Your Questions

Q: Dr. Eppley, Thanks for speaking with me last week for my breast implant replacement consultation. I am scheduled for breast implant replacement surgery next month and I have a question. On my pre-op papers, I noticed you are recommending a change from my current round 390 cc moderate profile to high-profile 595-655 cc implant. I am familiar with the moderate profile, but not so much the high. I just wanted to make sure the high profile is not going to be the “round ball” look. I am wanting a more natural look. Could you explain the use of the high profile for me? Again, thank you for you time and for seeing me last Friday. Im looking forward to my procedure.

A: Your question about the profile of the implants is a good one and understandably can be confusing. When comparing saline (your current implants) and silicone (your new implants) implants, the projection/profiles between them are not comparable or 1:1. Saline implants naturally sit higher (have more projection) than silicone breast implants because they are under some pressure or distortion from the saline. (particularly if they are overfilled) Silicone is softer and not distended because they really are to some degree underfilled for the bag. (this is demonstrated by looking at a silicone implant sitting on the table and it will have an ‘ashtray’ effect while a saline-filled one will be very round and puffy) Thus a moderate saline implant profile is really comparable to a high silicone implant profile.

There is also the issue that as you go bigger in implant size, you do not want the implant to be too wide. Thus a higher profile silicone implant allows for the increased volume but without adding substantial more implant width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m largely familiar with the constellation of procedures that comprise Facial Feminization Surgery and Sexual Reassignment Surgery. Procedures that ‘balance’ the lower-body to ensure it’s proportional to the upper body are much less clear. Would you please take a moment to help me understand your thigh and buttock augmentation procedures?

1. What is the vertical & circumferential extend of implants used for lateral augmentation of the thigh (in the region of the greater trochanter)?

2. What are the vertical & lateral dimensions of the buttock implants? My concern here is to understand how these implants, in conjunction with lateral thigh implants, will create a natural curved profile in the waist-to-thigh area (instead of being “localized” augmentation).

3. I have a ‘flat’ area just below the iliac crest. Since this is above the greater trochanter and will likely not change with lateral thigh augmentation, do you have a method (or implant) to fill-in this area for to create an more uniform curvature from waist-to-thigh?

4. How are implants in this area ‘secured’ in their desired location so there will be no dislocation over time?

5. Where are the incision(s) for lateral thigh augmentation?

A: Thank you for your questions. In answer to them:

1. There are no standard off the shelf thigh implants. They almost all have to be custom made so their dimensions can be largely what one chooses based on measurements of the patient. But one should not think of them as circumferential, they are lateral implants and that is the extent that they cover.
2. Even when put together at the same time in the same patient, buttock and thigh implants will be localized augmentations. They do not connect nor can they. Their implant pockets are separate.
3. The trochanteric drop area is best treated by fat injections if possible since it is a flexion area for which implants are not best used.
4. All forms of body implants are secured only by the pocket that is made for them. They stabilize because the body forms a layer of scar around them (the capsule) this locking them into place.
5. Lateral thigh implants are placed through a small (4 to 5 cm) incision over the upper thigh.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get a better idea if insurance will cover my gynecomastia reduction procedure. I have had gynecomastia since I was a teen, but it has bothered me enough lately to visit a Doctor. Up until the past few years it has only caused me a little discomfort. I have never been able to sleep on my stomach because of it. Lately I have had occasional pain in my right breast and a sharp pain when bumped into or after exercising, but mainly in my right breast. My Doctor confirmed that I had gynecomastia after a mammogram and x-rays. The radiologist diagnosed it and ruled out cancer. I have fibrous mass centered under my right nipple and smaller nodular lumps on my left side. Really only the right side causes me the most pain. I think insurance should cover it, since I have had the gynecomastia since I was a teen and it is causing me discomfort. I would like to know what if there is any chance that insurance will cover it?

A: Insurance coverage for gynecomastia surgery is a frequently asked question of men considering the surgery. No plastic surgeon can answer that question definitely since your health insurer has their own criteria for coverage and ultimately they have to make that determination based on their criteria…not whether you nor I think it should be covered. This is a process known as predetermination in which the treating doctor submits a letter requesting the surgery, lists the diagnosis and procedure codes and provides pictures of the patient’s chest. From this information, they will make a decision and notify you in writing since you are the subscriber of the policy.

