Your Questions

Q: Dr. Eppley, I am a 32 year-female with a chin issue. My chin doesn’t look too bad when I’m not smiling because I have a large nose so it is somewhat in balance.  However when I smile, I have excess soft tissue that almost looks like cellulite on my chin and it then sticks out more.  It is an appearance that is very similar to what I understand is witch’s chin deformity or chin ptosis.  I would like to know what you recommend for this problem and what the cost would be.  From reading your blog, I would presume that you would suggest some chin burring using the underneath the chin approach and soft tissue excision.  My concern of course is the length and visibility of the scar and I wondered what your experience with that has been. What is the average size of the scar? Is it visible from a frontal view and does it fade significantly over time? Also, do you think you can effect significant improvement in my problem or would the change be only minor?

A: In looking at your pictures, I suspect most of your chin issue is a soft tissue problem with a small bone component to it. That makes the submental approach the most effective treatment. The submental chin reduction scar is about 4 cm long and is curved to match the border of the lower jawline. Quite frankly, the effectiveness of the procedure is a balance of how much soft tissue tightening/removal can be done vs keeping the scar as short as possible. The scar is not visible from the front view and the redness of the scar does fade with time. I suspect the final result would be somewhere between a minor change vs a significant improvement. That is probably the best way to think about it. It is going to change, it is just a question of how much.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a healthy 65 year-old women with a large turkey-like hanging directly under my chin as well a bit of jowls. When I pull the skin back at the jaw angle/ear area, I see a great change and I look like myself again…like I did 20 years ago. What type of necklift is this? I do not feel like a need a facelift but just a necklift.

A: The turkeyneck is a common problem and there are many people who have this pessky aging issues but are happy with the rest of the face…or at least it does not look as bad as the neck and jowl area. This hanging neck skin must be treated by moving it up and backward to hidden incisions around your ears where it can be removed and invisible scars left in its wake. Your perception of a facelift is common with the belief that it is a top of the scalp down to the neck procedure, which it is not. A true isolated facelift only treats the lower 1/3 of the face, exactly where your concerns are. As a result, it is a much simpler and easier procedure to go through than most patients envision. Your proof that this is the correct procedure is evident by the presurgical facelift ‘test’, pulling up and back around the ears and jaw angles creates the desired neck and jowl changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have my buffalo hump liposuction along with my neck done at the same time. As I have gotten older the buffalo hump and bad posture have made my spine curve a bit. The hump is really visible when I straighten my back and when you feel it you can feel tissue but you can also feel my bone. My concern is does this put me at a risk for injury to my spine? is it possible to hit my bone while performing the liposuction and paralyze or injury my spinal cord in any way?

A: The buffalo hump is a collection of fat that appears above the fascial covering of the muscle. It is a subcutaneous collection that is far away from the deeply located spinal cord which is under the muscle. Also remember that the spinal cord is encased by protective bony vertebrae besides being deep to the muscle. Therefore, there is no chance of vertebral or spinal cord injury with liposuction surgery to the buffalo hump fatty deformity. The type of fat that is in the buffalo hump is also a more firm or fibrofatty tissue that can be more difficult to extract than softer fat like that in the stomach. For this reason, the use of advanced technology, like Smartlipo, may be more effective in the loosening or melting of the fat prior to suction extraction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 45 year-old female and I have concerns about my jaw line. I have attached some pictures and we would like to have your opinion on what would be some treatment options. I would like to have a return of firmness to my jawline.

