Your Questions

Q: Dr. Eppley, Hello, I am a 19 year old female with a high rounded hairline. I’ve always been picked on and teased due to it. Causing me to quit sports in high school because of my bangs blowing back when I’d run… Im always hiding behind my bangs but unfortunately I won’t be able to in Navy boot camp in six months . I am enlisted in the delayed entry program for the US Navy and I just know that in boot camp the RDC’s will make fun of my hairline as a part of breaking me down. I just want to know if your facility does any sort of military discount for the hairline lowering procedure? Or if fees can be waived out of generosity. I don’t know how that works but I figure it’s worth asking. If this is not possible, thanks anyway for your time!

A: Thank you for your inquiry. A hairline advancement/lowering can be a very effective method forehead reduction if one fulfills three criteria. First the scalp must be naturally mobile enough that it can be moved one to two centimeters forward. You can have a pretty good idea of that by pushing around your own scalp and seeing if it moves forward anyy. Secondly, one has to  have a good frontal hairline with adequate follicular density to position a well-designed incision. Lastly, one has to be willing to accept a permanent fine line scar along the frontal hairline. Please send me some pictures of your forehead for my assessment. I have asked my assistant to pass along the cost of such a procedure to you and she is the one to whom you can direct your financial questions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead recontouring. As you can tell from the pictures I’ve provided, I have two prominent structures protruding from my forehead which gives the appearance of two “horns.” I would like to know if it’s possible to “shave down” these bulges for a more natural look; they are completely bone in structure that began forming when I was around 11 years old. I’m particularly interested in how the procedure might be carried out and the approximate cost of the surgery. Thank you in advance. 

A: Thank you for your inquiry and sending your pictures. Your forehead shows two symmetric areas of frontal bossing. This is to be differentiated from frontal osteomas. Osteomas can be a source of forehead ‘horns’ and they represents a growth of new bone that usually has a well-defined separation or edge from the underlying forehead bone. This makes it fairly easy to separate it with an osteotome through an endoscopic technique from two small scalp incisions. Frontal bossing projections are different in that they are expansions of the natural frontal bone itself rather than just new bone growth on top of it. Thus they must be burred down and can not be done with an endoscopic osteotome technique but rather requires more of an open incision placed back in the scalp to do the forehead contouring. They can be very easily burred down to a perfectly smooth forehead contour but requires more of an approach to do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two small scars that are indented from a laser to removal 1-2 mm skin inperfection. I now have 1/2cm divots in place from procedure a year ago. I would like to just have scar revision where they cut out scar and bring the area together with stitches! Is this possible to have straight line scar without having indented wide divit? I am scared to ever have laser. One scar is in my furrow by eye brow and other is in location of where your fat bags under your eye/cheek area are. I can submit pictures. I am really just wanting area with flesh lined scar. Do not want fillers either. I’ve had good luck with past incision lines and guess I’m just old fashioned. Thank ou for your time in helping me find a verbal answer without actually seeing a picture at the moment.

A: Generally, indented scars or divots can be nicely treated with excision and closure to level out the skin edges with the trade-off of a scar as you have mentioned. The adviseability of this scar revision approach depends  on the size and location of the indented areas. Seeing a picture of the scars would be most helpful. You just want to sure that the straight-line scar trade-off is worth the exchange for what you have now. It is not a question of whether you can do such scar revision but whether you should. You certainly are so motivated to do so and that seems to be based on sound reasoning.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are you familiar with 2ndary rhinoplasty.? I also need to correct my septum which is crooked. My projection needs to be reduced and I need cartilage grafts placed in my nose because I can’t breath.

A: I am very familiar with secondary or revisional rhinoplasty procedures. Your use of rhinoplasty terminology suggests that you have not only had a primary rhinoplasty but have done some homework as well.  What exactly did you have done in your original rhinoplasty and how long ago was it done? I assume your septum has always been crooked and was not corrected during your initial procedure or was it the result of an inadequate straightening from the first surgery? Were any cartilages grafts harvested from the septum in your first rhinoplasty? I will assume that your use of the term ‘projection’ refers to the tip. Is it too high now because of the first surgery or has it always been too high? Are your breathing difficulties a result of the first surgery or have they always been present? I will also assume that you did not have spreader grafts placed during the first surgery.

Please feel free to send me any pictures of your nose with these answers. Secondary rhinoplasty can be a very effective procedure but the surgeon must have a thorough knowledge beforehand of what occurred in the initial rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a smaller waitst and larger buttocks. Would fat injections to my buttocks accomplish both goals? Here is a picture of me from behind in my underwear.