Having said that it is important to know what the criteria are that insurance companies use to make that decision about gynecomastia reduction surgery to see if you have any chance of success. First, the size of the gynecomastia problem must be a grade III or IV in adults based on a well known assessment scale. (yours by the way is a Grade II) Second, you must have had a endocrinological blood panel done to determine if there is any hormonal abnormalities that have not perviously identified and treated. Third, the breast enlargement must pose serious health concerns, such as being a tumor, that has a significant impact on the patient’s health or will so in the foreseeable future.

As you can see, unless there is compelling medical evidence, most insurance companies  view most gynecomastia reduction surgeries as a cosmetic procedures and not something that is done to treat a medically necessary condition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The corners of my mouth sometimes bleed and droops. Is there anything I can do for this? I LOOK unhappy. I don’t want to use needles and does medical insurance pays for this.

A: A downturned corner of the mouth can create more than a frowning or unhappy look. By acting as a salivary spillway, it can create chronically irritated tissue and yeast infections. This can make the corners of the mouth both red and prone to cracking and intermittent bleeding.

By your symptoms it sounds like you would benefit by a corner of the mouth lift. This is a procedure done under local anesthesia to lift the corners of the mouth by removing a triangle of skin from the overhanging portion. I would need to see a picture of your mouth to verify that this procedure can be helpful. It may or may not require more than a corner of the mouth lift to be successful which I can determine by a picture. (possible nasolabial fold excision as well) These mouth lifting procedures are not covered by medical insurance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 62 years old and I had a facelift done six weeks ago. I still have very dense numbness on both sides of my face which goes as far forward as my cheeks and straight down to and under my neck as far forward as my chin? Is this normal and, if so, when will it go away? 

A: When performing a facelift, the skin is raised up extensively to access the SMAS layer and well as to remove lax face and neck skin. Anytime the skin is undermined the tiny nerves that supply feeling to it are cut. This will result in numbness of the overlying skin that will persist for some time after surgery. Most if not all of the feeling will return but it will take time to do so. The return of feeling will begin in the most medial skin areas near the chin and nose and will work its way slowly back towards the ear. This is a process that will take months, often as long as six months to achieve maximal sensation return. In some patients they will be a small area of permanent numbness that may remain right in front of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a my first baby six months ago. Now I am not really happy with my belly. I have gained some weight that I never had before and can’t seem to get it off. What can I do that will not involve much time off work? I have read about Smartlip which seems like the best option and would not involve being off work.

A: Based on your pictures, you would be an excellent candidate for liposuction done under general anesthesia to really thin down your abdomen and waistline. There is always a misunderstanding that many patients are not aware that ‘Smartlipo’ is real surgery and is just another form of liposuction. While it can in the right patient be done under local or sedation anesthesia, it is still an invasive surgical procedure. It is not some external device that magically melts fat. The best results with Smartlipo are like any other method of liposuction…having it done under general anesthesia (if you want the most fat removed possible) and does involve some recovery.

For a treatment that requires recovery at all, you can consider a non-surgical approach like Vanquish. It will not produce the same result as any form of liposuction but does not involve surgery. It is done a series of office treatments, usually once a week for four to six weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently 26 and I had large silicone cheek implants placed two  years ago together with a buccal fat pad extraction. I had them removed two months ago as I just felt they were too big for my face. The issues I have now is that there seems to be a small degree of mid-facial sagging. I’m looking to get smaller malar implants later in the year, but I’m concerned that that will not be able to proper address this sag. Out of curiosity, since I’ll be undergoing a cheek implant procedure again, could a mini-lift help address this sag? I don’t think I’ll require anything too aggressive – do you know of any midface lifts that could help me out?

A: It is no surprise that once cheek implants are removed that some degree of midfacial sag will result. This is not just due to the stretched overlying tissues but because the soft tissue attachments to the bone have been permanently detached. Once the implants are out, the overlying midface soft tissue can not reattach to the bone (due to the slick surface of the residual capsule) and it thus slides ‘south’.

With your new cheek implants you consider a temporal suspension midface lift which can simply and easily pull back up the midface tissues over the new implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: What is the best buttock implant augmentation technique? I have heard differing viewpoints about inside the muscle and on top of the muscle.

A: Just like breast implants which can be placed under the muscle or on top of it, buttock implants share a similar two pocket location approach. (although intramuscular not under the muscle is where buttock implants are placed) Whenever there are two ways to do any surgery and different surgeons either approach, that indicates that neither method is perfect. You then have to look at the different advantages and disadvantages to either approach and figure out which one matches your needs the best and which risk profile is more tolerable.

