Your Questions

Q: Dr. Eppley,  I’m a skinny guy with puffy areolar tissue. I’ve had it my entire life. It is not steroid induced. Considering surgery, I am a student covered under Anthem Blue Shield insurance. I am not sure if it will be covered. I hunch my posture to conceal the protrusion in shirts, and it has lead to a lot of neck and back pain. I do not have a picture of it, but my build and areolar shape look exactly like the case study on your website for gynecomastia reduction for athletes/body builders.

A: The amount of gynecomastia the patient to which you refer had is the most type that I see. It is a harder type of gynecomastia that causes the puffy nipple appearance due to its mass effect. The amount of breast tissue present is much more significant that it looks on the outside. It must be removed through an open approach using a lower areolar incision. This smaller type of gynecomastia is not covered by insurance in my experience and is considered a cosmetic procedure. The overall cost of an open gynecomastia reduction procedure done under general anesthesia taking one and a half hours of operative time is in the range of $4500 to $5000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have HIV and my cdf is about 350 and i am non-detectable. I have developed a small hump in my back and large fat sacks on my legs in certain areas and excess fat in my stomach. I am always unconfortable from the extra weight. I cannot not afford to have this procedure done. I had a price for about eight thousand. I don’t unsterstand why insurance will not cover this.  Do you know of anyone who might put extra effort in to help you getting it covered by insurance.I i have medicare. M y knees hurt terribly from the extra weight. The weight is not from my eating habits. I just can’t get these areas down in spite of all the diets I try. It can be very depressing at times as I have so many people ask if i am pregnant because of the weight gain. Can you help?

A: The fat collections or lipodystrophy that you describe are  classic areas of collection due to the medications used to treat HIV.  They are not going to be removed by diet and exercise although doing both of those is always good. The reason that fat grows in thsese areas is due to a specific hormonal stimulation effect of the medications, not due to excess calories or food intake.  When it comes to insurance coverage for liposuction, the simple answer is that it is never going to be covered as it is considered a cosmetic issue regardless of what caused the fat to appear. Much of your stomach fat is actually not treatable by liposuction anyway since it is in an intraperitoneal location (around the organs) and not between the skin and the abdominal wall (subcutaneous layer) which liposuction can reach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some areas on my stomach and thighs that have a little extra fat and some loose skin. I do not want to undergo surgery however to make them better, that is just too much for me. I know that there are a lot of different non-invasive body contouring treatments out there that claim effectiveness. The one that has me intrigued the most is Exilis based on my research. How does Exilis work and what has been your experience with these treatments?

A: Exilis produces its effect through the use of highly controlled radiofrequency waves. It delivers high energy levels down to an inch under the skin. Its delivery technology allows that energy to be delivered without injury to the skin through a synchronized pulse delivery and cooling method. Thie keeps the treatments comfortable without risk of skin injury. (burns)  It effects fat by breaking down their cell walls so the lipid contents are released and absorbed. It help tighten skin through a process known as neocollagenesis, which is the unraveling of the collagen fibers by the energy and the subsequent stimulation of fibroblasts to produce new collagen resulting in dermal thickening and increased skin density.

The transducer delivery system allows 17 different body areas to be treated from the eyelids down to the hands and everything in between. Our experience has been extremely favorable in properly selected patients who have been educated about achieveable results without surgery. Incremental, lasting and measureable results  can be obtained in four treatment sessions or less of Exilis for many patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants and am confused about what type of implants to get. I have seen two doctors and one uses Mentor implants while the other uses Natrelle implants. I don’t understand the differences between these two company’s implants and I realize that choice is best determined by the doctor. I read recently that there is now another company offering breast implants known as Sientra. What are the benefits to these implants if any?

