Your Questions

Q: Dr.Eppley, I am interested in skull augmentation.  I have heard of Osteobond being used overseas.  Is an expander needed? I have a normal shape, just want to make it larger.  What is the estimated cost? Thank you, I appreciate your time.

A: Whether an expander is needed for skull augmentation depends on how much skull expansion is desired and where that expansion on the skull is needed. Please send me some pictures so I can do imaging to get a feel if yours is a one-stage or two-stage skull augmentation. Knowing that and the material used plays a major role in the cost of the procedure.

Osteobond is not an FDA-approved cranioplasty material in theU.S. The approved options here are polymethylmethacrylate (PMMA, Cranioplast) and hydroxyapatite (HA, Mimix and others).

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have gynecomastia reduction but my puffy nipples persist which was the problem in the first place. My surgery was in October 2012 and it was liposuction via the armpit area. I am a 31 year-old in good shape and this has been a problem in my life since I can remember. I can’t tell you how excited I was to have the surgery FINALLY after all these years. The end result, however, was a leaner chest (one side a little more than the other) and still puffy nipples. When I read some of your comments online I figured I’d look for a second opinion, as my first surgeon has offered a second surgery to correct my problem.

A: Your result does not surprise me with that approach. While liposuction can make the chest leaner, it will not in and of itself take away the puffy nipple. That is going to require an open areolar incision to directly remove the firm breast tissue that lies right under the nipple. This tissue is just too firm and gritty in many cases to be removed by liposuction. If there is one thing I have learned about the puffy nipple in young males is that they want it completely flat and that is only going to be most assuredly achieved by direct areolar excision. The liposuction is helpful for general chest contouring but rarely removes the puffy nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, first I appreciate your answers to the questions that I asked you about custom made facial implants. Recently I read of computer or CAD/CAM designed implants. What is the difference between them? The CAD/CAM designed implants would work well for the reconstruction. While custom made implants designs are made by hand, computer designed implants models could be created by using computer soft ware. If it is such, I think that the CAD/CAM designed implants would be more suitable for my case to restore the exact defects. Could you design and manufacture jaw angle implants through CAD/CAM system?

A: Custom made facial implants is a general term that relates to several methods of manufacture. Handmade custom implants are done using a prefabricated skeletal model (made off of a 3D CT scan) where either a technician or the surgeon makes the desired shape of the implants which is then transferred into a final implant design. CAD/CAM designed implants is done digitally by a technician using a 3D

CT scan of the patient. There are advantages and disadvantages to either approach. When there is a very specific facial bone defect and a normal side to compare it to, the CAD/CAM approach is a good one because the computer has a definitive target from which to shape the implant. When one is after general aesthetic augmentation of any facial skeletal area, there is no specific or predictable target. Whether it is done by hand or the computer, the exact implant design is still a guessing game so to speak in terms of what will create the desired aesthetic effect.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Firstly, I would like to take the opportunity to thank you endlessly for the abundance of information you have on your website regarding cranioplasty. You seem to be the only person that has posted information about it, which has in turn reassured

me throughout my own medical process.
The reason for my email is to find out the best proposed solution you can present to me for my current cosmetic concern.
I have noted in some of the answers you have provided prospective patients with, you recommend using Kryptonite Bone Cement. My enquiries all relate to the use of Kryptonite Bone Cement to amend some defects I have from a past cranioplasty. I would really like to avoid having to shave off my hair where possible as it is almost as devastating as the defects themselves.
Last year in June 2012 I had a titanium plate inserted to cover the bifrontal (top front part of my head) due to replacing bone from a decompressive craniotomy after sustaining Traumatic Brain Injury. After the swelling had subsided from the insertion of the plate, I have been left with a visible line (indentation) where my plate goes across my forehead. I have also been left with a decent sized dent in the side of my face in the temple area, there also seems to be a smaller dent on the other side too. I have attached photographs so you can see the extent of my concerns.
What I would like to know is:
1. Will Kryptonite Bone Cement be suitable to use with my titanium plate? It seems to be an ideal solution to conceal the indentation along my forehead (where the plate meets my forehead) and fill in the gaps around my temple area and being injectable reduced the shaving and scarring as I would imagine.
2. If Kryptonite is not suitable, please tell me what the other options are that you would suggest.
3. Are there any side effects that I would need to be aware of?
4. Are there any long term studies on Kryptonite or proposed solutions that are available?
Many thanks in advance for your assistance, I eagerly anticipate your response.

A: In looking at your pictures and the accompanying commentary, let me answer your questions in the order that you presented them.

1)      Kryptonite bone cement is no longer commercially available for reasons that are unknown to us as surgeons. But even if it were, it would not be appropriate for your case. Any injectable cranioplasty technique requires an unscarred scalp/skull area, no indwelling hardware and a defect surface area that is not unduly large. With your craniotomy history, presumably large titanium plate and the extent of the cosmetic deformity (bitemporal crossing the forehead), it is going to require an open cranioplasty approach to adequately correct. It should be approached no other way. While this is not the approach you would like to hear, the good news is that the procedure can be done without shaving any hair. I never shave any hair for an extracranial crcanioplasty procedure.

