Your Questions

Q: Dr. Eppley, I had an endoscopic brow lift 2 years ago. It was pulled far too high and has formed what I can only describe as crater-like vertical depressions. This is so strange looking. I was so much better before with my normal horizontal thin lines. Is there anything that can fix this….is a reverse brow lift successful….could fillers wk….or hair transplant to cover the high long forehead?

A: One of the trade-offs for an endoscopic browlift is a longer forehead because this type of browlifting procedure is really an epicranial shift…it moves the scalp backwards to create the browlift below. The length of a patient’s forehead must be assessed beforehand and this effect considered when choosing any type of browlift.

The vertical depressions that you have are the effect of the internal fixation technique used to secure the uplifted  scalp near or in the hairline. They are reflective of a really pulled up scalp and perhaps too aggressive browlift.

In terms of improvement, endoscopic browlifts can be partially reversed by the same method that caused the initial effects. Wide forehead and scalp loosening done through the same incisions as the initial operation may allow some reshifting of the tissues back to less stretched look. This may provide some improvement in the vertical depressions and partial lowering of the hairline. Fillers and hair transplants are also options to deal with the problems you now have but I would first try and treat the cause of the problem before exclusively treating the symptoms of the problem first. Those are always options if tissue loosening and reshifting is not entirely successful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I would like information on liposuction and butt augmentation. I would like information on estimated cost and recovery time. Thanks I hope to hear from you soon.

A:  Thank you for your inquiry. The questions you have asked are broad with different options and make your questions impossible to answer without being very procedure specific. I would need to know more specifics about what exact liposuction and buttock augmentation procedures you desire.

1) What areas of fat removal by liposuction are you seeking? How many different body areas?

2) For buttock augmentation, is it by implants or fat injections?

This information is vital because much of the costs of surgery are based on the time that it takes to do them. For the sake of the most common method of buttock augmentation, which is fat injections from abdominal and flank liposuction harvests (aka the Brazilian Butt Lift), I will have my assistant pass along some costs to you later today for this approach. Those costs will range between $6500 and $8500 depending on how much liposuction is done/needed. This combination has the dual advantage of contouring multiple body areas by reduction of body areas around the buttocks which makes any buttock size increase look even better. Depending on the type of work that you do, I would anticipate a minimum of 10 to 14 days until you get comfortably back to most normal activities of daily living.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been reading for quite some time on your website and I found a lot of terrific information.  I am looking for what you describe as the “Male Model Look”. Could you please tell by the enclosed photos what procedures you would suggest for my face in order to achieve this look. I have been reading about jaw angle, jaw, implants and cheek implants but would like to know what you suggest for my particular face.  What else would you suggest? I am 38 years old. I have already had my ears pinned one month ago. Could you also do a custom facial imaging so that I have an idea how I will look (more or less). 

A: Thank you for your inquiry. The so called Male Model Look is really about accentuating some or all of the skeletal highlights of the face. These include the brow bones, nose, cheeks, chin and jaw angles/jawline. One has to not have too thick of facial soft tissues to see the effects of the augmentations. When analyzing your face, you have the right amount of soft tissue cover to show these effects well. You are most deficient in the jawline area (chin and jaw angles) and secondarily in the cheeks. For starters, I have just focused on these three areas as you can see in the attached computer imaging. There would be the 'best value' procedures for your face. The only other thought would be some nasal thinning in the tip area. (but I have not done that so you can focus on the more important areas for now)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am at wits end. 🙁 I had goretex implants in nasal-labial folds about 12 yrs ago. They capsulated shortly after and I looked hideous. So I've been filling around them for years even had a face lift. Finally, about 6 months ago I had them removed and replaced with Alloderm.. It looks worse!!! One side is hard and they both show thru the skin. The company will not give me info. Can they be successfully removed??? Today, I am having Ultherapy in hopes of tightening to minimize the awful protrusions.:((I used to be a model and now I can't even look in a mirror)

A: I see no problem with easily removing Alloderm. It does not usually incorporate much into the surrounding tissues. It gets encapsulated, almost like your original Gore-tex implants, which is why it contracted and became distorted. In hindsight, that probably was not the best choice for a replacement for the Gore-tex as it did exactly what could have been predicted in that situation. I would not expect Ultherapy to make any difference. That approach is a hopeful but flawed concept.  A much better replacement once they are removed would be dermal-fat grafts or fat injections, a natural tissue that will heal into the surrounding tissues adding volume and will not develop contractures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting quotes and suggestions on liposuction and a breast lift. I already have implants but looking to go smaller and I'm up in the air on replacing them, removing, or keeping the ones I've got. I've have breastfed 4 children and also need a lift and full contouring. What are your prices and are you running any promotions?

