Your Questions

Q: Dr. Eppley, I am a 32 year old African-American female who is in need of a serious tummy tuck. I have had three children, the last two by c-section. I have a large amount of lower stomach skin with a lot of stretch marks. It makes my belly button look odd and almost buried with the loose skin around it. If I get a tummy tuck will they be able use my c-section scar? I need a tummy tuck so bad that if I had to have a new scar above the c-section scar I could live with it. But I would like if possible to keep it low and just have a longer c-section scar.

A: This is a common question and concern and one I think about when doing a tummy tuck in every women that has a c-section scar. I always want to use the c-section scar whenever possible for two reasons. The first is the one which concerns you and that of the unsavory cosmetic issue of adding another scar to the one you already have. But a more important consideration, and the one that I am most concerned with, is the survival of the skin between the two scars if the c-section scar could not be used as part of the tummy tuck. The intervening skin between these two scars may not have a good blood supply and could either not heal well or actually die…which would obviously create a significant after surgery complication. For this reason every effort is made to use a c-section scar in a tummy tuck and if you have as much loose skin as you describe this would not be a problem to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am hoping to reduce the size of my bulging head and brow bone to get an even and a more natural look. Please take a look at my pictures and tell me what you think.

A: There is no question that you have a significant forehead bulge or protrusion. In looking carefully at your pictures you can see a narrowing behind the forehead bulge running down the sides of the skull exactly where the coronal sutures would be. This suggests the reason for your forehead bulging is some variant of coronal craniosynostosis, probably a partial craniosynostosis deformity. Whatever the reason does not change how you might approach forehead reduction. While the most effective procedure would be removal and reshaping of the entire forehead bone flap and the skull bones behind it, this type of craniofacial surgery can only be done in infants and not adults. This is due to the inability to mold bone in an adult skull. Therefore, the only option as an adult is whether external bone reduction by burring would make a significant difference. That question can be answered by plain lateral skull x-rays. This x-ray would allow a measurement to be made as to the thickness of the forehead bone and, more specifically, the thickness of the outer cranial table and underlying diploic space. If up to 5 to 7mms of forehead bone can be reduced over the entire forehead, this may make enough of a difference to justify this approach to forehead reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several keloid scars that need to be treated. I had a submental tuckup procedure done and at the same time had a mole on my chest removed. My submental tuckup procedure was done in an unconventional fashion as it included removing neck skin vertically and not just horizontally under the chin. I now have a wide and raised keloid scar on the vertical scar in the neck as well as the one on my chest. I have done some research and have read about the use of steroids with scar revision. Do you think this combined approach will work for me? I have attached some pictures of the scars in question.

A: In looking at your pictures what you have on your chest and neck are not keloids. Those are known as hypertrophic scars which are quite different biologically from a keloid which is a true pathologic derangement of scar formation. Hypertrophic scars often result in very predictable areas, such as the chest and vertically in the neck, due to the tension that is placed on the scar line. Treatment of hypertrophic scars is excision and reclosure, not steroids. Steroids will likely result in a recurrently wide but depressed scar as it interferes with collagen formation and wound healing. Steroids should only be used in true keloids that are recurrent and not hypertrophic scars. The location of your two scars in question places them in jeopardy for hypertrophic scar formation, even with scar revision consisting of repeat excision and closure. But this is still a worthwhile effort to do and improvement in the appearance of the scars is likely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting some information on breast augmentation, particularly about the costs involved. Also if a lift is needed does that effect the cost and by how much? Thanks.

A:  The cost of breast augmentation is fairly standard and only differs by whether one uses a saline ($4700) or silicone implant ($5800), all costs included. If a lift is needed, there are additional costs. What those costs would be would depend on what type of breast lift is needed. There are four different types of breast lifts that differ based on how much and where the scars are located, the amount of the lifting effect that is created and the time it takes to do it. The complexities of the need for a breast lift and what type is best can only be determined by an actual physical examination and discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get breast implants but I am concerned about them since I work out a lot. Am I at increased risks for problems if I run a lot and lift weights? Also should I have them placed above or below the muscle?  I don’t want them to look and move unnaturally. I also don’t want them to be too big so what size do you think I should get? Thanks!