The arguments for the subfascial location for buttock implants is the following. This pocket location allows placement of the biggest implants with sizes up to 700ccs. It creates a nice ‘S’ curve by making the pocket up to the posterior iliac spine, where the gluteal muscles actually attach. It also has a faster recovery because the muscle fibers are not disrupted deep into the belly of the muscle. Its disadvantages are that it has a higher incidence of seroma formation, potential implant visibility (if you have little subcutaneous fat between the skin and the muscle) and a greater chance of implant displacement/rotation. (since there is less tissue resistance)

The arguments for the intramuscular location for buttock implants is the following. It provides a thicker more vascularized tissue pocket which lessens the risk of seroma formation, potential implant displacement and has less risk of tissue thinning over time between the implant and the overlying skin. Its disadvantages are that it is somewhat more technically difficult to perform, has a limitation to implant size that can be placed (350cc or less) and has a longer recovery.

When you put all this together you can see that it is not so simple as just one implant location is better than the other. You have to look at each patient and make a decision based on their goals, tolerance for recovery and their tissue qualities. For thin or small women that have little subcutaneous fat tissue, an intramuscular implant location is usually best. For larger women with thicker subcutaneous fat layers that want a larger buttock augmentation result, a subfascial location would be preferable

Regardless of buttock implant location, a very important element that affects the result is the strict adherence to postoperative instructions to avoid too aggressive early activities. This can increase the risk of incisional wound separation, seroma formation and implant displacement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you do the “drainless” tummy tuck surgery? Also, I have an umbilical hernia and am looking to have both procedures done simultaneously. Can this be done on the billing end so that insurance will cover the hernia repair, anesthesia, facility charges, etc and I self-pay the abdominoplasty procedure?

A: Thank you for your inquiry. Let me provide you with some clarification and additional insight in both your tummy tuck questions about a ‘drainless’ technique and the financial implications about doing combined medical necessary and cosmetic abdominal wall procedures.

I have done numerous drainless tummy tucks and there is an understandable appeal to it because of the absence of a drain. But there is more to it than just not putting in a drain. There has to be some additional steps done to close down the internal dead space and seal the wounds to prevent a seroma (fluid collection) after surgery. Drainless tummy tucks can be done by either using internal quilting sutures or a tissue glue prior to closure of the tummy tuck incision. These steps do take additional time (an extra 1/2 hour of operative time) and materials (tissue glues can cost up to $1,000) to do and thus the drainless tummy tuck is going to cost more than one in which a drain is used. A drain is a simple and quick method to manage potential seromas and also keeps the cost down. Thus one has to place a value on how much avoiding the drain is worth. And drainless tummy tucks do not have a complete absence of problematic serums afterwards, there is not a 100% guarantee that you would not get a seroma even with these maneuvers.

In what seems like a straightforward issue historically, the separation of a medical necessary procedure like a hernia repair and a cosmetic procedure like a tummy tuck should be simple. But in today’s health insurance world it is not. The first common erroneous perception is that somehow insurance is going to pay for the operative room and anesthesia charges for the tummy tuck portion of the procedure…and they will not. No facility will allow that to happen anymore so that all charges related to the tummy tuck portion of the combined procedure including operating room, anesthesia and any supplies used must be paid out of pocket and in advance of the procedure. While ‘sliding’ the operating room and anesthesia costs of the cosmetic portion of the procedure onto insurance was common practice 10 to 20 years ago, that is no longer permitted and is actually illegal today.

While there is no question that a hernia repair and a tummy tuck should be done together, and this is common practice, you have to look carefully at the cost issues to see what works in your best financial interest. Your insurance is going to require in almost all cases (with the exception of Anthem and a few other private carriers) that your hernia repair be done in a hospital or a hospital-owned facility. Such a facility may or may not have reasonable cosmetic fee usage costs. They will in most cases be higher than a private non-hospital owned surgical facility. Depending upon the difference in cosmetic costs between the two types of facilities will determine whether the combined hernia repair-tummy tuck is done through insurance using their required facility or whether it is just better to pay all of pocket for both procedures. (I have certainly seen that be the case many times) Each patient and what insurance carrier they have has to be considered on an individual basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would I be able to have any improvement on my cleft lip with a lip enhancement surgery (cleft lip revision) to make my lip more even?