A: Based on this one rear view picture, it appears like you would be a good candidate for fat injections to the buttocks. (aka Brazilian Butt Lift) What makes one a good candidate for the procedure is whether one has enough fat to harvest. Your one picture clearly shows some flank fullness so I will have to assume that there is also some abdominal fullness as well. Your fat supply is not enormous but narrowing of the abdomen and flanks will help make the buttocks look bigger as well. As long as you have enough fat to harvest (1.2 to 1.5 liters is usually the minimum needed) then it is worthwhile to place the subsequently concentrated fat (600cc to 700ccsor 300cc to 350cc per side) into the buttocks. One also has to accept the reality that fat injections into the buttocks usually make a modest change in size and the amount of fat survival is not always predictable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting my nose. I am a 22 year-old female who has a nose in which the tip does not match the rest of my face. My nose tip is too fat and there is like a line running down the middle of it. The rest of my face and nose is actually small and well proportioned. The tip of my nose does not match the cuteness of the rest of my face. Can this be fixed? I have attached a few pictures for you to see what I mean.

A: Thank you for your inquiry and sending your pictures. What I see is that the tip of your nose has the classic bifid tip deformity. This means that the lower alar cartilages do not come together or meet in the middle of the tip of your nose. As a result, this leaves a central groove down the tip of your nose the whole way down to the base of the columella. This also creates a wider or fatter tip due to the lateral cartilage displacements. Outside of tip the pictures show only one angle so I can not comment on the shape of the rest of your nose. The bifid tip deformity can be corrected by bringing the lower alar cartilages together by sutures as well as thinning their size. This will make your tip more refined, narrow and get rid of the groove  or cleft down the middle of it. I have attached some rhinoplasty imaging based on these potential changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am curious to the cost of Botox in specific areas on my face. My biggest issue is my  eyes as I am only 31 and am very attractive and often to I don’t look my age but I’m feeling as though I’m beginning to these days :-(. Also, am interested in the cost of breast augmentation. Thank you

A: Thank you for your inquiry. When it comes to Botox, the cost is completely related to the number of units delivered. Such units are usually very consistent for the area treated and so the cost can be well estimated. For between the eyes (glabella), which is the most popular area on the face for Botox injections that will take 20 units with a cost of around $300. For the crow’s feet area (beside the eyes) the number of units usually needed is 16 with a cost of around $225.  When the two are done together, the total units can be reduced to 30 with a cost of around $425. For breast augmentation the cost is completely related to the type of implant used. Total surgical costs for saline breast implants is around $4700 while that of silicone implants is around $5800.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old. In March I have planned some maxillofacial surgeries. Currently I have a chin implant large anatomical. I have a problem in my maxillary prognathism which is vertically long. A maxillofacial doctor also diagnosed me with micrognathia. I have no problems with my bite. My upper jaw is too long like my upper lip. Then I realized I needed an upper lip lift and a Lefort 1 osteotomy. The only plastic surgeon I have seen thinks I need a upper lip lift (remove 6-7 mm) but the problem is that I have a gummy smile. My question is what is best to do first? And how long should I wait to do them?

A:  With a vertically long maxilla and an overlying long upper lip, it is an interesting question as to which one should be done first. If I make the assumption that you really need both bone and soft tissue shortenings, whichever one is done first will leave you with an increased aesthetic deformity before the second stage correction. In these situations, it is always best to do the underlying foundational change first. Because the bone surgery is more involved and may change what is eventually done in the amount of upper lip lifting, the LeFort impaction procedure should be done first. Once the bone level is set then the upper lip lift can be done based on the position of the lip to the maxillary anterior teeth. Also dependent upon how long your upper lip is and how much vertical maxillary shortening is needed, it is also possible to both together…but using only a conservative upper lip reduction as more can be done later if needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast lift surgery about seven weeks ago. They were fine until three weeks after surgery when the bottom part of my incision opened up to about the size of a quarter. It has now finally healed but the healed areas are very sensitive and it hurts to touch. I can’t wear any type of bra and as light as shirts are, I can’t stand it touching it, I lay down and sleep at night but when when I roll over it rubs against the mattress and wakes me up throbbing. I have attached a few pictures for you to see. Is there anything I can do to be able to wear clothes?

A: Based on your pictures it looks like your breast lift wounds have nearly healed and now you just some sensitive scar formation over the wounds, which is very typical at this point in the healing. That sensitivity of the scars will decrease over time but the question is what you can do now. They would be best treated by either silicone topical gel or silicone scar sheets, both of which are available over the counter in a drugstore. Either way you need to keep them covered so they don’t get rubbed on which is obviously uncomfortable due to the scar’s sensitivity. As the scars settle down and mature more this sensitivity will go away. The silicone sheeting can be particularly helpful in providing both coverage of them and expediting the scar maturation process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a ‘cottage-cheese’ butt my whole life. I hate and want to get rid of it. Would liposuction help smooth out the dents on my butt by removing some of the fat? Besides making it smoother would it make it smaller as well?