A:  The debate about whether one should have their breast implants above or below the muscle is largely an historic one for most women. The benefits of being under the muscle, or a dual-plane approach, are significantly superior in the long-term. This would be particularly true in an athletic woman who often has little breast tissue to interface between the skin and the implant. Breast implants placed partially under the muscle tend to have fewer problems with visible rippling, long-term encapsulation, and interference with mammograms.  These advantages outweigh the potential for implant movement that can occur with pectoralis muscle flexion.

When it comes to implant size, this consideration would be of particularly significant in an athletic woman. You don’t want the implant size to interfere with any exercise activity. This basically refers to getting the implants too far to the side so it gets in the way of any arm swing. The best way to avoid this potential problem is to not get an implant whose base diameter is bigger than one’s own natural breast base diameter. This simple linear measurement will always avoid having a breast implant that looks too big as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need some type of implant to correct my severe case of temporal hollowing. I have looked at some of the available temporal implants that are available but they don’t seem thick enough to me. What type of temporal implants do you use? Do you use the silicone ones or the Medpor ones? What is the most thickness that I can get in a temporal implant?

A: Silicone temporal implants are but one type that I use. The largest commercially available temporal implant, in terms of thickness, is the silicone temporal implant. The largest silicone temporal implants measure 6cms x 4cms with 10mm thickness at one end. That would be more than adequate for the vast majority of patients. It can be quite surprising how ‘small’ an implant may look when holding it your hand and then how much change it actually makes when put in place. I have been surprised many times and have learned with many forms of facial implants that changes can be much more dramatic in place than one thinks, no matter who well one has measured and thought about the defect beforehand.

If one really needs a thicker temporal implant, it can be made through a custom fabrication process. But it is important to remember that subfascial temporal implants can only be so thick or they will be very difficult to fit into the tight space. Much thicker temporal implants need to be placed in a submuscular location which requires a more extensive scalp incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very severe case of dark circles under my eyes. I am 30 years old and am of Indian ethnicity. I know this is a common problem in people of my heritage. I have tried numerous topical crèmes for dark circles but none of them have done anything. I am sending you some pictures for your assessment. Do you think there is anything you can do to help me?

 A: Thank you for sending all of your pictures. There is no question that you have is a fairly severe case of dark circles. Much of it is actual skin hyperpigmentation rather than a hollowing effect.  And the zone of skin hyperpigmentation extends fairly far outward from the eyelid area. I don’t think on seeing this extensive collection of photos that you have a really significant tear trough or hollowing problem. There is some mild hollowing but that is not the true cause of the problem, the hyperpigmentation of the skin is.

I don’t know how much improvement can actually be obtain in such a severe case  of dark circles but some effort is certainly justified given the magnitude of the problem. I would approach your dark circles with a combination procedure of fat injections to fill out some mild hollowing, a pinch lower blepharoplasty to remove some excess skin (you do have some despite your young age) and a 25% TCA peel to try and remove some of the superficial hyperpigmentation. 

How effective this combined approach would be is undetermined and I would never assume it to be a complete cure or solution…as there is no such thing with such severe dark circles. The goal is to see what degree of improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been working out for about three months now, and the first thing that always goes first are my breasts. I am currently a 34B, and I would like to be one cup size bigger. I looked at your before and after photos, and they look very good. I know I want them, but the cost is a big factor. Would I have to schedule a consultation with you in order to know how much it would cost? Thanks so much.

