Your Questions

Q: Dr. Eppley, I am getting breast implants in the near future. I am currently a 32A and am looking at 400cc silicone breast implants. (high profile) My hope is that they will make a full C or a small D cup. I am 24 years old and am 5’ 3” and 115 lbs. I tried the 400cc sizers in the office and they looked a little big to me. But I was told that they may look a little smaller since they are going under the muscle and that it was always a good idea to go a little bigger than you think anyway. I’m not sure if I should go with 400 cc or go smaller to be safe. On the one hand I don’t want to be too big but I’d hate to wish I would’ve gone bigger afterwards.

A: There is no question that the biggest issue in getting breast implants, for the patient, is what size in volume to get. The reality is that there is no magical and assured method that can guarantee any patient that they will get end up with the exact breast size that they want. No matter how it is done there is some ‘guessing’ involved and there is always the unknown variable of how any patient interprets what a C or D cup looks like in their mind. With that being said, there are certain presurgical measurements that can be done to help hedge the bet so to speak.

The Volume Sizing System is very good at providing a good estimate of the final size and this should be a good guide. If you think it is just a little big then drop down 25cc to 50cc. From this volume, the patient’s breast base width can help guide the projection that the implant should have, keeping it within the dimensions of one’s natural breast base width. High projection silicone implants should only be used if one wants a very round or full look, If not then consider either a lower projection or even a shaped (teardrop) implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may need a revisional rhinoplasty? I did not have breathing problems before I had a rhinoplasty? When I went back for a six month follow up I was told I had a deviated septum and needed more surgery. I was told I did not have one before surgery but that it has grown back that way now. Could the rhinoplasty have caused the deviated septum? Or was the deviated septum there before and it was just missed during the initial rhinoplasty?

A: One of the most common reasons for revisional rhinoplasty surgery is nasal airway obstruction. A recent published study of revisional rhinoplasty reported that up to 70% of patients had some degree of airway obstruction and was a main motivating factor for the surgery. There are many potential causes of breathing problems after rhinoplasty of which a deviated septum is but one. Usually, however, a deviated septum is diagnosed before or during the initial rhinoplasty and only ‘recurs’ because it was inadequately corrected. If there were no breathing problems before surgery, it would be unlikely that a deviated septum has developed now. With cartilage graft harvest, presuming that was done, septal deviation is less likely to occur.

One of the most common causes from the initial rhinoplasty is if osteotomies or breaking of the nasal bones was done, particularly if a low-to-low or even a low-to-high osteotomy pattern was done. A low initial starting point for the osteotomy can partially close down the airway. Another common reason is collapse or pinching of the middle vault which narrows the internal nasal valve, a critical point for airway passage in the nose. Both of these sources of nasal airway obstruction come from the common aesthetic manuever of taking down a hump or bump in the nose particularly if it is large. This can cause collapse of nasal structures which have to be recognized during the initial procedure to enable preventitive manuevers to be done.

The short answer to your question is that there may be other causes of airway obstruction besides a deviated septum that must be taken into consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery 2 months ago and I am not happy with the results. It was initially very flat right after surgery but I have subsequently developed hard lumps under the nipples that now make them stick out a bit. This makes me mad since I paid good money to have a flat chest. What can I do about it now?

A: What you are describing is very common after gynecomastia reduction surgery in young men. Many open gynecomastia patients will develop a scar lump under the nipple after their procedure even though it looked initially quite fat. Whether this scar lump will go away or not takes time to see and two months after surgery is too early to tell. About 10% of open gynecomastia reduction in young men will develop these persistent scar lumps that may require a revision to remove and make completely flat if it persists. This is not reflective of a poor surgical technique or even a poor surgical result but is the unknown and uncontrolled variable of how one forms scar tissue in the space where a small or large lump of tissue had been removed. What I would recommend now is to have either Kenalog (steroid), 5-FU or combination kenalog/5-FU injections to try and soften the scar and make it go flat. Now is the time to do this, not 6 months after surgery where it would be much less effective when the scar tissue is mature. Whether this will be completely effective can not be predicted but at least this provides a chance for success. If not, you are going to require a revisional gynecomastia reduction procedure to remove the scar that has developed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual tummy tuck question. Can a tummy tuck be performed at the same time as when one is delivering a child? I have never heard of this before but it just seems to make sense to me. I have had two children by c-section and am thinking about having a third  and with the excess skin already present this just seems like a perfect time to do it. Is this a crazy time to do a tummy tuck? Or should I just wait and do it after? How much weight should I lose before doing it after delivery?

A: Having performed three tummy tucks at the time of delivery I can speak to the fact that it can be done. While a ​tummy tuck can be done at the time of delivery, it is not going to be the traditional or full tummy tuck procedure. Because of the enlarged uterus, muscle repair is not done in the traditional fashion (hard to close over a big uterus) and the tummy tuck is limited to the amount of skin that can be easily removed without too much tension. The scar will end up being much longer than that of the c-section scar you have now. While producing a significant improvement, it is never as good as a tummy tuck that is done six months or later after delivery. When done well after pregnancy, it is a good idea to lose as much weight as possible to get the best benefit from the tummy tuck procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an umbilicoplasty procedure. I hate the look of my bellybutton as it sticks out and want a prettier bellybutton that turns in like most people. How is the procedure done and was is the approximate cost of turning an ‘outie’ into an ‘innie’. Thank you.

A: The bellybutton or umbilicus is the residual attachment of the umbilical cord. It forms a visible depression in a very constant and central location on the abdomen. Underneath it lies the midline union of the paired vertical rectus muscles which will also have a depression or concavity in it, making it a structural point of potential weakness and the potential for a hernia. Most commonly the navel appears as a depression or innie which occurs in about 90% of people. In the minority (10%) an outie belly button is present which can either just be from extra skin left over from the umbilical cord or exists because the skin at the base of the belly button is pushed outward from a protruding hernia.

Differentiating the type of outie bellybutton is important as that determines how it is done and the cost of the surgical techniques to do it. An outie that is just a stump of skin (no hernia) can be done in the office under local anesthesia. The stump of skin is removed and the edges sewn down to create the innie look at a cost of $1500. If the outie has a palpable hernia, it will need to be repaired in the outpatient operating room under IV sedation. The umbilical hernia needs to be repaired at the same time with a total cost of between $2500 to $3000.

How do you know if your outie has a hernia? Push inward and see if you can feel a ring or hole underneath. Also an outie that is just a stump of skin can not be displaced inward. (the stump gets pushed in but the stump keeps its shape) The outie that can easily be pushed inward through the inner ring or hole has a hernia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering jaw angle implants. I have been considering your reply to me about the possible unaesthetic fullness of my lower face due to the horizontal impact of the implant. I was wondering if this is a set figure or if some of the width could be “shaved” off prior to insertion? I am anxious not to have a “chipmunk” roundness I am truly very aware that I am by no means a beauty, far far from it, but my reasons for the jaw angle option was that I could get rid of the prominence of the jaw in my profile. I think you can see that there is quite a difference in my profile looking left and right. There is also a slight asymmetric difference in my jaw angles as the right appears to be higher.  If this is to proceed then I am wondering about the length of time that I should set aside for a visit to you , consultation and surgery and recovery. I should mention that my current weight is 83kg and I understand that my proper weight should be closer to 77kg. Would dropping this weight have any affect on the procedure? I ask this as I am currently working very hard to reduce my weight with diet and lots of exersize. 

Many many thanks.

A: JAW ANGLE IMPLANTS COME IN A WIDE VARIETY OF VERTICAL AND WIDTH NUMBERS AND ANY OF THEM CAN BE ADJUSTED DURING SURGERY. THE BEST WAY FOR YOU TO AVOID AN UNAESTHETIC ROUNDNESS IS TO SHAVE THE JAW ANGLE IMPLANT sO THAT IT ACTUALLY COMES TO A VERY SHARP FLARE. WITH YOUR THICKER TISSUES THIS WILL THEN NOT MAKE IT LOOK ROUND BUT RATHER PROVIDE A HINT OF ‘ANGULARITY’. THE POTENTIAL UNAESTHETIC FULLNESS IS CONTROLLED PRIMARILY BY HOW THICK THE SOFT TISSUES ARE AND THE HEIGHT OF THE JAW ANGLE. MOST PATIENTS COME IN THE DAY BEFORE SURGERY, HAVE SURGERY THE NEXT DAY AND RETURN HOME IN 48 HOURS BASED ON THEIR COMFORT TO TRAVEL. I DON’T THINK THAT RELATIVELY SMALL AMOUNT OF WEIGHT MAKES ANY DIFFERENCE FOR THIS FACIAL SURGERY. I BELIEVE YOU HAVE EXPLAINED IT VERY WELL. THE KEY IS TO CUSTOM CARVE AN IMPLANT FOR YOU THAT REALLY ACCENTUATES THE ANGULARITY OF THE JAW ANGLES. MOST JAW ANGLE IMPLANTS HAVE ROUND ANGLES WHICH IN YOUR CASE MUST BE MODIFIED.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?

A: When it comes to reducing the raised hair plug areas, it is best to think of it as reduction of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation revision. I had breast augmentation three years ago. Right after I had major issues with my right breast implant.  It was smaller and now moves around a lot, almost like its not even in place now. In addition, it is painful. My previous surgeon went through my armpit to place them and whatever he tied his suture to it is no longer attached. And he doesn’t see an issue after multiple visits.  I just want to cry. I have decided to move forward and have heard multiple positive reviews from patients that came to see Dr. Eppley.  Very excited to see the light at the end of the tunnel!!!

A: It is hard to tell based on your description as to the exact nature of the problem with your right breast implant. Besides being smaller and moving around more, the source of the pain is not clear. Usually pain with breast implants is associated with either a tight pocket, capsular contracture or a ruptured silicone implant. I am going to assume that since your implants were placed through the armpit that they are saline implants.

Regardless at least a right breast implant revision is going to be needed. That will have to be done through a new inframammary fold incision. You talked about ‘ a suture that was tied that is no longer attached’ but such an entity during transaxillary breast augmentation surgery does not exist so that is an irrevelant issue. The question is whether this is a pocket adjustment with more volume added to the existing implant or whether a new implant is needed. This will require a physical examination to determine exactly what needs to be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom jawline implant. Roughly what is the cost of a Custom Jawline Implant and the procedure if I want a very large implant enclosing the entire chin and jawline and angles, adding quite a lot around the angles, increasing chin projection up to 25mms?

A: A custom jawline implant is fabricated from a patient’s 3D scan. From this a completely customized implant is made from one jaw angle to the other. While any dimensions can be made on the model using design software (up to 25mms at the chin), there has to be enough soft tissue along the jawline so that the implant will actually fit into place. Realistically, having placed many custom wrap around jawline implants, a chin enlargement of 25mm horizontal advancement is likely more than the neck soft issues (which is where the skin must come from) can accommodate.  This is too much soft tissue stretch when you factor in that the implant wraps the whole way around the jaw. A more reasonable approach is around 15mms or so of horizontal chin advancement. You must also factor in the lower lip position and the depth of the labiomental sulcus which will be severely left behind when the chin comes that far forward. The total cost of such an implant, all costs including fabrication and surgical placement, is in the range of $12,000 to $ 13,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.

A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)

Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.

Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures,   the order that are done on does not make a difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to see if you can do a lip widening surgery technique. I have tried fillers and implants and nothing seems to work as my lips are just toooo small for my face. I look so disproportionate and really I am tired of it. I’m still single, and would really like the confidence to know that I have a beautiful smile.

A: Lip widening surgery, know as a lateral commissuroplasty, is done by opening up the corners of the mouth in a Y-V mucosal advancement procedure. The Y is in the incision pattern with the vertical aspect of the Y being the horizontal incision that determines how much the corners should be opened up. The V part of the Y are the incisions that then follow the natural  border of the vermilion-cutaneous junction of the upper and lower lips. Small triangles of skin are then removed and the vermilion and mucosal are brought out from inside the mouth to make the new corner of mouth opening. This does result in very fine line scars that end up along the vermilion-cutaneous junction of the upper and lower lips at the mouth corners. This lip widening surgery is done under local anesthesia as an office procedure in most cases. Usually the width of the mout can be opened 5 to 7mms per side without causing any lip distortions. There will be a period of time when the mouth corners will feel a little tight and stretching exercises can be done beginning three weeks after surgery when the incisions are well healed to hasten the softening process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. I am a 25 year old male that has  suffered from an odd shaped head. Its wide on the sides and irregular shaped on top. For years I’ve had a great insecurity every time I looked in the mirror. I have tried many different hairstyles to hide my head shape but none work for very long. I just feel like its the only part of me thats incomplete and if i have it fixed i will be so much happier and confident. I am determined to have it fixed even if i have to do it myself. I have attached a few pictures of my head.

A: What your pictures show is that the shape of your head is due to a minor variant of sagittal craniosynostosis. This is why the shape of your head has a sagittal ridge or crest from front to back and is a little elongated. Accompanying this is a parasagittal deficiency, which with the sagittal crest, gives your head a peaked or more triangular shape. The typical skull reshaping strategy is to burr as much of the sagittal crest as possible and buildup the sides to create a less peaked and more rounded skull shape.

While this is surgically possible, and a major improvement can be obtained, this has to be done through an ear to ear scalp incision. This must always be considered careful in any man who shaves his head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a form of scalp scar revision I had hair plugs done many years ago which has left me with a lot of ‘bumps’ on my head since I now shave my head. Can these be reduced in any way so that my scalp is more smooth and not so bumpy and irregular?

A:  Your scalp issue does represent an unusual form of hair transplant scar revision. Most commonly this issue relates to the donor site scar on the back of the head. But old style large follicular unit plugs can certainly be an issue if one is now shaving their head or wants to. Trying to get good improvement in your scalp situation is not an easy one even though the techniques to do it are not hard per se. Ideally what you should do is a ‘test patch’ of a scalp area with dermabrasion to see how improvement you can get before launching forward on your whole scalp. If a small area done under local anesthesia shows good improvement then you could do your whole scalp under anesthesia. On the one hand this is not the most efficient way to do it but there would be little sense in doing your whole scalp if the amount of improvement would not be worth it. This issue applies to both the donor and recipient areas. It is just hard to predict what the level of improvement would be had with dermabrasion for your hair transplant scar revision so you want gauge the depth of your efforts by testing first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek and jaw angle implants four months ago. I see that you are ubiquitous on the Internet for cheek and jaw angle implants. My question: my right jaw has been very swollen to the point where I had an MRI that shows unusual swelling. As a result I’m scheduled to have that jaw area opened up and cleaned out with hopes of immediate replacement of implant. I was hopeful that during this same procedure I would have the cheek implants replaced with smaller ones and located a bit higher in my cheek area with more emphasis on the enhancement of the upper cheekbone. My surgeon said its not a good idea to work on the cheeks because of the inflammation in the right jaw. Is this true? If I’m going to be under sedation I would prefer to have the cheek implants adjusted. It would save me a third flight and money for sedation in the future. Your thoughts?

A: In regards to the simultaneous management of your cheek and jaw angle implants, I see no problem with doing them together. The ‘cleaner’ cheek implants should be downsized first and then the presumably infected right jaw angle implant should be opened and managed. I do not necessarily believe that one infected implant will affect unaffected ones of the sequencing in surgery is done in the right order.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?

A: When it comes to reducing the raised hair plugs, it is best to think of it as a scar revision of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reduction and hairline lowering. I would like to know if Im a great candidate for the forehead reduction and hairline lowering. I hit a brick wall when I was younger and that is how I have bumps on my forehead. Can you please respond back to me thank you!

A: Thank you for your inquiry and sending your pictures. I can clearly see your motivation for the forehead reduction and hairline lowering procedures with a long and high forehead and a large  protrusion of the frontal bone. You are correct in making the assumption that these two procedures would be of benefit. A less protruding forehead and a lower hairline would be very aesthetically advantageous. The key procedure of these two is actually the hairline lowering as a hairline that was 2 to 3 cms lower would help disguise the forehead protrusion significantly even though it can be reduced by burring somewhat. However, your scalp skin looks fairly tight, as most high foreheads are, and no more than about 1 to 1.5 cms of advancement could be obtained by simple loosening it up and bringing it forward. You would be better served by a first-stage scalp tissue expansion to create more hair-bearing scalp to bring forward. Then the second stage could be a large scalp advancement and bony forehead reduction. This would produce a much better result than a single stage procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rhinoplasty surgery. I have always hated my nose. It has a large bump on it and it slopes down at the tip. I have always wanted a smaller and more shapely nose. What type of rhinoplasty do I need?

A: Based on a review of your pictures, you are an ideal candidate a good rhinoplasty result. This is based on your pictures which show the type of nasal anatomy which is very favorable for surgical change to get near ideal nasal proportions and shape.

Patients with nasal nasal skin have the capacity after surgery to show quite quickly and completely the changes that have been done to the cartilaginous/bony framework. In addition, thinner nasal skin does not get as much swelling after surgery and it does not take as long for most of the swelling to subside. Such is the type of nasal skin that you have.

A very common and favorable type of nasal problem is the convex dorsum which patients know as a nasal hump or bump. This overgrowth of the cartilage always makes the tip of the nose look like it is pushed downward, even if it is not. Reduction of this hump completely changes the shape of the nose and the profile, which make the nose looks smaller and more proportionate. The tip of the nose can also be narrowed at the same time. The other consideration in your rhinoplasty is the potential benefit of a small chin augmentation at the same time. Your chin is naturally shorter which is common in a nose with a hump. Reducing the size of the nose (dorsal reduction) and bringing the chin forward creates a diametric change in the facial profile which makes it more balanced overall.

Computer imaging will demonstrate these rhinoplasty and chin changes and I will get those prediction to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation. After having two children I have lost all of my breast tissue, I am completely flat, the proverbial straight as a board chest look. I desperately need breast implants. What size and style of breast implant would you suggest? 

A: Based on a review of your pictures, you are an ideal candidate for breast augmentation. Let me detail what makes one an ‘ideal candidate’ . An ideal candidate for any plastic surgery procedure is the one that is most likely to get the best result based on their natural anatomy and the anticipated changes from the surgery.

The best breast augmentation results come from small breasts that have no sagging and with the nipples centered on the diminuitive breast mound. Thus when the mound gets expanded by an underlying implant the resultant shape assumes completely the shape of the implant with firm skin and a perfectly positioned nipple-areolar complex. Your pictures demonstrate that you have an ideal presurgical breast mound by this description.

When choosing a breast implant, the first thing to decide is between saline or silicone-filled. With your lack of any breast tissue, silicone would be a better choice to avoid the rippling of saline implants which would be revealed without a thick layer of breast tissue to disguise it. Implant size is a matter of personal choice but the volume of the implant should generally not exceeded your natural breast base width. The final implant decision is whether the implant should have a round or teardrop shape. That is a personal choice of whether you want an augmented breast look that is round (full upper pole) or a more natural or sloped breast shape. (lower pole fuller than the upper breast pole)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had skull reshaping with bone cement last year in South Korea as my back of head was pretty flat. Since then I wasnt told that much information and may have put pressure on the left side of the back of my head, and now the left side is flat. can you fix this and is it safe to re apply more bone cement on top? 

A: Since skull reshaping bone cement is permanent and does not move or degrade, the appearance of flatness on one side of the back of your head has nothing to do with what you did. (put pressure on it) This flatness has likely reappeared because all of the swelling has finally gone done and the complete result of the skull augmentation procedure is not evident. In other words, the application of the bone cement was likely not symmetric. When correcting a total flattening of the back of the head, the hardest thing to do surgically is to get both sides even. (symmetry) This is not a rare postoperative problem.

The good news is that this is a very correctable skull problem through the application of more bone cement on the flatter side. There is no problem with placing new bone cement on top of older or pre-existing bone cement in skull reshaping surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting  breast implants. I have been wanting bigger breasts since I was 16 years old,  I am 26 years old. I am currently a very small B cup and want to be a full D cup using gummy bear breast implants. I am 5’ 4” and weigh 135 lbs. I have attached a picture. Based on my picture and height and weight, what size implant should I get?

A: From the one picture you have sent, there is no question you would be a good candidate for breast implants. Having no sagging of the breasts with good tight overlying skin and centrally positioned nipples is the definition of an ideal breast augmentation candidate. Since implants largely just take what you have and make it bigger, the better-shaped breast (small as it is ) will always create the best looking breast augmentation result. Since you are young and do not have any sagging you should be able to have your breast implants placed beneath the muscle which is the best option for a young person for the long-term.

When it comes to choosing breast implant size,m it is not as simple as looking at a picture and knowing your height and weight. What counts is what volume will create the look of a full D cup on you. That, of course, is also open to your interpretation of what that is exactly. This is why I prefer the use of volume sizers for the patient to try on and see how it looks. It is also important to know what your natural breast base width is. With that being said, an experienced estimate would be 400c to 450ccs breast implant size for you, probably of a high profile style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I am a 32 year-old Asian woman that has a bad nose problem now. I had a silicone implant rhinoplasty done severn years ago. It looked good and was fine until about six months ago when my nose got really red  and the implant got infected for no apparent reason. It had to be removed.:( Now my nose is sunken in and the tip is really short, it looks worse now than beforeI had the implant put in. Based on what I have read, it appears that a cartilage graft from the rib would be needed to get my nose back to the way I want it to look.

A: A rib graft rhinoplasty is the best choice for you now without question. The short nose of Asians can pose a real challenge when complications have occurred from a prior rhinoplasty. Unlike Caucasians rhinoplasty problems which are often the result of too much supportive cartilage removal, revisional Asian rhinoplasty problems result from augmentation problems from implants or grafts. When nasal implants get removed due to either infection or skin thinning, scar contracture will cause the tip to rotate upward as well as lower the height of the bridge due to the implant removal. This accentuates the naturally short nose of most Asians not to mention the scar tissue that has been created.

How effectively the Asian nose can be effectively built back up and lengthened is the result the result of the cartilage donor source. (an implant is obviously not a good choice when a prior implant has had to be removed) The amount of cartilage then controls what type of structural support and lengthening manuevers can be done. Rib grafts provide the most amount of cartilage one can use allows long straight grafts to be made for septal extension, columellar strut and extended spreader grafts as well as dorsal onlay grafts. No amount of tip or dorsal grafting from the ear or septum can produce the effects of what a rib graft can provide.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am possibly interested in skull reshaping surgery. I have occipital plagiocephaly.  My head is  clearly flat on the back left side of my head. I am 67 years old and losing my hair which makes it more noticeable. Can surgery correct this at my age or is it too late?

A: Age is not a physical issue for this skull reshaping procedure as long as one is in good health for the surgery. Since the procedure is an extra cranial procedure (onlay augmentation), it is no more complicated to go through than many other cosmetic facial surgeries. Age is only a limitation if one decides that they are too old to care about it…then it is too late.

I would be happy to look at any pictures that show the flatness on the left side of the back of your head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting buttock implants and fat grafting to my hips and butt. I know I don’t have much fat but I really want a much bigger butt. I have attached some pictures of me and a picture of my dream butt. How possible is this result?

A: Thank you for sending your pictures. You clearly have little fat to contribute to your buttock or hip augmentation. Your buttock augmentation result will come largely (95%) from the effect of the buttock implants. The ideal picture you have shown is not a realistic result. That is not going to be achievable no matter what implant size is placed. With an intramuscular implant approach with a maximal volume  of 300 to 350cc, that result will be about 33% to 40% of your ideal buttock size result. If the implant is placed above the muscle (subfascial) with a maximal volume of 500 to 550ccs, you will get about 60% to 65% of your ideal result. Any addition of a small amount of fat will add little to the implant-created result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am quite determined to have temporal reduction surgery done (head width reduction), but there is still a couple of lingering question I need answered. I have attached several CT scans of my head to get a better visualization on the width of my muscle as well as my skull. I was born with positional plagiocephaly. This has caused my head to be misshaped and one side of my face is wider than the other side. Initially, I was thinking about getting the head width reduction for both side of my face, however, after a careful consideration I want to focus the head width reduction on just the right side of the face on the wider side.  If the result of the reduction is significant, I might consider a reduction on the other side of face as well as jaw and chin bone reduction on the wider side of the face. One of my main concern of the reduction is how much the width can be reduced. I recently took a CT scan of my head and I found that the size of the temporalis muscle at the widest area of my head isn’t very thick being about 6mm. Thus I felt through only muscle reduction there might not be as significance of reduction compare to when if both muscle and bone reduction is performed at some region of my head. Also I recalled last time we talked that you told me that you are not gonna remove a lot of muscle you simply reattach it and let it shrink. Since the temporalis muscle at some of widest regions of my head is only  6mm, I felt the shrinkage of muscle won’t likely achieve my desire width of reduction which is between 5mm to 7mm on the right side. Thus, I wanted to see if I can completely remove the temporalis muscle on that side above the ear.

A: It appears you have misinterpreted how I do the temporal reduction surgery. I initially detach and remove the posterior muscle in its entirety, then detach the rest from the temporal crest, shorten it and reattach it lower. So the entire posterior muscle is removed. That is critical to get a very visible width reduction from 5 to 7mms based on the thickness of the muscle present. Bone reduction is done based on what the CT scan shows although it is never as significant usually as the muscle reduction, but it is an additive component to the overall width reduction. Certainly only one side can be done if desired and, in cases of asymmetry, met be the best initial approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in one of the facial procedures (cheek augmentation I think) to improve my smile. I make an effort to smile only to find out that people don’t find it compelling. I am confused and this makes my self-esteem very low. I have small(weak) cheek bones which some how make me look like I am frowning all the time. It was after me noticing my self-consciousness that I started being aware of all the people I found very approachable or had friendly faces, in other words their cheek bones were gently protruding and noticeable from a profile(side view of the face). This, them having strong cheek bones, really made them appear to be ‘ever smiling’ and smile effortlessly even when it is just a grin their evoking. I looked at myself talking in the mirror lately and was evidently stunned, because I would say things but my facial expression was not corresponding with what I say or the way in which I respond to things I said to myself. For instance, when I am surprised my eyebrows don’t rise and no lines on my forehead show, because my eyebrow bone is also flat and I seem not to send my messages across to others other than verbally. A stronger cheek bone with lines on the corners of my lips and bigger eyebrow bones will make my smile sensible. 

A: It sounds like you have a good grasp on how to improve your facial appearance. By your own description you know that cheek augmentation by implants, possibly combined with brow bone augmentation, would help your smile both outside and in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in abdominal scar revision. I had a panniculectomy done six years ago and an original tummy tuck approximately 11 years ago.  I’ve been unhappy that the scar is so high. As you can see in the photos there are 2 scars. The one on the bottom was from my first tummy tuck. Do you think another surgery to lower the top scar could be done? There’s not a whole lot of skin to work with but low cut bathing suits are what I like to wear. I’m very self-conscious about my scar. Your thoughts are appreciated.

A: My first reaction is that I am stunned that the intervening skin between the two abdominal scars actually lived and not died. That was a very risky procedure from a skin necrosis standpoint. But it did work although the logic of two such displaced scars remains a mystery.

If the goal is to lower the upper abdominal scar (via an upper abdominal skin flap elevation) and bring it down to the lower one, that is not going to be possible. There likely is not enough skin looseness to allow that much downward mobility after having had two excisional abdominal procedures. I do think it is possible that the skin between the two scars can be removed and made into one scar, but that will only happen because some of the closure will come from the lower pubic tissue being elevated. This will then place the new scar about halfway between where the two scars are now. That will not meet your low cut bathing suit criteria. Unfortunately I do not believe your abdominal scar situation can be improved to meet your aesthetic criteria.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, will a buccal lipectomy make a noticeable difference in the shape of my face? I am trying to get a shadowing effect below my cheek bones so I will have more of a male model look.

A: While the buccal lipectomy procedure has a controversial side as to its long-term facial aging effects (creation of the gaunt face), it is also importanbt to look at their upfront effectiveness as well. In most cases, a buccal lipectomy is a complementary facial reshaping procedure whose magnitude of effects differ based on one’s facial make-up. In a thinner and more skeletonized face, its effects are more visible but this is also the patient who is most predisposed to have sunken in cheeks later in life. In a heavier rounder face, buccal lipectomies often have a more minor effect and other procedures must be done around it to create a more visible facial reshaping effect. These are also the same patients that will not have a sunken in cheek look later in life. Opting for buccal lipectomies in facial reshaping must take into consideration the balance of early facial shape improvement versus potential detrimental long-term facial shape changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in knee lifts. I am 50 years old and am very active but my knees look like an 80 year old women. I need a knee lift to regain my KNEE self-esteem. I am in disbelief as active as I am that my knees have aged so horribly. I have an adverse reaction to most anesthetics so hopefully this is a procedure which could be done under a local anesthetic. 

A: The knees, like any other structure on the body, are not immune to the aging process. the constant motion across the knee joint requires moveable flexible skin. But for some people (usually thinner and very active ones) that constant motion results in the development of loose skin. This loose skin appears as folds above the knees, often having two or three small skin folds that have ‘piled up’ above the knee cap.

The procedure of a knee lift can remove these skin folds by excising a crescent of skin above the patella. It must be marked and removed carefully so that enough skin is left for the knee to bend 90 degrees of greater without undue pulling on the wound closure/scar. It is a fairly simple outpatient procedure that for the very motivated could be done under local anesthesia. It does result in a fine line scar above the knee and this must be considered carefully as a worthwhile aesthetic trade-off for the removal of the suprapatellar skin folds.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get a buried penis repair done. How exactly is it done?

A: When you use the term ‘buried penis’ that unfortunately does not tell me what type of tissue problem there is and what needs to be done to make it better. Is it a short penis only, an isolated large suprapubic mound, is there an abdominal overhang or some combination of two or all of them? There are different plastic surgery techniques that are done for the buried penis problem with varying degrees of success. These could include pubic liposuction, a pubic lift, penile release and lengthening or some combination of all of them. Having a picture of the pubic area, ideally from the front and side views, would help me understand the buried penis problem and give you some recommendations on whether plastic surgery would provide a positive improvement. (increased penile show)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know I need rhinoplasty but am not sure what else I need. I would like you to analyze the attached photos in order to determine the ideal procedures to bring better balance to my face. These are my own assumptions about my facial appearance, both what I see as out of proportion and how to go about fixing it along with the objectives I hope to achieve

1. Droopy asymmetrical nose – It would be optimal to both straighten the entire nose and strengthen the tip (add cartilage). The tip would look best projecting forward more. I would still want to keep a high strong nasal bridge, so little shaving should be done there. Tip should still be turned down slightly a few degrees further than perpendicular to the face.

2. My eyes are too prominent relative to my other features and I would like a stronger, masculine look to eyes. I have looked at everything from malar to inferior, lateral, and superior orbital rim implants. I am less sure what would prove ideal for this issue, so your own suggestions here would be much appreciated (though if you think it is a bad area for me to augment please let me know as I want your complete objective opinion). Be as specific as possible, referencing both the individual anatomy and procedures that are possible.

A: Based on the one side view picture that you have provided, I did some imaging for the rhinoplasty based exclusively on tip rotation and elongation with minimal reduction of the middle vault height and no reduction of the nasal bridge bone. With this change I see no reason for chin augmentation which is the first other facial feature to think of when the nose becomes derotated.

From an eye standpoint, the only consideration you want to make is for infraorbital rim-malar augmentation. While superior and lateral orbital rim augmentation can be done, the effort to do does not justify the minimal benefits and risks. The focus for making the eyes less prominent should be on the recessed infraorbital-malar complex. I have factored this into the imaging.

Dr. Barry Eppley

Indianapolis, Indiana