Your Questions

Q: Dr. Eppley, I think I may have ruptured one of my saline breast implants. I had them placed seven years ago and they have been great since surgery. They look fantastic and they have given me some much more confidence. I was running and slipped and fell on my right side. My right breast ended up bruised for several weeks. Now that the swelling and bruising has gone away, my right breast looks smaller. What should I do now? Will I have to pay for a new breast implant and surgery all over again?

A: Low impact trauma is an unusual cause of shell failure in breast implants but it is possible. If you have noticed a breast size change after such an event, then you should return to your plastic surgeon and have it evaluated. Generally a saline implant failure is easy to detect because breast size will change. Loss of saline volume is the only reason one would have a delayed change in breast size. All breast implants from either manufacturer, either Allergan or Mentor, have lifelong replacement warranties should they need to be replaced due to shell failure. Since you are within 10 years from your original surgery, you will get a new pair of breast implants at no charge and up to $3500 towards the cost of surgery to replace them. So while the bad news is that your breast implant may have failed, you will not suffer a economic hardship to have them replaced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dent in the back of my head and it looks like where the anterior fontanelle is. I have had it as long as I can remember. I like the shape of my head but I want this dent filled so I have a shape that is no longer embarassing. I talked to my GP doc and he couldn’t do anything to help me because it would not be for medical purposes just cosmetic. What would this procedure be called and what specialty of medicine/cosmetics would a doctor be who performs this procedure?

A: What you appear to have is a skull indentation cosmetic deformity in the upper part of the back of your head. This may be where the original posterior fontanelle (not anterior) was. Regardless of why it is there, it is likely a simple contour defect over solid skull bone. This can be treated fairly simply with a variety of onlay cranioplasty materials. Some are placed through small scalp incisions and one of them can even be placed  through a minimal incision injectable approach. These procedures are usually performed by either plastic surgeons with craniofacial training or neurosurgeons. When skull defects are purely cosmetic in nature and have no neurologic basis, it would be treated by a plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a septorhinoplasty done late last year and I just don’t like the way it looks now. I didn’t know that my bridge would be built up to be higher and more prominent. I went in to just have a septoplasty to try and help me breathe better. The doctor suggested that my bridge be changed and the tip narrowed a bit, both changes which I now regret. I used to have a nice slope to my nose before and it looks so different that the bridge is so high. Do you think this could be just swelling? Is there any way to reverse these nose changes?

A: It is extremely common for the outer appearance of the nose to be changed at the same time that the internal breathing function (septoplasty and turbinates) is being improved. While plastic surgeons may suggest these changes in the patient who just appears for breathing problems, such recommendations are often welcomed very enthusiastically. The convenience of having both nose issues addressed simultaneously is obviously appealing…provided that one does have some real concerns about their nose appearance and they are very clear on what is going to be done. It appears you now have some early ‘buyer’s remorse’. This could be premature regret since it has only been a few months from surgery and swelling is most certainly present. It may also be that you did not have a clear understanding of what the objectives of the rhinoplasty were. This could have been avoided by computer imaging analysis before surgery. While you may have a rhinoplasty revision to try and reverse some of these changes,it is too early to consider that now. You should give your nose up to a full year after surgery for all swelling to go away and you to adapt to the new look. It could very be how you feel now may change at this time next year.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always hated my high forehead, to the point where it depresses me. I really want to look into getting it reduced, however I am only 18. I was hoping to be able to do some sort of payment plan, it would be a big help! Email back if a payment plan would even be allowed. Thank you!

A:  This is the type of surgery that has to be paid for up front, like all of cosmetic surgery. Many patients opt for financing their surgery through such companies as Care Credit to name the most well known. The typical cost of forehead reduction through hairline advancement is in the range of $5500 to $ 6500.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After breast feeding two babies my breasts have gone deflated. I know that I need a breast lift. My breast size now is a small 36C. Since the upper part of my breast (that part I see the most!) is flat, do you think I need an implant as well? I am not looking to be huge but think that it would help make my breast look fuller. If I get an implant with my lift, what type should I get? I’ve read that a silicone implant is more natural looking.

