Your Questions

Q: Dr. Eppley, I have had two cheek implant surgeries. Initially I had 4mm malar shell implants which were barely noticeable. Then I switched to 6mms implants which are now too big. I have a question regarding projection size.  I’ve attached two photos showing my face with Conform Terino Malar Shell medium implants with 4mm projection.  As you can see, I didn’t feel that these 4mm implants gave me enough definition in my cheekbones or enough outward projection. Therefore, I just had these implants exchanged with Terino Malar Shell 6 mm, but I now feel that the 6mm projection sticks out way too much.  I’ve heard that a 1 mm difference in implant thickness (projection) is equivalent to about 1/2 inch difference in actual cheek shape.  So, looking at the attached photos (and now that I know through trial and error that 6 mm projection is too large), do you think the same implant with a 5mm projection would still look too large, so I should go with a 4.5mm implant when I exchange the implants next month?

A: It is not true that 1mm of cheek augmentation equals a half inch difference in how the cheek looks. What I can tell you is that it can be striking how a few millimeters in the cheek area can make a big difference. So I think the statement that a little augmentation goes a long way in the cheek area. You case illustrates that in particular. If 4mms is too small and 6mms is too big, one would logically assume that 5mms would be the right size for you. Be aware, however, that in any cheek implant style and size that not just the thickness changes but overall size of the implant (height and width) as well. It is unfortunate that you will have had to go through three surgeries to finally get the right size implant. But there remains no quantitative way before surgery to determine how any amount of cheek implant augmentation will look

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, two months ago I got 6 mm silicone malar shell implants put in. I have flat cheekbones and full cheeks so the goal was to achieve higher, chiseled cheekbones (without placing them too laterally because I didn’t want the overall width of my face to look wider). To be clear, I do not have a combined malar/submalar implant because I did not want to augment my submalar region. Is the malar shell the implant you would have used or would the Medpor RZ malar implant work better to achieve prominent, high cheekbones? Thanks so much.

A: Quite frankly I would have used neither. All silicone malar shell implant styles are fairly wide which are going to give a round look to the cheek more than a high angular look. The medpor RZ implant is a lower projecting cheek implant style that will not give a high lateral look either. In reality, there is no really one good cheek implants style that will give that highly placed chiseled look in many patients. The best cheek implant that I have found is to either cut the silicone malar shell implants in half so that only the highest part stays or to use a so-called anatomical (style 1) implant that only imparts fullness to the high malar region.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have got a knife scar on my face since I was 5 years old. It is about one and half inch long, is not very deep by any means. I can really see it from 3 feet away. However, it still bothers me sometimes. Is there a way to make it disappear? Thanks a lot.
A: Scar ‘disappearing’ is not likely in any scar. Its further reduction in appearance may be possible, but there is no such thing as scar elimination. The involved skin can never be made completely normal. Scars can be made more narrow, more smooth and have a more normal color, but they can never be completely eliminated or made to completely disappear. Whether any of these techniques or changes will be beneficial to your scar,  I would have to see pictures of the scar to provide a more specific scar revision recommendation.
Dr. Barry Eppley
Indianapolis, Indiana

 Q: Dr. Eppley, I saw a doctor for a genioplasty consultation and he is supposedly a guru in the field. I have Class II, deep v shaped labiomental fold and my lower lip is behind my upper and my chin height is short and retruded back. He said a sliding genioplasty to horizontally and vertically lengthen my chin will work, but he also said he wanted to inject some kind of new stem cell bone material on my chin underneath the fold which will create new bone and fill in the valley on my chin, which would push out the soft tissue of the fold. I’ve never heard of this. He said bone augmentation was superior to soft tissue implants or fillers, and that this technique is very new.