A: Unfortunately based on the information that you have given me I can not be of much help to you. It is impossible to give reasonably accurate pricing when you don’t really know what the patient needs. Liposuction can be done on 12 different areas of the body, there are four different types of breast lifts and two types of breast implant options. That leaves a tremendous number of variables to consider all of which take differing amounts of time and effort needed to do the surgery…and that hugely impacts cost. The best way to figure out what you may need  is to either see some pictures of your concerns or give me a very specific set of procedures that you want to do. I suspect you need at least a full breast lift but knowing what to do with your indwelling implants is a very important consideration. Remember that when you do a breast lift, the actual size of the breast gets smaller. Taking out indwelling implants with any degree of sagging will leave you with very flat breasts despite the fact that they may be in much better position higher up on your chest after a lift. When it comes liposuction, I suspect you may be focused on your abdomen and waistline. But whether that would be an effective contouring technique in someone who has had four pregnancies with likely loose skin and stretch marks is an issue yet undecided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a combined breast lift with implants nearly 5 days ago. My recovery is going well I think, however, the appearance of my breasts concerns me.  I've attached two photos (front & side view).  My concern is that my breasts are oblong with a definite, large “indentation” above the nipple.  In the photos, you see the implant sitting high, then a big indentation above what, I think, is my own breast tissue below.  This seems abnormal to me.  My breast shape looks kind of like an eggplant. Is this a cause for concern? 

A:  When undergoing a combined breast implant and lift for severe breast sagging, the early appearance can be disturbing. This is because the implants often ride early and in conjunction with swelling can push the breast tissue forward and down. This creates the exact appearance that you are seeing. It is important to remember that it is early and many changes will take place. One of those is that the implants will drop. This can be helped by wearing a breast band to encourage the implants to move south into the bottom that has been created for them. Putting gentle sustained pressure on the upper pole of the breasts will help the bottom tissues to expand and allow the implants to drop. It will take 6 to 8 weeks before you have a clear idea as to how much dropping they are going to do. They will definitely drop, it is just a matter of how much. Once that happens the breast tissue in front of them will move up into a better position on the implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year old male. I would like to have Restylane injected under my eyes in order to reduce the appearance of my eye bags/dark circles. Is this something that you would do often at your clinic? Am I a suitable candidate? I would also like to increase the definition of my jawline/chin. Have you ever made a more male, square, enhanced jawline/chin by using fillers alone, such as Radiesse? Or would I need to get jaw and chin implants? Do you do this procedure often? I don't like the way there is a slight double chin at certain angles, as you can see in the photo, would fillers get rid of this or would I need a chin implant? The last three photos are of jawlines that I would like mine to be more like.

A: When you look at all of your facial issues combined, they have a similar theme…an underlying bone deficiency. In the words, you are structurally weak. This is particularly relevant in the lower eyelid area where the problem is a recessed infra-orbital rim and cheek bones. That is why you have this appearance at such a young age. The chin and jawline issue is not as weak as it is just your desire for a much stronger one.

As for injectable fillers, they are a poor treatment for the under the eye area and are absolutely a contraindicated treatment for the chin and jawline. While injecting Restylane under the eyes can be done, I have never been that impressed with its results for your particular problem and it is only a temporary fix at best. Irregularities are very common in this area with injectable treatments that will persist as long as the filler lasts. You would be much better served by a combined infra-orbital/malar implants in this area which would correct the entire problem from the rim to the cheek and be permanent. From a jawline perspective, every young male shows me male model/actor pictures just like the ones you have shown. Those type of results are only obtainable with chin and jaw angle implants, ideally custom made ones that connect the chin and jaw angles in one smooth line.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 35 years old and am 5’ 4” and weight 138 lbs. I had my last child one year ago and am back to my prepregnancy weight but can’t get rid of this loose tummy skin and fat. I went to a plastic surgery consultation and, in addition to a tummy tuck, was told that I needed liposuction as well. Do I really need to get liposuction on my love handles with my tummy tuck to get the best result? Since I am going for surgery I want the best result. I'm pretty happy with my general size, I just want to be firmer and smaller around my stomach.