A: You have very astutely pointed out one of the most overlooked deficiences in breast lifts for some women. The fullness that it creates in the upper pole of the breast will likely only be temporary and often an implant is needed as well. When using implants in a breast lift, there are two general size considerations. A smaller implant can be used in which the goal is persistent upper pole fullness but not a significant change in breast size. A larger implant is used for both upper pole fullness and an overall breast size change. That is a decision that requires patient input. Whether the to go with a  saline  or silicone implant is matter of personal choice, the most significant factor is a cost difference (saline less costly) and the risk of eventual implant deflation (saline) versus silent implant rupture. (silicone)

Q: Dr. Eppley, I had gastric bypass surgery in 2005 and I would love to have a tummy tuck. I’m sure this surgery would help me feel better due to other health conditions I have. I have severe depression, lower back bulging disc with nerve blocks and other health issues that have caused me to become disabled and last year I was approved for S.S.D.I benefits. A tummy tuck is a surgery that I have wanted for years because I have lost a lot of weight. But with the way my tummy looks it makes me feel incomplete and sad. I have pain with the sagging skin with my back and extreme rashes underneath the lower flabby skin around the panty line. Please help. I’m so unhappy with the way I look and feel. Thank you for your time.

A:  Your abdominal situation with your weight loss after bariatric surgery is a common one. The weight loss has been great but the abdominal overhang (pannus) is now a ‘new’ problem. Your description of symptoms is classic and I would have no doubt that a tummy tuck would be of great benefit. Your biggest challenge is getting a tummy tuck is an economic one. By being on disability I would assume that your health insurance is through Medicare or Medicaid. This would require you finding a plastic surgeon who participates in those programs which I do not. Even with private health insurance, there are fewer and fewer plastic surgeons today who will perform this surgery through insurance anymore. In addition, there is also the issue of whether you would qualify for an abdominal panniculectomy/tummy tuck which is an insurance determination not a plastic surgery one.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have concerns about my head shape. I know my head shape is not terrible but it bothers me enough to want something done. I know actually looking it over or feeling the shape would give better insight. The way it’s shaped makes it difficult for normal looking haircuts. I really want to try to do something about it so please try and help me. I think the one noticeable thing is that it’s not a smooth shape at the top, it divot’s a lot on the sides. I have attached pictures. Please let me know what you think.

A: I have reviewed your pictures and read your concerns. The exact area to which you refer is the transition zone between the superior attachment of the temporalis muscle and parasagittal bony skull area. There are many people who have an indentation or steep transition between these two aesthetic skull zones. In some people it is more severe and noticeable. That area could be augmented, it is a question of how that can be done. The method that would provide the smoothest and best contour result is an open skull augmentation (cranioplasty) using either PMMA or hydryoxyapatite. The use of an open cranioplasty involves a croronal incision and resultant scar may not be acceptable in many male patients. An alternative approach is an injectable cranioplasty using Kryptonite bone cement. While this does not have any scar concerns, there is a potential issue of visible edges in the anterior aspect of the defect in the upper forehead.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you please tell me the cost of a subnasal lip lift? I am not interested in having surgery on the muscle. I only want the lip lift where the skin is removed.

A: A subnasal lip lift should never have the muscle manipulated in any way. That leads to problems such as tightness, columellar base retrusion and an unnatural upper lip movement and smile appearance. In my hands, it is always a skin only procedure. While this may be associated with a 1 to 2 mm relapse in some cases over the first six months after the procedure, it does not in any way affect how the upper lip moves or alters one’ smile.

A subnasal lip lift for most patients is done as an outpatient procedure in an office setting under local anesthesia. The typical cost would be in the $2,200 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to send some photos so you could tell me the most appropriate surgery to have. I would like a wider face, a less pointy chin, a chin lift and jaw implants. I wore braces to correct an underbite and I had a mandibular osteotomy and genioplasty – the result is a long face. What can I do to bettr improve my overall appearance. I am 39 years old and terribly unhappy with my profile and double chins etc.

A: You have many of the sequeale of orthognathic surgery of the lower jaw which occur from both the surgery and aging. While a sagittal split mandibular advancement osteotomy and genioplasty have undoubtably done wonders for your bite and improved your facial profile, there are some skeletal deficiences from that surgery that have either been created or unmasked with aging that have affected your lower face. Your face has become narrower with that surgery as the jaw angles are usually lost from the ramus osteotomy and the chin becomes more narrower as its u-shape comes further forward. There also appears top be some asymmetry of the lower jaw with the left angular area being more deificient than the right. There is also the effects of aging as the neck has become fuller and dropped down due to soft tissue sagging. Collectively, all of these give you a narrow and longer appearing face with a double chin and obtuse neck angle.