A: What you are referring to is the simultaneous management of a deep labiomental fold during a genioplasty. Even though vertically lengthening the bony chin with the horizontal advancement will not deepen the fold any further, it is also unlikely to make it more shallow either. Filling in the bone gap of the osteotomy, while often thought as helping push out the labiomental fold area, does not. It is below the level of the labiomental fold. Thus a soft tissue approach is needed to help fill out the deep labiomental fold. That can be done by a variety of methods from injectable fillers, fat injections, allogeneic dermal grafts, and even silicone rubber (Permalip) implants. So-called stem cell injections (usually just concentrated fat injections) is a hot topic for injectable soft tissue augmentation. It is certainly a safe technique to do but its effectiveness is far from established.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, why are tear trough implants such a rare procedure? Can the implants pop out of place? What are some bad things that could happen with tear through implants? I am very young with very dark eye circles and I look terrible and need to do something about it.

A: Tear trough implants are very uncommon because other simpler alternatives exist such as the use of temporary injectable fillers or fat injections. These are far more appealing to many patients, and in the appropriately selected lower eyelid defect, they can be a good and effective choice. At the least, an injection approach is a good trial to see if this more non-surgical approach can be effective. For a defnitive permanent solution to the lower eyelid tear trough/infraorbital rim deficiency, a bony-based implant can be an effective choice. Tear trough implants are placed through a lower eyelid incision. They are attached to the bone by small screws so there is no chance of them ever moving out of place. The only issues that I have ever seen with tear trough implants is that you may be able to feel them through the very thin lower eyelid skin. In addition, carving and shaping them down so they have a natural flow into the surrounding bone is important so that there are no unnatural step-offs is an important aesthetic contouring step.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting liposuction to reduce the size of my waist and hips. Attached are some pictures of my waist and hips. I am after achieving very specific circumferential measurements in these areas. I have a measurement of 34 inches on my waist, and 46 inches on the widest part of my hips/ buttocks. I am 5 foot 8 inches in height. I need to be at least a 32 inches in my waist and 40 inches in the widest part of my hips/ buttocks. I am also interested in getting my thighs done. Is this possible.

A: Thank you for sending your pictures. On a realistic basis, I do think it is possible that your waist could go from a 34 inch down to a 32 inch waistline. However in the hip/buttock area a 6 inch reduction is simply not realistic. This is an area whose diameter is highly influenced by the hip and pelvic bones as well as the thickness of the attached muscles. Fat plays a role in its shape but not the level of a 6 inch reduction. A more realistic goal would be 1 to 2 inches, and maybe even 3, but I am not sure with your body shape how realistic a 3 inch reduction would be. My concern for any patient that comes in for any form of liposuction body contouring that is going to use a quantitative measurement as a determination of the success of a procedure is that they may end up disappointed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Oh dear, my pictures show how bad my neck really is. It looks worse in pictures than in real life! How you are going to fix it I don’t know. But I suppose you’ll be able to figure it out. The horizontal necklines I’ve had all my life. I recall a closeup when I was 20 that showed them clearly. But the sag is relatively recent. In the last 5 to 7 years I started to notice sagging. The wrinkly skin aspect is newer and that’s what I really hate! If I tighten my chin it doesn’t show, but I can’t go around looking as if I’m spoiling for a fight! Thank you.

A: Thank you for sending your pictures. I can see your neck skin concerns. This is due to the traditional sagging of skin that occurs with time and gravity. Your long-standing horizontal neck lines act like clothesline across the neck and the sagging skin now hangs between them. That is why your neck looks like it has multiple rolls.The fact that you can stick your chin out and it makes the neck skin smooth supports that a necklift (lower facelift) will be the definitive answer…and then you won’t need to constantly stick your chin out to have a good looking neck.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in jaw angle reduction surgery but I am worried about the risk of asymmetries. In most before and after pictures that I have seen, I do notice asymmetries… one side of the jaw is thinner than the other. Why is that happening since X rays are being taken before surgery? Is it difficult to see where to shave during surgery? Is that a common risk? I also have seen some patients complaining about bumps and dips on the jawline (bony irregularities), why does that happen? Is that a common risk? Thank you so much.