A: The search for an effective cellulite treatment has been ongoing for years and to say that it is elusive is an understatement. The buttocks is a prime location for the cottage cheese look of the skin. Over the years such treatments as Endermologie and VelaShape have been promoted but their effects are short-term and any improvement requires regular maintenance treatments. Liposuction surgery, however, is exactly what you don’t want to do. Liposuction removes the superficial layer of fat and removes the support from the overlying skin…this has the high likelihood to make the appearance of cellulite even worse. The newest cellulite treatment, Cellulaze, may offer improvement of buttock cellulite on a more sustained basis but long-term results (years) remain to be reported.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like information on breast augmentation. I have breastfed 2 of my children and my breast sag considerably. I compare them to a much older woman. It is very difficult to buy bras that fit well without adding any padding and I am not happy with the way I look shirtless. I would like some info emailed to me so i can think about my options.

A: Based on your own description of ‘ my breast sag considerably’, it sounds like you would need some type of a breast lift if implants were placed. Breast implants have no capability of lifting up a breast and moving the nipple to the center of the breast mound if the starting position of the nipple is below the lower breast fold. Therefore you have to think about the trade-off of scars for fuller and uplifted breasts. You will also have to consider whether you would want saline vs silicone breast implants. I would be happy to look at any pictures that you want to send to me to give you a more exact recommendation. But for now I will assume that you need full breast lifts with implants. I will ask my assistant to send you some cost information for such a procedure for your further education on the matter. If you have any other questions, please let me know.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have very thin skin under my eyes and they are puffy 🙁 I always look so tired and worn out) Just curious if surgery could correct this ?! 🙂

A: The puffiness under your eyes is a common problem and is due to intraorbital fat that is now sticking out. This is a typical development that occurs as we age. Normally the fat around the eyeball is contained behind the eyelids by certain supportive tissues. As we age these tissues weaken and the fat begins to protrude against the lower eyelid. This creates the classic lower eyelid puffiness or bags that many people have. With time these lower eyelid bags can become quite pronounced. Because fat has a high content of water, this is why these eye bags may be bigger in the morning or after eating foods with high salt contents. While some people have these bags naturally even as early as their teens, most people develop them to varying degrees after the age of 40 or so. This fat removal is a common component of most lower eyelid blepharoplasty procedures, If one does not have any or too much loose skin, the fat can be removed from inside the eyelid. (transconjunctival lower blepharoplasty) When loose and sagging skin needs to be removed and tightened as well, an external transcutaneous lower blepharoplasty technique is used. (traditional method) Both techniques can result in a significant change that removes that tired look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have thin uneven lips due to an injury as a child. When I was seven years old I fell of my bike and split my face open on the concrete. I had a long laceration that ran from my lip down to the underside of my chin and now it is a long wide scar. My lips are naturally thinner but this scar as it crosses the lip also makes the lip uneven as well. Is there a surgery that could correct this lip step-off and in the process make them a bit fuller as well? I don’t expect Angelina Joile lips, but just some normal looking lips. I would appreciate any help you can offer me.

A: Mismatched vermilion-cutaneous edges along the lip line can be easily corrected by either reopening the lip vermilion and realigning the edges or doing a transposition of the edges through a small z-plasty scar revision. Making the lips fuller at the same time can most effectively be done by an upper and lower vermilion advancements. But whether that fine line scar along the lip lines is a good trade-off depends on how thin your lips are and if you have enough vermilion that a filling material or an implant may offer enough size change that would avoid the need for vermilion scars.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,   I was just curious if you personally perform orthognathic surgery on a routine basis (I know your website primarily focuses on plastic surgery procedures rather than maxillofacial ones) and if so, whether you ever perform it in an outpatient setting?  I know that I have a long road with dental work and orthodontics before I could even consider it, unfortunately, but I think the only way I could realistically afford to have jaw surgery is in an outpatient setting as I have heard how outrageously expensive it is in the hospital setting (and I do not expect insurance coverage in my situation).  My understanding is that some surgeons do in fact perform it in outpatient facilities (which is a more recent development due to the high cost) and I was wondering if that is something you have personally done or are familiar with.  