A: Almost all cleft lip repairs, no matter how beautifully done as an infant, will end up needing some additional revisions to optimize the repair appearance. The one area of the the lip that almost always need adjustment is that of the vermilion. (pink part of the lip) It is frequently volume deficient on the cleft side and makes a major contribution to lip asymmetry.

I think there are several aspects of your cleft lip that can be improved and all of your cleft lip issues are common. There is a lack of vermilion fullness down at the lip line which needs to be augmented by a small dermal-fat graft. The cupid’s bow area is indented, again due to lack of volume which also needs to be grafted. The outer aspect of the cleft lip side along the vermilion-skin border is shorter in height than than the non-cleft side and that can could be improved by a lip advancement on that side. The actual philtral skin scar looks pretty good and I don’t think that scar could be improved with the exception of adding a few hair transplants into and along the scar line.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making my forehead wider and more squarer to balance out the width of my new custom jaw implants that will be placed in about a months time. I have booked in for temporal implants at this stage but not forehead as I don’t think my doctor or any doctors here are quite familiar with the procedure. I wanted to know if it is ok to request to my doctor to use Medpor temporal implants? This is because I had a look at the Medpor catalogue and have found that the Medpor brand offered a significantly BIGGER size compared to the silicone ones offered my Implantech (which my doctor will use). Medpor ones go up to 20mm in augmentation. I’ve read your resource millions of times (very helpful) and want to know do temple implants sit only on top of the soft tissue or can the implant itself be placed higher if the implant overlaps onto the bone? Or is that something a custom made forehead implant would fix? If so are there any off the shelf forehead implants available on the market to widen the forehead? 

I also wanted to know if I was certain that I need a forehead augmentation in future are temporal implants necessary? Or are they needed along WITH forehead augmentation. I just don’t want to waste my money on temple implants if a custom made forehead implant will fix both areas.

A: I would never use Medpor temporal implants myself. They are too big, are very difficult to modify and are very difficult to remove should that ever be desired. (and there should be a high probability that they would) No one ever needs a temporal augmentation that requires a 20mm thick implant. They are simply too big for most cases and were initially designed for patients that suffered significant temporal muscle atrophy from neurosurgical procedures not for patients that want a pure aesthetic augmentation with a normal tenporalis muscle.

If you are seeking a temporal augmentation that reaches the high temporal region to make the forehead wider as well, only a custom designed temporal-forehead implant can achieve that aesthetic change. No current implant style, Medpor or silicone, are made to create that look as a ‘catalog’ item.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know that the two most common surgeries in cosmetic ear plastic surgery are to 1) remove cartilage from behind the ear and move the concha closer to the head and 2) reform the antihelix. In my case, the size of my concha and antihelical fold are OK. In my opinion my main problem is that the outer helical rim is short and dipped in. What I am asking is whether you have the ability and experience of building up the helical rim? In my self diagnosis, I think that we don’t have to fix the helical rim all over the ear, we can just fix something like a one centimeter area at the top of the ear. In my self diagnosis it gives me my ideal result.  Thank you very much.

A: What you are suggesting by self-diagnosis for your ear helical rim reconstruction makes sense and is possible. The helix exists as an outward curl of cartilage distinctly different than that of the anti helical fold. How to build out the helix at the top of the ear comes from knowledge of performing microtia, cryptotia and other congenital ear deformities. Based on the attached pictures of your ears, this is going to require the placement of a cartilage graft which could be harvested from the backside of the concha with no change in its appearance. The only question is whether this is best done by placing the graft on top of the existing helical rim or by placing it into a cut below the helical rim as an interpositional space to push the height of the helical rim higher. In my opinion this would best be done with the latter technique to prevent graft show through the very thin overlying helical rim skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Is the V-Y plasty the same thing as a lip advancement? If so, is that a procedure that can raise the height of the lower lip to have less tooth show? That is an option that I am exploring. 

A: A lip advancement and a V-Y advancement are two completely different operations with varying effects on the lower lip. A lower lip advancement removes a horizontal strip of skin on the outside so the vermilion can be rolled outward making the lower lip look bigger. It will not raise up the lower lip but is done to make the lip look fuller. (have more vermilion show) A V-Y advancement is a internal vertical mucosal procedure done on the inside of the lower lip. It is designed to try and lengthen the height of the lower lip and/or release any contracture or shortening of the anterior mandibular vestibule.