A: In regards to early onset jowling/laxity, there are two basic options depending upon how one wants to approach the problem. From a non-surgical standpoint, there is a slew of energy-based devices out there that do create some degree of skin tightening/fat reduction for minor degrees of jowling. Devices such as Exilis, Ulthera and Thermage all drive energy into the dermis of the skin to heat it up creating some new collagen production and a tightening effect. Given Melinda’s good skin thickness and minor amount of jowl softening, you could argue that she is an ideal candidate for this non-surgical device approach. Its negatives are that it requires a series of treatments to get the desired effect, usually four separated by a week or two between them, and it is indeterminate how much improvement can be obtained. While I find these devices effective, it is best to view these treatments as a delaying manuever or bridging step to an eventual  surgical treatment. For some patients, it may put off the ‘inevitable’ for years. Remember that you don’t cure aging, you just temporarily improve it. As a surgical approach, a very simple and easy jowl tuck-up can provide an immediate improvement that will surpass what any device can do. This one-hour tuck-up with less than a week social (appearance) recovery is a common facial rejuvenation procedure today as people seek earlier treatment for their jowls and neck issues than ever before. It is really just a miniature or microform version of a lower facelift.

In conclusion, either jowl tightening approach is perfectly valid and the choice depends on what result someone wants and what they want to do to get it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had fracture of my cheekbone and eyesocket and four plates with eight screw were implant in my face…………..I want to ask can I remove these plates once if my fracture got healed??……Will there be any problem of refracture or any another problem after plate removal??

A: It sounds like you have a very typical zygomatico-orbital complex fracture which required three/four point fixation for anatomic realignment.There should be no problem with removing your fixation hardware 6 to 12 months after your original facial fracture repair. Facial bones generally heal completely by 6 months after surgery so removing them should not be a problem. Barring any future facial trauma, removing your plates and screws will cause the bones to collapse or refracture. Given the re-entry operative trauma to remove your hardware, there should be compelling reasons to do so such as uncomfortable palpability, cold temperature transmission or plate and screw loosening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Has you ever successfully micropigmented a donor strip scar from a hair transplant?

A: In my experience, it is virtually impossible to match skin colors with micropigmentation tattoos. There is always going to be some color mismatch. But your specific situation in the scalp is unique. There are two approaches you could use, all based on the concept of if you don’t like it you can also just excise the micropigmented area and be right back where you started or maybe even with a better looking scar. You could try and match the skin colors by micropigmenting the skin. Or you could place micropigmented dots to represent hair shafts.  Which approach may be better would require me to see some pictures of your scalp scar. But I would imagine that trying to create ‘shaved’ hair dots would be more a more effective camouflage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 27 year-old Asian female who would like to change the shape of my nose. I have a low nasal bridge and a flat tip of my nose with low projection. I would like to get my nose more Westernized with a higher bridge and more tip projection. I have read that this takes cartilages grafts that either come from my nose or from my rib. I definitely do not want a rib graft done so I am considering implants instead. I know about the implant used to build up the bridge but how does the tip get more projection as well? Is cartilage used to do that or can implants be used for it?

A: In changing the tip and columella of the Asian nose, a septal extension graft as well as a columellar strut graft is used. The septal extension graft is placed along the caudal edge of the septum and out onto the anterior nasal spine. This graft not only helps tip projection but also improves a retracted columella and opens up the nasolabial angle. When combined with a columellar strut, these two tip grafts together give more tip support for the weaker lower alar cartilages and is a standard technique in my practice. It is entirely possible, and very likely, that the septum of the nose may not provide an adequate donor source for the amount of grafts needed. If the septum is inadequate, one can use synthetic implants instead. The best choice of implants would be Medpor or porous polyethylene sheeting from which to fabricate these grafts. Usually a combination can be used, using the septum or the columellar strut and Medpor for the septal extension graft for an Asian rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read this article on bone erosion from chin implants and wanted to make sure I understood it. I am a 28 year old male and have been debating getting a chin implant for awhile now. What I got out of the article is that the bone structure in the chin is going to change with age no matter what and when it does the chin implant has no choice but to settle into the bone because of the muscle behind it is going to press to the bone causing resorption. Is it only until it settles back again? I’ve been debating this for awhile and it is the one thing that keeps me from going thru with the procedure. Also is it something that most people won’t notice you had done? I wouldn’t want anyone to know I had the procedure.

