Your Questions

Q: Dr. Eppley, I have had five pregnancies and my muscles are separated as well as I have a skin flap that hangs down. My back hurts all the time since my stomach muscles are so weak. My skin flap hangs down and rubs on my thighs. I have done physical therapy but it doesn’t help. My insurance says they won’t cover it and I can’t afford to get it fixed on my own. Being in this plight, how can I get my insurance company to pay? It seems like they should but they just don’t understand. What do you suggest?

A: The reality of medical insurance today is that coverage will not be provided for ‘muscle separation’, medically known as a rectus diastasis. While this is a common occurrence after multiple pregnancies, it is not interpreted as medically necessary to repair by the insurance industry. There is no getting around this ruling nor do such symptoms as muscle weakness make it possible for insurance to pay for surgery. It is different if an umbilical hernia is present as this is a true defect in the abdominal wall. The same consideration applies to abdominal skin flap surgery, known as an abdominal panniculectomy. Only in large abdominal pannuses that hang way down onto the thigh and have associated chronic skin infections underneath will insurance consider coverage for its removal.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi. My jaw points down and my chin is very weak. I would like my jaw to appear more square shaped. I don’t think this is a problem with the growth of my jaw as my bite is excellent and I wouldn’t want to mess with it anyway. I considered a chin implant but that seem to just make my jaw longer as it would sit on a backward angled segment of bone.  Also, my nose has a high bridge, so I am wondering if rhinoplasty might off set the look of the jaw. Right now, my jaw line and the bridge of my nose are almost parallel lines. What is your suggestions?

A: In looking at your pictures, your mandibular plane angle does parallel the dorsal line of your nose. This is not a nose problem as its shape and size looks good. A rhinoplasty you most certainly do not need. You need to reorient the plane of your mandible. This would be best done by a combined chin osteotomy and jaw angle implants. The chin osteotomy would bring the chin forward but would also bring it upward due to the angle of the osteotomy cut. This will actually shorten the vertical length of the face. The jaw angle implants will bring down or lengthen the ramus of the mandible of posterior length of the face. These two procedures together will create a counter clockwise rotation of the mandibular plane angle.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my labiomental crease is very deep and I don’t like it. When you look at me you would first think that I have a big chin. But then when you look at the rest of my face you see that compared to everything else my chin is fine. My labiomental crease is so deep probably because my teeth are located far back in my head. And it looks like I have an overbite, but I really do not have one. I would be very interested to hear what you could do to improve this. I know that fat transfers do not last in this area, so I am looking for some kind of implant for a permanent result.

A: Based on your side profile, one reason your labiomental crease is deep is because of your prominent chin. The more chin projection one has, the deeper the crease will be. Otherwise, a Class II malocclusion can be a cause due to the overprojecting front teeth and the recessed lower teeth…but this does not seem to the case in you.

Short of a chin reduction, reduction of the depth of the labiomental fold can only be done by some type of implant. But the implant can not be primarily bone-based because the labiomental fold is not influenced much by bone augmentation as it is a soft tissue structure situated just in front of the anterior mandibular vestibule. Over the years, I haved used many types of implants from fat injections, intraoral dermal-fat grafts, mersilene mesh bone augmentation, and Advanta (Gore-ex) tubular implants. Of all of these, I have found that Advanta implants work best because they are placed directly under the skin and have permanent volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a forehead augmentation. I know that there are different materials to use, one of which is PMMA. I have a few questions about PMMA. Does PMMA bone cement have a risk of granulomas like PMMA injections? Are the outlines of it visible? Does it have a risk of extrusion? Thank you!

A: In answer to your questions: 

1) PMMA cranioplasty material does not cause granulomatous reactions. That is a unique phenomenon of small PMMA particles in soft tissue

2) Besides getting getting the right contour and amount of augmentation, one of the major objectives of any form of cranioplasty is to get a smooth transition form the material to the surrounding bone. This usually requires intraoperative burring of the edges after the material is set to have feather edges so there are not visible outlines after surgery.