A: While all silicone breast implants contain silicone gel material, there are different formulations of that silicone used by each company. These formulations are proprietary and are given different names by each company. What is becoming most important in gel formulations is how cohesive they are, also known as form stable. The more form stable implants have become known in urban terms as ‘gummy bear’ breast implants.  Sientra offers only silicone breast implants that are composed of what they call ‘high strength’ silicone gel, which is their version of the so-called gummy bear implant. What I like about the Sientra implants that they may be form stable but are also very soft. If cut in half, the gel material does not extrude or break down and remains intact. You can actually take the implant and twist it 360 degrees and the implant shell/material will not fracture or break. This is a very important feature to decrease the effects of shell stress on insertion and lower long term implant rupture rates.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have gotten lip injections using fillers for the past five years. While my lips are not really that small, I like the plump up that fillers give them. But after five years and over a dozen injection treatments, I am tired of the expense and the hassle (pain!) of the lip injections twice a year. I have read that there are permanent materials for lip augmentation. This is of interest to me now as I need to really explore how to end injections by a single operation if possible. What can you tell about permanant lip implants?

A: The concept of lip implants has been around for a long time. Despite their existence for over fifteen years in the plastic surgery world, they have never garnered much traction as an everyday procedure. Part of that is because of problems in implant design and materials and partly because of a general fear of having an ‘implant’ in the lip. I have used every developed permanent lip implant available and have seen many of their benefits and potential problems. I have had good success over the past ten years with the use of Advanta implants but for a variety of reasons they are not as available as they have been in the past. But the newest lip implant, called PermaLip, is the best design and material that I have seen to date. It is made from a very soft and flexible silicone elastomer. Based on how it feels, it could easily be called the ‘Gummy Bear Lip Implant’. It has well designed tapering edges, which is very important, and has sizes up to 5mms in thickness. Based on my experience, this is a good safe size for the soft tissue tolerance of  the lip tissues. They are placed in the office under local anesthesia with some swelling and occasional bruising which is largely resolved in a week after the procedure. The real test of the success of any permanent lip implant is the ‘kissing test’  in which the patient has no concern that they or the recipient may be able to feel the implant…and Permalip passes that test!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to achieve a male-model look. I think that I have rather feminine facial features and I would like to look masculine. I was thinking about a square and a big jaw to match my high and curved forehead, a Rhinoplasty, Dimples, and high cheek bones implants. Do you think I will need anything else? I want to look handsome, a 1010 by most women scale. I don’t have a precise male model look that I thought of, but I guess I will choose the one that would naturally suit my face the most. What do you think, can we achieve it? Do I need all of the procedures I listed? Do I need any other procedures?

A: Thank you for your inquiry and sending your pictures. Let me first start off by making some general comments about structural facial surgery, particularly in men. The use of the term, ‘male model look’, really refers to creating some angularity and definition in the facial bone highlights  and overall better facial balance and harmony of the features. This does not mean that one will ever look like a male model or may even be considered strikingly more handsome after such features. All plastic surgery can do is help a patient have better facial features and improve the facial foundation and the face that nature has given them. Therefore, while I understand quite clearly your objective and improvements can be made, I do not like young male face patients to have goals such as ‘male model’ or ‘I’ll be a 10’ after surgery. This is a setup for disappointment.

That being said, I will work on some computer imaging and show you what may be achieveable with a variety of procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking at the tummy tuck pictures and was interested. I looked again the next day and I was able to get a closer look and the scars are very big. I have decided I’m going to try and go to a center for weight loss and see how that works first. Approximately, how much does a tummy tuck with flank liposuction cost?

A: While a full tummy tuck will solve the problem in a manner otherwise not achievable, the ‘price’ to be paid for it is the trade-off of the a long horizontal scar. While very effective, you have to be certain that this aesthetic trade-off is worth it to you. That is why I could not agree more that you pursue every non-surgical option first and only consider surgery when you have become convinced that all other methods are not achieving what you want. Much of plastic surgery is about trading one problem for another, you just have to be certain that the other ‘problem’ is more acceptable that what you have now. In the case of a full tummy tuck that aesthetic trade-off is the scar. The approximate total cost of a full tummy tuck with flank liposuction, which is what you ideally need, is around $8500 all costs included.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Since you are experienced in migraine surgery, would you mind answering a few questions? 1) How does surgery for migraines work? 2) How many people undergo the surgery? 3) How often does it work? 4) What are the costs? 5) Is it covered by insurance? 6) What should people try before undergoing the surgery? 7) Why are you the only doctor in Indiana who performs this surgery?