Raising the height of the lower lip is challenging and there is no one single procedure that can consistently do so. It usually require a combination of procedures through mucosal lengthening and vermilion augmentation to create such an effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, These are a few pictures of my crown and a short video of my head. The hair on the ridges is sparse but in the furrows there is some. I’m not sure if I’m losing hair in this area due to mail pattern baldness or the cutis verticis gyrata. I just want to know my options for conceiving this. Wether it be a hair transplant over it or cutting it out.

A: Thank you for sending your pictures and the video. What you should do is based on how large of an area is involved in your scalp and how progressive or stable the cutis vertices gyrate is. If the area is small and stable and is not causing any other symptoms, it be left alone. I do not think it necessarily is causing hair loss but may just be spreading the follicles out further as it expands. (although I can not say for sure whether it is) The involved scalp area should only be excised if it can all be removed and should first have tissue expansion. The scalp is not very flexible and will leave a wide scar if it is all removed at once. If the scalp area is larger and it seems to be growing, then excision would not be advised. You may consider fat injections or PRP injections in an effort to treat it although such treatment is theoretically beneficial but not yet proven.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wanting to find out more about the different options available for forehead reshaping. Are there alternative procedures to the shaving technique? For example are there any kinds of forehead implants, fat injections that can be used to smoothen the forehead. I will also be sending pictures within the next week or two for a more accurate price range, but can you tell me the average price range for these kinds of procedures? Thank you very kindly.

A: There are numerous different options for forehead reshaping including bone cements, custom implants and even fat injections. (not my preference but an option) When it comes to brow bone reduction, bone removal and reshaping usually works much better than shaving/burring for any significant reduction. As you can see between manipulation of the brow bone and the forehead above it, there are a variety of techniques. Which one may work best for you and what trade-offs you are willing to accept in doing them are issues to yet be discussed. It is better to determine first what methods you would choose and then an accurate cost for the surgery can be given. There are no ‘average’ costs for possible combination forehead procedures that we yet don’t even know what they would be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been reconsidering a sliding genioplasty procedure recently due to the great deficiency my chin has. As I stated in my last email, I am on Remicade and there is a good chance I will still be on that medication when then time comes for the procedure. Does it concern you doing a sliding genioplasty procedure while I am on this medicine? I assume healing may take longer. You have also mentioned that a sliding genioplasty with a chin implant overlay may be necessary. Will this have any negative effect on healing or increase the risk of infection?

A: I have operated on numerous patients who have been on Remicade for Crohn’s disease and I have not seen any healing problems. Such surgeries have been much bigger in surface area trauma and operative times than a sliding genioplasty. The face is uniquely well vascularized and unless there is direct impairment of the blood supply through prior radiation it will not inhibit healing difficulties. The orthopedic literature supports that major bone surgery and joint replacements can heal uneventfully with patients on this medication.

That being said, it is important to work around the dosing of the medication to reduce any risk of adverse healing. Given that Remicade is a TNF blocker and is done by infusion, it would be important to do the surgery about 3 to 4 weeks after the last infusion. This is will than allow a few weeks before the next infusion. With such an approach for a sliding genioplasty I do not envision any difficulty with healing or a prolonged recovery time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 40 year old male who had my buccal fat pads removed about 10 years ago. My issue went unresolved however as the puffiness was closer to my mouth. There was no information online at the time and I have just lived with it. Recently, I came across the term ‘periorial mounds’. I went to see a local plastic surgeon about it and he admitted that he had never heard of such a procedure, that it would be much too risky and that there is no fat there regardless. I came across your name when further researching it. You seem to be alone in addressing the needs of people with this issue. I have attached photos of my condition and would love to get your feedback. I should mention, it is not only the visual aspect I am hoping to change, but also the constant weight I feel around my mouth. My questions are:

1. do I qualify for perioral mound reduction?
2. do I risk damaging nerves?
3. will the amount you are able to reduce have a noticeable effect physically?
4. will a reduction aid in reducing the fat on my jawline?

Thank you so much in advance for any further knowledge you can bring me,  I really appreciate it.