3) There is no risk of extrusion of a PMMA cranioplasty. Extrusion of any implant material occurs because it is either placing excessive pressure on the overlying soft tissues or is infected and it is being pushed out by the pressure of the purulent fluid build-up. A PMMA cranioplasty is rigidly fixed to the underlying bone by microscrews prior to it being placed as a rebar method. This prevents any micromotion or displacement after surgery. The material is also impregnated with antibiotics which provides several weeks of antibiotic release after surgery for infection prevention.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a problem since I was in 10 years old. I have visited many doctors but none have had a proper remedy. Ever since I have started feeling it, I am been taking medicines. And right now I am frustrated with taking medicines. The problem is that my face clamps down suddenly on my right upper and lower jaw while I am talking, eating, brushing or even when I am not doing anything. I have visited many neurologists and finally visited orthopedic surgeons but nothing works. I was just going through some internet sites and visited yours and would be very kind if you could help me out. Thank you.

A: While I don’t have the insights that would be provided by an actual examination or knowing what treatments you have had, your description sounds like a condition known as hemifacial spasm. This is caused by involuntary contractions of the muscles of mastication, the temporalis and masseter muscles. Since you have visited neurologists I will assume that causes of intracranial pathology (brain tumors, vascular lesions) has been excluded. I would recommend a series of Botox injections into those muscles which exhibit spasm. Botox is very effective for masseteric spasm in the treatment of bruxism and myofascial pain disorders.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got punched in the face a year ago and my eyeball has been sinking since. I am pretty sure  that I fractured my eye socket but it was never treated. I didn’t go to the hospital when it happened at the time. My eye got very bruised and swollen afterwards and it took about three weeks for all of it to go away. I’d like to know if my eye will keep sinking. Please see the photo and let me know if you think this problem can be fixed. Thank you.

A: The description of your facial injury most certainly sounds like an orbital floor fracture. This is classic for orbital trauma as the thin bone of the floor of the eye blows out and downward as a decompression mechanism for protection of the eyeball. When displaced and untreated, the eyeball will sink downward afterwards as the floor that supports it is lower. After a year, the eyeball should sink no lower as the soft tissues under the eyeball has fully settled into the hole in the orbital floor. The level of your eyeball can be restored by orbital floor reconstruction. The scarred soft tissues under the eye can be freed up and the bony hole rebuilt/covered with either thin synthetic materials or bone grafts. This will bring the horizontal level of the eyeball up to its preinjury position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 52 years old and had eyelid surgery, both uppers and lowers, a month ago. My problem is my right lower eyelid droops. It is not level with the other lower eyelid and a lot of white is showing. It was worse the first week after surgery and then it got a bit better.  But it has not improved anymore since then. My doctor told me to be patient and keep ointment in the eye at night, massage it several times a day, and keep it taped up at night. My doctor said he can fix it later by tightening the corner if it does not improve. How long should I wait before having it fixed?

A: What you have is ectropion or lower eyelid drooping at the outside corner due to loss of structural support from the transcutaneous lower blepharoplasty. This is one of the known potential complications from this surgery. You are following management instructions which are what should be done in the first month or two after surgery. As long as the lower eyelid position is slowly improving and/or eye symptoms such as dryness, itchiness or excessive tearing are not too severe, the more healing time the better. Improvements in ectropion can continue to improve several months after it has occurred. A full three months should be allowed to pass before undergoing lateral canthal/eyelid resuspension, which is the definite answer to ectropion. This can be done earlier if eye symptoms warrant.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery two years ago. Breast tissue was removed through incisions on the underhalf side of the areola. No liposuction was done. The incisions healed well and, while it looks a lot better than it was, my nipples are still a bit puffy. My doctor said it was swelling for several months after surgery but it never got better. I want my nipples completely flat with no puffiness at all. I don’t want to see them poking out through a shirt. I can not feel any hard lumps under the nipples so I think it is just fat. The puffiness has a soft feel to it. It pushes in easily. I am thinking this residual fat may be able to be gotten rid of by exercise or losing some weight. Do you think this will work?

A: Gynecomastia surgery, when done through an open resection of glandular breast tissue, is an art form in terms of how much tissue to remove. There is no precise method during surgery, when the patient is laying horizontal on the operating room table, to determine if the nipples will lay completely flat afterwards. The one thing a plastic surgeon wants to avoid is over-resection or removing too much breast tissue. This will create a crater deformity after surgery. To avoid this problem, surgeons will be more conservative rather than aggressive in tissue removal. This means that in some cases after surgery that most of the nipple protrusion is gone but it does not lay completely flat. This is due to residual breast tissue or incomplete resection not fat. This can only be improved by secondary gynecomastia reduction surgery to remove more breast tissue. It will not respond to any method of fat burning or weight loss.  