A:  You are somewhat correct in your assessment of the unique phenomenon of chin implant settling. Note that I do not call it erosion which would indicate an active process caused by inflammation…which is not the case for a chin implant. This settling phenomenon is more likely to be seen with larger chin implants that are under more pressure from a tighter chin pad in front of it. In many chin implants, this settling is not seen at all. Also, implant settling is more likely to occur when the implant rides high on the chin bone where the cortical bone is much thinner. When a chin implant is placed in the ideal l position on the low end of the symphysis, where it is more dense cortical bone, settling is either not seen or is very limited. (1 to 2mms)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young man with a skull that is flat at the back. It has caused me a lot of grief as a teenager and to this day and I think it’s time I did something about it so I can stop being so extremely subconscious about it. I have attached pictures which show how flat the back of my head is when the hair is parted in such a way or id wet. The flatness is pretty much only isolated to the back of my head. At  the very top of the head near the crown there is a noticeable ‘bump’ then the skull goes in a drastic decline. The forehead, and front sides of the head appear and feel normal/symmetrical it just the back which is causing the aesthetic issues for me.

From my research you appear to be the most qualified to do such an operation as you’ve had a great number of patients with the same issue as me therefore I would fully feel comfortable with you doing this procedure because of your extensive experience. This brings me to my next question, can you help me? From the pictures provided do you think you could give me the normal male skull I desire? There is nothing more I want than being able to shave my head really short. I understand there are different methods of operation some more intrusive than others. I am actually not concerned with the scars the operation will leave so long as it gives me the normal shape I have always desired, a skull that appears normal and wouldn’t get a second look from passers by because it’s normal. I would only want one operation to fix this issue and would like to avoid having to come back to do revisions to the operation. Now, having that in mind what type of procedure would you recommend for me?

A: Thank you for your inquiry and sending your pictures. I can clearly see that your degree of occipital flattening is significant. It is probably one of the more flat back of the head cases that I have seen. When it comes to correction, I think you have two options. First, using a standard open technique a cranioplasty can be done to build out the flat area somewhat. Stretching of the scalp is the limiting factor and you could get about a 10 to 15mm build-up. That I feel would be a mild improvement but I think is inadequate for a significant improvement. It would be better but not ideal. The second and more ideal option is a two-stage approach using a first-stage tissue expander followed by a secondary cranioplasty build-up. This could get upt to 25 to 30mm of skull expansion which ideally is what you need. The tissue expansion provides the necessary creation of additional scalp tissue to cover the size of the build-up tension-free. Computer imaging will show the differences in the result between the two approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to lift the eyebrows of the forehead area and reduce the protrusion of the forehead bone but I don’t want a coronal incision to do it. I need minimal incisions as I am a male.

A:  Browlift surgery in a male is a challenge due to the hair issue or lack thereof. Male browlift surgery can be performed either through an endoscopic technique with an epicranial shift or through the eyelids (transpalpebral) with or without an endotine device. The frontal hairline and density will determine which option is best.  When it comes to brow bone reduction, however, there are no other options that a coronal approach. The male brow bone is really frontal sinus expansion and must be reduced through an osteotomy approach. Even if the brows could be reduced by simple burring, good access is needed and an endoscopic approach can not be used. For most men, the coronal incision is an understandable objection and brow bone reduction is not possible.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a single cardio bypass done last fall. My doctors failed to notice that my sternum was not healing together. The doctor who performed the surgery knew ahead of time that I have EDS with sublexes of all joints, discs and sternum. Because of the surgery I am still being told I can only move as if the surgery was just done, that the sterna wires were holding me together. The sternum has shifted and even if it does mend together eventually it is still causing more dislocations of the collar bones. I have problems with collapsing lungs from the inflammation because of the movement all the time. What are my options for repair? Living like this I am unable to breathe or move without pain. This is not my idea of living. Please respond as I am getting very depressed.