 A: Your description of the desire for breast augmentation is a common one. Whether it be from weight loss, exercise or pregnancy, breast tissue shrinkage or involution is one of the most common reasons for why women want breast implants. Their desire is to either return to a breast size that they once had or just get some more volume to fill out deflated and saggy breast skin. When it comes to determining cost of breast augmentation, an actual consultation is not necessary. The pricing of breast augmentation is one procedure in most plastic surgery practices which is fairly ‘standard’ and usually published. In my practice it would be around $4700 for saline breast augmentation and $5800 for silicone breast augmentation, all costs included. This pricing assumes that no other procedures are required such as any form of a breast lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are the various mini- or limited types of facelifts effective and how long will it last?

A: The numerous type of franchised forms of quick recovery facial tuck-ups are well known versions of limited facelifts or a jowl tuck-up procedures. There is nothing magical or unique about this operation or approach. It is a scaled down version of a more complete facelift or a neck-jowl lift. It can be very effective if done well and will get years of sustained improvement which will vary by a patient’s skin type and genetics. It could be anywhere from 5 to 10 years depending upon where one starts and how well one ages. The more relevant question, however, is whether this type of facelift approach is right for you. The vast majority of unhappiness with these franchised named ‘mini-facelift’ is that the patient wasn’t a good candidate. Their facial aging issues were more advanced and they should have had a fuller facelift to get the kind of result that they were expecting. Patients understandably are tempted to choose a facelift operation based on how it would be done (local or IV sedation), a short recovery and/or a low cost rather than choosing a facelift operation that better fits their actual needs. This is the real issue you should be thinking about.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I been looking for a expert on lip reduction for a very long time. About five years ago I had silicone injected into my upper lip and I have regreted it everyday since,  its ruining my life. I would really appreciate it if you could just give me a honest answer as to what be done about it. I want my four front teeth to show again and make the upper lip smaller than my bottom lip. I have attached some pictures of my lip including what it looks like underneath.

 A: Based on your pictures I can see that there are many bumps on the underside of your upper lip on the mucosal surface. This would likely be the location of much of the silicone material, either being pooled collections of the oil or silicone granulomas. While it is probably impossible to ever completely get rid of all of the injected silicone material, the good news is that much of it appears to lie in the tissue zone of excision where an upper lip reduction would be performed. A lip reduction typically removes mucosa from the inside of the lip from the junction at the wet-dry vermilion. This allows the upper lip to roll in and become vertically shortened. Where this tissue is removed is also where most of your bumps are so you would get a dual benefit of a less full upper lip and some of the silicone material removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How could I get any lifts or tucks via my insurance which is Medicare. I know alot of it would be seen as cosmetic. However,  I can assure you  that all I want is to look normal and able to wear real clothes and not tents. I’m 45 and need my life back.

 A: While all plastic surgeons are emphatic to your plight, the reality is that Medicare will simply not provide coverage for any type of so-called ‘lift or tuck’ procedures such as tummy tucks, pubic lifts and thigh lifts. Medicare is unique amongst insurances in that it will provide no predetermination before surgery to validate whether it will or will not pay for such procedures. Having provided a lot of these services in the past only to learn later that Medicare will not pay, many plastic surgeons will no longer  perform such procedures for Medicare patients. They are viewed as cosmetic procedures to be done as a fee-for-service basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck last year but it did not fully correct my sagging mons. I would like now to have that fixed as well. Where are the incisions for a monsplasty placed? Can they be placed in the groin crease to avoid a visible scar? I don’t want any more scars than the long tummy tuck one that I have now. Is it better to have a monsplasty lift or monsplasty by liposuction?

A: With significant amounts of pubic sagging or fullness, a tummy tuck may not ideally reshape the mons area. If recognized before surgery, modifications can be made in the tummy tuck incisional design or through the combined use of liposuction to get a good mons correction as well. When done secondarily, a direct mons lift is done using the central part of the tummy tuck scar so no new incisional locations are needed. Ususlly liposuction is done with a mons lift in most cases as the combination approach produces the greatest amount pubic reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 36 yrs old , weigh 132 lbs and work out three to four times a week. Despite these good numbers, I have big saddlebags that definitely don’t fit the rest of my body. I have had them my entire life ever since I was a teen. They make my bottom half completely mismatched to my small and toned upper half. I have read that after liposuction fat can reappear and in different places. I would not want to ruin my upper half at the expense of improvement in my lower half. Is this something that I should be concerned with?