A: The perioral mounds are a well known collection of subcutaneous fat that exists at the level of the corner of the mouth that is distinctly different than that of the buccal fat pads. It can be reduced by very small cannula liposuction and even a 1cc to 2cc fat reduction can make a noticeable difference. Although some plastic surgeons make not be familiar with its treatment, that does not mean it does not exist nor is it risky to do. In answer to your questions:

1. You do have a fullness in the perioral mound area with an overlying skin fold which presumably is due to aging. (descent of the midfacial tissues) It is impossible to know beforehand how much the skin excess or subcutaneous fat is contributing to that appearance. But in my experience removing the subcutaneous fat through perioral mound liposuction can make that skin fold ‘lay down’ so to speak.
2. This is a very safe facial area to do liposuction in. The buccal facial nerves run above it and the marginal mandibular nerve lies below it. This is a safe facial triangle for subcutaneous fat removal.
3. There is no way to absolutely predict the change but I have yet to see a patient who did not get some improvement in their perioral fullness.
4. The liposuction can and should be carried down to the jawline to maximize the procedure’s effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have low set tilted back ears. I want to know if it is possible to bring the ears forward, thus raising the top vertically? In other words, is it possible to rotate the right ear clockwise, the left ear counterclockwise;  thus, rotating the top of the ear forward.  I obviously do not know anything about this, but it would seem that the rotation would result in the top of the ear being ‘higher up’ five millimeters or more depending on what is possible. I understand the canal cannot move upwards. If this is possible, how much vertical increase in the top of the ear would result from the forward rotation? Is it possible to rotate them forward so that the top of the ear is the eyebrow level without relapse? 

I also desire the lobes to be shortened and the ears pinned so they do not stick out so much.  Attached at the bottom are pictures. Lastly, if this is possible, is this an otoplasty procedure that you perform?  Thank you for your time and consideration.

A: I have done numerous ear lifting type otoplasty procedures, some with moderate success and some with little vertical change at all. You are correct in your assessment that the fixed point of the cartilaginous ear is the canal which prevents any significant cartilage relocation. Whether the upper half of the ear can be moved upward at all this depends on the flexibility of the superior helix. Any lifting effect at all comes from relocating the area behind the anterior crus of the helix upward. By suturing this cartilage area up higher on the temporal bone with microscrew fixation, some vertical lengthening of the upper ear can be achieved. That effect can be maximized with setback of the upper helix since this also can cause a rotation effect if desired and appropriately sutured. Putting the two together can help raise the vertical height of the ear but not to the level of the eyebrow however. A vertical reduction of the earlobe will also help not only shortening the vertical length of the ear but may also help create the illusion that is actually higher.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am asking an identical array of questions of different surgeons both to become more knowledgeable on the topic as well as making a decision on choosing a surgeon. If you were to undergo sliding genioplasty, which five top surgeons would you choose based on experience and reputation.

A: This is an excellent question and I wish I had a similarly good answer for you. There are many surgeons of different specialities that perform sliding genioplasty but who would be ‘top five’ would escape me. Since I have never seen another surgeon actually perform this procedure other than myself (and that was decades ago in my training), all that I have to go on is whom writes clinically and scientifically about the procedure. And because it is an historic maxillofacial procedure of which there is little new, few surgeons today publish on this procedure. Thus creditable knowledge of who performs a sliding genioplasty technically well I do not know. That does not mean they do not exist, as obviously they do, but I could not honestly give you a list based on useful knowledge of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was interested in getting a consult for myself for the Vanquish vs. Exilis for several areas. I was also going to potentially buy a gift for my significant other as he is very concerned about abdominal fat. He also is considering Liposuction, so I looked that up. In your article about Liposuction you indicated that non-surgical, non-invasive fat removal methods are often not realistic and over hyped. Now, I am not sure whether to pursue the consult for the Exilis and/or Vanquish.

A: Any non-invasive body contouring procedures can not be compared in results as to what surgery can do. (e.g., liposuction) They rarely are even close. In general, there is a often a disconnect between patient expectations and what these types of treatments can do. Between a patient’s hopefulness and device marketing (by both manufacturer and practitioner), there is ample opportunity for patients to be disappointed. This does not mean that these devices are not beneficial and can not create moderate body contouring results, but each patient needs to be assessed individually to determine how non-surgical vs. surgical ROI (return on investment) compares. That requires a thoughtful and honest discussion which I regularly do for many potential patients seeking such treatments. I own both Vanquish and Exilis, so I have great insight into their potential value, but I also have no interest in patients making a ‘poor investment’ either if they are not good candidates for them. I would recommend that you and your husband come in and talk to me about it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have breast implants and I want them removed. I do not want another implant and instead want fat transferred to my breasts.