Dr. Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t like the shape of my jawline as it goes from front to back.  I would like the front of the jaw profile to be less angular and also look deeper. I think this would improve my face shape and make it look more symmetric. I have attached a few pictures. What type of operation do I need to make this improvement?

A: I am not sure I understand what you mean by the desire to have the ‘jaw front profile less angular and also deeper’.  I would need a better explanation to be sure what you see. But looking at your pictures, I think you mean that the chin is pointy (rather than square) and the jawline from the chin angles back sharply as opposed to being more square and vertically longer. The angular chin/jaw line is more associated with females while the square and broader chin is associated with a stronger male look. This could be improved by geniomandibular groove implants that fit on the bottom of the chin and go back to the anterior body of the mandible. They can be used to widen the chin as well as provide structure at the turn of the chin into the jawline so that there is a stronger jawline appearance. This is done through a submental incision and the two implant halfs are assembled into a unified implant with screws once into place. How close or separated they are in the midline affects how much the chin width is increased.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in trying to make my face more symmetric. My main problem is around my eyes and they are not even. One eye is definitely higher than the other one or it could be that one eye is lower than the other. I am not sure which eye is the right one, all I know is that they are different. I think though that the left eye is too high as I like where the right eye is as it sits on my face. I have attached a front picture for you see what I mean. Is there anyway to make the eyes more even?

A:I would have to say that the vast majority of your facial asymmetry is based in the eye area as you know by looking at your pictures. The position of the two orbits/eyes is the most striking issue. Either eye position is acceptable but it is just that they are different and they are side by side. While one can have a debate about which one is the ‘goal’  to achieve (the good looking one), that discussion is largely irrelevant since you really can not correct one fully to be level with the other.  Their differences are too great. The left eye can not really be brought down as far as the right and the right can not be brought up as far as the left. They are also lid issues with those movements, particularly the position of the medial and lateral canthi.

That being said, the only approach I envision that could work is a combination of making changes on both eyes, build up the floor on the right orbit  and drop the left eye down. Each could be moved 2 to 3mms and together this ‘ying and yang’ approach could overcome the 5 to 5mm difference that currently exists in the horizontal pupillary levels. This may not create perfect orbital symmetry but it would be an improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a non-surgical way to reduce my belly fat. I have had two kids and as a result I have a little loose skin on my lower belly but it is really not too bad. I don’t have any stretch marks except a few fine ones. My problem is this little bulge below my belly button which just won’t go away no matter how much I exercise or do situps. I can’t justify in my mind to go through liposuction surgery to get rid of it and I know my husband would never permit it anyway. I have read about several non-surgical methods but what do you think is best and do they really work?

A:  Let us start with the premise that surgery, liposuction, is the most effective method of SPOT fat reduction that we know. And any non-surgical method is never going to be as good. Whatever result any non-surgical method can achieve can never compare to that of actual surgery. And thus by comparison it will be a have a poorer return on one’s economic investment.

Once one accepts that premise then the consideration of non-surgical fat reduction can begin. While there are many energy-based devices that currently exist to reduce fat without surgery, my current one of choice is Exilis. This is a deep radiofrequency device that targets fat below the skin but can also do a little skin tightening as well. (I said a little skin tightening, not to be confused with more than a small pinch) Treatments are fairly comfortable and a series of 4 to 6 sessions over 6 weeks can make a very visible reduction. The radiofrequency energy breaks down fat cells walls, causing them to spill their lipid contents which is then absorbed. In addition, there is no recovery or pain afterwards and one could go and work out immediately afterwards if they were so motivated. For the devout non-surgical person with some localized fat collections, this can be a good alternative to liposuction. You might also consider Smartlipo done under local anesthesia. While this is still surgery, small areas can be done without being put to sleep for the best result in the shortest period of time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had some computer imaging done for some facial change that I want to make but I am not completely happy with the imaging predictions. I’m very particular of what I’m trying to go for, but I don’t even know if it’s possible. I went on facetouchup.com last night. Have you heard of it?  It’s like photo shop and you can  adjust any part of your face to your liking. I played around a bit with my nose and I really like the end result. I attached it on this email. If that’s not possible, I understand, but I was wondering actually,  if you could tell me, if you could do absolutely anything with my nose what would you change?  Also I’m not too crazy about the use jaw implants from the front view. I guess it’s one of those things that work on someone else’s face but not on mine. The main purpose of wanting a jaw and chin implants was to make my face less round more oval shaped. Do you think you can get a similar result like the attached male model example?