A: It is a common misconception as to how far the effects of a tummy tuck reach. The main effect of a tummy tuck is seen between the hip points, it is essentially a 180 degree procedure of the trunk.. One must remember that waistline reshaping is closer to a 270 or 300 degree procedure. To extend the benefits of a tummy tuck, whose tissue excision and scar stops at the hips, fat removal by liposuction must be done to continue the narrowing benefit around the corner of the hips and into the back. This liposuction effects what most people call the love handles or the flanks. This not only flattens or indents the love handles but also decreases the risk of dogears or fullness at the ends of the tummy tuck incisions. I would estimate that about 2/3s of abdominal reshaping patients in my practice need the combined tummy tuck and flank liposuction procedures for the best result.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, what is a mini facelift with a simple subtuck treatment? Is a subtuck treatment to the neck area, and how is it performed?

A: When you use the term ‘subtuck’, you are referring to the submental area of the upper central neck. That is an area that will not be affected by a mini-facelift unlike a full or regular facelift. In a mini-facelift (aka Lifestyle Lift amongst many names) the jowls and the face behind them is effectively lifted and tucked. But the submental area is not changed by a mini-facelift because it is a more limited type of facelift that does not reach this far forward. This is why some type of submental treatment, such as liposuction or a submental tuckup, often needs to be done at the same time as the mini-facelift to get a more complete result. These submental procedures are done through a small incision underneath the chin.

Not every mini-facelift needs to have submental manipulation, it just depends on how much loose skin or extra fat is in this area. I would estimate that two-thirds of mini-facelift patients do need submental attention as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One month ago I underwent surgery on my left cheekbone which was fractured fixed after being punched in the face. The surgery was done through a lower eyelid incision. My surgeon warned me that there was a chance that my lower eyelid would sag lower afterwords and, if it did, he recommended massaging of the lower eyelid and cheek a few times a day for a few minutes. If time and massaging is unsuccessful at bringing my lower eyelid back into place, what can be done? How long should I wait before having additional surgery to fix the lower eyelid sag?

A: Lower eyelid sag, also known as ectropion, is a known potential complication from any surgery that passes through the lower eyelid. Scarring of the layers of the lower eyelid or loss of lateral canthal tendon support can result in lower eyelid malposition. In some cases it is temporary until the swelling from surgery goes away and the lower eyelid skin relaxes. But if it is persistent  or significant still at 3 months after surgery with no significant change, then a lower eyelid revision procedure will be needed. There are a variety of options to get the lid back up to a more normal horizontal position, the most common being release and lateral canthal tightening. This works satisfactorily when the ectropion and scarring is not severe. In more difficult cases, the release and lateral canthal tightening needs to be combined with a dermal graft in the middle lamellar tissues to add tissue that is scarred and provide good support for lateral canthal attachment.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m an Asian patient who underwent augmentation rhinoplasty 4 months ago with diced rib cartilage, but the augmentation isn’t enough. When I consulted the surgeon, he said the diced cartilage technique either undercorrects or overcorrects the nose. With bloc rib rhinoplasty, it’s easier to control precision of the augmentation required but subject to warping. Is that true? I’m planning to have another revision to augment the height again using bloc rib cartilage. What do you think? How long more do I have to wait for a revision? I just wish to push for more height. Thanks.

A: In general, diced cartilage for total dorsal augmentation can be a very satisfactory technique if the amount of height required is no more than 3 or 4mms. For most Asian rhinoplasties, sufficient dorsal height is usually closer to 7mms. Thus a diced cartilage dorsal augmentation may be insufficient because the push of the skin at this amount of augmentation is significant and the diced cartilage construct is not strong enough to resist it. So even if the diced cartilage roll was 7mm in height, it would be pushed back down and flattened somewhat. A bloc cartilage graft is much more successful in displacing the dorsal nasal skin upward the required amount for the obvious reason thatit  is solid and can not be deformed. While it is true that bloc cartilage has the risk of warping, the key to prevention of that problem lies in the harvest. Rib grafts are absolutely needed and getting a fairly straight cartilage graft of 3.5 to 4cms in length can be difficult but it can be done.

As for the timing of the revision, since you know you desire more now that the initial swelling has gone down you could proceed at any time with a revisional rib graft rhinoplasty.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, hello, I am 37 yrs old and I have a 100% overbite with a deep labiomental fold. I want to have that fixed and get a better jawline and chin and don’t know what procedure would work for me.