This could be improved by a single procedure combining a chin-prejowl implant, mandibular angle implants, neck liposuction and a limited or short scar facelift. I have done some computer imaging from the front and sides to illustrate what changes may be possible through this approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 19 years old and very thin. But still the skin on my face is very loose. When I pull my cheek and jaw skin towards my ears, my face looks chiseled. Otherwise it looks round and slight chubby. I want to know if a facelift is good for me? If not what I can do to improve my face?

A: It would be hard to imagine under any circumstance that a facelift would be warranted on someone your age. Pulling one’s facial skin back does make  everyone’s face look more defined as the bony prominences, particularly the jawline and chin, become more pronounced. But that does not mean that a facelift (neck-jowl lift) is warranted. A facelift’s primary objective and indication is for skin laxity and sagging not to make the face appear more sculpted. (although it can create that secondary effect) You are likely in need of facial procedures that provide enhancement of your facial bone prominences, such as the chin, cheeks or jaw angles. Such facial implants can help create a more defined or chiseled face. But a facelift is definitely not what you need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 36 yrs old and have been wearing padded underwear since I can remember. I am ready to have a bottom of my own that I can feel good about.This is my only insecurity and I am ready to do something about it. I want to be able to for the first time fill my jeans out and not have a belly that hangs over them.

A: There are two types of patients that seek buttock augmentation. The first and by far the most common is the patient who simply wants to make larger what they already have. They do not really have buttock hypoplasia or underdevelopment but want to enhance what they already have. This is very common in certain ethnic groups, particularly African-Americans and Hispanic women. The second group and the least common is the patient who really has not buttocks at all. They are completely flat and may even have resorted to padding as you have described.

This second group is the most challenging to treat because they have little to no subcutaneous fat in the buttocks and small gluteal muscles. This makes the recipient site for the most common method of treatment, fat injections (aka Brazilian Butt Lift), very limited. Often they may be quite thin as well without adequate fat donor sites. This leaves them the only option of an actual silicone buttock implant. Such implants can be very effective but they are associated with a longer recovery and other implant-related risks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation six months ago and I feel that my implants are way too small. (I got Mentor 275cc silicone moderate plus gel implants placed under the muscle) I thought they were too small from the beginning but my surgeon said I would get used to them and come to feel that they were just the right size. I never have and I wear the same bra size as before surgery. When can I get new implants and what size implant should I get?

A: While some women come to accept the size of their breast implants, whether they are a bit too small or too big, they do not if the size is way off from what they expected. You have given it enough time after your initial surgery to try and accommodate to them and it is obvious that you can not. You can have replacement surgery at any time at this point. The implant size you should have based on your desires is based on information that I do not have such as breast base diameter, what your chest and body looks like and the ‘look’ of your breasts that you visually desire. But when changing out implants for a breast augmentation revision to go to a bigger size, there is one rule that I have learned. Make sure that the new implant volume is at least 30% or more from what you have now. Otherwise it will not create enough of an external visible difference. This means in your case of at least 100cc or 375cc to 400cc implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gastric bypass surgery two years ago. I lost 90 lbs and my weight has been stable over the past year. I am now ready to get rid of my loose skin around my waistline. I want an adominoplasty that is extended to lift up the thighs a little, as demonstrated in some photos that I have attached. I don’t know if that will be enough skin removed though so a belt lipectomy / body lift may be necessary. What do you think?

A: Thank you for sending your pictures. They are well detailed and I have reviewed each one. There is no question about the need for a complete abdominoplasty in the front. Ideally the most abdominal tightening would come from a combined horizontal and vertical cutout pattern. (fleur-de-lis tummy tuck) But the addition of a midline vertical abdominal scar may not be worth the transverse tightening that it provides. You are correct in assuming that a circumferential body lift is really needed to get the type of lifting in the upper thigh and buttocks that you have illustrated. Compared to many extreme weight loss patients, you actually have less excess skin around the waistline and into the back than most. Some such patients may consider the scar goiing across the back as undesireable in order to gain a buttock lift. That is a personal decision and it is just a question of the amount of scar created vs the amount/extent of lifting that one desires.  

While a circumferential body lift will provide some upper thigh lift, it will not deal with much of the loose skin in the thigh that extends nearly down to the knees. This requires an independent thigh procedure which should not be performed at the same time at the body lift due to concerns about the vascularity of the intervening skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift and upper and lower blepharoplasty a year ago.  I always had a youthful round face.  The facelift did give me a nice neckline and tighter skin, but changed the shape of my face which now looks thinner and older.  Now I am considering fat transfer to restore my face to a more rounder look.  Should I have the fat transfer in the malar area or submalar or both.  Iam afraid I could get my jowls back.   My face used to have the shape of Valerie Bertinelli’s if you know that actress. Thanks for your advice.