A: Liposuction of your saddlebags will provide great improvement and patients like yourself are exactly what liposuction was designed for and is best at…spot fat removal. There are many fallacies and inaccuracies about what happens  to fat after liposuction. When it comes to potential future weight gain, the saddlebags unlike the stomach and waistline is not an area that fat will reaccumulate. It is not a metabolic depository site for extra calories. But other body areas are and it is certainly possible that fat can appear in other body areas with weight gain. The concept that you are really referring to is known as ‘fat equilibrium’, the  belief that everyone has a certain amount of fat that they are genetically predisposed to have. And by removing one area of fat, the body in an effort to maintain a fat balance will just have it accumulate elsewhere. This fat concept, while often talked about as if fact, has never been scientifically proven. A recent small study in plastic surgery did show that abdominal and thigh liposuction patients one year after surgery did have some measurable increase in thickness in the arms and upper back. But it was not something that the patients noticed. I would not be concerned that your saddlebag liposuction by Smartlipo will change your upper body shape to any noticeable degree if at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very weak jawline and some fullness to my cheeks and face. My face is sort of round and not very distinct. I went to one plastic surgeon and he said that a chin implant would change  my facial shape. But I have read that many chin implants also have liposuction under the chin as well. This seems to make sense to me but I still don’t see how that will improve my chubby cheeks. What would be your recommendations? I have attached some pictures of me from the side.

 A: I think there is no question that you have a short chin and a rounder fuller face. A chin implant will definitely over good improvement of your profile. But to really ‘deround’ a fuller face it is going to take other adjustments. These would include some fat removal as well. Liposuction under the chin would also be a definite plus and, with the chin implant, can dramatically change the jawline. But the cheek area needs thinning by a partial buccal lipectomy with perioral liposuction. Buccal fat removal only affects the upper cheek area below the cheek bone. Perioral liposuction is needed to remove fat from the lower cheek area at the level of the corners of the mouth. The combination of chin augmentation and fat removal from the neck and cheeks can very effectively make a round face have a much more defined shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline breast augmentation in 2005. Over the past year or so they see, to have gotten smaller. I know they are not broken or deflated but they definitely don’t seem to be as big or firm as they initially were. Is there a way to make the, bigger without having to pay for new implants? My original ones were put in through the armpit.

A: There are two reasons why many women find that their breast implants seem to be smaller years later. The first is a psychological one, the novelty over times passes and they just seem to be smaller. This is what I call cosmetic accommodation and it happens with many cosmetic procedures. The second is a real physical one. The breast tissue between the implant and the skin may actually become thinner due to pressure resorption over time. When combined with natural skin relaxation, there can be a definite looser and smaller feel to the breasts in some women. This is also why in saline implants there may be the feel of implant rippling over time.

A more firm feel and slightly larger implant size can be obtained in saline implants without having to replace them. More saline can be added to them through a very simple procedure of reattaching a filler tube. This can not be done through the old armpit scars, however, and requires a nipple incision for direct access to the fill valve area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I just had a quick question regarding the forehead lowering procedure. I want to get my forehead lowered however I have a “Y” shaped vein that runs right down the middle of my forehead. Is it still safe to perform the surgery with this and have you ever personally encountered this? 