A: In answer to your questions:

1) Migraine surgery works on the principle of sensory nerve decompression by removing the constructing muscles around the nerves, known as trigger points. I would recommend you go to www.eppleymigrainesurgery.com to learn more or go to www.exploreplasticsurgery.com and search under migraine surgery where the details of surgery are discussed in multiple blogs in detail.

2) Migraine surgery is for those patients who have very specific types of migraines that have been fully worked up and treated by a neurologist and have received either no or little relief. Surgical candidates are chosen either based on their response to Botox injections or by their migraine history.

3) The one and five year results show that over 70% of people experience significant and sustained relief. About 30% of patients are cured and subsequently experience no or few migraines again. About 10% of patients experience only temporary relief and long-term do not show significant improvement.

4) Costs are based on how many migraine trigger sites are released and the time to do the surgery. Costs could range from $3500 to $8,000.

5) It is usually not covered by insurance. Insurance companies, despite the overwheling evdience, feel that it is still ‘experimental surgery’.

6) As per #2 above.

7) Migraine surgery is usually done by plastic surgeons who express an interest to treat this medical condition. The surgical techniques used are common to board-certified plastic surgeons and come from procedures learned from cosmetic and craniofacial surgery, microsurgery and hand surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is it possible to lift the ears in a higher position, perhaps for about 10 mm. If it is possible, how is this procedure performed and is there any risk that the shape of the ear changes?

A: Lifting of the ear superiorly is ultimately limited by its cartilaginous attachment to the ear canal. Essentially you have to rotate the superior ear cartilage in an upward direction with either fascial suture plication to the temporalis fascia or using a micro-bone anchor to the posterior temporal bone. This will cause the ear position to elevate, it is just a matter of how much. It is possible that it may move as much as an entire centimeter although it may be less. This type of otoplasty does not generally change the shape of the ear although it could slightly decrease the aurico-cephalic angle somewhat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, first of all I want to say that your site is full of information and i have learned a lot of things. I want to do an osteotomy/genioplasty on my chin to achieve facial balance cause I have a receding chin. I also want to do this surgery to shorten and make my lower lip thinner. Will this surgery tighten the lip and chin musculature and will it cause my chin to look thinner? I am looking forward to hearing from you.

A:  In most cases of an osteoplastic genioplasty where the chin is advanced, it will make the width of the chin thinner. This is because a chin osteotomy is like advancing the front part of an upside U forward. It is elongating the U and makes it more narrow. Whether that effect is significant or not depends on how much advancement is being done. But anything over 5 to 7mms, the thinning effect will be seen. It does not usually make the lower lip any thinner however.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was all ready to go ahead with the chin implant, but I have read some disturbing stories and research papers about how “silastic implants” lead to bone erosion in chin implants only, and how they could be as deep as 1.5 to 4 mm in depth, and their close proximity to root apices. Also, I am wondering why some surgeons, such as yourself, use screws to secure the implant while others just insert and leave it in the created pocket. I never thought of this aspect of chin implants, the complication with bone erosion.

A: You are referring to an old phenomenon that is largely irrelevant today. If a chin implant is placed too high up off the chin point (which is not where it should go), there may be some settling of the implant over many years into the softer alveolar bone under which lie the tooth roots. Some refer to this an ‘erosion’ but it is not an active process but a passive one representing pressure release. (meaning it stops once the pressure of the push of the overlying soft tissues is released)  If properly placed on the basal bone of the chin, which is 10 – 15mm below the lowest level of the tooth roots, this is an issue which is not seen. If this is an unsuppressed concern, I can also use chin implants made of Medpor material which have little history of showing the same effect. The difference is that the cost of surgery will increase as these implants are more expensive.

The number one complication of any facial implant, chin implants included, is shifting of the implant causing implant malposition and asymmetry. The most assured way to avoid that problem is to secure it to the bone, a very simple and effective method using screw fixation. It makes me feel the most comfortable that there is no chance the implant will shift either after surgery or later in life for any reason.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thrilled about which intervention I have to have done to my lips. They are both thin and fillers give me a duck look. I can’t decide if a vermilion advancement or a V-Y plasty is the best for me. Thank you for taking the time to answer me!