A: While facelift do a nice job of redefining the jawline and neck, tightening facial skin in some patients can make their face more gaunt in appearance. This can counteract the favorable anti-aging effects of the skin tightening. This is particularly prone to occur in Caucasian females who have a thinner face to begin with. This is why many plastic surgeons today, myself included, advocate a combination of fat injections for volume and less skin tightening for this type of facelift patient. The injections will usually be in the submalar and lateral facial area. Whether the fat injections should extend up onto and across the malar area would depend on what your facial skeletal structure is like. Flatter cheeks would benefit by some volume but strong cheekbones will not. The real benefit of fat injections in facial rejuvenation/facelifts is in the submalar or buccal area and extending outward and down from that area. I would have no concern about recurrent jowling from the fat injections as they do not fall because of their linear placement.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am primarily concerned with the lower third of my face. I think my chin is too long and pointy which contributes to the long, thin face look. Do you think a chin reduction combined with jaw implants or a pre jowls chin implant would do the trick? If so, do you perfom such procedures? Do you have any other suggestions as to how I could improve my facial features? Please do not be afraid to hurt my feelings!

A:Thank you for sending your pictures. Your long thin face is partly the result of a long sweeping jawline with a modestly steep mandibular plane angle.  This makes for a lower face that appears vertically long. This is magnified by the observation that your midface (cheek and paranasal areas) is relatively flat/recessed. That combination makes for what you see,, a face that has a greater vertical component than horizontal projection and width.

To address this concern, I would recommend a chin osteotomy which, based on the angle of the cut, allows the chin to become vertically shorter as it comes forward. You need both a mild amount of horizontal increase with an equal amount of vertical reduction. Only an osteotomy can make this bony chin movement possible. In addition,. I would place jaw angle implants that both widen and vertically drop the jaw angles downward. Between the chin and the jaw angle changes, the lower third of your face would become shorter and wider. That will help counter the long thin face look. I have attached some predictive imaging to illustrate these changes.

The other change that would be helpful is cheek augmentation. That would bring the midface more forward, again a manuever that counters the vertical and thin (horizontally deficient) facial appearance. I have attached an image that shows where this cheek augmentation would be. Your pictures are not of a good enough quality to really show what cheek augmentation can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 56 year-old man who has always had a weak chin. While I have always wanted to do something about it, I could just never get the nerve to go in and see a plastic surgeon. My girlfriend has given me the encouragement to now do and I am going to make the move to see what is possible. Could you give me some direction in what you think I need? I think the problem is more than just a short chin, my overall jaw just seems smaller. I don’t want to get a chin implant placed on the end of my jaw if it does not look right or natural. I have attached some photos of me from the front and side for your evaluation.

A: Having a weaker jaw/chin in an older male always raises questions about both bone and soft tissue management since there is some degree of sagging of the jowls and neck. While you would undoubtably be helped along the jawline with a facelift (neck-jowl lift), I am going to pass over that issue for now as dealing with the bony deficiency should always been done first. Since a lower facelift affects the posterior jawline and neck angle the most, it would have its greatest effect on the jaw angle area. Whether you would benefit by jaw angle augmentation or a total jawline procedure is unclear to me at present. (and also unlikely) Therefore for this discussion I am only going to focus on your chin deficiency and submental fullness which are your biggest facial imbalance issues.

What you need is a chin implant and neck liposuction/submentoplasty. The question is whether a preformed or off-the shelf chin implant will work or whether a custom implant is preferred. Both will make positive changes. It is just a matter of degree and how substantial that change is. You do have both horizontal, vertical, and transverse (width) chin deficiency which is common when the chin is very weak. The problem, as you have accurately pointed out, is really an overall jaw growth issue not just a simple short chin. This makes the entire lower face short in every dimension.

I have done some predictive imaging based on both off-the-shelf and custom implant approaches so you can get a feel for how the two type of chin implants differ. A custom chin implant will address all dimensional deficiences. and produce a more profound change..if one finds that look appealing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just had a old tragus piercing split. Is this something that can be stitched back together or will the skin grow back? Or does it require plastic surgery? If the latter, will it look normal after plastic surgery? Thanks.