 A: Many people have prominent veins in their forehead that undergo browlift and hairline type procedures. Because the veins are in the subcutaneous level of the forehead tissues, they are out of the plane of dissection which is at the deeper subperiosteal level. So they do not pose any ‘risk’ for a hairline lowering/forehead reduction surgery. If the vein(s) crosses into or from the frontal hairline, it will be tied off or cauterized in a hairline advancement as it will be encountered in the dissection from the skin down to the bone. Either way, veins are not an issue in any type of forehead surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a 50 year-old female. I am bothered by sagging jowls. What are the various procedures and how much do they cost ?

A: There are a variety of options available for sagging jaws from non-surgical (Exilis radiofrequency) to different types of jowl lifts. Which one is best depends on how much jowl sagging one has. While I don’t know what you look like, it is more likely than not that you probably need some form of a jowl-neck lift (which is really known as a facelift) based on your age/ Whether this is a more limited variety or a fuller neck-jowl lift (facelift) again depends on how much jowl sagging you have. If you could send me some pictures, I can answer that question based on this visual information only. Once we know that then accurate surgical costs can be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a combined rhinoplasty and sinus surgery nearly three years ago. The rhinoplasty result turned out to not be so good as the middle part of my nose was too pinched inward. I then underwent a revision about a year ago where cartilage was taken from ear to build up the middle part of my nose. I am still left with one problem that has not been corrected. I have a hanging columella with a slight outward rotation of the cartilage. Is it repairable? What is the cost and since my previous surgery was covered by insurance would the revision be as well?

 A: A hanging columella deformity can occur for two reasons. The underlying caudal end of the septal cartilage may have been adequately reduced or overresected, leaving excess mucosa and skin ‘hanging’ off the cartilage. This usually leaves an outward curve of soft tissue from below the tip down to the base of the nose. The other type of hanging columella, which is not a true columella deformity but may initially appear so, is when the infratip lobular cartilage is too prominent and pushes outward on the columellar skin. This creates more of a ‘hard’ hanging columella because it is composed of cartilage.

Either way, both types of hanging columellas can be corrected fairly easily a minor revisional rhinoplasty procedure.. This type of nasal problem would not be covered by insurance as it is a cosmetic problem, regardless if the original nose procedure was covered by insurance. The cost would be influenced as to whether it is done in the office under local anesthesia or in the operating room under some form of anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 74 years old and am really beginning to show my age. I really hate the loose skin on my face and my neck wattle. I have read about a facelift procedure that sounds almost too good to be true.. I like that it is done under local anesthesia and there is little recovery. Do you think that it would be a good choice for me? I have attached some pictures of what I looked like last year at our family Christmas party.

A: These marketed and franchised forms of facial rejuvenation are simply scaled down versions of a facelift.  This is typically a “mini” lift of the jowls (primarily) and the neck (secondarily and more limited) that is sometimes performed in the office with no general anesthesia. Understandably this makes it very appealing to some people. But just because it is appealing does not mean it is a good choice for everyone. Whether it can meet your expectations and is worth the cost is a key question for every patient who undergoes limited types of plastic surgery. This is particularly true when trying to improve the degree of facial aging that exists in someone 74 years of age.

You do have a significant amount of loose skin and the very presence of a neck wattle illustrates your degree of facial aging. On the one hand, these mini-facelifts will not produce an ideal result. So if your goal is a smooth and completely uplifted neck and jowl line, you will be disappointed. If, however, you can accept that some improvement is better than none then it may be a reasonable choice.

Rather than getting hung up on a marketed facial procedure, you would be likely better served to consult with a number of plastic surgeons and get a customized approach to your facelift needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have 38 DD breasts which sit on my stomach with the nipples pointing downward. I want them lifted back up but am afraid of the scars of a breast lift. I have seen some pictures and videos of the surgery and, quite frankly, it scares the hell out of me. I don’t want ugly scars on my breasts. What type of breast lift is available that does not leave any scars?