A: Usually the vermilion advancement  or lip advancement works best in very thin lips because they lack adequate vermilion height for exposure. The V-Y advancement is an internal mucosal roll procedure that primarily creates greater central lip pout and increased vertical lip length, in essence a greater effect on mucosa than the vermilion. They actually are quite different procedures on their effect on creating lip size and shape. The vermilion advancement is also much more versatile in shaping the cupid’s bow area of the central upper lip which the V-Y advancement can not do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some non-invasive body contouring. (stomach and flanks)  I have read about the Exilis device and it seem very promising. I know it uses radiofrequency energy to do its work. But there are other devices out there that all use the same type of energy. Why would Exilis be any better than these other ones?

A: There are many new radiofrequency devices on the market and a lot of them are claiming that they have a similar or superior technology to that of Exilis.  Regardless of what their product is called, almost all of them use bipolar radiofrequency.  Bipolar radiofrequencies only have the capability to penetrate fairly superficially, generally no further than the deep dermis. Thus they are good for skin tightening but can not reach the fat layer nor reduce it effectively or consistently.

Exilis is different in that it uses monopolar radiofrequency. This allows it to penetrate more deeply generally up to inch (2.5 cms) below the skin. This does reach the fat layer. The cooling component on the Exilis allows it to bypass the dermis to effectively place the energy into the desired tissue (fat) and maintain penetration depth, all while keeping the skin cooled and uninjured. There is also an energy flow control on Exilis that allows the target tissue to quickly reach the desired treatment temperature. The combination of these two technologies allows Exilis to have effective fat reduction and skin tightening capabilities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in 1) reduction of large occipital bone by burring and 2) forehead augmentation. Due to a narrow and recessed forehead above the brow bones, this needs to be built up with implant material. Can the scar follow the hairline if it naturally angles back laterally from the most center front couple of inches of the horizontal hairline?

A: Let me answer your two areas of concern with some general statements.

1) Reduction of a large occipital bone is always a question of how much be removed. In other words, is it worth it or not. That is best determined by getting a lateral skull film so measurements can be made to determine how much the bone can be reduced. It definitely can be burred down. The question is…is it enough to make a visible difference.

2) Forehead augmentation does require a scalp incision. generally, it is placed way back in the hairline…more than just an inch or two behind one’s existing frontal hairline. That would be particularly good if one is desiring some occipital reduction as well.

That being said, the first place to start is for you to send me some pictures of yourself for my assessment and then we can have a phone or Skype consultation for further discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I went to see a dermatologist for the first time due to dark marks on my hips and buttocks. I have been getting “boils” for the last 10 years…on and off, but recently it seems to be under control since I have been exfoliating and applying topical creams. My dermatologist tells me that I have “post-inflammatory hyperpigmentation” from folliculitis. He has prescribed a 4% hydroquinone cream which is to bleach these darker spots and will take approx. 6 months. When I asked him about any other method of treatment, he had no suggestions. I noticed on your website that you also offer laser treatments for skin problems. I’m wondering if there is anything more effective that can be done for my hyperpigmentation? I had read about certain types of lasers specific for the treatment of hyperpigmentation online but unsure how effective it would be. Being Asian, I’m not sure if these other treatments would be suitable for me. Could you please advise on the treatment for my case?

A: As you may know being Asian, hyperpigmentation is a common problem and a difficult one. Bleaching creams are the standard approach and, while they don’t pose any risks with use, are slow to work and often not that effective.

One technique that can be effective with a more rapid response is pulsed light therapy, often known as IPL or BBL. While often perceived as a laser, it is different being high intensity pulsed light not focused beam light. With selectivhe filters it can reduce the hyperpigmentation in a single treatment by selectively targeting the brown pigment for elimination. This in combination with hydroquinone can help reduce hyperpigmentation fairly quickly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can one have a facelift without any visible scars in front of the ear? I have darker skin and like to wear my hair back. I am worried that someone may be able to see the scars running down in front of my ears. I need a mini-facelift but many results I have seen show the scar in front of the ear. I like to pull my hair back & up!