A: While piercings are common on both the earlobe and the tragus of the ear, there is one anatomic difference between them. The earlobe is completely comprised of soft tissue, skin and fat only, and this is what holds the piercing in place. The tragus, however, has a central core of cartilage with skin on top. It is the cartilage which holds piercing in place and it is usually much more secure and resistant to stretching unlike the earlobe. When a tragal piercing splits, presumably by it being pulled on, the underlying cartilage may have split as well.

Like the earlobe, a tragal split will heal on its own due to the excellent blood supply. Whether it will heal with a notch or cleft in it is impossible to say. I would allow it to heal on its own and see what it looks like later. Scar revision can always be performed of the contour of the tragus is not perfectly smooth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar from a tummy tuck in 2007. I also have scarring under my breasts from a lift and augmentation at the same time. While the mommy makeover boosted my confidence by not having sagging skin it also left me with these horrible scars. While I can cover them up in a bikini when I couldn’t cover up the sagging skin, it still leaves me very shy and not confident when I have no clothes on. It doesn’t seem fair that I spent so much money in 2007 for a mommy makeover to be left with such embarrassing scars. I don’t know if you can help me but I would appreciate your advice. Thanks so much.

A: While the combination of a tummy tuck and breast implants with a lift can remake the female torso altered by pregnancies, there is always the tradeoff of scars. While these breast and abdominal scars are usually quite acceptable, there is always the risk that they may not be so. When the scars are not aesthetically pleasing it is almost always because they are widened or hypertrophic. Improvement in these scars can be achieved by revision consisting of excision and re-closure. The scar outcome is likely to be improved because the tension or tightness on them will be much less now than the original procedure where much more tissue was removed. While the scars can not be removed or significantly repositioned, they can be narrowed such scar revision surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, While searching the internet I found a program that allows one to change things on their face. I have always been interested in having a nosejob so I went ahead and did my own picture. I really like how it turned out as I have always wanted a thinner looking nose. My question is whether you think I could get such a result from actual surgery. The skin on my nose is thick so I don’t know how realistic this program is?

A: Morphing or imaging programs are very valuable is aesthetic facial surgery, particularly in rhinoplasty surgery. Their accuracy in predicting achieveable results, however, is primarily determined by whom is doing the imaging. The computer software is just a tool and has no ability on its own to predict how body tissues will respond to surgical manipulations and healing. Only the user of the computer tools who is a rhinoplasty surgeon can use them to demonstrate results that may actually occur.

 What you have demonstrated by doing your imaging is what you would like. While I agree the change is very favorable, it is not realistic. One of the most difficult problems in rhinoplasty is the male with thick nasal skin. While the cartilage underneath the skin can be changed and reduced, the thick nasal skin often dampens what is seen on the outside. Realistically, you can achieve the amount of nasal thinning that is about half of what you have imaged.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 57 years old and have just discovered that my hidden penis condition can be treated and improved. I have suffered through my teenage years and adulthood with the taunts  in gym and the odd looks of women when I could of had something done about it! Doctors told me that I was OK and said that some men have an inee and others have an outee. I knew that something wasn”t right. My folks and the doctors back then could circumsize me, but they couldn’t fix this! While most of my sex life has passed me by at this point, I’d still like to look normal before I die.

A:  While having either an inner or an outie may be normal for the appearance of the bellybutton, it definitely is not normal for penile exposure. The buried and hidden penis is often a developmental condition that can become apparent early as a child or in the teenager years. It is caused by a tethered or retracted penis that is often accompanied by a larger surrounding suprapubic mound. This combination can frequently result in partial or complete coverage of the penis. While a majority of buried penis cases do occur  in males that are overweight, it is not exclusively so. This penile problem can be improved by a combination urologic and plastic surgery approach. The buried penis needs to be released while the suprapubic fat mound needs to be reduced by liposuction with or without a suprapubic lift. While there are some cases where suprapubic mound reduction alone is sufficient, most long-standing cases in adults benefits by dealing with both anatomic issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead contouring surgery. My forehead is kind of rounded and I would like to have it more like square-shaped. When looking at a profile view my forehead sticks out where my brows are and my eyes look deep in the face. I also have attached a picture of a gentleman that his forehead looks more like square and that is exactly what I’m looking for or something close that will reduce my forehead. Thank You