A: . Fat grafting to the breast can be done when implants are removed. But the advisability and success of the procedure is predicated on several important issues. First, do you have enough fat to harvest to make the procedure worthwhile? Since only concentrated fat is injected, it takes a greater fat harvest than most patients think to have enough injectate to produce any significant breast volume. Secondly, it is important to know how much actual breast tissue you have between the breast skin and implant capsule as this is the layer that is injected. Fat can not be injected directly into an empty implant capsule. There must be enough tissue between the skin and the capsule to serve as a recipient site. Lastly, what are your size expectations and can fat serve as an adequate substitute in volume for your existing implants. Unlike implants which have stable volume, injected fat has a variable take which will always be less than what was initially injected. Therefore patient expectations should be tempered with what fat can actually achieve in terms of final volume retained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I exchanged my saline implants for silicone about 3 years ago and my new scars never healed as nicely as my original (invisible) scars. Immediately after replacement surgery I could tell these were wider, longer and more irritated looking than my originals (particularly my left). I have had a few different Fraxel and V-beam treatments to see if that would make me happier but I wasn’t too impressed. While these are not horrific scars, I am definitely self conscious of them compared to my originals..Do you think it would be possible to improve these scars with a revision, ultimately aiming for thin, non-pigmented scars like my originals? Thanks!

A: Breast implant scar revision usually produces a better result than any type of more superficial treatments like laser or light treatments. The only improvement that can come for your breast implant scars would be through this type of scar revision. This means actually cutting out the existing inframammary scars and re-creating new scar lines. I believe this will provide an improvement in their appearance but whether they will every return to what the scars initially looked like can not be guaranteed. It is difficult to ever go back to the scar result that occurred from cutting into new unscarred skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Wondering if you do maxillomandibular advancements surgery for sleep apnea or know of any other plastic surgeons that are also dentists/oral surgeons that might do this procedure. Would prefer to have a oral surgeon that is also skilled as a plastic surgeon in hopes of having not only a successful surgery, but also a better cosmetic outcome. Thank you.

A: I do perform bimaxillary (maxillomandibular) advancements for obstructive sleep apnea. You are correct in that there can be a delicate balance between how much to move the face below the eyes forward and not so much that it creates facial disharmony. (resultant infraorbital-malar hypoplasia) As a general rule it is recommended to move the maxilla and mandible as far forward as possible. (usually about 10mms) But in some patients that may well create a ‘protruding lower face’ that is disproportionate to the natural facial appearance above it. This requires insightful planning beforehand based on the patient’s facial shape. Using computer imaging and VSP (virtual surgery planning) for the facial bones from the patient’s 3D CT scan, more thoughtful surgical planning can be done that takes into account both the functional and aesthetic needs of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was inquiring to see if masseter muscle reduction surgery is something you can do? So rather than a jaw reduction of the bone, just reduce the muscle in the jaw. I’d be coming in from Arizona for surgery so approximately how much would something like that cost me? And what would the recovery time be? Thank you.

A: Masseter reduction surgery can be done but it does slightly different than one would think. You do not go in and cut a portion of the muscle out as that would be very bloody and would likely leave the outer facial contour irregular when it heals. Rather the muscle is lift off the bone from the inside of the mouth and its inner surface treated by electrocautery. This will cause some muscle fibers to die and a portion of the muscle to atrophy obver time. Also Botox is injected into the muscle at the same time to help the atrophy process. I assume you are aware that you can treat masseter muscle hypertrophy with repeated Botox injections to help it shrink without surgery.

Other than some swelling there really is not much recovery or limitations after surgery. The jaw will feel stiff for a few weeks from the muscle treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a mild chin cleft that I would like corrected. I have attached a picture so you can have a better understanding. It drives me nuts when I smile as it is so visible particularly in pictures. 

A: By your picture what you have is a chin dimple not a chin cleft. That may seem like a semantic difference but anatomically there are somewhat different entities and are treated a little differently. A chin dimple that presents itself when you animate (smile) represents a defect in the mentalis muscle that covers the chin. Lacking fat underneath it and a defect in the muscle, the skin is pulled inward acting like an adhesion to the underlying tissues. Conceptually, volume needs to be added under to dimple to push it outward. This can be done by a number of ways but the simplest method is to place some injectable fillers (e.g., Juvederm) underneath the chin dimple. While this simple office treatment will not be permanent it will last 6 to 9 months and will answer the question whether the ultimate placement of fat injections would be the best long-term treatment of your chin dimple correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in your custom one-piece wrap-around jawline implant but have a few questions.

1. I saw an example of your custom wrap-around implant in an article you published on August 24, 2014 on your website. It was very impressive and exactly what I’m looking for. How difficult is that procedure compared to the standard 3-piece chin/mandible implant?