A: While this is an issue for your cardiothoracic surgeon to determine, it appears that your primary problem may be a sternal non-union and instability. If the sternum has not healed and become stable at more than nine months after surgery, then it is not going to be. While wires are a common method of sternal fixation, they may not be sufficient in some cases. One option to consider is that of sternal plate rigid fixation. Removal of the wires, interpositional allogeneic bone grafting with PRP (platelet-rich plasma) and compression and fixation of the sternal edges by plates and screws designed exactly for this use is the only treatment option at this point. Its use depends on how good the remaining sternal bone is, of which only your cardiac surgeon knows. It may well be that he chose wires exactly because the bone quality was inadequate. There is also the issue of whether having EDS (Ehlers Danlos Syndrome) leads to impaired bony healing and non-unions given the underlying genetic disorder of connective tissue and collagen formation. Your sternal non-union may have been unavoidable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 31 year-old male interested in chest reshaping. I have large man boob and pointy tits. I am specifically interested in the SmartLipo or VaserLipo male breast reduction. How many surgeries have been performed? Do you offer a consultation by video chat? It’s a pretty long drive to come into the office for a simple consultation.

A: I routinuely do Skype consultations for far away patients, or even patients locally, to make talking to a plastic surgeon as asy as from your own home. I will have my assistant contact you to schedule a convenient time for a Skype consultation. It would be helpful to have you send me some pictures of your chest so I can determine what the best option may be. Smartlipo my be it but that is not an assured treatment if you have ‘pointy tits’ and large man boobs, which suggests that there may be a significant glandular component to your gynecomastia. It may need to be combined with open excision as well. Gynecomastia is a surgery that I regularly perform for men who range with gynecomastia problems from the puffy nipple to actual large breasts. There is no one single treatment method that works for every gynecomastia problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t know what they call this defect but my ears are too far back like Paul McCartneys. They don’t stick out, just too far back, the whole canal. Is there a surgery to move everything or just cover the ears?

A: There is no surgery to move the ear forward. The ear canal is the fixed point of the ear which stakes it to its position of the side of the head. No significant movement away from this point can the ear be moved other than a very limited amount of rotation around the canal. The cartilage of ears can be reshaped through various otoplasty maneuvers but the entire ear can not be picked up and moved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to reduce the size of a skull/head when it is too big? My head has a circumference of 23.6 inch/60cm. I have attached pictures of where I would reduce the skull to give it a better shape.

A: Thank you for sending the computer imaging showing the areas of your skull you would like reduced. These images make it very clear your areas of concern and I will define these as three skull areas. First, on the low back of the head is the prominence known as the nuchal line. This is a naturally raised area in many people because it serves as the attachment of the neck musculature to the back of the skull. This is why it is thicker and raised. Second, there is a prominence in the bi-occipital width as seen in the front view. Lastly, there is a midline ridge on the top of the skull known as the sagittal line that is prominent giving your skull a bit of a peaked appearance.

Based on these locations and the amount of skull reduction you have shown in the images, I think that is a very achieveable aesthetic change with burring reduction in all areas. The key question is the need for an incision to get there to do it. Given that you are a male with a close shaven head, this is a serious aesthetic consideration. There are two fundamental approaches. A limited posterior scalp incision that will good access to the back of head for nuchal line and bi-occipital width reduction but a more limited reduction of the midline ridge due to the curved surface of the skull and how far the ridge goes frontally. Good access could be obtained to all areas with a full bicoronal incision but that is less desirous in a man with a shaved head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Medpor chin implant placed 3 years ago and now there is an exposure of the right corner of my implant. I know I have to remove it but my concern how I will look afterwards if it is removed. I like my look with the chin implant but now that I have to lose it I am afraid of looking like an old woman. I actually did this implant to help make my jaw bone stronger and correct the small skin sagging on my two side of my jaw bones. Tomorrow I have appointment with a facial plastic surgeon. Do you believe I am too concerned? Thank so much for understanding.