A: Various forms of orthognathic surgery have been performed in surgery center locations for decades. While it is true that increasingly limited insurance coverage has made the concept of out of pocket orthognathic surgery more common, it is not new to perform it outside of a hospital setting. The key concept is that some orthognathic procedures can be performed this way but not all. Isolated maxillary (leFort 1), mandibular (sagittal split) and chin (sliding genioplasty) procedures can be safely done as an outpatient. It is when these procedures are combined, which often may be needed, that a hospital setting is not only preferred but should not be done outside of it due to aiway and recovery concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Rich Text Area Toolbar Bold (Ctrl + B) Italic (Ctrl + I) Strikethrough (Alt + Shift + D) Unordered list (Alt + Shift + U) Ordered list (Alt + Shift + O) Blockquote (Alt + Shift + Q) Align Left (Alt + Shift + L) Align Center (Alt + Shift + C) Align Right (Alt + Shift + R) Insert/edit link (Alt + Shift + A) Unlink (Alt + Shift + S) Insert More Tag (Alt + Shift + T) Toggle spellchecker (Alt + Shift + N) ▼ Toggle fullscreen mode (Alt + Shift + G) Show/Hide Kitchen Sink (Alt + Shift + Z) Format – Paragraph Paragraph ▼ Underline Align Full (Alt + Shift + J) Select text color ▼ Paste as Plain Text Paste from Word Remove formatting Insert custom character Outdent Indent Undo (Ctrl + Z) Redo (Ctrl + Y) Help (Alt + Shift + H) Q: Dr. Eppley,   I was just curious if you personally perform orthognathic surgery on a routine basis (I know your website primarily focuses on plastic surgery procedures rather than maxillofacial ones) and if so, whether you ever perform it in an outpatient setting?  I know that I have a long road with dental work and orthodontics before I could even consider it, unfortunately, but I think the only way I could realistically afford to have jaw surgery is in an outpatient setting as I have heard how outrageously expensive it is in the hospital setting (and I do not expect insurance coverage in my situation).  My understanding is that some surgeons do in fact perform it in outpatient facilities (which is a more recent development due to the high cost) and I was wondering if that is something you have personally done or are familiar with.   A: Various forms of orthognathic surgery have been performed in surgery center locations for decades. While it is true that increasingly limited insurance coverage has made the concept of out of pocket orthognathic surgery more common, it is not new to perform it outside of a hospital setting. The key concept is that some orthognathic procedures can be performed this way but not all. Isolated maxillary (leFort 1), mandibular (sagittal split) and chin ( sliding genioplasty) procedures can be safely done as an outpatient. It is when these procedures are combined, which often may be needed, that a hospital setting is not only preferred but should not be done outside of it due to aiway and recovery concerns. Dr. Barry Eppley Indianapolis, Indiana Path : p  » span

Q: Dr. Eppley, I want to have CO2 laser resurfacing to reduce my facial scaring and would like to explore the possiblities of custom facial implants and a subtle chin dimple. The look I seek to obtain would be simular to Mario Lopez. Attached are some pictures of my face so you can see the acne scarring.

A: The question in any facial acne patient is how much scar reduction can be achieved and what is the best method to do so. Your pictures show a rolling hill-type pattern of acne acne scars across the cheeks. These would not be able to be improved by laser resurfacing. Rather they are best treated by a technique known as subcision and fat grafting where the base of the scars are released and then filled underneath with a fat filler. This is best way to make rolling hill acne scars have less indentation. Whether you would need custom implants to achieve your desired look is up for discussion. Chin dimples are straightforward and subtle is always a more achieveable result than a deep dimple.

Dr. Barry Eppley

Indianpolis, Indiana

Q: Dr. Eppley, I had an unfortunate fat graft and if englarged my masseter muscle (among other things).  I am looking to reduce the masseter area surgically. I do not think that botox will help as some of the bulk is fat. I was told that it was placed UNDER the masseter.  Do you know or can you suggest any local maxillofacial drs that could help me with this? I am worried about nerve damage. I also had too much fat along the lower jaw and it looks like jowling.  What are your thoughts on smart lipo type procedures? I had regular liposuction to try to fix this with no positive improvment at all. Thank you for your informative website and any advice you can give me. 

A: Given that you had liposuction of the masseter/jowls with no improvement, this would indicate that the fat is not in the subcutaneous space (of which you have already mentioned) and therefore no form of liposuction will work. This means then that the fat is either under the masseter muscle, in the masseter muscle or a combination of both. I would think it would be very difficult to get all the fat under the masseter muscle and some of it is likely in the muscle as well. Thus removal would require an intraoral submasseteric approach to get access to the fat. There is no risk of nerve injury in doing so so that should not be a concern. The only issue, in my mind, is how much fat could be removed from this approach and whether any masseter can or should be taken if there is not much fat visible in subperiosteal/subfascial plane. One way to really know where the fat is is to get a high resolution MRI of the masseter area. That would give a good idea beforehand of the success of such a procedure. The jowling fullness is another issue and, if not improved by liposuction, may have to consider some form of a jowl lift for improvement.

I can not give you any recommendations for any local doctors that may perform such procedures as I would think it would be very uncommon and may even make most uncomfortable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Am I too old for a tummy tuck? I am 61 years old and am 5’5″ and 165 pounds. I have an abdominal skin overhang that has been there for years which will not go away with exercise or anymore weight loss. I had a consultation with a doctor who said that liposuction wasn’t right for me. I now know that a tummy tuck is the only thing that is going to work. Despite my age, I am healthy and take no medications. Do you think I can still have a tummy tuck done at my age. I don’t want to live the rest of my life with this overhang if I don’t have to and I don’t want to regret later if my health ever worsens that I could have had it done. I would value your opinion on this matter.