A: In looking at your pictures, I can see the external symptoms of the 100% overbite to which you have described. The jaw is overrotated upward causing a vertically short chin (albeit with a touch too much horizontal projection) and a deep labiomental fold. Thi is what happens when there is not an adequate occlusal stop on jaw closure. (overbite should usually be about 10 to 20%)

Correction can be done by one two approaches.  One option is a vertically lengthening chin osteotomy with an interpositional hydroxyapatite block graft. This would need to be at least 1 cm (10mm) of vertical lengthening if not more. This would create more of a prominent chin and would help lessen the visible depth of the labiomental fold as it stretches down the chin tissues downward. I have attached some computer imaging of that potential result. The other option is a custom chin implant that would vertically lengthen the chin as well as back along the jawline. In either case, a labiomental implant could also be used to shallow the depth of the fold although this may not be needed with the chin osteotomy as the fold naturally becomes a little less deep as the soft tissues are moved downward with the bony movement.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, What I am wanting to do is just reduce the high ridge on my head. That’s the only problem I have. My head seems as it has a bump right on top. I have attached three pictures to show you what I mean. it is pretty obvious.

A: What you have is a common condition that I see in aesthetic skull deformities, the prominent sagittal or midline ridge running from the front to the back. This gives the head  a high arching or a triangular shape. What is important to realize about this skull deformity is that it is more than just a prominent midline ridge, the sides of the skull next to it are also too low. It is the combination of the two that makes it look that way. Thus to do its correction and achieve a rounder skull shape, both problems must be simultaneously addressed. It is more than just burring down the midline ridge as there is a limit as to how much that can be done. (usually 5 to 7mms) The sides along the ridge out to the temporal line must be built up as well with cranioplasty material. When done together the desired look is obtained as I have illustrated in the attached computer imaging prediction.

While this skull reshaping can certainly be done and is not difficult to go through, the key decision as to whether this is right for you is whether the incision and the resultant scar to do it is an acceptable trade-off. An incision would be needed across the top of the head with a resultant fine line scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know what kind of result to expect by injecting 1cc of fat grafting in the upper lip. Thanks for your answer.

A: Your question in regards to fat injection grafting of the upper lip has a two-fold answer. First,  fat injections to the lips are associated with a very high rate of reabsorption often being completely gone within 6 weeks of the procedure. This is the most difficult area of the face in which to get fat to be persistent. Lip tissue is different than the rest of the face and their near constant motion all contribute to the low rate of sustained augmentation. When fat injections into the lips are done, overfilling is a common technique in the hope that even if most of it is reabsorbed some will remain. Based on this premise, usually 2 to 3ccs of fat is injected into a lip. Second, while 1cc of a synthetic injectate would be considered more than adequate for any lip (because the objective is to have an immediate but not overfilled result) that would not be a good approach with fat for the reasons just described.

Thus 1cc of fat injected into the upper lip will produce an immediate and satisfying result (just like that of a synthetic filler), I suspect most of it will be gone before a month has passed after the injection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 22 year old female who underwent a forehead lipoma removal by a neurosurgeon two years ago. He did a bicoronal flap and a small frontal craniotomy because part of the lesion that was tethered in the bone and he didn’t want to just pull it for fear of intracranial extension. The pathology showed it was a lipoma and I now have plate and screws in the forehead which are palpable. I now have a 3cm x 3cm area in the middle of my forehead that is excess tissue where the lipoma was. It is basically a balloon (hollow) with slightly thinner skin. I attached some photos.

My surgeon gave me the following options for correction:

1) A hairline incision appraoch but that would pull my already normal brows up.

2) A bicoronal incision would already raise my already high forehead and pull my brows up.

3) A direct horizontal incision (I have no forehead rythids) but maybe this is the best option and I have to settle for a scar? If I have a direct excision it gives my surgeon the advantage to go subperiosteal and remove the plate which is palpable.

I am stuck in terms of knowing what to do and would really appreciate your opinion!

A: The simple answer to your case is why don’t you just do a bicoronal incisional approach? You already have the scar and a bicoronal flap does not raise up the eyebrows unless scalp skin is removed and that is the intent of the procedure. This will provide a direct approach to removing the plates and screws and possibly filling in the craniotomy defect/irregularities with hydroxyapatite cement.

I would never do a hairline incision when a bicoronal incision exists behind it. You have no way of knowing how well the vascular inflow to the intervening skin segment between the two incisions is and there is a real risk of scalp necrosis.