A: It depends on how you define a scar in front of the ear. All effective facelifts require some type of incision in front of the ear. Most plastic surgeons place this incision behind the tragus of the front part of the ear so that final healed scar is virtually undetectable. A few others, particularly those trained only a mini-facelift technique, still place the incision in front of the tragus so the scar can be potentially detected no matter how well healed it becomes. Why they do this is unclear to me other than it is simpler and makes the operation faster. It clearly does not lend itself to a better scar result. So all facelifts create incisions on the front part of the ear but where they are placed determines whether it is ‘scarless’ or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a female and have a steep jaw angle which makes me look witchy from side. I think I may have a long face as well. Would getting jaw angle implants make my face look longer because I do not want this.

A: The best way to answer that question is by computer imaging. Lengthening the jaw angles with implants will increase your posterior facial height but whether that will create a longer look to your face would be best determined by imaging predictions. It obviously will not change the length of the front part of your face but how it would affect the perception of the overall face is very important to viualize. Seeing is convincing…one way or the other.

Please send me some pictures to image.

Dr. Barry Eppley

Indianapoolis, Indiana

Q: Dr. Eppley, However, is it really not possible to reduce the temporo-occipital region of the skull through some bone reduction and some reduction in the temporalis muscle in order to maintain proportionality if a reduction malarplasty is done?  Something of the order of 6 to 7mm either side would still be very significant to me. I realize that there are limits to what can be done due to outer cortical table thickness. Would a CT scan be useful in determining feasibility or do you feel that nothing can simply be done?

A: The most limiting area of the skull to reduce, because it is the thinnest is the temporal/temporo-occipital region. I know that without even seeing any formal radiographic studies by experience. More significant reduction can be achieved by temporalis muscle reduction/thinning. This is more effective because the muscle is so thick, particularly near the forehead and lateral orbital rim. In essence, it is located closer to the face thus creating a greater effect. I could envision a temporalis muscle reduction combined with zygomatic narrowing as being a viable procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in paranasal implants. I am not sure whether I’d be better served by a permanent filler or an implant. I had my nose done along with a lip lift about 3 years ago. I’m very happy with the positive change it affected, but the base of my nose is retruded, and so my mouth protrudes. I also think it would look a bit nicer if my nasal tip had more projection. Would I achieve the same volume increase and tip projection with a permanent filler as I would with an implant? Also- if I had paranasal implants how long would it take for the swelling to subside and would this affect my smile?

A: The simple answer based on not seeing you is that implants would be far superior. Besides the fact that there are no permanent fillers, they can not create the same degree of nasal base/columellar base push that paranasal or a premaxillary implant can. There really is no comparison when judged by long-term result and cost efficiency.

Significant swelling would be about three weeks. Your smile will feel a little stiff  but should return to normal by 6 weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have the exact condition of the 24 year old male described on your web page as “Case Study: Reduction of the Prominent Nipple in Men”.  I’m 45 years old and enjoy running marathons and I think this surgery would greatly help my situation.  I would hope I wouldn’t need to wear band aids during the marathons after the procedure, but even if so I would also would like to look better if I’m wearing a thin t-shirt or dress shirt. I don’t know what your schedule is like at the moment, but if at all possible I would like to get the procedure done right after  my next marathon which is in May as I will be taking two weeks off after that before resuming training for my next marathon in the fall.

A: Nipple reduction is a very simple procedure that offers a permanent solution to the prominent and protruding nipple. I hear stories from men every week that speak to the same problem…’I can’t find shirts that hide my nipples’ or ‘Everyone asks me if I am cold’. Nipple reduction surgery is done in the office under local anesthesia. One only wears band-aids for dressings for a few days. One can shower and work out the very next day. Men do not report much, if any, discomfort. Once removed, the nipple will never grow back and one can wear shirts comfortably or take off their shirt without the embarrassment of nipples that stick out too far.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had gynecomastia surgery performed, but there are areas where liposuction was done that I am very unsatisfied with. I would like to know if there is anything I can do with these areas in regards to slim lipo or laser. I’m not looking for perfection by any means, but currently I feel like the job is half done and am looking for someone to help me finish it.