 A: Breast lift surgery is about moving the nipples up to a more central position on the breast mound and reshaping the breast mound so that it sits back upon the chest wall. This is done by a geometric rearrangement of the breast skin that involves a fair amount of breast skin removal. This where the typical inverted-T or anchor scar pattern comes from in a full breast lift procedure. While there are several more limited breast lift operations that involve less scarring, the amount of lifting and breast shape and position change is also a lot less. In short, there is no type of breast lift that does not involve scars. With the amount of breast sagging that you have, only a full breast lift will do any good. If the scars you have seen from breast lift surgery look worse than the sagging that you now have, then such surgery is not a good choice for you. Satisfaction after breast lift surgery is about feeling that the scars, undesireable that they may be, are a better problem than sagging unscarred breasts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, While I think I am aging fairly well at 48 I am bothered by my jowls that I have developed. My neck is just a bit saggy as well but not too bad. I am not ready nor do I think I need a facelift but a little tuck might be good. I saw a doctor on TV advertising some type of quick facelift procedure. It sounds like it might be good for me but I am leery as it sounds too easy. Is this type of facial tuck-up procedure legitimate and is it really like what is advertised?

A: Facelift surgery is done in variety of operations based on how severe the facial aging is on each patient. Since the average age of a patient seeking a ‘facelift’ has gotten younger over the past two decades, many people now appear with early signs of aging such as jowling and  a little neck sag. These signs of facial aging can be treated by a smaller type of facelift, generally known as a limited or mini-facelift. The improvement is a smoother jawline and neck.

There is nothing unique or novel about this type of facelift and it is an operation that has been around since facelift surgery began. What is new is that the ‘limited facelift’ has become packaged and marketed by different companies. These types of facelifts essentially are forms of franchises that are sold or licensed to doctors to sell this scaled down form of a facelift. There is absolutely nothing wrong with the operations that are advertised. What you have to be careful about is who is really performing them, are they a good choice for you based on your amount of facial aging, and is it done under safe and comfortable environments. While these companies advertise and stress the rapid recoveries after these small facelifts, which can be true, it is still surgery and has all the risks that go with it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I  have a problem with one of my ears. My right ear at the top part that is supposed to curve inwards… doesn’t. It’s like it’s sort of unraveled and basically it looks like I have one ear that protrudes. i am not sure if I want to have a surgery done. Is there another way to fix it because it really effects my self-esteem. I can’t wear my hair the way I want as people will notice it straight away. Please help me.

A: Your description sounds like a common protruding ear problem. It is not rare that it may only affect one ear. The ear is indeed unraveled so to speak as the antihelical fold is either weak or absent in that ear. This makes the ear stick out rather than being folded back with a more natural shape. It can easily be corrected through a simple otoplasty procedure with the placement of one two horizontal mattress sutures from behind the ear. This is the only way to correct this ear problem as there is no non-surgical method that can reshape the ear cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in building up the back of my head.  It slopes backward and is flat and makes my head look asymmetric and unbalanced. I have attached pictures so you can see that the back of my head slopes downwards in an abrupt manner. By adding a round and nice piece my head would maybe look normal and my ears would even look smaller. But I have a few questions:

1. So what would be the next step for me?
   2. Seen from the pictures, do you assess that significant scalp stretch is required?
   3. What if I’m active in sports and wrestle alot ie, is there a risk of misshape in the future?
   4. What method do you feel is the most adequate for my head?
   5. Would hair transplantation be necessary?
   6. What is the recovery time?
   7. What are the approximate costs?

I am aware that there may be scalp scars but that’s less severe than the current situation.

A: In answer to your questions:

1) The next step is to have either a phone or Skype consultation. This would be the best way to go over the different cranioplasty methods and their advantages and disadvantages. No cranioplasty method is perfect and each patient make make their choice based on good information. I have done occipital cranial augmentation by every conceivable method so I am very familiar with each of them and their indivdual pluses and minuses.

2) Stretch of the scalp is always needed because the material occupies space. The question is how much stretch can the scalp safely do. That is what limits how much material/augmentation can be achieved. 