For a cosmetic forehead problem in a young woman, it would be a near surgical crime to put a horizontal scar on your forehead, trading off one cosmetic problem for another…and the scar will likely look worse than what you have now. This would be particularly egregious when a bicoronal scalp scar already exists and there are no cosmetic trade-offs for using it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, if I was to have a rhinoplasty to augment the bridge of my nose and a forehead/eyebrow augmentation, which should be done first? Will having the raising of the nose bridge first and then the forehead/ brow augmentation mess up the profile of the nose together with the brow ? Which procedures should I do first for best results ? Does it make a difference ?

A: I think the best aesthetic sequence is to do the forehead before the rhinoplasty. That way the position of the nasal implant can be optimized to that of the frontonasal level of the brow augmentation. That is a lot easier to do than the other way around. Getting a significant augmentation of the brow, particularly in the glabellar area, is more difficult that just forehead augmentation where you leave the brow area alone. Once a forehead/brow augmentation is done it is very difficult to change particularly if you are trying to add more to the brow or glabellar area. Therefore, create whatever brow/forehead augmentation that can be done and then set the level of the nasal bridge to that. In essence, work your way down from the top based on the difficulty of doing the procedure. When brow augmentation and rhinoplasty is done at the same time, it is easier to make both meet in the ‘middle’ so to speak.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttock augmentation. However, looking at the before and after pictures, it doesn’t look like much of a difference. I would like a really big butt.

A: While the definition of a really big butt is open to various opinions, let me give you the overview of buttock augmentation options and the reality of their outcomes and the process.

SYNTHETIC INJECTIONS Known as black market injections of silicone oils and even caulking compounds, this is an illegal procedure that has a high rate of conplications. While a much larger buttock size can be immediately obtained at the cheapest price, this is not a good trade-off when one risks severe buttock lumpiness, skin pigment changes, infection, chronic pain and even death from necrotizing fasciitis and pulmonary emboli. But when you injected in a hotel room or house by someone of absolutely no training with non-medical and non-FDA approved materials, these results should not be surprising.

FAT INJECTIONS This is the most common method of buttock augmentation today and the most popular. The name Brazilian Butt Lift is what it is most known by. While it is the most popular, that does not mean it is the most effective because it isn’t. Improvements in buttock size can be expected to be modest as best. It is popular because it is a natural material and there is the concomitant body contouring benefit of the liposuction procedure that is needed for the fat harvest. The survival of fat, no matter what you may read, is far from assured and even at its best a 50% survival of what was be injected I would consider a spectacular success.

IMPLANTS The most assured method of sustainable buttock augmentation is with the use of FDA-approved soft buttock implants made from silicone gel elastomers. Implants will produce the biggest size that will last but is a more invasive surgical procedure with a significant recovery and costs. There are two ways to place buttock implants, above and inside the gluteal muscle, and this will also influence the result and the recovery. The best place to put implants is inside the muscle. (intramuscular) This is the best for implants long-term and is associated with the least potential complications but the size increase will be moderate (350cc or less) and the recovery is the hardest. In a small person the buttock size change can be very significant. In larger patients, it will be more moderate. If the implants is placed above the muscle, the largest available implants can be placed in most people (up to 600cc) and the recovery is less than when placed inside the muscle. But there are higher risks of infection, fluid collections and implant shifting than when the implant is placed inside the gluteal muscle.

In short, you can now see that different methods of buttock augmentation have different outcomes, risks and recovery associated with them. So when your goal is a ‘really big butt’, your only good options is a buttock implant placed above the muscle. Whether someone is willing to expend that effort is why so many patient opt for fat injections…but should only do when they are understanding of what the final result will likely be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty done in 2008 which was the worst decision I ever made. The surgeon overresected my dorsum, leaving me with an unsightly saddle nose deformity. I lost many friends and my confidence suffered for years because the nose was simply wrong. I am considering your diced cartilage injection technique because it’s the fastest way for me to regain my dorsum. May we discuss further?

A: What is important in any revisional rhinoplasty procedure is the result not that any one technique is faster or less invasive. When it comes to rebuilding the dorsum, you need cartilage and ac cartilage harvest. Whether this  could be done from the septum, ear or rib depends on how much volume you need. Then there is the issue of a scarred dorsum as a result of the first procedure. This makes the skin much harder to raise and more difficult to get a good pocket. Diced cartilage, unless it is wrapped in a carrier (fascia or surgical) can create an uneven contour if it is merely injected in large volumes. It is more appropriate for small defect areas.