A: When it comes to dissatisfaction with liposuction, anywhere on the body, the issues primarily revolve around whether adequate reduction was done or that areas of irregularities or indentations exist. While both can be treated, the methods and the success of secondary revision are different. Irregularities pose much greater challenges than inadequate reduction. On the chest, I suspect the liposuction issues are more inadequate reduction. This is because the chest skin and tissues are thick and are less prone to irregularities than other body areas. Further liposuction reduction may be possible. If the issue is persistent areolar fullness or puffiness after liposuction, it may be that you really need open gynecomastia excision to remove the remaining excess breast tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am contacting you in relation to an inherited issue with width of the zygoma and my face more generally. When my face is viewed from a perpendicular angle it is quite clear to see that zygomatic area adds width of 1cm either side of the face. Now I am not sure whether this is to do with lateral projection but given that I have quite small eyes, it makes the facial features appear too small for the width of my face. I know that zygomatic width is an issue that people of Asian ethnicity usually suffer from and that a reduction malarplasty can to some extent tackle it. But my question is to what extent is that feasible given that the width of the face is an issue in relation to the forehead as well, is it the case that the skull base will likely simply be too wide or can the forehead be tackled simultaneously? Is what I am seeking actually capable of being done?

A: If I understand your inquiry correctly, your question is whether zygomatic arch reduction in your case would be beneficial. The zygomatic arch is a separate entity from the skull base so it can be reduced. The question is whether a 5mm to 7mm cheek (zygomatic)reduction per side would be beneficial. I would question that given that the temporal fullness is also adding width which can not be reduced. So in the spirit of an overall facial narrowing, I would not be enthusiastic that such an endeavor for you would be highly beneficial.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got Medpor cheek implants five weeks ago and I am totally unhappy with the result. Is there something like a deadline for Medpor implant removal? I was told that it can be more difficult to remove Medpor if you wait too long.

A: There is no deadline for removal and/or replacement. Does it make it a little more difficult to remove later…yes. But it is not a big problem to remove later in my experience. The issue of bone ingrowth into the implant and being impossible to remove later is a myth. You are better off giving the face time to settle down and shrink around the implant shapes before possibly make a premature decision about revision/removal. My minimum time for facial implant removal/adjustment, particularly in men, is three months.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested to find out about a surgery known as ribcage reduction or waistline narrowing. The lower part of my ribs stick out and makes my body look funny. I would like that area to be more narrow or go in. I have heard that some of the ribs can be removed which will make for more of a tapered look. How is this surgery done and what is the recovery like?

A: Rib removal is a real operation that can be done. It specifically refers to removal of any of the ribs on the lower end of the rib cage, from 8^th to the 12 th ribs. All of these ribs are largely made of cartilage with some bone on the back end of them. Usually only the cartilage portion is removed. Which cartilaginous ribs are removed is matter of what one is trying to achieve. This is not, however,  a waistline narrowing procedure since the ribs do not go down that low. This is to achieve a more narrow upper trunk/abdominal region around the ribcage area. This operation is, however, fairly ‘radical’ since it will leave a small scar and is associated with a fair amount of pain afterward. Realistically it would take four to six weeks to have most of the discomfort subside.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I had custom jaw implant surgery a while ago. The sizes are 9mm for each side. I would like to increase the sizes but I’m not sure how large I should go for. I was thinking 12mm for my left side and 14mm for my right. Is this too large?

A: I would not think that jaw angle implant change is too large aesthetically. I would worry more that it may not be big enough. On pure ratios of measurement change that is a 25% increase on the right side and a 45% increase on the left side. From a tissue stand tolerance standpoint, you could double the size of the implants and the tissues would have no problem expanding too them. Your issue is one of desired amount of aesthetic change not what is physically possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering what are the prices of your procedures I have been looking into mommy makeover for several years, (breast life/augmentation,tummy tuck, and some liposuction of the inner thighs and back flanks. I’m not looking to be a supermodel/size 6, I would be quite happy size 12 – 16. I just want a flatter tummy, non droopy boobs and thighs that don’t rub together. I have attached several pictures, could you please tell me what the cost would be, and if there is anyway to have our insurance company pay. I’m very depressed with the way I look, I just want my outside to reflect the way I feel on inside. I want to be that sexy person for my husband, and confident for myself. I hate trying to find clothes that hide my tire ring for a tummy, and replace pants because they got worn in the thigh area. I would also like to wear shirts without having my breast hang down to my tummy area. I need help, can you help me………..