A: As you have observed with excisional jaw angle reduction surgery, symmetry can be difficult to achieve. Having an x-ray before surgery is not helpful in executing the actual procedure. Doing the procedure inside the tight confines inside the mouth is quite different than making drawings on an x-ray. It may help estimate how much bone one wants to remove, but during surgery there is no way to see both sides simultaneously and no way to know if one side matches the other. In essence, excisional jaw angle reduction surgery is a guess on each side of the angle of the bone cut and how much bone is being removed. This problem can be magnified if the patient already has some existing asymmetry in the shape of the jaw angles. Converselly, burring or shaving the jaw angle is different. Because you are keeping the existing outline of the jaw angle bone and merely making it thinner, the risk of irregularities/asymmetries is dramatically reduced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can jaw angle implants be custom made out of Porex? I had Porex jaw angle implants placed to restore my jaw bone deformity after jaw reduction surgery. but I am not happy with the result. I realized off- the self implants do not suffice in my case. I am considering my implant removed and replaced with custom made ones. All I have seen of custom made implants is to be made of silicone. Is it difficult to make a custom made implant out of Porex or too much expensive?

A: Quite simply, the manufacturer of Porex implants  is not willing to make custom jaw angle implants. This is undoubtably because the Porex material has to be machined (milled) to create the implants which is both time-consuming and expensive. Conversely, silicone implants are poured into a mold which is far easier to manufacture and more economical. It sounds like you had jaw angle reduction surgery (amputation of angles) and then had them restored by jaw angle implants. I have seen this scenario numerous times. It may be that only custom implants are an appropriate solution for your problem or it could be that the implants you have in place have either not been the right style or not well placed. Medpor (porex) jaw angle implants are notoriously difficult to properly position. So unless your surgeon has tremendous experience in doing jaw angle implants the problem may be in the implant selected or how it was positioned. Unless you have a 3-D CT scan of your face/jaw done it would be hard to know what the real problem is.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, At the age of 23, I am in the Navy, and I have always had a tough time with the tape measuring. I was doing some research for liposuction reduction on my butt, thighs, and waist, so I wouldn’t have to worry about the measuring around my hips and waist. And I came across your website. I live in Florida, but I can get time off to complete a liposuction surgery. I was just wondering how much the procedure would cost? Thank you for your time and please reply.

A: I am very familiar with the tape measuring that is done to pass a fitness test as that is the number one reason most people in the service have liposuction in my practice. So your request is not a rare one. How effective that would be in your case, how much fat could be removed and what that would cost would depend on what your areas look like. In other words, what do I have to work with and how big are they? If you can send me a few pictures of the areas in question that would be very helpful. In the interim, I will have my assistant send you an estimated cost based on what I would envision the areas to look like. That may or may not change based on a review of any pictures you would send.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am possibly interested in a limited facelift. I am generally taken for younger than my 64 years and have been told by physicians that I have very good skin. But my neck, to me, is hideous. There are some other signs of aging about my face, but in general I can live with those–it’s the neck that upsets me in my mirror view. I assume you do consultations? Are there brochures you could send or websites to recommend? Thank you.

A: While the entire face ages in everyone, many people are most concerned about the changes in their neck as they get older. The neck angle opens up and drops as skin sags, fat accumulation develops and platysmal muscle separation occurs. In women in particular they will often develop wrinkled or creepy skin as well. At age 64 the only good and effective solution is going to come from a lower facelift, often called a necklift or a neck-jowl lift.  This procedure lifts up and redrapes all of the neck skin back up over the jawline and around the ear. In essence, putting the tissues back up from where they came and turning back the clock on how the neck looked 10 to 15 years earlier.

The best way to a consultation with me is to send me some pictures and we can initially talk by phone or Skype. You never have to leave your home to get all the information you need to know!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have very little earlobes. Can I increase their size and shape using dermal fillers??