In short, the diced cartilage injection technique may not be suitable for a larger augmentation of a low dorsum. I would have to see pictures to be sure. Standard techniques such as cartilage onlays or block rib grafts may be suited for your revisional rhinoplasty. Don’t compound your original problem by seeking a technique that is ‘fastest’ or has the least recovery, have a technique done that offers the best result even if it is not the ‘fastest’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know I have an asymmetric face. Do you think that I’m going to benefit from a  buccal fat removal or my problem is the bone structure? I’m 5’3, 120 pounds and 36 years old. I have these chubby cheeks my whole life. At home, when no one is around, I suck my cheeks in. My definition for a beautiful face is the almost gaunt effect. Thank you.

A: Thank you for sending your pictures. I do think the combination of buccal lipectomies and perioral mound (lower cheek area just opposite the mouth, is not part of the buccal fat pad nor would be reduced by the buccal lipectomies) would be beneficial for slimming your face. I don’t think you can get to a gaunt face, nor would you really want to long-term, but it would make a noticeable difference with your facial structure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in occipital cranioplasty, and I have a couple of questions. The flat area is on the upper part of my head. I will be having hair transplant surgery and right now I’m probably a Class V. If I want to go ahead with the cranioplasty should I do it before the transplant procedures or after. I will have to have at least two sessions and I might not be a candidate for FUE. If that’s the case then the strip method will be used and the doctor will have to undermine my scalp. I’m afraid that if the cranioplasty is done first the doctor might have trouble undermining my scalp for the transplant. Second, with the cranioplasty I would want the stronger material (acrylic) and would want it to be fixed to the bone with screws, mostly because I’m active. The question is, would I be able to do a headstand with the material attached to my skull? Would it hold up to my full weight even if I do neck bridges, like in judo? Or once I have it done I would have to kiss those kinds of exercises goodbye? I would want that puppy in there permanently and solidly attached to the back of my head.

A: When it comes to occipital cranioplasty and hair transplantation done with the strip method, they are mutually exclusive. Occipital cranioplasty requires scalp expansion of which strip harvesting takes away scalp in the same general area. The two can never be done on the same patient no matter how they are sequenced. There is also the issue of vascular compromise to the posterior scalp caused by strip harvesting which make the blood supply to the scalp precarious in the midline if an occipital scalp flap was ever raised.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am one month post surgery for chin implant done through the mouth. There has been a lump on one side right below the jaw line that is very hard, size of a pencil eraser. My sugeon want to correct it in the office under local anesthesia but plans on taking it out and putting it back in and going through the mouth again. This terrifies me for many reasons. I just now got all feeling back in my lower lip. I had a lot of pain from the stitches and I’m afraid of a worse outcome, and being awake in the office. I’d rather be put out. Should I get a second opinion? He is ready to do the revision now.

A: I think the timing for the chin implant revision is appropriate but you should have it done under the circumstances of which you are most comfortable. You should tell your surgeon you are not comfortable under local and perhaps he will consider some IV sedation which can feel very much like going to sleep. If not, then you will have to consider another surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, right now I have 250 cc mentor smooth round moderate profile implants. I had the surgery 7 years ago and have been in pain all these years. I am finally able to get a revision and switch over to silicone gel implants. I would like to be a bit larger, but very minimal…where me and my husband can notice, but not so much my co-workers and family. I would like more cleavage and not such a big gap in between my breasts. I am 5’7, 118lbs, and naturally was a 32 AA. I am considering either 350cc or 375cc silicone gel moderate plus implants. What would you advise between the two? Isn’t it different when switching over from saline to silicone gel? Meaning adding 125cc’s going from saline to saline, would be much larger than going from saline to silicone gel. The cc’s are the same of course, but because of the way the gel conforms to the body (and is dense), it appears smaller. –so is adding 125cc’s going from saline to silicone 50% bigger?

A: That size difference, 350cc vs 375cc, is visually irrelevant. Always go with the very slightly larger size when choosing between a 25cc difference in implant choices..Regardless of this size change, you will not get your breasts any closer. That would require a much larger implant size to push the volume in towards the sternum. The volumes of saline and silicone implants are identical per cc and there really is no significant size difference between the two. There may be a slight difference in shape with the same size but that is also affected by the projection of the implant shell so saline and silicone breast implants can look very similar depending on what projection of implant is chosen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have bad stretch marks on my stomach and a lot of skin hang over. I’m 5’2 and weigh 159lbs. I have lost 20 pounds and now I’m at a stand still. What can I do now and no amount of exercise seems to work?