A: Programs like Face Touchup are for fun, not for reality. You can do anything on these programs or with more sophisticated programs like Photoshop. This does not mean that it can be created surgically. Photo imaging is about communicating goals, not about guaranteeing a result or the ability to create that exact look. You are much better off considering and undergoing surgery with what may realistically happen,, nto with what you hope will happen. A plastic surgeon driving the imaging program is going to be closer to reality than any patient doing it.

I don’t think jaw angle implants are for you. You don’t have the anatomy for it to create the right effect. Your facial tissues are too thick and all those implants do is make your face fatter not slimmer. The only slimming effect that will work for your face is a vertical lengthening chin osteotomy and buccal fat removal.

One reality that you will have to accept is that your face is never going to look as refined and angular as the faces of the model images that you have shown. (aka male model look) You don’t have the right facial tissues for it. The best you can achieve is somewhere between what your face look like now and those pictures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get information on cost and recovery time for different lipo procedures for various parts of my body – arms, chin, stomach, hips and thighs.  I’d like to explore smart lipo and lipo dissolve, but would like to know if I can get good results.

A: Fat reduction by liposuction has a myriad of considerations including effectiveness, cost and recovery. It is impossible to give any reasonable answer to these questions without actually seeing a patient and evaluating each one of their body areas of concernb. The variables that affect these issues you have asked, such as thickness and size of the fat, quality and amount of overlying skin, how many and what body areas would be treated and what one’s physical health and occupation is makes any answers to these questions truly an individual one. I would recommend that you have an actual consultation with a plastic surgeon to get meaningful answers to your very relevant questions. While many people would like fat reduction, most commonly done by liposuction, it may not be the right answer for  everyone.

Dr. Barry Eppley

Indianapolis, Indiana

There are many options to tighten loose skin in the neck and jowls, the most common aging problem in the bottom half of the face. One of the most significant developments in the past decade has been to limit the scarring that goes with the more traditional forms of facelifting. These procedures have become known by a lot of names including short scar facelift, S- lift, MACS lift and dozens of other catchy marketing names. But in the end, there are all ‘Mini-Facelifts’.

These smaller facelifts tighten up sagging jowls and droopy neck skin and do so with less scar. The scarring that is eliminated is in two specific hairline places, in the temples above the ear and in the crease behind the ear. Why is it important, if possible, to eliminate such scarring? The issue is one of scar widening and hairline displacement. When a facelift scar runs up into the temple hair, it will always move one’s sideburn hair up.  (not important for men who can just grow new sideburns) When scars are placed back into the hairline behind the ear, they will become noticeable if one has very short hair or wears a pony tail that may expose the scars.

The incisions for a mini-facelift starts at the top of ear, goes inside it behind the tragus (bump of cartilage in front of the ear), and then tucks around the earlobe. It stops in the crease of the ear just above the earlobe. This incision pattern (and ultimately the scars) prevents loss of the tuft of sideburn hair and eliminates scarring behind the ears. This allows one to wear their hair any way they want without being ‘discovered’.

While less scarring would be an important part of looking better, these mini-facelifts are not for everyone. The vast majority of patients that benefit by them are under the age of 60. Today many people seek neck and jowl improvement by age 45 or 50. These short scar procedures are designed to smooth out the jawline, soften the nasolabial folds and restore a more sinuous and curved facial shape. As one ages, sagging of facial skin and jowls create a more square or ‘bulldog’ look for some. A mini facelift reverses this facial shape change into a more triangular shape which is more synonyous with youth.

The one disadvantage to a shorter scar facelift is it is not as good as improving the significantly droopy neck as that of a traditional lift. This is why older patients with more advanced neck problems have to accept the trade-off of greater scars from more extensive facelifts.