A: Age is a minor issue compared to your health when considering a tummy tuck. Many women over age 60 have successful body contouring procedures such as breast augmentation, breast reduction and tummy tucks. While twenty years ago this wasn’t that common, it is today. As the contemporary phrase goes…today’s 60 is yesterday’s 50. If one is concerned about the magnitude or length of the operation, tummy tucks can be done that do not include the muscle repair and just focus on removal of the skin overhang. That simplifies the surgery and removes much of the discomfort of it. The one thing that age does do in any plastic surgery procedure is to draw focus to the most efficient way to do the surgery to lessen operative time and sometimes actual recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 27 years old. I need your help to correct my facial cosmetic problem. I had chubby cheeks and broad nose tip, a saddle bulbous appearance. It did not go well with my body as I’m of medium built. I always wanted to have chiseled face and sharp nose. I finally went to a cosmetic surgeon to get this corrected. The doctor performed a face liposuction, rhinoplasty and he also made a cut in my upper eyelids as I had some fat there as well. This procedure was done in January 2009. After this I developed facial asymmetry. The outcome of this surgery is listed below:

Cheek liposuction :

– The right side of the cheek looks more chubbier than the left one.

– The right corner of the mouth does not move as much as the left one.

– The right side cheek pad is sagging in mid cheek region towards the nose.

– Both cheeks lack toning.

– Face still looks chubby & not chiseled.

Rhinoplasty :

– Hardly any difference.

– Nose still looks bulbous.

I went to the same doctor asking for correction but he never agreed to these flaws and in fact tried to ignore. I felt cheated and went to another surgeon.  He extracted the buccal fat from my cheeks. However, still my cheeks look chubby. For my nose he has just placed the L-shaped implant through inside of the upper lip without making any other changes to the nose. I like the upper half of my nose as i needed little augmentation there but not in the later half. This has not solved my bulbous nose or wide tip problem. The shape of my nose has not changed. It just looks ” Over Augmented” specially in the lower part. This was done recently in September 2012. The surgeon says he can remove the implant if I don’t like it and give a stitch in the tip to narrow my tip.

I really wish to get this fixed as soon as possible as my life has stopped I really need to move on. Although I belong from a middle class family, I went out of the way to get this done but just ended up wasting my hard earned money. I am a focused person about what I want to achieve in life. I know things have gone wrong but I have not lost hope as I believe nothing is impossible if you are hopeful.

 I just need right guidance & skilled specialist who can help me correct this. I have read good reviews about you and seen your picture gallery. I really appreciate your contribution in the field of cosmetic surgery. Please help me with whatever best can be done. I have attached my photographs for your kind reference. Please revert to me and let me how we can take it further.

A: Thank you for your inquiry and sharing your unfortunate cosmetic surgery experiences. Your issues break done into two areas; your nose and your chubby face. It looks like you have had some negative effects of liposuction including asymmetric fat removal and weakness of the buccal branch of the facial nerve on one side.  Since you have already had the buccal fat pads removed, ti is not clear how much more improvement, if any, can be gained by further attempts at subcutaneous facial liposuction. I know that you are very unhappy with your fuller cheeks, but I do not think there is any ‘magical surgery’ that can provide the amount of facial slimming that you desire. It may be worth an effort to do some small cannula liposuction to try and get some areas more even but there is no operation that is going to make your face chiseled…it simply does not exist from where you are now.

Conversely, I think your nose does have room for more significant improvement from a further rhinoplasty effort.. What is not clear to me is exactly what has been done. (or even why) It is not clear at all what was done on the first rhinoplasty and the second rhinoplasty appears to merely have been the placement of an L-shaped silicone implant. It does not appear that you have had any real tip work done other than to try and stretch it out with an implant…which may have only pushed the wider tip up higher. I think you would benefit by some tip work for narrowing but the real question is what to do with your L-strut that is in place. There is dorsal augmentation benefit to it being there but it has also now stretched out the tip skin so removing it and not replacing it with something is going to make the tip situation worse. Normally I would opt for a rib cartilage graft replacement but that may further than you want to go.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had my saline implants since 1997 and my pockets have stretched. I am looking for breast revision. I’m interested in the techniques used along with before and after pictures.