3) All cranioplasty materials set up and become solid like bone so no deformation will occur later with impact or trauma.

4) The best method for you require your understanding of each approach.

5) I do not envision hair transplantation being needed for the scar later. 

6) The recovery is quite quick, being just a few days.

7) The cost will depend on the technique used, which is yet to be determined. The costs could range from $6500 to $9500 depending upon what cranioplasty material is used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to have corrective jaw surgery for my long face.  I don’t have an under/overbite but I do have longer face which I would like to be shortened. What are the options  available for doing this? I have attached a picture for your assessment.

A: There are two fundamental approaches to aesthetically shortening the long face. The first is a vertical chin reduction osteotomy in which only the chin length is reduced. (shortening of the lower third of the face) I have attached an imaging picture of what that may look like on you. This would be the simplest technique but it only deals with one area of vertical excess, the chin. A true long face is most people involves the entire face. The second approach, which is usually combined with vertical chin reduction, is a maxillary impaction or shortening. This requires that the patient has a vertical maxillary excess to start with as reflected in having a lot of tooth exposure and/or a gummy smile and lip incompetence. This shortens the middle part of the face which when combined with vertical chin reduction gives the maximal shortening effect. This is a more extensive approach requiring a LeFort I osteotomy and, again, requires that the patient have vertical maxillary excess. Your pictures suggests that you have that to some degree based on your tooth show/lip incompetence at rest. This is a harder area to image given that it is in the middle part of the face.

Which approach is best for any patient depends on how much vertical shortening they need and what one is prepared to got through to get what degree of shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my buccal fat pads removed nearly fifteen years  ago at age 31 for some facial sculpting. Now that I am older, I look completely different. My face is very flat and not as attractive. What can I do to look like before? What are my choices for making my face now a little fuller?

A: As you have aged, your face likely has lost overall fat and the prior removal of the buccal fat pads has only accentuated this natural fat involution process. There are several options available to consider for facial volume restoration. The first approach is fat injections which focuses on replacing like with like. The only question is how much fat will survive after transplantation. This is an overall facial volume approach. The next approach is focal or spot treatment, just adding volume to the buccal or submalar area. This could dbe done with either submalar cheek implants or injectable fillers. The real value of injectable fillers in your case, in my opinion, is to be an initial test to determine if augmentation of this area is what you are looking for. It serves as a test to determine if more formal augmentation (implant) is worthwhile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck done two months ago and am unhappy with the results. While the front part of my tummy is flat like I wanted, the sides stick out. It now appears that liposuction of my hips should have been done with the initial tummy tuck. My doctor said that I didn’t need liposuction at the time of the surgery. Will it help now and can it be done in the office under local anesthesia?

A: When evaluating someone for a tummy tuck, I always look carefully at the fullness in the flanks and at the sides of the waistline…areas that lie outside of the zone of excision of the tummy tuck. As these areas will not be improved by what happens in front of them. It is actually uncommon in my experience that most tummy tucks would not benefit from liposuction of these areas at the same time. Once the tummy area gets very flat, these ‘muffin tops’ can appear. They actually were there all along but have now become ‘bigger’ because the front area is much flatter. That is a matter of a change in perspective. Flank liposuction can be done in the office, and many doctors do perform it that way, but it is not a a preferred choice of mine. You have to be very aggressive in the flanks to get a substantial result and having an awake patient often makes that difficult.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast implants six months ago. I initially was a small A cup and became a full B cup after surgery. While I am happy with the size and shape of the right breast, the left breast is not even close to the same and is very uneven. It is smaller and hangs lower. My doctor said my breasts were different from the start and this is why they look uneven now. I want a revision to make them look more even but fear that this might happen again since no one seems to know why this happened in the first place. I have attached some pictures for your review. Can you tell me why they look so different?