Many mini-facelifts are done with other facial aging procedures as well to get the maximal benefit. When potentially combined with such procedures as liposuction of neck fat, removal of excess eyelid skin and chemical or laser skin resurfacing, that tired aging look can be completely wiped away in a few short hours.

Q: Dr. Eppley, I had a sliding genioplasty two years ago and have suffered with iatrogenic chin ptosis since. I have read in your writings that there is the possibility to resuspend the mentalis muscle using bone anchors to a higher level. Also you have recommended a VY lengthening of the mucosa of the lower lip at the same time.What is very hard to find out is how the patients feel after this surgery concerning to the ability to move the lip sidewards and forward and the movement to evert the inferior lip. Is this type of lip movement uncomfortable afterwards? How is the patients’ sensation moving their lips after a mentalis resuspension?  Does it continue to be uncomfortable because of the devascularing nature of the intraoral incision or the mentalis muscle turning it out into an atrophic scar?  My concern is that my most important issue that I would really like to repair is functional and I would really like to correct the discomfort I have. Would really appreciate if could please write a few lines about how patients feel moving their lips after this procedure.

A: Chin ptosis after a chin osteotomy is very unusual as the bony movement forward (typical direction) picks up any loose tissue. But it is possible if the chin osteotomy is used to vertically shorten the chin and move it backwards (not a good idea), if the surgeon does not tighten the now excess soft tissues. In my experience with chin ptosis repair, complaints about difficulty with moving the lips or loss of feeling have not been voiced. This does not mean that they may not exist, but that they were not considered significant. I suspect I have have not heard of them because they do not turn out to be problems after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to get rid of a scar on my forehead. Here is my picture and I’m hoping that this is something that you would be able to erase. I hate this scar on my face. I am getting married in three months and I need this scar off so I can look my best for my wedding and pictures. Please let me know how soon I can get in and how many sessions it will take to get rid of it.

A: The scar on your forehead that runs vertically down through your eyebrow and into the top of your nose can definitely be improved. But one reality that needs to be faced about scar treatments is that such outcomes as ‘being erased’, ‘gotten rid of’ and ‘removed’ are not possible. Scars can be improved but, in general, there is no such result as being removed like it was never there. The realistic result of scar revision efforts is to lessen its appearance. Some remnant of the scar will always be there. The features of your scar would be best treated by surgical scar revision and an irregular closure pattern.  Because the scar will be initially red and will take time to mature and lose its color, having scar revision done three months before your wedding is the minimum amount of time you should allow.

Dr. Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have indentations on my forehead. On my right side, there is less volume so I have more loose skin and my eyebrow droops. I would like to get the indentations filled in so my forehead looks smoother. Since filling out the area would make my skin more taut, would it fix my eyebrow into a more normal position so it doesn’t droop anymore? My brow bone is also smaller on the right side. Could bone cement build up my brow bone? If so, could that also help lift my eyebrow up? If some skin removal is also necessary, would it cost a lot more?

A: Forehead augmentation (onlay cranioplasty) by virtue of adding volume would potentially make the skin tighter. There may even in some cases be a slight browlifting effect, although this would be greatest with the brow bone is directly built up. Whether this would occur or not would also depend on how much volume is added. To ensure that this stretching and lifting effect occurs, it would usually be best to do a browlift with the forehead augmentation. This would be easy enough to do since there would be a coronal incision already present. It would not add any appreciable time or expense to do so because of then existing scalp approach for the forehead augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 55 years old and am interested in doing some with my aging face. I think I need a facelift or something along those lines. I do have numerous medical problems including rheumatoid arthritis which is under control at this time. I am taking Methotrexate, Arava and Plaquenal for it. I also take medications for high blood pressure, high cholesterol, underactive thyroid and I smoke one pack of cigarettes per day. I would be willing to quit. I am 5’ 2” and weight 180 lbs. I also have restless leg syndrome and back pain. I also take Xanax, Xanaflex and a sleeping pill.