A: When you refer to having your breast implant pockets stretched, I will assume that means your implants have both dropped (too low) and are even too far to the sides. (particularly when you lay done) Revision of your breast implants by etightening the implant pocket (making it smaller) is done by two fundamental techniques. The most common method is to remove part of the inferolateral capsule and tighten the pocket and lift the implants into a higher position using permanent sutures. This will be successful in the majority of cases. In patients that fail this method or have very thin capsular tissue and overlying skin, the entire lower breast pole may be supported by a sling of allogeneic dermis to provide the necessary lower pole support. This is not a first choice method due to the high costs associated with it although it is commonly used in breast reconstruction because insurance pays for the material. (the dermis material alone can cost anywhere from $4,000 to $6,000)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting my hairline as well as my forehead bone reduced. I was wondering do you also reduce the brow bone as well as the area below them and above the nose? I think it’s called the glabella and the bone around the eye socket. Do you do hair transplant procedures too? Do you think I should have my hair line lowered first or get my hair transplant before?

A: There is no question that if you were going to do both a hairline lowering/scalp advancement and hair tranplants, you would always do the hairline advancement first. It would be counterproductive to do hair transplants first and those would need to be cut out for the hairline lowering. Hair tranplants are used after hairline advancement to hide either the hairline scar better or to lower the frontal hairline further than what the scalp advancement can achieve. Whether the brow or lateral orbital rim (eye socket) is reduced with a forehead reduction depends on two factors. First what does the patient want to achieve. Would reducing those areas be aesthetically beneficial? It is really up to the patient to determine if that is needed to get the look they are after. Secondly, what is the thickness of the brow bone over the frontal sinuses. Is it thick enough to allow enough burring to make an external visible change? That can be determined by a simple skull x-ray beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 23 year old male with an indentation on the back left area of my skull. It has been there as long as I can remember. It is made worse by the the fact there is a slight bone protrudence to the right of the indent. I have no idea if it is congenital or not. This is clearly visible when my hair is cut short and I am looking to get it fixed. I have attached pictures so you can take a look. I have done a little research and discovered kryptonie, the bone cement and was wondering if that would be an option, or would you recommend something else? I have seen a plastic surgeon in where I am from but he’s not too sure if he could even help. I stumbled across your website and from your previous work, I am very interested in your opinion and setting up a consultation/procedure. I would much rather prefer to make only one trip if possible. I would like to know what are your thoughts on my skull and have you ever dealt with a case like mine before? Would a large incision with scarring be the only way to go about fixing this? Also, what is a rough estimation to what it would cost? Thanks so much for taking the time to read my email.

A: Your pictures show a skull indentation directly over the original site of the posterior fontanelle. This is where the back soft spot was as a baby that did not develop enough skull bone thickness as that of the surrounding skull when it fused. That indentation has probably been there since you were one or two years of age. That is why you have it and I have seen it and treated it before. Basically it is a simple indented skull area that can be built up and smoothed out. The key question is what is the best way to do it. It can be made absolutely smooth and level through a longer open incision but that is understandably not desirous due to your close-cropped hair. That leaves the other options of a minimal incisional approach (maybe 1 to 2 cms) which would allow the indented scalp soft tissues to be adequately elevated from the bone and through which some material could be used inserted. Understand that an injectable technique does not mean incision free, it means that the material as the ability to flow through tubes (not needles) and thus only a small incision is used to place it.  This is best thought of as a ‘minimal incision cranioplasty’. Kryptonite as an ‘injectable’ material is no longer commercially available to do this so that leaves us with two other options, PMMA or OsteoVation. There are minor advantages and disadvantage to each material which can be discussed later. Both are liquid and powders that are mixed into an initially runny material which allows it to be pushed into a pocket by syringe created over the bone indentation after the release of the attached soft tissues.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to get rid of my facial wasting due to HIV. I am interested in cheek implants and fat fillers for lipodystrophy. I have attached a picture of my face for your evaluation.

A: In looking at the one picture you sent, your greatest area of lipoatrophy is in the temples and secondarily in the submalar regions. Compared to many patients that I see, your degree of facial lipoatrophy is fortunately more moderate in severity. Given that you have existing lipoatrophy, and I assume you are on antiviral medication, this makes the use of injectable fat survival precarious at best. For this reason, I make an effort to use permanent synthetic implants when possible for its treatment. These would be applicable to the temporal, submalar and even the nasolabial fold areas. But facial implants do not cover all facial lipoatrophy areas and are at best thought of as building blocks from which to fill around with fat injections as needed. Even though fat injection survival is unpredictable, it is the best filler to use for broader facial areas. And since it is not the only method of treatment that is being done, any survival that is achieved is a bonus to the underlying implants.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 27 year old male. I am in good shape and workout all the time. I have lipomas all over my body and have had four surgeries to remove them. I have always had excision. I now have near 100 scars and would like to figure out another option for myself. I have read about your practice and wondering if you could help. I have done a little research on fat dissolving injections. I would prefer not to have as many scars as I do now, but I know that surgery is the best option. So far I have had four surgeries and have removed about 90 small lipomas. I don’t understand why I get them as I am very healthy and in good shape. I exercise regularly and eat a well balanced diet. I would prefer the injections if you feel it is worth my time and money or a possible liposuction technique. I’m not against excision but would prefer no more scars. Thank you for getting back with me.