A: It sounds like to me that your chin implant was placed through the mouth (intraorally), which would be the only way the implant could be exposed at this point. Taking out the chin implant is going to have a negative impact on your chin and jawline appearance to be sure. It is likely that this implant is placed too high. You will likely have to have your current implant removed and allow it to heal for a few months. Then you can have a new implant placed through a submental skin incision form under the chin. It may be possible that a new implant can be placed at the same time as your exposed one is removed. But that would be impossible for me to say just based on your description alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several body problems that I would like to get rid off. I have lost 100 pounds and have kept it off for 11 years. First, my large batwings are causing strain on my shoulders  I exercise five  days a week but they will  not go away. Will insurance pay for this since I am having it done to decrease my pain and not for  cosmetic reasons. Also the loose shin around my inner thighs is increasing. I also have engorgement of  my varicose veins  I am currently looking to have surgery for these three problems. Will insurance pay for this two also.

A: After a 100 pound weight loss, most patients will suffer loose and redundant skin which can not be exercised off. Such loose skin in the arms and inner thighs is common and can be removed through arm lifts (brachioplasties) and inner thigh lift procedures. It is highly unlikely that either procedure would be covered by insurance. These are viewed as procedures that largely have cosmetic benefits not functional ones. But no plastic surgeon can tell you whether any procedure would be covered by insurance. There is a process known as insurance pre-determination in which the information would be submitted by the consulting plastic surgeon on which your insurance would make the final decision. My experience has never been favorable in that regard. Conversely, the varicose veins should be covered by insurance but you will need to be evaluated and treated by a vascular surgeon for that problem. Varicose vein surgery should not be performed at the same time as the body contouring surgery. It should be done first so that your risk of DVT (deep vein thrombosis) is lessened for the body procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a jaw angle implant for just one side. I have facial symmetry on my right side which is smaller. Not sure why. I’m saving up for that type of procedure now. Is there anyway you can give me a ball park estimate of how much something like that would cost and is any part of it ever covered by insurance? Also, is the surgery normally done when you are asleep or awake and if it’s asleep will I wake up with a tube down my throat? I know it sounds like a dumb question but the thought of it makes me nervous. And lastly, how much of an improvement would this make because I know it won’t make me look perfectly symmetrical and everyone’s results are different. I just want to make sure it’s the best thing I can do.

A: If your facial asymmetry is relegated primarily to the posterior face in the jaw angle area, then unilateral augmentation can be very helpful. You just have to make sure that the asymmetry is located down by the bulk of the masseter muscle area. The effectiveness of jaw angle implant augmentation depends on the size and shape of the implant. How much width and if any vertical lengthening is needed are critical question before surgery to select the proper implant. Because this surgery is for cosmetic enhancement (appearance), it is not ever covered by insurance. The surgery is done through an intraoral approach and involves lifting up the masseter muscle. Thus this is a procedure that requires general anesthesia with endotracheal intubation. The tube will be removed before you wake up so this is not a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting breast augmentation but need to know the cost. I am 48 years old and have always been small. My breasts are in good shape but I want them larger and lifted. What would be an average cost as I am shopping.

A: The specific answer to your cost question depends on what type of implant you desire (saline vs silicone) and whether any formal type of breast lift is simultaneously needed. These two issues have a major role in the cost of the procedure. Without seeing pictures of your breasts, the best I can do is give a range from the lowest cost procedure (saline breast implants only) to silicone gel breast implants with a superior crescent and/or vertical breast lift. All costs included would put that cost range from $ 4,800 to $ 8,450. So you can appreciate how not knowing exactly what you need makes an accurate price quote impossible. The key question in this price range is whether one needs a simutaneous lift or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two questions. Do you do permanent eyebrow shaping and coloring? How often does one have this procedure done? What is the fee? What is the cost of earlobe repair as my hair is short now and I have worn heavy earrings making my lobes longer.