A: Thank you for your interest in facial rejuvenation surgery which may possibly include a facelift. You are correct in assuming that you would need to quit smoking at least one month before surgery and for at least one month after any procedure. In addition, however, you have multiple other medical problems that need to be addressed before you should consider any type of elective facial surgery. It would be best that you loss some weight before surgery, getting you down to at least the 155 lb to 160 lbs range. This may also help your high blood pressure and back pain. Because of your rheumatoid arthritis medications, they do place you at risk for healing problems. I would have to talk to both your primary care doctor about your general health and your rheumatologist about your medications and their dosages to see if any of these can be reduced for a short period of time around surgery. You would also need to be done some supplements to help with collagen production and healing, such as temporary high doses of Vitamin A and C. While you may benefit greatly by a facelift, you have numerous medical issues that must either be improved or management strategies implemented for them for you to have a successful and uncomplicated outcome from any type of facelift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a chin implant, I want to ask you is a chin implant with a screw holding it into position a must so that it won’t move? One doctor said screw is not necessary as she said you can extend anteriorly more than 1 cm it and it depends on how the doctor carves out the implant so it won’t move place. Is what she said true and effective?

A: How any surgeon secures their facial implants is a matter of personal preference and experience. I prefer to screw all facial implants into place when possible to get the best aesthetic result (assured position) and never have to worry about them every moving or sliding from where I want them. That is my personal preference and has served me and my patients well over the years. Just because other surgeons make not choose that technique of implant fixation, or any fixation at all, does not make them wrong. That is obviously what works for them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a bump on my forehead which is the result of a fall. I’ve tried putting ice bags on it as well as the white of an egg to shrink it’s size. It’s become smaller but I can’t seem to find a way to get rid of it. I’ve been in the hospital after the fall and ice bags were applied to the bump and a test was done to determine that there are no broken bones. Please help me get rid of the bump. Thanks!

A: One key question is how long has it been since this head injury has occurred. Often times small hematomas may occur and this, combined with swelling, can take months to resolve on their own. But they usually will go away completely on their own if given enough time. If the hematoma is big enough, and one can tell that it is if it feels very spongy and compressible, then the hematoma should be aspirated for more rapid and assured resolution. If the injury was more than 3 to 6 months ago, a hematoma may becoming calcified which could result in a bump which will not go away on its own without surgical intervention. (limited cranial reduction)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a skull problem that bugs me and I would like it corrected. I have taken some pictures of my head so you can see. They are not the best but they show that my skull shape problem is that I have a bony growth and a deep groove on my crown area and the back of my head has several bumps and grooves!! I was wondering if you can use the bone cement kryptonite to fill in the grooves all over my head?? Please let me know as I really want to have this done. Thank you so much for your time.

A: I see that you have two distinct skull contour problems. The first is a deep groove on the top of your head along the course of the original coronal sutures on both sides. It runs identically along the suture line into the temporal regions. The second issue are the multiple irregularities, lumps and bumps, on the back of your head. There are two approached that can be used to improve these skull contour irregularities. The first approach is an open technique where the entire skull can be filled in and smoothed out. While this would produce the best result, the placement of a scalp scar makes it unacceptable for most male patients. The second approach, as you have mentioned, is an injectable technique using Kryptonite cranioplasty material. While this can certainly be done, an external ‘blind’ approach will help fill in many of these cranial depressions but it will be perfectly smooth. The trade-off of not having any significant scalp scar is that the skull contour can not be made perfectly smooth. You have to accept the concept of improvement but not perfection of your skull reshaping effort.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard of facelifts being done under just local anesthesia. How safe and comfortable is that approach for this kind of surgery? It is appealing to me but it makes me nervous being awake.

A: There is little question that limited or mini-facelifts are very popular today and are widely advertised. Many surgeons and companies have even named their own versions of these mini-facelifts. Their premise is based on being performed under local anesthesia for a quick recovery and usually a lower cost. While there is merit to this approach, the key is whether a more limited facelift result will meet a patient’s expectations based on their degree of neck and jowl sagging beforehand. While eliminating the risks, cost and recovery from anesthesia is appealing, that can be a poor trade-off if the ‘problem is bigger than the solution’. Such mini-facelifts are best used in younger patients who have early signs of facial aging or in older patients, while really needing a fuller facelift, simply doesn’t have the time, resources or desire to completely address the extent of their aging issues.