A: The condition that you have is known as familial lipomatosis. There is where someone, like you, develops recurrent and new subcutaneous lipomas all over their body. It has nothing to do with your weight, diet or exercise habits. It is a genetic condition where these lipomas develop and no one understands the cause and how to control it. All that can be done is selective removal of the most problematic lipomas. While surgical excision is the established and most definitive treatment for lipomas, it can certainly be taxing to undergo recurrent surgeries for them. Lipodissolve is a generic name for the injection of a known fat dissolving solution that contains phosphatidycholine, deoxycholic acid or various combinations of both. This is a compounding pharmacy injection not an FDA-approved drug. (although it is currently under current phase II clinical trials by Kyphera for neck fat reduction) This approach for fat reduction achieved notoriety in the mid-2000s when it was widely used across the U.S. for cosmetic body contouring and fat reduction. Its use collapsed when the company promoting it collapsed and the FDA stepped in and stopped its widespread use as an unregulated cosmetic treatment.

When it comes to the use of these injections for lipomas, I have used them in numerous patients with reasonable success. It does shrink them by fibrosis and scarring. It may take more than one injection session to get the maximal reduction. The lipomas may or may not regrow based on their original size and how much reduction is obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 5’ 5” and weigh 172 lbs. I am considering a tummy tuck to get rid of my belly that is hanging over my pant line. I am not completely sure I am done having children but I want to go ahead and have a tummy tuck anyway. I am tired if carrying around this belly. My question is can I have a tummy tuck under local or something less than general anesthesia? Also if I should have another child in the future will I be able to get by without changing the look of the tummy tuck?

A: To get the best result from a tummy tuck, it really needs to be done under a general anesthetic. A tummy tuck is one cosmetic operation where the option of a local or IV sedation is just not practical and would not even be considered. Any pregnancy that goes to full-term is going to affect the results of any tummy tuck procedure. It is just a question to what degree will the tummy tuck change and how much loose abdominal skin will result. While it is likely that it will not create a complete return to the way you look now with a significant abdominal overhang, some new skin rolls will likely result.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question what is the difference between the custom implant and the off the shelf jaw implants? I think for my ideal face I would like to achieve is to vertically lengthen my chin only a bit and make it more wide. For my jaw I think just maybe only a little bit widen but more lengthened so I would have a longer smaller looking face. I think for me its not so nice to widen it too much). I want the same face I have now only smaller looking with a better jawline. I have attached a male model’s photo which is what I want to reach is something like that possible for my face?Also I am a bit concerned if something would go wrong, is it being corrected for free then? And how long should I stay in Indianapolis as I don’t want to know people at home.

A: The role of custom facial implants is useful when off-the-shelf implants can not produce the desired effect either due to the size changes needed, a special shape of the implant is required or there is asymmetry between two sides. Another difference is that custom implants cost a lot more and will add $7500 to a surgical procedure such as yours. So you have to have a real good question to go the custom route. 

The model photo you have shown can not be exactly achieved on you because only a custom jawline implant can create a perfectly smooth wrap around effect.

If revisional surgery is needed, the patient is responsible for the costs of the operating room and anesthesia costs. No revisional surgery procedure is completely free.

Most jawline implant patients will stay 2 to 3 days before returning home. But if you are not desiring to go home until most of the obvious swelling is gone, then it will be several weeks. (which is a bit impractical for most patients)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a combined forehead augmentation and rhinoplasty. Please see the file attached for my thoughts on how I want to look on the front of my face. Please forgive the crudeness of the drawing, I only have Windows Paint on my computer to play with, which is very limited in abilities ;-). It should give you a general idea however. One of my questions is will the forehead augmentation result in a possible simultaneous hairline lowering? Also, how long would the recovery period be?

A: That is actually a very good drawing as it is always important to understand what the patient actually wants. Any forehead augmentation procedure requires a scalp incision which is almost always placed way behind the hairline and does not really result in hairline lowering. That raises the other possibility of making a hairline incision (what we call pretrichial) to do the forehead augmentation and then try to bring the scalp forward to lower the hairline. This would obviously place the incision at the hairline. Just an additional thought although I always feel it is better to have the incision way away from where the cranioplasty material is placed.

When it comes to recovery from a combined forehead augmentation and rhinoplasty (which is actually not a rare combination in my experience), you would expect to look pretty reasonable in about 10 to 14 days. (although all swelling takes about 6 weeks and final refinements up to 3 months after surgery) It is not really a physical recovery but one of appearance.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hello! I have a scar on my forehead indented with a small amount of tissue over and it is same color as skin. Any options for improvement? Here is a picture of what it looks like. I am just particular about it and cover it with makeup daily:) My brother thought Juvederm would work, but I am looking for something a little more long term. Thank you so much.

