of the eyebrow or distorting its shape. In these size defects, eyebrow hair transplants are needed. The hair grafts are harvested from behind the ear. It may only take 10 to 25 hair transplants to correct most eyebrow defects. Meticulous placement is needed to get the right hair orientation that matches the natural changing orientation of the hairs as they go from the inside of the eyebrow out to the tail of the eyebrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am in the military.  I am 40 years old and have been  selected for promotion to Commissioned Officer.  I have a large build and constantly struggle with the military’s height vs. weight standards.  A secondary circumferential method is used for the neck and waist.  I am always just at or above the limit.  I have found it even harder now that I am older. I think liposuction would get me ‘over the hump’ with some stomach and waistline shaping as I just need to drop an inch or so around the waistline. I have attached some photos for your assessment and would I qualify for the Patriot Plastic Surgery program.

A: I receive a fair number of requests from men and women in the military for plastic surgery and it is almost always about trying to pass the measurements that are used in the service’s fitness evaluations. While the physical part of these required tests are based on push-ups, situps and a 2 mile run, there are also circumferential measurements done with an important one being that of the waistline. To help men get to their desired waistline measurement, liposuction can be very effective by aggressively treating the entire abdomen and the flanks as they head around into the back. For some women this is effective also, but there are some women that really need a tummy tuck to get rid of the excess skin and overhang if they have had children. We do offer discounts for these surgeries for active military peronnel.

Dr. Barry Eppley

Indianapolis Indiana