Local anesthetic facelifts can be made fairly comfortable through the use of oral or IV sedation drugs. The wonders of modern pharmacology allow one to reach a pleasant and relaxed state of mind so local anesthesia can be adequately injected for the facelift procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need some help in selecting the right breast implant size for me. I am 5’ 2” with a 32B cup size. After having breastfed two babies, I need some breast volume back. It has been sucked out of me.. I am going to get 500cc high profile gel implants. My doctor suggested 450cc but I want 500cc. Do you think this is a big difference. I don’t mind if they are a little big and look somewhat fake. I actually like that look. Are there any health risks from going big? I value your opinion.

A: On a volume ratio basis, the difference between a 450cc and 500cc implant is not that significant, around a 10% size difference. A sized difference in implants that is barely visible. Since you appear to have no fears about being too big, I would definitely go with the slightly larger 500cc implant. While there are no health risks with larger silicone breast implants, there is always the consideration however of loss of tissue support over time. When a breast implant becomes too big for the tissues that must envelop and support it, there is the risk of bottoming out or dropping of the implant position. Whether this is a potential issue with you can not be determined based on this discussion alone. The key determinant of that is whether the base diameter of the implant stays within your own natural breast base diameter. That is a simple measurement that can quickly be done in an examination. The use of HP or high profile implants is helpful in keeping a good implant-breast base compatibility.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two inverted nipple correction surgeries by two different doctors, both of which were unsuccessful. My nipples are grade III inverted. I am at a loss as to what to do. Do you think that breast implants would help in my inverted nipple correction. Would they help push the nipple out once it has been released?

A: Inverted nipple correction has a high rate of recurrent contracture/inversion after release. Your experience is not completely rare. Many methods have been described in plastic surgery for the correction of inverted nipples which speaks to the fact that it is both a difficult problem and that none of them work that well. Once the nipple has been released and brought out by suture traction during surgery, there remains a dead space or tissue deficiency underneath. I have found that filling this in with either a dermal-fat grafts or allogeneic dermis is the best way to prevent recurrent inversion. The fill must be immediately underneath the released nipple. The push from a much deeper breast implants will not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the Exilis device for my stomach area. I am only 5’4″ and weight about just under 120 lbs. Despite my rigorous workout schedule of running and working with a trainer 3 to 5 days a week, I just can’t get rid of my lower  stomach fat. At 42 years old, I do not want invasive surgery so I believe this device currently offers me my best hope of  solving this problem. Do you think I am a good candidate? I am going on vacation in March so I would like to have some tummy reduction before I get into this season’s swimwear? I am currently training for a marathon in the summer so would I still be able to run? Please let me know! Thanks so very much!

A: By your description, I could not imagine a more ideal candidate for Exilis fat reduction treatments. This is a spot reduction problem and undoubtably is not a large area. In addition, with your high level of physical activity you will helping the treatments work better by enhanced fat breakdown. One of the really nice things about Exilis is that there is no recovery or restrictions after any of the treatments. Each treatment is about 30 to 40 minutes so you can just get and go right afterwards. It usually takes 4 to 6 treatment sessions to get the best result and we like to space them, if possible, no more than a week apart.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in dire need of a nose job.  My nose is extremely wide and my profile slopes terribly, which explains my insecurity. I was hoping I could get an estimate for the surgery. I have attached pictures so you can see what needs to be done. Thank you for your time.

A: Thank you for sending your pictures. What you have is a a very specific type of aesthetic nasal deformity in which the lower alar cartilages are very thick and strong. They overproject beyond the tip of the nose making it very broad and fleshy. With that comes broad widely-spaced nostrils. Since the tip is so broad, the area above it (known as the middle vault) looks collapsed and sunken in on profile. This then makes the upper part of the nose where the bones are also appear wide. This can be treated by an open rhinoplasty procedure that narrows the nasal tip cartilages, narrows the width of the nostrils at their base, builds up the middle vault and narrows the upper nose by osteotomies. Together this will help change your nose to one that is less broad and more refined looking. This is a 2 hour rhinoplasty procedure done as an outpatient under general anesthesia. All costs combined place the price of such surgery between $ 6,000 to $ 7,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two children, the last one being two years ago. As a result of my pregnancies, I have some loose skin and stretch marks which are greatest right around my belly button. I would like to get rid of how my belly button area looks as I just hate it paticularly when I bend over or sit down. I know because I am very small and thin that I don’t have enough loose skin to do a full tummy tuck. But I want to have a completely flat stomach with no loose skin. I am thinking that if I have the skin cut out from around my belly button, rather than low like done in a traditional tummy tuck, that I will get the tightest result. I know this will leave me without a bellybutton but that would not bother me. Have you ever done a high tummy tuck like this?