A: Thank you for sending your pictures. Your forehead shape is a combination of brow bone protrusion and an upper forehead that slopes backward. Together this gives your forehead a 50 to 55 degree backward slant in a profile view. The desired forehead shape that you have shown is almost completely vertical. While that is not completely possible from the forehead shape that you have now, you can make significant improvement in your current shape. To change the slant of your forehead, you need to address the two components of the problem, brow bone protrusion and upper forehead retrusion. This is done through a combination of brow bone protrusion and forehead augmentation above the brow bone area. Neither brow bone reduction or forehead augmentation alone will make this improved shape. It takes this combination ‘ying and yang’ approach to create the substabtial forehead shape change that you desire. I have attached an imaged result of what I can think can be achieved by this approach. This would be done through an open coronal incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year-old female who has been considering breast enlargement for a long time. My right breast is significantly smaller than my left breast and I have never been comfortable with them being so lopsided. I am pretty sure that I want this procedure done but I am a bit nervous about how they will be made more even. I don’t want to larger breasts that are just as lopsided. How would you go about making my breasts more even?

A: Congenital or developmental breast asymmetry is one of the most challenging problems in breast augmentation. This is because the two breasts are not different in just mound size but also in the amount of overlying skin and in the position and size of the nipple-areolar complex. While implants are an integral part of this ‘reconstructive’breast augmentation, consideration must be given to adjustment of the nipple position as well as a possible staged approach using  a tissue expander if the asymmetry is severe enough.

The key phrase here is ‘making your breasts more even’ or decreasing the magnitude of the breast asymmetry. Perfect breast symmetry is not possible in these cases and one has to be prepared for a higher risk of the need for revisional surgery to try and achieve the best result. Breast implants alone, while making the breasts bigger, often unmask or reveal the many differences between the two sides in breast asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a zygomatic surgery four weeks ago. My right cheekbone was broken.  The swelling has not completely gone down yet, but I can not understand the asymmetry in my face. My question is when these swellings will go away completely?  I feel very anxious about if my cheekbones will  have good symmetry again. It seems like I still have a collapse in my cheek bone even though there still is swelling present.

A: There is no question that zygomatic fracture repair can be associated with a large amount of eye and cheek swelling, particularly if it required a combined intraoral and eyelid incisional approach. Less swelling occurs from a more simple intraoral reduction. Since I don’t know the classification and magnitude of your cheekbone fracture and how it was treated, I can not say with any certainty about when most of the swelling will subside. But six weeks is a good time period to judge the results even though it may take until three months for all swelling and tissue contraction to occur.

However if in the face of swelling a cheek bone fracture repair shows persistent asymmetry, it may well be that the fracture repair was inadequate or not stabilized ideally. If this is the case, it is still possible at six to twelve weeks after surgery to do a revisional fracture repair with an improved outcome. (secondary facial fracture repair) Very delayed zygomatic fracture repairs may require camouflage procedures such as a cheek implant and/or combined with an orbital floor implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I gave birth to twins over three years ago and since then I now have an abdominal hernia and umbilical hernia due to my abs splitting from being pregnant with twins. I also just have extra skin that exercise will not help with. I currently have surgery scheduled for next month with a general surgeon to fix my hernias. He is doing it laproscopic. I was curious if you would be able to fix my hernias by repairing my abdomen muscles and removing my excess skin. Or if you could do the tummy tuck the same time as my surgery with the general surgeon so that would reduce my anesthesia cost and then my insurance would cover some costs. Please let me know your thoughts.

A: Your questions are good ones and fairly routinue inquiries in regards to combining tummy tucks with hernia repairs. Let me discuss the aspects of such a combination from both a medical and financial standpoint.

Most hernias from childbirth are going to be in the midline between the rectus muscles and around the umbilicus. This would be the standard location for a woman who has been considerably stretched from having twins. In a tummy tuck procedure an umbilical hernia would be encountered, reduced and repaired with the midline rectus muscle fascial plication that is almost routinue in most tummy tucks. I have done this many times and there is good logic in combining these procedures in terms of operative efficiency and recovery. If an open tummy tuck is being done then there would be no need to do a laparoscopic approach to a hernia repair.