A: Thank you for your inquiry. What you are referring to is known as permanent makeup or micropigmentation. It is done for the creation or restoration of eyebrows regularly. I have a fully trained and certified aesthetician who is our micropigmentation specialist. This is done in the office under local anesthesia and takes a few hours to complete.  I will have her contact you to provide the costs of the procedure. It is important beforehand to have a consultation where the eyebrow shape and color can be selected. Usually we like to apply with an eyeliner pencil the shape of the eyebrow and color so you may wear it for a few days to be certain it is right for you. Micropigmentation, like many tattoos, can be difficult to reverse and it is best to think of this procedure as irreversible. 

Earlobe repair/shortening is also an office procedure done under local anesthesia. So combining earlobe reduction and eyebrow procedures would be a convenient approach to solving both concerns in but a few hours. Neither one is associated with any recovery issues. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m going to have a hysterectomy and wanted to have a tummy tuck done at the same time and heard this may be possible. Two questions, what is your experience in doing this combination and how do you go about arranging for an Ob-Gyn to do the procedure? Also, what is the average cost for a tummy tuck although I know each patient is different.

A: The combination of a tummy tuck with a hysterectomy is the most classic and commonly performed cosmetic/reconstructive surgery combination. There is no question about the efficiency of the hysterectomy/tummy tuck combo and the convenience of the recovery. Many times the patient’s Ob-Gyn has a working relationship with a plastic surgeon so the coordination of the combination procedure is easy. Conversely, most plastic surgeons know Ob-Gyns they can refer you to if you do not have one that can work in the same facility. That is the first hurdle, getting an Ob-Gyn and a plastic surgeon who have operating privileges in the same location. Since this involves a hysterectomy and an overnight stay (at least), the facility will need to be a hospital and not an outpatient surgery center.

Despite these procedures commonly being done together, it is important today to look at the economics of this surgical combination. While in days gone by the costs of the use of a hospital operating room and anesthesia were largely ignored and rolled into the insurance coverage of the hysterectomy, that is no longer true. That approach is both fraudulent and unaccepted by hospitals today. Therefore, a tummy tuck with a hysterectomy is going to incur more costs than just the plastic surgeon’s fee alone. The hospital is going to ask for operating room and anesthesia fees incurred by the tummy tuck to be paid beforehand. With the high costs of hospital care today, it would be very important to look at the total expense of the tummy tuck when performed in a hospital setting. In the past few years, despite the convenience of putting these two procedures together, I have seen patients opt to separate them to save significant costs. Tummy tucks performed in outpatient surgery centers are almost always less costly then when done in the hospital. How much difference there might be depends on the specific hospital and if they have reasonable flat fee rates for cosmetic surgery in place.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in forehead reduction/hairline lowering. I am 21 years old and have not been able to find any local surgeons that can perform forehead reduction surgery. My forehead is incredibly long from the top of my eyebrows back to my hairline. It is like the entire front part of my skull is way in front of my hairline. I am looking for more information as to how this procedure is done and what my options are. I have sent some pictures so you can see for yourself my issue.

A: In looking at your pictures I can see the amount of frontal and temporal recession of your hairlines. You forehead is at least 8cms if not more. While vertical forehead skin reduction and hairline advancement can be done, its success and method depends on how much laxity or looseness your scalp has. Using the natural scalp laxity that can be obtained by surgical release, you will likely get a 1 to 1.5 cms advancement in the midline of the forehead and less so as it tapers into the temporal area. Up to 3cms or more can be obtained with a two-stage approach using a tissue expander first, followed by a second-stage scalp advancement. To find out what you need and which method may be best for you, do the marking test. Trace out the desired hairline with eyeliner pencil and then do a measurement to see how much advancement in centimeters that you need. Also take a feel of your natural scalp tightness by pushing forward on it and see how tight or loose that it is. These are the tests I would do if you were sitting in front of me to answer what method is needed to achieve your forehead reduction goals.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, the forehead bone above my eyes is pumped out or sticks out which makes me looking different. It just curved out like bumps. I have good insurance which covers everything 100 % but I’m not sure if it covers plastic surgery. My questions are what is the best surgery to remove some of the bone thickness and will you accept insurance?