A: Thank you for sending your pictures. I can not comment on your breasts since the pictures have a bra on but I will assume, for the sake of this discussion, that you need a full breast lift. Otherwise, you would benefit tremendously by having a full abdominoplasty to get rid of the overhanging pannus combined with liposuction of the flanks. This is the one procedure that will provide the greatest overall change. You do not have enough of an abdominal pannus to qualify for insurance coverage based on my experience. From a thigh standpoint, I don’t know that liposuction can ever take you to the point where your thighs don’t rub, that is not a realistic goal. Some improvement can be achieved in their fullness but to say they would not rub together would not be an accurate statement about the achievable result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have breast asymmetry with two completely different sized breasts. One is like a B cup and the other one is more like a D cup. I’m a thick girl so I would probably want a lift, a smaller areola, and reduction  in size on the bigger breast maybe down to a C cup. I know the other one will need an implant but my frame is too large for something like a B cup. I want both breast to be a C cup. I just want to finally be happy with my breasts and not hiding them all the time. Please let me know what you think this would take as far as cost and down time. Thanks.

A: The most difficult challenge in cosmetic breast surgery is management of the significantly asymmetric breasts. This is because one invariably will require some form a reduction/lift and the other one will need a breast implant. This also places scars on one breast and not the other and one breast will have an implant while the other one won’t. What this implies is two important concepts. First, breast symmetry can be improved and made a lot better but it is not attainable to have perfect or close symmetry between the breasts. Secondly, the difficult in trying to match the breasts with two different procedures indicates there is a high probability of the eventual need for a revision of the initial surgery for the best result possible. Expect to pay for total costs in the range of $ 7500 to $8500 for the initial surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have stretched earlobes that I would really like to have reversed so that I can join the Marines. How is the procedure done and how much does it cost?

A: One of the most common reasons patients present for stretched or gauged earlobe repair is because they want to enter some branch of the Armed Services. All branches of the military have a strict rule about any size hole in the earlobe. If you have any form of ear piercing, the test is to place a white 3 x 5 card behind it. If any white is visible through the hole, then it must be repaired for medical clearance for entrance. Earlobe repair is done as a simple office procedure under local anesthesia. It takes about one hour to complete for both earlobes. The holes are cut out and the earlobe reconstructed with the remaining tissue. In almost all cases the size and shape of the original earlobe is restored with a very fine line scar down through the center of the earlobe. The cost for both earlobe repairs is $1500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am two months after having a rhinoplasty. Th swelling has gone down considerably and my doctor said that about 75% of it is gone. But my tip is still rock hard. It is so stiff that it barely moves and the tip is very numb. I have not had a significant other since my operation, but am afraid my very stiff  nose will affect kissing. Will my tip ever soften or am I stuck with a hard numb tip?

A: Hardness of the nasal tip after rhinoplasty is very common. It initially occurs due to swelling but persists much longer after the swelling has subsided due to scar tissue and what was done to the tip cartilages during surgery. In most rhinoplasty surgeries the tip is narrowed, lifted and strengthened with sutures and cartilage grafts. This helps give it a new shape but also prevents it from shifting or changing shape after it has healed. This causes protracted stiffness of the nose for up to nine months to one year after surgery. It will eventually be much softer and can be moved around normally again but it is an issue of more healing time. As the stiffness finally goes away, normal feeling to the tip skin will return.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 21 years old and have lost 65 lbs over the past two years. This has left me with a lot of excess skin and an overhanging abdominal apron. I have been researching tummy tuck surgery to remove it. My main concern is if I will still be able to have children in the future? I am not planning on having children anytime soon as I still young but I know someday I will when I meet the right man. I just need the tummy tuck now so I can feel better about myself. Will the tummy tuck scar in any way interfere with my belly stretching during pregnancy?

A: There is no problem with becoming pregnant and having children after a tummy tuck. This is not a rare occurrence at all. The slow stretch of tissues during pregnancy easily expands the abdominal skin. Since you are young and have never had children (and likely will), the muscle should not be tightened during your tummy tuck. The overhanging skin and fat should only be removed. This will make a dramatic change in your waistline and provide you years of feeling better about your body.

Dr. Barry Eppley

Indianapolis, Indiana