The issue of doing the two together through insurance is the intriguing twist to this combination. Contrary to popular perception, there is no financial benefit to putting these procedures together. Many years ago there was but those days have long passed. The hospital is fully aware that a tummy tuck is being done and will charge a full rate for the tummy tuck procedure including OR and anesthesia charges. There is no such thing anymore as the insurance covering the OR and anesthesia charges for a cosmetic procedure when done with an insurance covered operation. Both the hospital and the insurance company consider that fraud so there are extremely vigilant about that issue. Interestingly, doing a cosmetic procedure with a covered insurance procedure in a hospital could very well end up costing you more, a lot more, than having a tummy tuck and the hernia repair being done in a surgery center on a purely cosmetic basis. These are the realities of today’s hospital and insurance economics.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had a bone cement for 10 months on my forehead and this was done by my neurosurgeon. He had to elevate the depression on my forehead and on my frontal sinuses due to an accident 10 years ago. I am planning to learn mixed martial arts in a few months but I am worried that my bone cement will get hit and break. Is my bone cement as strong as the rest of my skull? Thank you very much!

A: The term ‘bone cements’ refers to a family of synthetic materials that can be used for cranioplasty purposes. Historically, this used to refer to the material PMMA or acrylic which has been used for over fifty years in cranioplasty surgery. This is still a very common material that is used by many neurosurgeons in particular. It is mixed together and creates a very strong composition similar to what most people known as plexiglass. This would resist any type of trauma much like normal skull bone would do. In the past decade new cranioplasty materials composed  of various forms of hydroxyapatite have emerged which are also known as hydroxyapatite cements (HAC) or bone cements. These are not nearly as strong and are much more brittle. These are more likely to fracture if exposed to trauma.

Your cranioplasty was an onlay or augmentative one in which whatever material was used was placed on top of existing but depressed skull bone. This is much more supportive of the cranioplasty material than if it was used to replace a full-thickness cranial defect so impact resistance is greater regardless of the material used.

If you had a PMMA cranioplasty I would have no concerns whatsoever about sustained implacts. If this was a HAC cranioplasty, however, I would be more cautious.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Many years ago I had an absessed septum in my nose and had to have emergency surgery. The doctor wanted to do plastic surgery after the procedure due to the excessive loss of cartilage in the nose, but because of the trauma of the initial surgery, I did not want it. After many years, I wish I had done the corrective surgery. Is there a chance that insurance might cover some of a corrective nose surgery for me after so long?

A: Loss of portions of the septum due to infection or hematomas creates, sooner or later, collapse of the overlying nose. This creates what is known as a saddle nose deformity with collapse or inward deviation of the dorsal line of the nose. With the sinking in of the middle vault, the tip of the nose will turn upward with excessive nostril show. With loss of portions of the septum there may also be a hole or perforation of varying sizes between the two sides of the nasal airway inside.

 Reconstruction of a saddle nose almost always requires a rib graft to rebuild the dorsal line of the nose. The septum usually is not and cannot be rebuilt due to loss of lining nor would it have any influence on the appearance of the outer nose. Such rhinoplasty procedures would most certainly have some coverage under one’s health insurance due to the medical basis (infection, loss of septum) for the cause of the problem. This would be ascertained before surgery through an insurance predetermination process.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation last year and was advised before surgery that I needed a breast lift also to get the look that I wanted. I have had two children and had a bit of breast sagging. But I didn’t want the scars or the extra expense at that time. Now I have come to realize that the doctor was right and feel now that the scars would be better than the way the breasts look now. The implants have actually made my breasts look worse even though they are bigger. Can I still get a breast lift now even though I already have implants in place?

A: For those women who have some minor amounts of breast sagging that present for breast augmentation, the idea that they need a lift as well is often a bit much. Due to concerns about scarring and the extra expense from a simultaneous lift, they may defer and let the results ‘prove’ that a lift is beneficial or not. While in hindsight you may have regretted this decision, the possibility of avoiding scars and saving some money was not an unreasonable one. Now that you have the implants in place you can certainly go on to a have lift as a ‘two-stage’ approach to your breast enhancement. The good news is also that you might get a better breast lift result because of working with an established breast mound underneath from the previously placed implant. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very petite frame and am 5’1”and weight 108 lbs. But despite this small size I have a little area of stubborn belly fat that won’t go away. My weight doesn’t fluctuate that much and runs anywhere from 105 to 110 lbs. If I get this fat removed by liposuction what are the chances that it will come back? Since my weight fluctuates a little while this cause it to return?

A: The retention of liposuction results is definitely influenced by one’s weight. I tell all my liposuction patients that the long-term reduction seen will only be as stable as one’s weight and it also depends on what body area has been treated. The abdomen and waistline for both men and women is the area at greatest risk for fat return after liposuction since it is a primary depot site for excess caloric intake. However given your small frame and the relatively minor weight fluctuation that you have, this should not be a significant concern since you are talking about a weight fluctuation that is around 5% of your  total body weight. Fat return is more likely when weight increases are in the range of 10% to 15% or greater.