A: The skin hangover to which you refer is known as a pannus, which is a fancy word meaning a skin apron. Even if you could lose more weight this abdominal pannus is not going to go away. It is excess skin that can not be lost by diet and exercise. It is excess skin created by pregnancies and weight loss. It is also skin that had lost any ability to shrink or contract as this is clearly demonstrated by the presence of stretch marks. Stretch marks are basically incomplete tears in the skin. This is like making little snips partially through a rubber band, it weakens its ability for elastic recoil. Most abdominal pannuses represent inches of skin (one foot or more) that has been stretched out.

You are correct in stating that exercise is not going to tighten skin nor will any more weight loss. (although there still may be some other medical benefits for more weight loss) This is a surgical problem that will require a large horizontal ellipse of skin and fat removal that will completely eliminate all loose skin over the central abdomen, a procedure otherwise known as a full tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need to remove excess skin from below my belly button and lift my breasts. I breast fed all four of my children and had a set of twins that stretched my stomach out tremendously. I have tried situps but they won’t take care of this loose skin.

A: Multiple pregnancies, particularly twins, push the skin past its elastic deformation limit. In  essence, it snaps the rubber band nature of the abdominal skin forever relegating many women to loose and often floppy skin that is seen the most between the belly button and the pubic areas. The surest sign of permanently lost skin elasticity are stretch marks which represent incomplete tears in the skin. This is like making little snips partially through a rubber band, it weakens or eliminates its elasticity. You are correct in stating that exercise is not going to tighten skin, nor will weight loss. This is a surgical problem that will require skin excision and underlying muscle tightening, a perfect description for a tummy tuck. Whether your tummy tuck would be a partial (mini-) or a full tummy tuck I can not say without seeing pictures of you. But my guess would be that after four children, a full tummy tuck with maximal skin removal is likely in order.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about jawline implants. I work in extreme environments overseas and, in addition, my group trains in hand-to-hand combat as well as boxes. Would I be able to take blunt force to the implants as well as I can without any implants? 

A: Obviously you are in the military. That is a good question and, quite frankly, is pertinent to any procedure that you would have done on the chin or jawline that involved any form of an implant. I have had patients who have had chin implants before that boxed afterwards and did not have a problem. I have also had other males in the military who have had chin and jaw angle implants. But I can’t say that I have had a similar situation with full jawline implants. I suspect it would not be a problem but I have not yet run across this situation yet. In other words, if the entire jawline was an implant (two-piece that it would be) could it sustain blunt force to it without causing a problem of displacement? I suspect that they would be fine since I always screw facial implants to the underlying bone. If the force is enough to fracture the lower jaw that is another issue but then surgery is going to be needed anyway. It is also possible in this scenario that the implants may have a protective force, like a bumper, and prevent the bone fracture from occurring. That is a conjecture, of course, but not an unreasonable one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face is twisted with the right side smaller than the left. Honestly, I’m not exactly sure what all I will need done. I want a softer look overall, less square, more symmetry, and a more youthful appearance. I am a 35 year old female. I know perfect symmetry is unnatural but I know my face is less symmetrical than normal. Pics do not lie.

A: In looking at your pictures, there is an overall comprehensive approach that can be done to improve your facial asymmetry. The fundamental problem is that the right side of your face is smaller than your right, accounting for the entire right facial deviation in development. What I see that can be helpful is the following from top to bottom; right endoscopic browlift,  right lateral canthoplasty, right cheek implant, rhinoplasty and a chin osteotomy that moves the deviated chin point to the left to make it centered. These would be the collection of procedures that would make the biggest difference in improving your facial symmetry. I have attached a frontal imaging prediction to show the predicted changes. The most challenging part of any facial asymmetry improvement is in the eye area. I am unsure how much orbital dystopia you have so there still remains the possibility for right orbital floor augmentation to raise the right eyeball as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have a much better jawline that I currently have. I have attached a picture which shows the perfect jawline for me as well as a picture of myself. What is the best way for me to get this result?

A: To no surprise, every male who wants a better jawline and chin will show me some male model/actor picture as you have done.  That is an ideal male jawline for sure. The only way to get that result are custom jawline implants made off of a 3-D model of the patient’s lower jaw.  The ideal jawline look requires a square chin, some prominent jaw angles with flare and the key…a smooth jawline and connection between the chin and the jaw angle area. That can only be achieved by a two-piece implant that is custom made from the jaw angles on each side to the chin and then meets in the middle of the chin where the two halfs are connected.. Short of the custom approach, the only other alternative is a large chin implant/osteotomy and  jaw angle implants but they will not have a smooth jawline connection between the two.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a plastic surgeon in New Mexico and need your thoughts on a facelift patient that I did six months ago. She is a 65 year-old woman that I did a full facelift on. Despite pulling and getting her as tight as I could, she is now left with some loose residual skin in the neck. She nor I want to go through another facelift procedure and I doubt very highly I could get her neck to get any better by this approach. Do you have any suggestions.