A:  It is very common that many of the stretch marks and loose skin that results from pregnancies is around the belly button. This is because this is the region of the stomach that undergoes the greatest amount of skin expansion. After delivery, wrinkling and belly button deformities are common. While the type of ‘high’ tummy tuck that you are describing can certainly be done, I would advise against it. Regardless of how flat and tight the abdominal skin would be, having a horizontal scar across the center of your stomach without a bellybutton would create a secondary cosmetic deformity of its own that would not be very natural looking. You would be better served by having a mini tummy tuck with an umbilical float technique. This would create a very low horizontal scar just about the pubic hairline and keep a belly button that is positioned lower with less wrinkled skin around it. While this may not create the supertight abdominal skin that you desire, you would have substantial improvement but having a more natural look.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lipodissolve or laser liposuction of the lower abdomen. I am having a breast reduction done next month. My question is when is the best time for me to have the lipo procedures performed, before surgery or after surgery? I was informed that the best time would be during the same time as my breast reduction surgery. However, my insurance is covering the breast reduction and it does not cover the liposuction. I am also unsure if the doctor performing my surgery performs the lipo procedures I am interested in receiving. I was hoping for a lipo procedure that was less invasive such as lipodissolve or laser lipo.

A: Let me clarify some misconceptions that you have about various ‘lipo’ procedures. Lipodissolve injections are only useful for very small fat collections, no more than the size of one’s hand. I suspect your lower abdominal issue is bigger than that in size. Laser liposuction (aka Smartlipo) is simply an advanced form of liposuction and is just as invasive, it is not a minimally invasive procedure. In short, there is no non-surgical way to get rid of your abdominal fat concerns that would be as effective as liposuction. You could try Exilis radiofrequency treatments which does have some fat reduction effects.

In reality, there would be no better time than doing abdominal liposuction with your breast reduction and this is a common combination of cosmetic procedures. Otherwise you will have to have liposuction done separately where the out of pocket expenses will be higher.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering skull reduction done through an open approach and have afew questions about the scar. In your opinion is the scar with very obvious to you. I always grow my hair out so with that, what level do you think it may affect me? I am not bald or shave my head so I assume the hair will help hide it. More in depth, could I see pictures of the scars from open cranioplasty? How long are they and such. I’m really leaning towards this, would like to know all about it.

A:  It is important to recognize that there will be a scalp scar in any open cranioplasty procedure. That does not mean, however,  that it is necessarily a bad scar that is wide and highly visible. It almost never is. But in men, whose hair pattern is less than stable over their lifetime in over 50% of the male population, it is important to consider this aesthetic trade-off. It is obviously a lot more relevant issue in men who are bald or shave their head. You do not so this is one favorable factor for you. I harp on this issue so every patient gives it careful consideration. The incision/scar usually runs from about one inch above the ear across the top of the head. It is hard to get good pictures of the scalp scars to show since most patient’s hair obscures it.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my head is mildly deformed looking from the side. The forehead bulges out at the top and makes my head look too long from the side view. I want my forehead to have a more curved look that angles backward. I have attached a side view which shows me before and after I have done some computer imaging to show the forehead shape I am after. Can this look be surgically achieved?

A: Thank you for your inquiry and sending the photo attachments. What you are talking about is a cranial reduction/forehead reshaping which would be done by a burring removal technique. The important question is whether it can be reduced enough to achieve the result you are looking for. That is best answered by knowing how think the outer table of the cranial bone is. That can be evaluated by simple plain x-rays of the skull (AP and lateral views). From these films the amount of bone that can physically be removed (outer table) can be measured. There is no question some reduction be done, I (and you) would want to know the best we can beforehand if it is enough to justify undergoing surgery for it.

Dr. Barry Eppley

Indianapolis, Indiana