2. Is the recovery time and swelling reduced in the one-piece wrap-around implant compared to the 3-piece (because it is inserted only under the chin and not inside the mouth as in the 3-piece)?

3. Is the incision under the chin larger in a wrap-around implant compared to just a standard chin implant incision?

4. Apart from cost, what disadvantages do custom wrap-around implants have against an off the shelf 3-piece? (In other words, if cost wasn’t a factor, why would I or anyone ever consider a 3-piece implant?

A: In answer to your questions about a custom wrap around jawline implant:

1. If your questions about difficult relates to its surgical placement, it is not more difficult than placing standard chin and jaw angle implants…if one had done it a fair number of times.
2. Usually three incisions are still used for a custom wrap around jawline implant because it is critically important to check and ensure that the posterior jaw angle portions are properly positioned on the bone. But the overall swelling and recovery are no different than placing three separate chin and jaw angle implants.
3. The incision under the chin is the same for either standard chin implants or a custom jawline implant.
4. Good question! They are so superior that cost would be the only reason not to use them…and when the costs are considered for either a standard or custom jawline implant approach the custom implant is not significantly more costly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old male. I have a very flat brow bone and have been looking at getting something done as I believe it detracts from my overall appearance. My biggest concern has always been about the severity of the surgery to do something about it. It seems to me that you have multiple solutions which offer a more minimally invasive procedure. My question is about the cost of Endoscopic Placement of Custom Brow Bone Implants and the lifetime of those implants. Do they need to be replaced? And what are the complications with the procedure. If you could please let me know that would be greatly appreciated. Thank you. 

A: Custom brow bone implants, like all custom facial implants, are made of a solid silicone elastomer material. They are permanent implants, will never degrade or breakdown and will never have to be replaced. They are placed through an endoscopic technique using two small incision either in the scalp or at the edge of the hairline. While there are potential complications with any facial implant procedure (e.g., infection, malposition), I have yet to see any with that of the brow bone. The one huge advantage to a custom approach is that the implants will have a precision fit and the their size and shape will have been designed in advance to the aesthetic desires of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am unhappy with my nose and I have been considering rhinoplasty for a while as well as jaw augmentation. For my nose, my first main concern is that I don’t like the bulbous tip it has. I’d like the tip to look pointier and to project a bit more. Second, I think my nose is too wide. I would like my nostrils to be narrower from the front view. I have attached a few photos of my face, as well as a couple models whose noses I like.

For the jaw, I have been considering some combination of chin and especially jaw angle implants. Perhaps even sliding genioplasty, the latter I understand is the only way to add vertical chin height. I basically want to create a stronger looking profile that balances my face.

I also have a few secondary procedures I am considering but not sure about. A reduction of my lower lip reduction (I think it is too big compared to the upper, and might make my chin appear larger if it were reduced). And also forehead augmentation (to reduce the appearance of my sloping forehead/prominent brow bone)

I am trying to figure out which procedure/s would produce be the best result in my case.Would it even be possible to do all of them at once?

A: Briefly, all the facial procedures you have discussed can be done as the same time and it would not be rare in my experience to do so. But first we must go through each procedure and determine what is the best approach for each change and how much change you desire for each area. Options in rhinoplasty and jawline enhancement are best done through initial computer imaging. I will do some computer imaging using your pictures of these changes and this will be a good starting point for our treatment planning discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, the right side of my face looks bigger and more elevated than the other side, and the position of my right eye socket is higher than that of my left one. My jaw is also asymmetrical. When I bite, I can feel that the left side of my upper jaw and lower jaw is higher than the right side. I can also feel that the bone between my right eye socket and.my upper jaw is bigger than that on the left side when I touch. Is it possible to make my right side identical to the other side? If so, could you advise me on what procedures I should take and their costs? Thank you.

A: For your facial asymmetry correction, there are some structures that can and can not be changed.  It is not possible to lower a higher eye socket. (orbital box) A lower eye can be raised somewhat but a higher eye can be lowered. Your maxillomandibular cant (jaw asymmetry) can be corrected by a LeFort I osteotomy to shorten the longer side. (vertical maxillary reduction) To keep your current occlusion (bite) a sagittal split ramus osteotomy is needed to rotate the lower jaw back into occlusion as well as complete the vertical shortening of the right lower face.

Dr. Barry Eppley

Indianapolis, Indiana