A: For residual loose central neck skin after a facelift, one option is either a submentoplasty or a direct neck lift.  A direct necklift is always more effective if she is willing to accept a fine line central enck scar. A good direct necklift option for this lady is what I call the Zipper Necklift. It is just a running w-plasty from the submental crease down to a low horizontal neck crease no lower than the thyroid cartilage. (never go as low as into the sternal notch area) By the pictures you can see it is just a running w-plasty excision/closure. The key is the markings. Halfway between the submental and thyroid cartilage pinch the loose skin together and mark it. That will be the point of the widest arc of excision. Then make a vertical ellipse from top to bottom but make the lines INSIDE your previous pinch mark. Then mark your running w-plasties going to the outside of that mark. Excise full thickness skin and fat right down to the platysma muscle. Then you can sew the platysmal muscle together from submental to thyroid cartilage like never before. Close the skin with 4-0 or 5-0 Vicryls for the dermis and 5-0 or 6-0 nylon for the skin. Ointment or glued on tapes is the only dressing. They will have virtually no pain and very minimal swelling and bruising. This will be the sharpest neck angle that you have ever created! The w-plasty concept is to prevent a straight line scar contracture which is greater in women than men because men do a daily scar treatment….shaving. (microdermabrasion)

There are different variations of the direct necklift and the most common is the ‘candelabra’ pattern which adds horizontal excisions at the submental and thyroid cartilage areas. But given that your lady has already had a facelift, she may only need more central neck tissue excision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I see that you perform gynecomastia surgeries and wonder whether you also perform mastectomies for FtM transsexual patients. I am investigating surgeons for the procedure who are closer to my home than the big-name options often reccomended to trans men. Thanks for your time.

A: Maximal breast reduction, often called Top Surgery in transgender patients, is merely an extension of a typical female breast reduction procedure with the more extreme goal of a completely flat chest. There are three basic techniques to do it, two of which are based on a free nipple graft method. For breast of some size, the classic inverted-T pattern is done with the removal of all breast tissue leaving only the skin flaps to heal back down to the chest. The nipple is then put back as a free graft at the apex of the vertical incision. This will result in the anchor-style breast reduction scars.  In smaller to moderate-sized breasts, the lower pole of the breast may be removed by a horizontal ellipse, the upper skin flap defatted and closed and the nipple graft placed where desired. This results in only a horizontal scar along the inframammary crease/fold. In very small breast mounds, liposuction may only be needed to create a nearly flat mound. This is the ideal way to do FTM breast reshaping because of the lack of scars but can only be used in a minority of patients.

I would need to see some photos of your chest to determine which method may be most applicable to you.

Dr. Barry Eppley Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a variety if procedures including brown bone reduction, rhinoplasty, chin augmentation and correction of my chest which I think is a pectus excavatum deformity. I have attached a variety of pictures so you can see all of the problems. I would like to know what you think. 

A: I have taken a careful look at your pictures and can make the following comments.

1) Your chest deformity is very slight and not a true form of pectus excavatum. Regardless of what it may be called, I see no surgical procedure that would be worthwhile. Given the mild nature of the sternal groove/depression, the only option would be to build up the sternum with an injection technique to avoid any significant visible scarring. The problem is that it would be virtually impossible to get a smooth result. Without such a result, you would end up with an equally distracting aesthetic problem.

2) Forehead/brow bone reduction is not an option for you due to the mild nature of the bossing and the need to have a scalp scar to do it. That is always a challenging problem in a male. The trade-off of a scalp scar is not a worthy exchange.

3) Your chin shows both a significant horizontal and vertical deficiency. Its amount of deficiency makes your nose look bigger than it really is. It is the one feature on your face that would make the most dramatic change. Because of these three-dimensional chin deficiences, a chin implant is not a good option as it only brings it forward. Only a sliding genioplasty can bring the chin forward and down which are the changes that you ideally need.

4) The only beneficial changes that I see in your nose is the tip. It could be made thinner. But I would not change the height nor the smoothness of the dorsal line. I would also not change the tip position by making it any shorter or have anymore upward rotation. In essence, a tip rhinoplasty is all that you need.

I have attached some computer imaging based on the chin and nose changes.

Dr. Barry Eppley

Indianapolis,Indiana