A: Brow bone prominence or protrusion, contrary to popular perception, is not caused by increased bone thickness. Rather it develops because of overgrowth or excessive pneumatization of the frontal air cavity sinus. Thus the large brow bones actually have a very thin layer of covering bone. To reduce them requires an osteotomy of the anterior table of the frontal sinus bone, reshaping it, and then and then replacing it. This is the only way to reduce a large brow bone, particularly in a man. This is a cosmetic condition not a medical necessary one that improves appearance but not function. Therefore  brow bone reduction surgery is not covered by insurance no matter what plan one may have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty two years ago of which I am not happy with the result. My nose now looks too feminine. It is upturned rather than long like I wanted it and the bridge of my nose seems too low now. The tip of my nose is still too wide and I see too much nostril now. I know that revisional rhinoplasty is difficult and my option are limited at this point. But what do you recommend as I trust your judgment. I have attached some pictures for your review and comments.

A: While I do not have the advantage of see what your nose looked like before, I can tell that you had a rhinoplasty and I see several improveable problems. First, the tip is overrotated superiorly, making the nose look short and giving it the false impression that the nasal bridge is low. Secondly there is alar rim retraction probably caused by lack of support from the lower alar cartilages from too much cephalic trim and/or as part of the tip overrotation. These conditions could all be improved by a secondary rhinoplasty which will require septal cartilage grafts to support tip derotation/lengthening, batten grafts for lower alar cartrilage support as well as alar rim grafts for nostril rim lowering. With your thick nasal skin, there is a limit as to how much tip narrowing you can achieve and you may have already reached the best that you can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffered facial injuries due to which my surgeon have to put two plates on my eye socket and two on my mandible fracture. I am 19 years old and I want to know can I remove these plates after my bones get fully healed?. Please reply to me as fast as you can.

A: Once the bones from facial fractures are healed, the indwelling metal plates and screws can be removed. As a general rule, that is six months after the initial injury and repair. Because it is another invasive surgery, there has to be a good reason to remove them. Palpability (I can feel them), cold temperature transmission (around the eye) or if they get loose and cause pain are all good reasons for their removal. But short of these reasons, there is no medical necessity to remove other than if having them out provides some psychological solace and a closure to why they needed to be put in there in the first place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am bothered by my downturned corners of my mouth. It makes me look sad even though I am not. I am tired of people asking me if I am sad or mad. My mouth has a bit of an upside down U-shape to it. I just need my smile line leveled out like it used to be. What are my treatment options?

A: The downturning of the corners of the mouth primarily occurs due to the tissues above it falling downward. As the cheek tissue above the nasolabial fold descends with age and gravity, it pushes the corners of the mouth down with it. This creates the classic smile inversion and the expression of sadness. The muscles around the mouth, particularly the depressor anguli oris muscle, can also contribute to pulling the corners down. Contrary to popular perception, a facelift will not lift up the corners of the mouth. The problem must be treated, not from a distant pull of skin.

The arc of the smile line can be improved by two methods. The most common approach is the injectable approach. By adding volume to the tissues underneath and under the mouth corners, a definite lifting effect can be seen. The best injectable fillers to use for this are hyaluronic-acid based such as Restylane or Juvederm. Adding Botox or Dysport is also helpful because it weakens the depressor muscle and will cause the unopposed lip elevator muscles to pull the corners up. These injectable effects can be subtle and will only last as long as that of the materials used. A more permanent and dramatic effect can come from an actual corner of the mouth lift. By removing a small triangle of skin from just above the mouth corner, the commissure is actually repositioned upward. This is a simple procedure that can be performed in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My skull shape is rather problematic. I have a weak forehead (probably about 1 inch), the problem is that the top of my head is not round, there is a noticeable gap, once you hit my hairline, my skull goes flat, it isn’t until about 2 inches further that there is a slope where it increases. I could upload and send you pictures so you can see. Would it be possible to actually build up that ‘missing’ forehead? My other question involves my face width from ear to ear. With the weak forehead, and noticeable cheekbones, and jaw…they add up to making it appear as if I am fat. Other than removing buccal fat, is it possible to shave off some of that and moving the bones further in to reduce the width? Thank you for your time.