Dr. Barry Eppley

Indianapolis, Indiana

Today’s patients are more concerned about treating the early signs of aging and unwanted fat than ever before. Women and men alike are looking for faster, less invasive procedures with little if any downtime that can reduce their wrinkles and improve their figure. While many devices have been touted over the years, most have failed to produce satisfactory results for many patients. But a new technology is now available that offers the  latest advancement in nonsurgical, pain free therapy for the reduction of targeted fatty deposits, skin tightening, and sun damaged and/or wrinkles skin anywhere on the face and body.

Exilis is an FDA approved device that offers a non-surgical solution using radio frequency (RF) energy for fat reduction and tissue tightening anywhere on the body. The procedure uses safe radio waves to heat your skin and targeted fat cells. This thermal energy speeds up the metabolic activity of the fat cells causing them to shrink. At the same time it stimulates and strengthens the collagen network which improves skin texture.

Exilis is one of the first systems that produces actual circumferential reduction. By combining RF energy with cooling, all areas of the body where stubborn fatty deposits persist or tighter, firmer skin is desired can be treated. While Exilis is heating the tissues, patients remain relaxed and comfortable. Having no pain alone is a real advancement in non-surgical device treatments.

The most frequent areas treated with Exilis Therapy in men are the love handles, chest, abdomen, face, jowls, and neck. In women they include the face, jowls, neck, decolletage, arms, bra fat, thighs, hips, breasts, buttocks, stomach, and knees. Exilis requires a series of treatments, usually four, to get the best results. The results from Exilis Therapy are gradual and may take from two to four  months to see the maximal effects of the treatments.

During the procedure the Exilis computer-controlled delivery device is guided over the treatment area. One feels a deep heating sensation as the Exilis RF energy is delivered to the deeper layers of the skin. The therapy causes the collagen support tissues to remodel and tighten. The applicator provides cooling to the skin’s surface as the energy is delivered, keeping one comfortable during the treatment. Many patients report the treatment similar to a ‘hot stone massage’. Exilis therapy is performed in the office and takes from 15-30 minutes depending upon the size of the treated area.

The highlights of this new Exilis therapy is NO downtime and NO pain, NO anesthesia, NO numbing creams and NO after care, reasonably quick treatment sessions, progressive results that last, able to treat all areas of the face and body and is scientifically proven and FDA-approved.

Exilis offers a revolutionary non-invasive form of treatment for the reduction of wrinkles and for the reshaping of unwanted fat deposits. Exilis also provides a method of after surgery smoothing and skin tightening from invasive liposuction procedures. Exilis treatments can postpone or eliminate the need for invasive surgery particularly for patients with mild to moderate fat deposits and who may not want liposuction surgery. As the only provider of Exilis therapy in Indianapolis and the state of Indiana, I am very excited to offer my patients a real alternative to fat reduction and skin tightening surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard that some breast augmentations have resulted in a decrease in feeling or sensation in the breast, especially the nipple area. Is it true that a breast lift can be done in a way that will not result in the loss of feeling?

A: While the potential for loss of some or all of nipple sensation can occur with any breast operation, that risk differs based on what type of breast surgery is being done. Breast augmentations and breast lifts are both procedures done to enhance the look of the breasts. But they are completely different operations and should not be confused in their potential effect on nipple sensation. Breast augmentation involves the placing of any implant in a pocket either on top of or under the chest muscle. It is in essence an ‘internal’ breast procedure whose pocket dissection may place at risk nerves that are making their way to the nipple from the chest wall through the breast tissues. Breast lifts are done by removing skin, lifting the breast tissue which contains the attached nipple upwards and tightening the remaining skin around the elevated breast mound. It is thus largely an ‘external’ breast procedure and does not usually involve dissection near the nerves that supply sensation to the nipple. These differences make the risk of decreased nipple sensation greater in breast augmentation than in breast lifts. Often implants and lifts are combined which pose the greatest risk to nipple sensation.

There are different types of breast lifts and some have virtually no risk of changing one’s nipple sensation. These are the first three types of breast lifts (superior crescent, periareolar and vertical) which do not involve dissection around the base of the breast mound.

Dr. Barry Eppley

Indianapolis, Indiana