A: While identically-sized and shaped breast implants are twins, that doesn’t always mean the result will be perfectly symmetric and have twin breasts also. What breast implants really do is take what someone already has and makes it bigger. If there are significant differences between the two breasts initially, those differences may become greater afterwards. Asymmetry of breast implants is one of the most common reasons for revisional surgery in breast augmentation. In looking at your pictures, however, that does not appear to be the case. You left breast implant has bottomed out and sits much lower than the right one. This can be significantly improved by breast implant repositioning and tightening of the lower pole of the surrounding capsule. Your breast asymmetry appears to be surgically induced and not a naturally-occurring one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my cheeks are very low and I would like them to be higher. When I pull upwards on them, my face looks better. That also helps soften the lines around my mouth. Will cheek implants create this effect or so I need some form of a facelift to get that look?

A:The question you are asking is an important one because there are clear differences between what cheek implants and a cheek lift achieve. Cheek implants are about creating a bony highlight for improved facial contours purposes. While there may be some cheek lifting effect, it will be relatively minor and one should not think of cheek implants as a soft tissue lifting method. (even though it can complement cheek or midface lifting surgery) A cheek lift is about lifting and resuspending sagging soft tissues that have fallen off of the cheek bone. This does create an effect sometimes similar to a cheek implant but it is more similar to what most patients thinik that a ‘facelift’ does in that area. This will help soften the nasolabial folds because it is pulling upward the soft tissues that lie above it. Based on your description, I suspect you would benefit more by a cheek lift than cheek implants. Whether that is a worthwhile surgery for you depends on numerous factors including your age, your cheek bone and lower eyelid anatomy and how much malar soft tissue ptosis you have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I work out almost every day during the week and am very adamant about a healthy diet. But despite these efforts, I have the same stubborn fat areas that will not go away. I am 5’ 4” and weight 118 lbs so I know I am at a very good weight, so more weight loss and conditioning is not the answer. My problem areas are my saddle bags on the outer thighs, my upper arms and my chubby cheeks. As a result, I have been considering liposuction for awhile. My question is can all three areas under liposuction at the same time? Or is this too much?

A: What you have is a common problem, some fat areas that are not really responsive to reasonable amounts of diet, exercise and weight loss. And these are some of the classic body areas in which the fat that is there is not that ‘metabolically responsive’. That is because it is a different kind of fat and its primary purpose for being there is not as a fat depot site. It is more of an insulating or contouring fat role. In essence, you are trying to modify the way your body was built not get rid of accumulated fat from too much storage. That is a surgical problem not a lifestyle one. Those are all areas that can be treated with liposuction as a single procedure. It is very common to treat numerous body areas with liposuction at the same time. And as long as the total volume of fat removed does not exceed 5 liters or take more than few hours to do, you are well within what would be considered  the safety zone for liposuction. Be aware that the cheeks may be bettered treated by direct lipectomies from inside the mouth rather than liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley  I´m a 34 year old healthy man interested in enhancing my poor defined jaw line. Have read some awesome reviews of your work and feel really drawn to having this aesthetic implant procedure performed by you. It would be easier and less expensive to go to another country but I really feel you should be the one to treat my case. I would like to know the average cost and the downtime it will require.  I´ll be more than greatful for any info you can provide me with.

A:  The most important decision in regards to jawline enhancement with implants is whether stock preformed  or custom implants would be most beneficial. I can make that determination by looking at some picture of your face from different angles. The critical determinants of whether custom jaw implants are needed  are the size of augmentation that a patient desires, whether there is any significant vertical increase needed in the jaw angle (and the chin) and whether a smooth continuity of the jawline from the chin back to the jaw angles is desired. Until that determination is made, it is not possible to give an accurate cost quote. But as  general guideline, off-the-shelf chin and jaw angle implant surgery is around $8500 while custom chin and jaw angle surgery will be nearly double that cost. Either way, recovery is the same which is largely about facial swelling which takes about three weeks to go down and look normal again.

Dr. Barry Eppley

Indianapolis, Indiana