A: I would first recommend that you send me some pictures for my assessment. But to provide some general comments, the forehead can definitely be built up with cranioplasty material. The buildup can be extended back up into the skull area. This would need to be done through an open coronal (scalp) approach. When it comes to the face, however, such bony width reductions are much more limited and unlikely to be able to do what you want to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just in the beginning stages of planning for surgery to change my poor sagging body. I am interested in the procedures of breast augmentation, body lift, liposuction and a tummy tuck.. I need to know an approximate cost and payment options available. Thank you.

A: Based on the list that you have proposed of interested procedures, there are a wide variety of body contouring options available for all of those changes. With such a list, it is best to come in and get a thorough treatment planning session to see what is possible and place a priority on the different body areas. Because of the options available, it is not really possible to give you any good cost estimates other than some general pricing. For instance, a body lift includes a tummy tuck so they are quite different procedures. Liposuction is based on body areas treated and often is not needed in the face of a body lift. Breast augmentation costs vary based on the type of implant used (saline
vs silicone) and whether a lift is needed at the same time

I will have my assistant contact you to answer many of your general cost questions including how to finance. She can also arrange for a consultation for you to develop a surgical body contouring plan based on your priorities and cost. This is the best way to pick the operations that will have the greatest return on your effort and investment. For those patients who finance, the use of Care Credit is the most common method used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have significant pectus excavatum which I want improved. I had a Nuss procedure done many years ago and, although it is improved, I am not satisfied. I have already explored the option of silicone implants but didn’t preferred it since it is artificial  and I don’t want the risk in future for problems with it or any further surgery.  I request you to kindly advise me an alternative option other than silicone implants. I had been exploring the
option of “artificial bone”. I understand artificial bones are almost like natural bone and so I would like to use the artificial bone for the dent portion and fat grafting for remaining portion of the chest above the dent filled portion. I request you to kindly advise me on having the option of artificial bone and fat grafting for attaining the required shape of the chest.

A: I am afraid that you confusing synthetic bone substitutes as having the same physical properties of natural bone, which they do not. There are hydroxyapatite cements which ultimately behave more like ceramics. They do not
become bone nor do they act like real bone. In essence, they will not result impact trauma and will fracture. They work well on the skull and face where the risk of impact injuries are fairly low but also have the benefit of being covered by thick well-vascularized soft tissue over relatively smooth convex surfaces. On the chest for small or minor amounts of pectus excavatum, I think they are fine because the surface area being covered is small. But when trying to use them to cover larger sternal/rib areas in more substantial pectus excavatums, the material is more exposed to the potential for fracture. In short, they should not be considered for use for chest volume restoration because that is beyond their potential for long-term success.It is possible that the lower end of the pectus excavatum could be treated with hydroxyapatite cement and then injectable fat grafting for the other larger areas of the chest deficiency.
Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 52 year-old female and am interested in reshaping my chin. I have always been bothered a bit by the squareness of my chin which is a bit unfeminine.with aging But now that I have developed some jowling, it makes my face look more square. I want to get my chin reshaped to a more narrow appearance and then have a facelift afterwards. How would this be done and how far apart should the chin reshaping and facelift be? I have attached some pictures and have done a ‘homemade’ facelift by pulling up on my skin so you can see the squareness of the chin better.

A: Thank you for sending your photos. Your homemade facelift shows the exact location of the squareness of your chin. Now that I know the location of bony excess, that would be best reduced by an intraoral approach given that it is fairly anterior. It would be reshaped by a saw technique, taking off the wings of the chin.  I have done an image showing its reduction result, more can be done but this is a good starting point for discussion. Given its very anterior location and away from the plane of dissection of a facelift, I see no reason why the two procedures could not be done at the same time. The distal tightening effect of the facelift would help any soft tissue slack/swelling that would occur from the chin ostectomy/reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana