Your Questions

Q: Dr. Eppley, I am 29 and I had received 8 laser sessions under eyes for dark circles in which 2 were on full face. The skin subsequently turned saggy and became fatless under eyes and temple area. I waited 9 months but the skin did not improve. In fact, it became worse with time. I gone through two sessions of fat grafting now in the last six months, of which the last one was two months ago. My skin quality improved somewhat. In my case, little fat actually stayed and most of the grafted fat got reabsorbed. I have learnt with time I have to go through one or two more sessions to get better skin. Each time I was given about 10 to 15cc of fat under and near eye area. I did gentle massage after fat grafting to avoid lumps. But I now know that I will need a total of three or more grafting sessions to get a satisfactory result.

A: This is not the first time I have been told of someone receiving IPL (not laser) treatments with a large number of treatment sessions who subsequently had fat atrophy over the treated areas. The only restorative therapy for this facial fat loss problem is fat grafting as it provides autologous tissue and cells. But your story also shows that fat grafting is far from a perfect treatment as it can have very unpredictable survival. One has to be prepared to undergo multiple fat grafting sessions if needed, spaced about three or six months apart depending upon the response seen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting silicone oil injections in my buttocks and hips. I want 1400 to 1600cc. I’m not sure which one yet though, but I would love if you gave me an estimate on pricing so I can be aware of how much money I would actually need. This would be my first time getting the injections. With that being said I need to know the pros and cons of the injections.  I know some doctors won’t use silicone so, if not, can Artefill be injected in the buttocks instead?

A: I do not do silicone oil injections for buttock augmentation. They are not only illegal from an FDA regulatory standpoint but are unsafe as well for large volume augmentation. Silicone oil and may other injected substances in the buttocks have clearly been shown to cause a lot of potential problems from foreign-body reactions, hardening and infections.

Although Artefill is an FDA-approved material for facial injection, its use in the buttocks would be off-label and ill-advised. Aside from the unknown tissue reactions that may occur from a large volume injectate in an unstudied tissue site, it is economically impractical. At $800/1cc syringe, you can quickly see that using 1400cc to 1600cc would cost over $1,000,000 just for the material alone.

The only safe and large volume material that can be injected into the buttocks is your own fat. While how well fat survives after being injected is variable, it has the advantage of being the most economical method of natural non-implant buttock augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation using silicone gel implants one month ago. The implants were placed through an incision underneath. Ever since surgery, my left has an indentation about halfway up from the bottom. It is an actual deep crease and it looks like two bulges. The other breast is perfectly smooth. My surgeon said it should go away and, if not, I will need another surgery to fix it. (ugh!) Can you explain to me why this happened?

A: The ‘double bubble’ problem after breast augmentation is not a rare phenomenon. It is the result of changing or lowering one’s existing inframammary or lower breast fold. This is often necessary to accommodate the size of a breast implant and to prevent too high of an implant position, resulting in excessive upper breast pole fullness.

What many women do not realize is that much of the work or volume addition that a breast implant does involves expansion of the lower pole and sides of the breast. While every breast is different, about 1/2 to 2/3s of breast size increase involves these breast areas. These means that the breast base size in a vertical dimension must change. When the breast is smaller, the inframammary fold or crease is higher because the existing volume only needs a certain amount of skin between the nipple and the fold to accommodate it. When an implant is added that dramatically changes the volume, not all is just needs to be pushed outward. Some of that volume needs to expand the breast mound lower. For this reason, the augmented breast may require dropping the position of that fold.

Because the inframammary fold has been in its present position for years, the skin has an indentation or crease in its basic structure. When the fold is lowered to accommodate an implant, that crease can take some time to relax and go away. In many cases it will but in others it will not…thus creating the double bubble problem. This is why plastic surgeons do not like to drop the lower breast fold unless they absolutely have no choice but to do so.

If the double bubble problem fails to resolve itself by three months to six months after surgery, then it will require a surgical procedure for correction. This involves tacking back down the fold into its original position and raising the implant slightly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am investigating the possibility of narrowing my wide chin. I am 55 years old and have noticed the characteristic age-related lower face widening as a result of the increasing tissue laxity. While I am planning a facelift within the next year or so, I think a narrower chin will look nicer, more feminine and less bony once I have the jowls tightened. I have the following questions.

1) Am I a candidate for the submental approach and would this involve just burring down the sides of my chin? (I think my profile is fine and don’t need an implant)
2)  Wait time after chin reduction before a lower facelift could be done. 
3)  Likelihood of complete resolution of any numbness?  And additional risks due to my age?

A: 1) I would have to see pictures to determine your candidacy for the procedure. But usually the submental approach is best due to better access to the bone with a minimal risk of any nerve injury. If side chin reduction is only needed, an ostectomy with a saw for narrowing would be the technique used.

2) If one has to stage it, the chin reduction would be done first with a minimum three month delay before the lower facelift. The two procedures could also be combined.

3) When done from below, the mental nerve is well visualized so permanent injury to it is unlikely. Simple stretching and elevation of the soft tissues off of the bone will likely cause some mild temporary numbness or none at all. Other than the age-independent risk of mental nerve neuropraxia, I can foresee no other significant risks other than achieving the desired chin shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking into a chin reduction for quite a few years now, but I have never gone through with it because I’ve always been afraid that the results would be terrifying. I read through your case studies on chin surgeries, and I must say it’s a relief to see someone with as much experience on the subject of chin surgery. Perhaps other Doctors have just as much experience or more, but it’s relieving to be able to read about it instead of them briefly talking about it. My main reason for wanting a chin reduction is because I feel that I look weird when I smile.The other goal is to ensure that the chin surgery doesn’t make me look like I’ve had surgery. I have attached pictures of me (non-smiling) from different angles for your assessment.

A: Thank you for sending your detailed non-animated facial photos. What they show is one of the more uncommon, but more favorable, types of chin hypertrophy. Your chin is distinctly large in one dimension, a central horizontal projection known as an enlarged central chin button. It is not long vertically nor is it too wide horizontally. The chin excess is relegated completely to the central chin pad. This type of chin excess is usually composed of a combination of bone and excess soft tissue. It can be reduced by a chin reduction procedure consisting of shaving down the bone and reducing the soft tissue excess. It can be done from either an intraoral mucosal or submental skin incisional approach but coming from below allows a better management of the soft tissue excess.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello. I am interested in fraxel CO2 laser surgery for skin resurfacing. I am 48 yrs old and have sun damage, wrinkles and some acne marks. I do not know if I would be a candidate for this procedure. I had a kidney/pancreas transplant almost 22 years ago after being a type I diabetic for 20 years. I am on cyclosporine, prednisone, imuran immunosuppressive medications daily. Please let me know if there are any risks. Thank you.

A: The risks of laser skin resurfacing on someone who is taking immunosuppressive medications is two-fold. First, most long-term immunosuppressed transplant patients develop skin thinning due to dermal atrophy. This can lead to increased depths of penetration (injury) of the laser not seen in immunocompetent patients. Therefore typical laser settings may be too deep in the immunosuppressed patient. There is no way to accurately predict the skin’s response to any depth/power setting of the laser. Secondly, as you know, your healing capabilities are diminished. Since the laser essentially creates a burn injury, the skin must be able to heal the expansive skin wound. In the immunocompromised patient this could be an understandable issue. One can partially overcome the delayed healing effects of steroids with pre-treatment high-dose vitamin A supplements, but that may not be enough to reverse the effects of the other medications.

While all of this sounds very pessimistic, it is fair to say that one has to be cautious about laser resurfacing with your medical history. Fractional laser resurfacing is better than completely ablative laser resurfacing because it only treats a portion or fraction of the skin’s surface, leaving areas of normal skin between the vertical columns of the fractional laser beams. The best way to approach whether you are a good candidate or not is to do a test patch area. Only treat a small area first and see what the healing response is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have poland syndrome, dextrocardia and pectus excavatum. My left side chest is sunken because of pectus excavatum and heart is located on right side because of dextrocardia. I do not have any disabilities in my day to day activities but I’m not happy with the physical appearance of my chest. Also, since I got Poland syndrome the left side of my chest seems to be slightly smaller while compared to the  right side. I had undergone a plastic surgery procedure a few years ago in which my back muscle was transposed to fill the absence of pectoralis muscle but still the shape is not good. After going through your website I felt you could help me to get my left chest same to look more like my right. I have been analyzing various options and I came across the application of kryptonite in filling up the dent due to pectus excavatum so I thought the same procedure can also be used for my case. But still the muscle is absent which may need fat grafting from other parts of the body or adjustment of LD muscle further. Please find attached photos for your kind review. I request you to kindly advise me on your recommendations.

A: I have taken a look at your pictures and what I see is a lack of pectoral/chest volume on the left side and a typical high positioned nipple. I do think you would benefit by volume addition but I would not use bone cement. Besides the fact that Kryptonite is no longer commerically available, it would be very difficult to get it in the right place and have a smooth contour. The chest volume you are missing is much more than a cement can do anyway. I would use a modified pectoral silicone implant as you already have the LD muscle flap coverage for it. It could be inserted through the upper end of your midline abdominal scar. This would add volume without increasing scar burden. In addition, I would do an inferior crescent nipple lift to move it downward. This would not create complete horizontal nipple symmetry with the other side but would be helpful. Usually you can get about a cm. nipple movement. These would be two helpful manuevers to lessen your current degree of chest asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have extreme burn scars on my face as I got burned with boiling oil when I was 2 years old. I am now 26 years old. I had skin grafting surgery back then but after these 23 years still there are scars which really destroys my appealing facial aesthetics. I’ve heard a lot about you. Please respond to my email. I have attached facial pics from different angle for you to see. Thanx.

A: From a burn/skin grafting scar standpoint, I not believe that you can make any significant improvement in their appearance. The old scars/skin grafts would have to be excised and regrafted and the likely outcome with that effort is from guaranteed to be better. With your dark skin pigment, I don’t envision that would be a substantial improvement. I do, however, see numerous other facial issues which can be improved. These include correction of the left lower eyelid retraction with a skin graft and lateral canthoplasty, left eyebrow reconstruction with hair transplants, left temporal/side burn alopecia camouflage with micropigmentation tattooing, and left lower lip retraction correction with release and skin grafting. I think correction of these four areas would be very beneficial with predictable improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get liposuction for my heavy neck and jowls but am afraid of potential nerve injury causing a droopy mouth. I don’t want to run the risk of trading off one problem for another. But I just hate my profile. I want a more defined neck. At age 35, I should still have a younger looking neck with an angle not a full fat one wiithout one. What are the chances of nerve injury and how can it be avoided. If it is injured is it ever permanent?  Thank you

A: Like all surgeries, even relatively simple neck liposuction has risks. The potential nerve damage to which you refer that is in the area of submental and neck liposuction is that of the marginal mandibular branch of the facial nerve. This tiny single branched nerve supplies some movement to the lower lip, primarily being responsible for the depressor anguli oris muscle which creates downward lip movement. It crosses over the lower border of the jaw at the side the chin. It can potentially be traumatized if liposuction is done too far up around the jowl area where the nerve is. It can be avoided by not trying to be too aggressive with treating the jowl area and staying below the border of the jaw, confining the movement of the liposuction cannula to the neck area only. Even if the nerve is traumatized, the blunt cannulas will not cut the nerve but bruise it. This may cause some temporary weakness but almost never permanent paralysis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been researching your site. I am hoping to have breast reduction covered by insurance after the first of the year. I have a doctors appointmentt with my primary doctor next week to hopefully begin the process for this to covered by insurance. My question is that I would also like to have butt augmentation with fat transfer. Is it possible to have both surgeries at the same time?

A: It is possible to have both a breast reduction and buttock augmentation at the same time. From a recovery standpoint, it is really a combined breast reduction and abdominal and flank liposuction since the harvest for the buttock augmentation is from liposuctioned fat. I have done this exact combination of procedures a few times and patients have had no problems. As an aside, your primary care doctor can do little to help you get your breast reduction approved. Such as approval must emanate from a consultation with a plastic surgeon who will write a predetermination letter. Ultimately your insurance company will decide based on your weight, breast size and the amount of anticipated breast tissue removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know your opinion on what results a person can expect to achieve from perioral dermabrasion percentage wise.

A:  I assume that the basis of your question is how to best improve lip lines and creases around the mouth area from aging. There are numerous methods of skin resurfacing around the mouth, historically dermabrasion was used  and today it is different types of lasers. With dermabrasion (not to be confused with the more superficial treatment of microdermabrasion which would be completely ineffective for lip lines) hat answer would depend on the depth of the vertical lip lines one has and how thick the perioral skin is. There is a tricky balance with the aggressiveness of diamond wheel dermabrasion between getting a good result and causing scarring if one goes too deep. There is also risk with dermabrasion of creating irregular skin removal. This is why the use of lasers today, particularly fractional laser resurfacing, is a much more predictable. Consistent depth penentration because it is computer driven by the settings makes it less risky than dermabrasion. Dermabrasion can be a very effective treatment for lip wrinkles but it requires good operater experience and a lot of artistic skill for consistent results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how can I lengthen my short forehead? I know many people want to shorten a long forehead and bring the scalp forward but I can’t find anywhere about doing the reverse of that. My forehead is so low that I think it makes me look unusual and almost simian like. The distance between my eyebrows and hairline is only 4.5 cms.

A: A traditional coronal browlift will lengthen your forehead to some degree but with that increase will be a resultant elevation of the brows as well. The problem is that simple stretching of the skin will not necessarily make for more than 1/2 to 1 cm of forehead lengthening without changing your brow position. There simply is not enough skin to stretch to make an appreciable difference. The most successful treatment of the short forehead is a two-stage approach with a tissue expander placed first followed by a pretrichial browlift approach. This is the most assured method of lengthening the forehead skin and moving the hairline back without adverse brow alteration. This works because the tissue expander is placed in the forehead and creates more forehead skin. The undesired amount of low scalp hair is then removed and replaced by new forehead skin.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a medpor implant 3 years ago. I had a heavy infection 2 weeks after the surgery that cured by antibiotics. I have also had 2 more small infections during last 3 years which all happened in the right side of my implant. Now there is no infection. Finally after a CT the doctors noticed that the right side wing is too big and irritate my mouth tissue in that spot. Now you can see a tiny white spot there that doctors say that is my implant showing off!!! I do not want to remove it. I like the shape and I am totally afraid of removing it and having wait for 6 months to replace it. Is there any possibility of just fixing the right side by surgery and not removing it? I do not have access to my original surgeon who did it and I need to fix it with another doctor. Please help me!

A: You did not say what facial location was implanted. I will assume since you mentioned that it has sides that it is either cheek or jaw angle implants. Given that you are a female I will also assume that these are cheek implants. With both acute and chronic infections of the implant, and perhaps even a large size, the overlying soft tissue coverage of the implant has thinned resulting in implant exposure. Usually when this happens the fate of the current indwelling implant is sealed and the need to remove it likely. You wanting to keep the implants is understandable given your current investment into them. One option is to simply cut back the exposed portion of the implant sufficiently to allow soft tissue closure over it. In so doing you have to realize that healing over the implant is not assured and that the risk of failure with this approach is high. But you have little to lose by so doing other than the operative experience and cost and in some cases it may be successful. If this should fail then you have done all that is possible to salvage the exposed facial implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a man that currently weighs around 320 lbs, am 6’2, and was wondering how much weight I could take safely off via liposuction. I am trying to lose weight and change my life around and I feel like this would give me a big mental boost and push me towards a healthier lifestyle. How much (ballpark estimate) would the full treatment cost? Thank you for your time.

A: While I do not have the advantage of seeing what your body looks like, one important general concept about liposuction is that it is not a weight reduction method. Liposuction is for body contouring of select areas for people who are at or close to a reasonable weight for their height. Patients should have a relatively normal BMI (body mass index) or at the least a non-obese BMI which is anything under 30. With your BMI of 41, you need to consider standard weight reduction  methods through medical approaches of diet, exercise and even supplemental medications. As a man you should also realize that much of your abdominal weight is visceral or intraperitoneal, an area in which liposuction can not treat even if it were attempted.  This is why the large stomach in many men feels hard like a watermelon. That is the fat pushing out the abdominal muscles from underneath, leaving a surprising limited of fat that could be removed between the skin and the muscles which is what liposuction can access.

In addition, you are looking at your weight problem in reverse. You first need to get a healthier lifestyle, lose some weight, and then consider liposuction to clean up any persistent fat areas. This is a strategy that will have longer term benefits and is also more likely to keep the weight off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been reading on your website and found a lot of interesting information. I was looking at pictures for patients, but did not see any that resemble my condition. Do you have any with flat spots that have been filled out in the back of the head? From what I have gathered while reading your site, you can only build out up to 10 cm. I’m just trying to picture how a fix for my condition would look after. My head is normal except for the back and then it has a slope. However, the slope is not uniform. It’s less of degree on one side vs the other. So from the top down there is a slope in the back, but from left to right it is almost like it is angled. Meaning if you looked at me from the back, the right side is not as sloped as the left. In fact, the right side is a little more “normal” I guess. Thanks for your help and information.

A: The most common skull augmentation procedure that I do is an occipital cranioplasty for a flat spot on the back of the head. You are correct in assuming that the buildup would be about 10 to 12mm maximum. Much greater buildup than this may pose problems with incisional scalpclosure or undue tension on the wound which usually lies directly over it. Bony asymmetries are dealt with by a differential application of the material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Have you performed many/any superficial temporal artery procedures, either removals or ligations? I am considering this route to rid myself of the unsightly and anoying pulsation feeling. I am concerned about possible negative effects of tampering with an artery, especially one in the head. Thank you for any help or advice you may offer.

A: Improvement of a large and prominent superficial temporal artery can be successfully done. Patients may desire that the artery be diminished in size due to its appearance or from uncomfortable pulsations in it. Manipulation/ligation of the branches of the superficial temporal artery will have no negative effects on vascularization of the scalp and forehead. Thus I have seen no adverse effects from its manipulation other than some minor scars for entrance to the ligations. Generally, at least two small access incisions are needed, one in the temporal hairline and another in the forehead. The artery must be ligated from different areas since there are multiple backflow points into the artery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my 18 year old son had his ears gauged several years ago to a size of about 2 1/2 inches. I have attached pictures as he is now. I was never for it but what can a parent do. He is now ready to have them fixed. I have Anthem insurance. How much would it cost and do you have payment options?

A: Thank you for sending your son’s picture. I have seen many gauged ears such as your son’s. Such earlobe reconstructions can be done very successfully and a normal sized earlobe, albeit with a fine line scar, canc be achieved as an office procedure done under loca; anesthesia. It would be important that the gauges are removed at least 6 weeks before earlobe reconstruction is done. That will allow the earlobe to shrink somewhat and get a better vascular supply to the remaining rim of earlobe skin for optimal healing after the procedure. These are not procedures covered by insurance since the origin of the problem is a cosmetic alteration not a medical one. The cost range is between $1500 to $2,000 for both earlobe repairs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making my forehead wider. I think it is too narrow for my face. My face has good features and dimensions but starting with my lower forehead it goes up into scalp like a triangle rather than having a forehead width that matches my lower facial width. I think it would look better of my forehead was wider and more prominent. Is this procedure possible and, if so, how is it done and what are the potential complications?

A:  Widening a forehead as you have described means expanding its bony contours. Traditional forehead augmentation is done through a scalp incision to build out the forehead with onlay cranioplasty materials but it usually lies on the bone within the edges of the anterior temporal lines. Building out or widening a forehead behind the temporal lines is problematic as that requires lifting up part of the temporalis muscle, which will can easily be done, but almost always results in muscle atrophy seen months later. This potentially can expose the edges of the built out area (cranioplasty material) if they are not perfectly smooth and may make a once smooth transition between the two become more noticeable. Some may refer to widening the forehead as augmentation of the temporal hollows, although that would not normally be considered part of the forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I have read that you are familiar with using platelet-rich plasma. (PRP) I have an unusual inquiry. In certain countries in Europe, they inject PRP into the nasal lining and sidewalls and turbinates to restore function and regrowth of the lining.  I can send the article and I was wondering if you could do this. They say it adds volume and helps the lining function better from prior surgery.

A:  I have read many ‘unconventional’ uses for PRP, but must admit that I am unfamiliar with its potential use in the nasal linings. As an autologous material, its use there would certainly be safe with no untoward effects. I could not attest, obviously, to its effectiveness for this use and would be happy to review any article that reports on it. Doing the procedure would be no different than any other PRP procedure using a 60cc blood draw from the patient. Centrifugation of the extract is then done to create an approximate 3cc concentrate of platelets.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I’ve lost more than 200 lbs. The extra skin is making it harder every lb I lose for me to get around. How will I know when I need to have surgery to take off the skin?

A:  I would say that after losing 200lbs, almost no matter what weight you started out at, that you have a substantial abdominal pannus that would benefit by being removed. If this weight loss was achieved by bariatric surgery, then you should get the advice of your bariatric surgeon as to when would be a good time for some body contouring surgery. Usually bariatric surgery patients have to be at least one year from their bypass surgery and they have stable and normal laboratory studies. If this weight loss was achieved by dieting alone, then you may be ready at any time with this amount of weight loss. You may be getting to the point where not much further weight loss can be achieved because of having to drag around this large amount of loose skin. It would be important before this surgery that you have laboratory studies that show a good blood count, normal electrolytes and adequate protein levels that would support good healing. 

I would recommend that you get an evaluation by a board-certified plastic surgeon at this point and be evaluated for your readiness for abdominal plastic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  even though I am fairly young (35 years old), I have some bags over my cheeks. These are not lower eyelid bags but cheek bags/puffiness. I tried injectable fillers in the tear trough but that just made me look puffy and did not solve my problem. I have heard about using some external devices to help shrink them and tighten the skin. In talking to several doctors and reading, I am looking at the Exilis device for the treatments. But one doctor is saying the Exilis is the first generation radiofrequency device (RF) and they now use this Ultherapy instead. There is also an  Apollo device whichi is powered by TriPollar technology which is the 3rd generation of RF, allegedly the most advanced RF technology currently in the market. Many clinical studies published on the TriPollar technology demonstrated that it is very effective for wrinkle reduction, skin tightening and body contouring I don’t understand why or what to do. I have set up some consultations with some docs but I am worried. Can you tell me what I should do? 

A:  The world of non-surgical fat reduction and skin tightening devices is very confusing. It is filled with much inaccurate and sometimes deceiving information. Between manufacturer promotions of the devices that they make and doctor’s pushing the devices that they own, it is impossible for any patient to weave their way through this maze of voluminoos and often contradictory information.

What I can tell you with great certainty is that there is no single device out there that has been proven to be superior to any other…no matter what you are told or have read. Many devices may have comparative results but none can claim to be more effective at fat reduction or skin tightening than another one. We know this because no comparative studies have ever been done between the devices that exist nor it is likley any will be done.

I mentioned Exilis only because I am familiar with it and use it in my practice so I know its effects. This is what I would try if you were coming to my practice. This does not mean it is the best device available or that there may be others that worko just as well and perhaps even better. Exilis is not a first generation RF device nor is it similar to ultherapy which uses a different enegy to creates its tissue effects.

I think the conclusion is that some effort using any of the available energy-based devices is what you should try. I would not get hung up on which one. Availability and reasonable costs are the parameters to use on what device to try. The point is that if it does not have any effect, it is not likely any other device will be any better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a significant flat spot on the back of my head. Starts at the area of my crowns and then goes out. It is kind of big in size (12 oz can circumference). It is really a flat spot/slope down. Is there a procedure for fixing this or can material be injected to build up the low area? What options are available to help make an area like this look normal? Thanks in advance for your help.

A:  There is only one basic option for your concern, a procedure known as an occipital cranioplasty. That is a sophisticated medical term meaning to build up the deficient or flat bone area. This is done with a variety of potential cranioplasty materials including PMMA, hydroxyapatite and even custom silicone implants. These materials need to be placed through an 8 to 10cm posterior scalp incision. This is a fairly straightforward procedure that is done as an outpatient surgery. Since the buildup is on the outside of the skull, there are no major medical risks in having it done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a straighter more refined nose and a stronger jawline. This may require a chin augmentation but I am not sure what I really need. I just want to look more refreshed and have a more attractive face. I have attached some pictures for you to see and give me your recommendations.

A:  Thank you for your inquiry and sending your pictures. I have taken a look at them and can give you the following thoughts.

Your chin deficiency is as much a vertical one as it is a horizontal one. This can not be treated by a traditional chin implant as they can only provide increased horizontal projection. Vertical increase is very important in your chin augmentation. Either a custom chin implant needs to be fabricated or a chin osteotomy needs to be done. Either approach can be successful and I have done many both ways. There are advantages and disadvantages to either approach and they can be discussed in detail further by phone or by Skype.

Your nose shows a lack of tip projection and definition. The nasal tip is rounded and more ball-like. I do not see the lack of straightness in your nose that you have indicated in your inquiry. This can be improved by an open rhinoplasty with the use of a columellar strut graft alar rim grafts and tip reshaping. 

I have attached some before and after computer imaging to show the potential changes of the nose and chin based on these approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orthognathic surgery three years ago when my upper jaw was moved forward. While the surgery was successful and my underbite was fixed, I have a persistent problem with my lower lip. My lower lip hangs down and I have too much tooth show. I notice now that when I pull my lower jaw back, the lower lip comes up and corrects the problem. I am now thinking that instead of having my upper jaw brought forward, I should have had my lower jaw moved back. What do you think?

A:  It is hard for me to pass any comment on your previous orthognathic surgery, not having seen any preoperative x-rays or work-up. It can be difficult to determine in a Class III malocclusion (cross-bite) whether the upper jaw should come forward or the lower jaw to go back. Either manuever will correct the malocclusion but they can have different aesthetic outcomes, even if that can be somewhat subtle.

Everyone when they move their jaw backward creates more lower lip and allows it to move upward on the front teeth. So I don’t necessarily think that you doing so proves that a sagittal split setback of the mandible was a better procedure than the LeFort advancement.  

At this point, this discussion is somewhat irrelevant. You can’t undo your jaw relationship without repeating your orthodontics and undergoing further orthognathic surgery…a process that would take years and likely result in some permanent loss of sensation of the lower lip from the mandibular setback.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First of all I would like to appreciate your approach to educate general people like me about plastic, reconstructive and cosmetic procedures. I have a question regarding my scar revision. I have done scar revision yesterday. The revision was done to revise a pox scar on the lower middle forehead about 1 cm up of the starting of nose bridge. The scar was 5mm in wide and 6mm in length. Right now I am very much concerned about the post scar it will leave. I am hoping for a linear scar rather than the circular one. I would really appreciate your feedback regarding this.

A: Not having any knowledge of how your scar revision was performed, this is a question you should ask the doctor who performed it. By your description, I would assume that a simple horizontally-oriented elliptical excision of the forehead pox mark would be done with a resultant linear scar trade-off.  This circular scar result is a bit confusing to me unless some form of subcision was done in an effort to raise up a depressed scar rather than excising it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can silicone implants be replaced and the procedure partially paid for by your insurance company if they are entirely encapsulated?

A: No physician can tell you for sure whether your health insurance company will cover any plastic surgery procedure. There is a process known as predetermination which makes that decision about any elective non-urgent procedure. This requires a written letter by the plastic surgeon to the insurance company with the medical issues, diagnosis and proposed surgery outlined. The insurance company will then review it and make its determination to you, a process that will take at least several weeks.

That being said, a general rule is that insurance will not pay for any implant-related plastic surgery procedures in which the implant was not initially placed for a medically necessary reason. This refers to breast reconstruction procedures with an implant done to restore a breast partially or fully removed after cancer. It is unlikely that capsular contracture in breast implants placed for cosmetic reasons, unless there is evidence of an implant rupture, would be covered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am female, 35, interested in brow bone shaving. My brow bone is a bit too thick, and I feel it looks a bit masculine. Is there any risks to shaving the bone in the glabella area? Would this make the bone there too thin and easier to fracture in the event of an injury? I don’t need too much shaved, but wondering if even a bit of shaving is risky. Thank you.

A: The issue with brow bone shaving is not one of real medical risk. The only issues with brow bone reduction are two-fold. First, you need a scalp incision and turn down flap to do it. So there will be a resultant fine line scar in the scalp. Secondly, and more relevant to your question, shaving the brow bone has the risk of burring right into the frontal sinus cavity. Most of the brow prominence is not composed by bone at all, but by air from the sinus cavity undermeath. How significantly one can burr down the brow bone depends on how thick the outer cortical table of the frontal sinus is. Often times it is no thicker than 2 to 3mms. The glabellar area, the part of the brow bone between the eyebrows, often will have no frontal sinus cavity underneath so it may be able to be reduced much more.

For these reasons, it is necessary to determine a patient’s eligibility for brow bone reduction knowing in advance the location of the frontal sinuses and measuring the thickness of the bone. This can be done with simple plain x-rays taken from the front and side views. For some patients, brow bone reduction by burring is adequate (minority of patients), but other patients need to have done an osteoplastic bone flap technique due to their thin outer bone covering of the sinus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is about face fillers. I had some permanent filler injections done on my cheeks 4 years ago. I am now developing hypersensitivity, not at the site of the filler, but over the sinus and neck muscles and headaches. Plus my eyebrows are thinning .The surgeon told me the filler used is BIOALCAMID .What is your opinion on can the filler be removed?

A:  Bio-AlCamid is a gel polymer filler that is composed of a 3% to  4% concentration of alky-amide polymer and 96% water. It is used around the world but is not approved in the U.S.  It maintains it volume through the attraction of water to the non-resorbable polymer which is then surrounded by a scar capsule. The manufacturer says that it can be removed relatively easily and this may be true if it is well encapsulated and can be palpated. Once the capsule is entered, the material will likely be expressible. The other key question is what to do after the material is removed as there may likely be a deflation effect seen on the outside of the face. While one could use any of the available temporary hyaluronic injectable fillers, I would strongly think about fat injection replacement. Otherwise, I see no direct correlation between it and your hypersensitivity symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read and would like to have rhinoplasty done with you if its possible. However I don’t have a visa to come to Indiana. I don’t know if it’s possible but I am just inquiring, is it possible for me to travel to indiana without a visa if I have a doctor’s letter from you? And that letter can be posted to me in my home country? Thanks.

A: I could not answer your question about traveling to the U.S. without a visa. That is a question for your country’s immigration department and U.S. foreign visitor policy. We do not provide medical letters of necessity for cosmetic surgery procedures, such as rhinoplasty,  to any international inquires or consultations. One has to work through the proper visitor/immigration procedures for their country and abide by the regulations for U.S. foreign visitors.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to improve the appearance of my lips, acne scars, and face contouring. I have very large lips and the upper lip is very full and bigger than the lower one, it gives me a duck lip appearance. The upper lip rests above the lower lip instead if the other way around. What would be the best thing to do about that? I have also attempted to loose weight to slim the face yet there is much fat around the lip area and the cheek bone area which does not go well with the full cheeks. I am attempting to achieve a slim-defined male model type of face as well as diminish the appearance of my acne marks. Somehow my facial features don’t mix well with one another. I believe my face is feminine in a way, is there a way to give it a more masculine look?

A: While many people want to achieve an upper lip size that matches the  lower one, you have an opposite concern. The upper lip can be reduced by an internal vermilion reduction to reduce its size and roll back the pout of the upper lip. That leaves any scar on the inside of the upper lip.

From a face standpoint, I don’t see large buccal fat pads to remove but I could see some benefit by perioral liposuction to reduce the perioral mounds out to the side of the lips. While you did not provide a side profile view, chin augmentation with more width and horizontal projection may be more masculinizing for you. But I would need to see some additional photos to be sure that is of benefit.

Acne scars can be improved by fractional laser resurfacing but it is important first to have the acne eruptions under control. With laser resurfacing the ointments needed afterwards as it heals can cause a lot of pore obstruction and an onset of new eruptions.

Dr. Barry Eppley

Indianapolis, Indiana