A: When evaluating scars it is first important to evaluate its physical characteristics. That is the key to determining the best treatment for its potential improvement. Your vertical glabellar (between the eyebrows) scar has one feature that makes it the most visible…it is wide with a depressed gap between the skin edges. When you have a depressed scar the only chance for improvement is excision and reclosure to level out the skin edges and make the scar more narrow. In addition to prevent recurrent collapse of the scar line, the closure should not be a straight lone closure but that of a broken line or geometric closure like a w-plasty pattern. Your small forehead scar revision could be done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Could one have a custom made implant for the chin based on a facial casting to set up a mold for a bone paste like kryptonite. The theory here is that if the implant is a perfect fit then the paste will be a fit perfect too. To clarify… The paste would need to be pressed into the custom mold to set up the shape and then inserted into a ready pocket created with the help of the solid implant. You would avoid the blind aspect of shaping from the outside and complete the critical portion within the 4 minutes allotted to hardening.

A: Your thoughts are good ones but is limited by one major factor. Kryptonite is no longer commercially available (for reasons I do not know) and this is the only calcium-based bone cement that has the biomechanical properties to be molded and inserted similar to a solid implant. The other issue is that bone cements, even if preformed, are not flexible so intimate adaptation to the underlying bone may not occur. This could create some rocking and movement of such a custom made chin implant afterwards.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been bullied for a number of years over the shape of my skull and I am looking to do something about it as it’s ruining my life. The width is an abnormal shape and above the ears it sticks out quite a bit. I have read some of the questions on the website and seen Doctor Eppley’s answers which seem like it would be something that can assist me. Am I right in saying Doctor Eppley is the only person in the world who performs skull reduction surgery? I have spoken briefly with someone over email where I live but I am not sure the procedure they suggested is what I am looking for. I need to find the right procedure as I feel  it is a necessity to have it done to be able to enjoy my life at all. I’m so depressed about it and I’m really searching for someone to help me before I get myself in to a bigger hole with the depression.

I have attached a picture. Are you able to say whether I can be helped or not please?

How long would I need to be in hospital for and when could I travel back home?

I’m worried about the strength of my skull after the surgery, I will be able to live a normal life afterwards won’t I, like play football etc??

I really appreciate your help and you taking the time to read this I understand you are very busy. Another question is that my ears are quite pointy/large and if I was to undertake this surgery I’m worried they will stick out even more, can anything be done with them so this doesn’t happen and they look a bit more normal?

I’m so sorry for so many questions. Whereabouts on my head would the incisions be? Would they be behind the ears and would they be quite deep scars?

I had thought about hair transplants at some point in the future because my hair seems to be disappearing rather quickly but I do prefer the shaved look if I’m honest. Do you think this would be a major problem?

I have to admit it has put a smile on my face knowing that you can possibly help. From the picture do you think the 5mm-7mm you mention in your questions section on the website will be enough to make my head look more normal in terms of shape?

Thank you so much for getting back to me.

A: Thank you for your inquiry and sending your pictures. From what I can see in this one picture (which is the most helpful view), there is temporal skull/muscle protrusion as well as ears that stick out a bit. This could be improved by a combination temporal muscle/bone reduction cranioplasty combined with a setback otoplasty.

This is a procedure that is done as an outpatient and one could return home in 48 hours. There would be no worries about the strength of your skull and you would not have any restrictions after surgery.

The most relevant issue is that an incision is needed on both sides to do the surgery and this is always a concern when it is a male who shaves his head or a has a close cropped hairstyle. We just have to be careful to not ‘trade-off one problem for another’.

To be certain we are looking at the same thing, I have done some before and after imaging to see if the changes that are possible is in line with what your objectives are. This is probably what a 5 to 7mm reduction can achieve.

The incisions would be vertical in the hairline just behind the ears and extending upward about 6 to 7 cms. They are not deep or indented scars but rather just fine lines.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 42 year old male and I am interested in a Chondrolaryngoplasty. (adam’s apple reduction) I am just very self conscious about my large adam’s apple and I am just tired of being harassed about it. I have heard that the cartilage turns to bone at a certain age so at 42 can I still have this procedure done?

A: While it is true that many cartilage areas in the body get partially calcified as one ages, and the thyroid cartilage is no exception, this is not a concern for you at age 42. At this age the thyroid cartilage is still mainly cartilage and it does not change the ability to shave it down. The reality is that even if you were older and the thyroid cartilage was more calcified, it could still be reduced and would be burred down by a machine-driven rotary drill as opposed to shaving. Thus, you should feel completely comfortable being able to have a successful adam’s apple reduction (chondrothyroplasty) at any age regardless of whether the cartilage is uncalcified, partially calcified or even completely calcified.

Dr. Barry Eppley

Indianapolis,Indiana