A: The size of your earlobe can be increased (expanded) by the use of either injectable fillers, fat injections or even a small dermal-fat graft placed from an incision on the backside of the earlobe. Which technique is better for you depends on the current size of your earlobes and the amount of earlobe skin that you have. You may feel free to send me pictures of your earlobes for a more definitive recommendation. But as a general rule, the first step to do is to use temporary injectable fillers to see of you like the change they make. If so then you may consider a more permanent solution with one of the fat grafting options.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently 30 years old and after a long career of modeling I see that I’m not longer as popular as when I was younger. Since I have seen good plastic surgery turn people 5 to 10 years younger, I was wondering if the same thing could be done for me. Could implants help me to retrieve a more youthful look. I’m not expecting to look any younger then 25, I am realistic about the possibilities. What would you suggest? What would help me the most to fight the “aging”. Even though I’m still young, it is important to me to know what my options are. From what I have understood. Elasticity of the skin declines and the cheeks start to sag, so will an implant help with that? I also have a bit hollowness under my eyes. What could be done against that? People have advised me to get some kind of fillers, or fat transfer to create that younger look again. But what is your opinion? Is it surgically possible to make even a fairly young person look younger? Thanks.

A: Most likely at your age the initial changes that you see are best treated by some skin rejuvenation techniques and fat injections. The quality of your skin can be improved, at any age, by such techniques as light fractional laser resurfacing. Loss of some facial volume, particularly over the cheeks, is very amenable to improvement by fat injections as is the infraorbital hollowing. Depending upon your natural skeletal anatomy of the infraorbital-malar area, the concept of cheek implants is also an option. But I would have to see pictures of your face for further assessment as to the benefits of fat injections vs cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had lumbar spondylolisthesis from birth. I had gastric bypass to help with weight on my lower back. I didn’t lose the 100lbs requested to get tummy tuck but the lumbar pain is still horrible every day and night. Can insurance cover a tummy tuck as medically necessary ?

A: The only way to know whether insurance will cover any plastic surgery procedure is to send in a pre-determination letter with photos and wait to receive a written response. The size of your abdominal overhang must meet very specific physical criteria and documented medical symptoms to qualify for medical coverage. As a general rule, I would not be optimistic. Most insurances turn down every request for any form of an abdominoplasty no matter how big it is or what symptoms that it is associated with it.. Send me some pictures of your abdominal area and I’ll tell you what I think your chances are based on my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My 19 year old daughter has some facial deformity and atrophy secondary to scleroderma. Although we are still in the early stages of diagnosis and treatment we are beginning to look for an experienced cosmetic surgeon that has dealt with this unfortunate condition. She has one side of her chin that is considerably smaller than the other. She also has some thinning of the upper lip unilaterally and a small amount of wasting to the same side cheek area. Again, we are still in the early stages but this appears to be a limited scleroderma with morphea traits. I would expect a chin implant would give her the best results but I would be very concerned to have any foreign substance placed in her at this time with the possibility of reactivating the condition. So I would expect “fat injections” to be the next best option?? Thanks for any insight you may be able to give.

A: Your daughter’s case sounds very classic in my experience and fortunately fairly ‘limited’. (I am certain she does not feel that way) You are correct in your assumption that fat injections are one good treatment option as that is the tissue that is largely missing/absorbed.  Concentrated fat injections have one significant advantages, the introduction of stem cells with the fat that may help soft tissue rejuvenation. Often I will use PRP (platelet-rich plasma) with the fat injections to get optimal fat cell survival and perhaps stem cell stimulation. Although depending upon the degree of soft tissue indentation and its location I would not exclude the possibility of bone augmentation with an implant or even a dermal-fat graft. The best facial recontouring results come from using any of these available techniques based on the size and location of the defects. There is no evidence that treating this form of scleroderma reactivates or exacerbates the condition no matter what treatment is done. While it’s etiology is very poorly understood, it is believed to be of neural origin and of an automimmune nature.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgery to improve my skull shape, I would just like to clarify some things first. You mentioned 60 grams of PMMA to obtain the predictive image results which would indeed be quite good for me. However I’m wondering if this quantity would be enough to make this aesthetic difference. Indeed I’ve read that PMMA has a density around 1.2 g/cm3, thus 60g of PMMA would have a volume around 50cm3, which seems to be quite small (I checked with 50g of water).As you’re quite experienced with skull aesthetics, do you think this would be enough in my case, and are you positive that the predictive image is obtainable? Maybe it would be preferable for me to have a first stage to stretch the skin, then have a bigger implant inserted? Please excuse my uncertainty, I’m trying to find the best option I have. I have seen one of your skull reshaping surgeries on your blog of a 42y old man with a flat spot much like mine. Do you remember what kind of surgery he had? Thank you for your help and advice.

A: I can certainly appreciate your volumetric computations of the biomaterial mass. But one aspect of that assessment that is missing is how any implanted volume of material translates into a change in external appearance. One thing I have learned over the years is that small volumes can usually make a much bigger change that one would think in many cases. In other words, one can easily be fooled in seeing how something looks in your hand than when it is implanted in the human body. The use of 60grams of PMMA in skull augmentation is usually the upper limit of how much the scalp can stretch over a skull augmentation without undue tension.  With longer or more full coronal incisions, one may be able to get up to 90 grams of material implanted as the scalp flaps are more fully mobilized. In your case, I would much rather take this approach as I do think that somewhere in the 60 to 90 gram material range should be more than adequate to achieve the predicted result. The patient to which you refer in the blog had 25 grams of PMMA implanted for that unilateral occipital skull augmentation result.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my mother has a grade 5 abdominal pannus that covers her knees and below and 2 years ago developed a lymphedematous mass and hernia through the abdominal wall. It drains fluid off and on chronically and she has been taking antibiotics chronically off and on for years. She is on Medicare and they have denied coverage for the panniculectomy portion of the surgery, stating they will only do the hernia repair and not the panniculectomy which is coming out to 7000 dollars. Is there any advice you can give to help us appeal this? She has been on South Beach diet for 2.5 years, lost 44 pounds on the diet, and been at a stable weight for many years. She can no longer walk due to the herniated pannus. She has atrial fibrillation and a pacemaker and diabetes (although well controlled on oral hypoglycemics) I believe that leaving the pannus in place poses a significant risk to her to develop infection and a clot or other dangerous complications. I would appreciate any advice you can give. We need to fix the hernia and also want the panniculectomy so she can walk again and continue her diet and exercise program as weight loss may also help her atrial fibrillation problem as well. I cannot believe the insurance company considers this cosmetic in a 74 yr old woman. 🙁

A: It certainly sounds like your mother would benefit greatly by a combined abdominal panniculectomy and hernia repair. But I believe you may have a misconception about how Medicare works. Medicare, a federal program, does not preauthorize or preapprove any surgical procedure. They never have. A surgeon must do the procedure and then wait and see if Medicare will actually approve (pay) for the procedure. When it comes to an abdominal panniculectomy, no matter how medically indicated it might be (and your mother certainly fulfills that criteria), Medicare will almost certainly deny it after it is done. This leaves the patient with the benefit but the doctor will rarely ever get paid and if they do it is pennies on the dollar. An abdominal panniculectomy is a lot of work, risk and after care for little if any reimbursement. A patient may say that this is not their problem but the doctor’s…but it influences the options for many  prospective patients. This is because very few plastic surgeons are willing anymore to do such procedures under Medicare. Thus the origin of the $7,000 fee to which you refer must be a cosmetic fee quote to do the procedure, allowing Medicare to pay for the hospital, operating room and anesthesia fess which they are obligated to do. Short of doing it under this fee for service basis, you will have to seek a plastic surgeon who accepts Medicare coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is there a procedure to reposition the lateral canthal area into an uptited eye or narrow eye? If so what is the price range? Thank you.

A: Such an eye reshaping as you have described is one in which the outer corner of the eye is more narrow and slightly longer to the side. This can be achieved by an eyelid procedure known as a lateral canthoplasty. This is a change in the position of the lateral canthal tendon in its attachment to the inside of the lateral wall/rim of the orbital bone. The lateral canthal is usually detached and moved up slightly higher and tighter on the inside of the bone. This will then pull the corner of the eye more laterally, making it more narrow and with a slight upward tilt. This is done an outpatient procedure under anesthesia which takes about an hour to do. My assistant Camille will pass along the cost of the surgery to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, will ObamaCare affect the cost of any of your services? I know it impacts in some ways the cost of general medical care but I assume that in cosmetic surgery and cosmetic services that it will be unaffected since these are cash and not insurance-reimbursed procedures.

A: Unfortunately, your assumption is incorrect. ObamaCare impacts all medical services including that of surgical and nonsurgical cosmetic services. The Affordable Health Care Act, passed into law in 2010, has imposed a few changes on the way we conduct business. One of those changes became effective in January 2013 – the new Federal Excise Tax of 2.3% on all medical devices. This tax affects any cosmetic procedure in which a device is implanted. This includes surgical devices like breast implants, facial implants, metal plates and screws and various mesh support and fixation devices. This also affects the very popular injectable fillers such as Juvaderm, Radiesse, and Restylane which are classified as medical devices and are thus included in the new federal excise tax. Interestingly Botox is not classified as a medical device but as a drug so it is excluded from being taxed.  In order to maintain the fiscal health of my practice, the price of all medical devices will be increased to absorb this new tax.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going through back problems at the moment but didn’t know if it was still ok to get breast enlargement and a tummy tuck. I am already on all kinds of medicines and have back pain but I think I am getting to the end of this, finally. I had worked out and walked four miles a day to loose weight and quit smoking then my back started acting up the tummy tuck and breast enlargement is something I have wanted since I had my three kids which I love dearly but ruined my body. I would like to know how long I should wait, I also have a hernia that they said unless it didn’t hurt all the time then don’t come back until it did . I’m sorry but I just feel like my life is on a complete hold while still wanting to look better and feel better about myself. I have to be at the mercy of all of these other problems before I can have my life back and have these things done to make me feel better about myself. Please reply with an honest answer all of what I am going through now is very heartbreaking so a reply soon would be greatly appreciated. Thank you.

A: While breast and abdominal reshaping can make some dramatic changes in any women who has been through three pregnancies, I have numerous concerns in your case if this is appropriate. Your history and ongoing back pain are concerns as well as what medications you are on. Breast augmentation and a tummy tuck are not a cure/treatment for back pain and may well make it worse in the short-term after surgery. I would imagine that some of the medications you are on are for pain relief, which would make any narcotics needed after a breast augmentation and a tummy tuck less effective. A detailed medical and medication history would have to be assessed to see if such body contouring would be advised. In addition, your hernia repair history is also significant for consideration for tummy tuck surgery. Your surgical records for this procedure(s) would need to be reviewed to determine what type of hernia repair was done and if there is any synthetic mesh in your abdominal wall.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 25 and have one child, I would like to have breast implants but I’m afraid the cost and recovery time is too long. Can you give me any advice and info on the payment plans and the recovery times. Thank you.

A:  Cost and recovery are always the biggest issues when any women is considering getting breast implants. So every potential patient has to contend with these issues so let me discuss the facts on both of them. The recovery from breast augmentation is really a physical therapy one since the implant is placed under the muscle. (in reality, partially under the pectoralis muscle) So how does one recovery from a muscular injury…use it! I place all patients on arm range of motion exercises the night of surgery and no physical restrictions thereafter. The more you use your arms (within reason) the quicker you will recover. With there be discomfort after surgery…absolutely, but most patients do not find it severe enough to be very limiting for very long. I would have to know what type of work you do to better answer how many days you would need to return to it. From a cost standpoint, the issues are the type of implant where does one get financing to do it. Saline breast implants are the most economical and we have all of our patients use Care Credit for financing. They are a national company that we have found to be the best to work with and has the greatest option of repayment plans.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can the pubic lift affect the nerve supply to the penis or interfere with erection in any way?

A: This is actually a common sexual function question whether it is liposuction or a lift in the pubic region. Men are concerned that it will affect erection while women are concerned that it may interfere with having an orgasm. While the pubic region is near the sexual organs of either gender, neither a pubic lift or pubic liposuction will interfere with their function. The nerves to the penis lie deep and way below the tissue planes for either procedure. While the female clitoris is just below the pubic fat pad, liposuction does not traumatize it even though there is the possibility of some temporary labial or clitoral swelling and bruising as gravity pulls down any blood released during the procedures. Conversely in a handful of cases, I have had reports that a pubic lift in women has enhanced orgasmic sensations which may be due to changing the exposure of the pubic area. For men, pubic reduction may improve penile exposure and length.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am sending you some pictures of my lower eyes so please let me know what you think. I have bags and many wrinkles under my eyes even though I am only 29 years old! It’s so much worse when I smile because the wrinkles show much more!! I’m really excited to do something about it but scared of surgery!!

A: Thank you for sending your pictures. What I see is not really much infraorbital fat herniation. Rather I see some infraorbital rim hollowing and a lot of skin wrinkles when you smile. The infraorbital hollowing could be treated by fat injections and perhaps a little lower eyelid skin removal. But many of those lower eyelid wrinkles are impossible to treat surgically because they mainly appear when you smile, thus they are dynamic wrinkles. Much of your lower eyelid wrinkling needs to be treated by Botox injections to stop the muscle action.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am an active lady just turned 80 and I have a small amount of normal puffiness under my eyes.  My concern is that I have puffiness in the corner of my eyes between my eyelid and nose bridge.  It looks like a lump or a swollen gland and is puffy.  Is there anything I could apply that would reduce that puffiness cosmetically or is this a surgical issue?  Would cold or hot compresses reduce the size of this area of the eye?  Could the fat behind the eyeball be causing this area to swell?  What works best? Thanks for any suggestions you might have for this problem.

A: Undoubtably the puffiness that you see between your nose and your eye is not swelling. That is actual tissue, a combination of skin and fat, that is causing the bulge. Your assumption is correct that it is bulging eye fat.  It will not be remedied by any type of external compression. Rather it is going to require surgical excision to remove the now protruding and excessive upper eyelid tissue. This can be done through an upper eyelid incision. (blepharoplasty)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had read online some of your comments about jawline reduction for square faces. So far, I have only seen jawlines that look like they have been cut and it looks unnatural and too short from the sides, and also, from the sides it shows no angles at all. I am therefore hesitating to do this surgery. Asymmetries (I wonder how that can happen since X rays are being done) and sagging skin. I am just looking for the angles (the whole jawline?) to be rounded off just enough so my face doesn’t look square; I have done Botox but it created some jowls and my face got hollow and it only reduced the masseter muscle, I had a hard time smiling too and the muscle would bulge when I ate.
What should I do to have a more feminine, natural, softer jawline? I want to avoid sagging skin too (I’m 42 years-old); will shaving only a bit would avoid this? Is it worth it then?

A: The key to jaw angle reduction is understanding whether jaw angle ostectomy (amputation) is needed or whether jaw angle outer corticotomy (width slimming) is needed. Unfortunately, the historic concept of jaw angle amputation persists and is commonly used, whether that is what the patient really needs or not. That is why you see faces, as you have described, that have had jaw angle reduction and look like they have no angles at all. Your jaw angles would need to be reduced using removal of the outer cortex only, thus reducing width but not losing the support of the bony angle completely. Your ‘failure’ with Botox injections indicates that the muscle is not the primary reason for the excessive contour. Whether reducing the outer cortex of the jaw angles is worthwhile depends on how much the bone is contributing to the flair that you have. The Botox treatments you had is a favorable indicator but it would be conclusively helpful knowing what the bone looks like as well. Therefore a simple AP facial/jaw x-ray view would be most helpful to decide either way if this procedure would be helpful.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Hello! I found you searching the internet and I find your work great. I just can find information about recovery for lips enlargement for this kind of operation http://exploreplasticsurgery.com/wp-content/uploads/2009/01/lip-advancement-surgery-indianapolis-dr-barry-eplpey1.jpg .How long does it take for scars not to be visible anymore? Or how long it takes for it to be slightly visible?

A: Other than some moderate lip swelling, there usually is no bruising with lip advancement surgery. Patients report little to no pain as the upper lip will have some temporary numbness. So the recovery is very quick as there are no physical restrictions after surgery. The scars from lip advancements heal very quickly and are minimally visible in 3 to 4 weeks after surgery although that will be somewhat dependent on the patient’s age and the preoperative shape of the lip. (younger patients take a little longer than older patients) Full scar maturation is a process and one should anticipate that the final appearance of the scar is one of months and not weeks. As there will always be a permanent lip scar, one has to have a thin and small lip that justifies that trade-off. One can wear lipstick one week afetr surgery so scar camouflage is easily done through the scar maturation process.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m 22 and I’ve had bags under my eyes for a long time. I believe in my case it’s hereditary. I’m tired of hiding my eyes behind my glasses. I would like to know about procedures( a little scared) and around how much it would cost.

A: Given that you are only 22 years old, any bags under your eyes is congenital herniated infraorbital fat. You are too young to have any excessive skin of the lower eyelids. This could be improved by a transconjunctival (through the lower eyelid) blepharoplasty procedure. By going inside the lower eyelid, bulging fat can be removed from the lower eyelid area without an external incision underneath the lashline. This is a procedure that has a very rapid recovery with minimal bruising and swelling afterwards. There is usually a little drainage from the eye area for a few days from the incision inside the lower eyelid. (the incisions are not closed as sutures would rub against the eye ball and risk a corneal abrasion) Patients report little to no pain after the procedure. The typical cost of the procedure would be around $3500 which would include all associated costs.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am hispanic and I had rhinoplasty ( alar reduction) almost 4 years ago. A revision was subsequently performed as well because my nostrils were uneven and I also noticed one side had a depressed scar. Fast forward 4 years, my nostrils are even but the scar stayed the same. I started with Kelocote scar gel, then at-home glycolic peels, and surface microdermabrasion but these have only worked for a minimal amount of time. I have done all sort of research regarding scar removal but, wanted to have a professional opinion on what other options I may have for diminishing the appearance of my scars.

A: Without seeing pictures, it would be impossible for me to say what scar approach would work. But knowing that you are Hispanic and have tried most topical approaches, I suspect that only excision of the scar would be beneficial. But this would only be advised if the scar was wide. If it is a narrow but visible scar, there is likely no improvement that can be done. In this case, you may be searching for a scar revision solution that does not exist. Unfortunately in patients with greater skin pigments, this is always a risk in alar reduction surgery. However, I would not commit to any of these statements before seeing a picture of your alar scar concerns.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been searching the Internet for resources on augmenting the brow ridge and have come across your very informative website. I would like to have deeper and a more masculine brow ridge. I understand that it can be done with bone cement. However, would fat transfer to the area work if only a moderate correction is needed as I would prefer to avoid the scalp scar.

A: I would certainly agree that fat injections would be a very reasonable alternative to the formal placement of bone cement for modest/moderate changes in brow bone projection. There is always great uncertainty as to how much fat would survive and its potential for asymmetry/unevenness. But those risks seem as very tolerable when one wants to avoid a scalp scar in brow bone augmentation. In other words, there are not other non-incisional options and this is a very safe and low risk approach using one’s own natural tissues. I have used an injection approach numerous times with synthetic injectable fillers and good results have been seen even if they are only temporary. The thickness of fat allows it to give a better tissue ‘push’ than the softer synthetic fillers.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I live overseas and am interested to fly over and get the corner of mouth procedure as shown on your website. I have had many small surgeries so I am not at all apprehensive and understand more or less what will happen. The only request I have is will there be a scar?

A: While a corner of the mouth lift is a fairly simple procedure, it is important to understand that there may be a small outward scar from the corner of the mouth in most patients. In many cases I try and keep the scar to stay along the vermilion-cutaneous border (lip-skin border) particularly in younger patients. In looking at your pictures you will note that the downturned corner of the mouth is also associated with an upper lip vermilion (pink part of the lip) that completely tails off before it ever reaches the corner of the mouth. This is actually very common and indicates that it may need to be part of the solution as well. Thus the most effective corner of the mouth lift in your case is one where the skin removed also involves a vermilion advancement that encompasses the outer 1/3 of the upper lip border.

Dr. Barry Eppley

Indianapolis,Indiana