2)      The only issue with an open cranioplasty is what material to use. It could be either hydroxyapatite (HA) or standard acrylic cranioplasty. (PMMA) There are some minor advantages and disadvantages with either material. I would have to see some x-rays of the extent of the plate location to answer that questions better.

3)      The only real risks of this procedure are aesthetic in nature. Can a seamless transition be done in building up all the areas from the temples across the forehead. The front of head looks very much like a ‘vice’ across it so more volume is needed to build out these areas in your cranioplasty than one would think.

4)      There are no long-term studies of Kryptonite that have ever been published. But this is irrevelant now since it is no longer available for clinical use.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 37 year old male. I have been feminizing my face for the last few years. I’ve already had my brows shaved and my hairline brought down. I wonder if you can help with 2 other areas that trouble me.
(1) I used to have a narrow, pointed chin. Unfortunately I had it shaved flat. Then I had a shaved medpor medium sized anatomical implant inserted. But my chin still looks wide, rounded (not pointed) and too long.
I have read a lot about you. I understand that you can use a smaller implant and shave the wings off to make it more narrow, and shave the point of the implant to be more pointed and shorter.
I have enclosed a photo of how it used to look, which I liked, and how it looks now which I don’t like.
(2) I also had high and narrow cheek implants inserted. Unfortunately the left implant became displaced after a car accident

and then removed. So now I only have the right implant in.
I wondered if you could place feminine implants in to replace the cheek implant i already have.

A: In looking at your chin and cheeks and your accompanying commentary, I can offer the following recommendations:

1)      Your chin is now broader and more masculine than it was because of the use of an anatomical chin implant design. The Medpor chin implants have very broad wings that add fullness to the side of the chin making it wider. That could be changed by either altering the implant you have in place (difficult to do because of the material) or remove and replace it with a more central button implant style which will return the chin to more or of a triangular shape. The length of the chin may just be a function of the size and location of the indwelling implant. But if some real vertical chin shortening is needed, the lower edge of the chin bone will need to be reduced.

2)      The cheek implants you have in place produce a more sculpted male look being high and lateral. A more feminine cheek appearance requires a rounded more anterior cheek look. That could be achieved by replacing the cheek implants you have in now with those that are better shaped for that look.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I believe I need a pubic lift. I have lost 100 lbs and am still over weight by a lot. But I had an abscess removed from one side of the upper pubic area and I’m also uneven on both sides. If you type in pubic lift blog on yahoo and under images there is pictures I believe of one you did that is quite large like mine little different I presume. My question is cost and what would be the steps and healing?

A: When

one has lost 100lbs, I would have no doubt that a pubic lift is needed. But I am suspicious that you may need much more than that. Usually such weight loss causes a lot of abdominal tissue overhang which is most commonly called a pannus or apron. This is a hip to hip removal of the abdominal overhang that would include a pubic lift. It is possible that an isolated pubic lift may suffice, or be partially helpful, but I would have to see pictures of your abdominal area to make a visual evaluation. There is a big difference in the cost and recovery of a pubic lift vs. abdominal panniculectomy so knowing what you look like is essential to answer your questions with any accuracy.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, have a little crater on the outsite skin on the top of my nose. I tried filler, excision, laser and dermabrasion. Nothing helps. The crater is 2/3 millimeter deep. Now a doctor in Switzerland want to put a little piece of cartilage under the skin to lift the crater. But I have no confidence because they all have no experience in this case. Can you help me? It’s no problem for me to visit you because I love your country….

A: It is hard to comment on such a nasal defect without seeing a picture of it and knowing where in the nose it is located. The key question is whether this defect is located to just within the skin (dermal indentation) or whether it is located in the subcutaneous tissues between the skin and the underlying bone/cartilage. Only a subcutaneous defect will be positively affected by any implant placed

underneath the skin as this will push out the overly skin indentation. If, however, the indentation is a result of dermal thinning (which I suspect may be the case) then no implant under the skin will help as it will just make a bump appear with the skin indentation merely pushed outward….actually making it look worse. Dermal skin indentations, which are common in the nose, are virtually impossible to improve as you can’t smooth down the surrounding skin and there is no way to make the dermis thicker. In rare cases, it may be possible to place an allogeneic dermal graft directly on the underside of the dermis but even this approach does not assure elimination of the skin crater. This type of nasal scar is very difficult to improve regardless of the method of scar revision that is tried.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I

Am 73 years old. Is blepharoplasty an answer to my swollen, puffy under eye condition? If they can be removed, will they come back?

A: Lower eye bags are caused by the progression herniation of fat that comes out from under the eyeball. Many people will eventually get them as they age although some people will actually have the opposite effect…loss of fat and deep set eyes with hollowing as they age. A lower blepharoplasty procedure will remove the protruding fat, a little bit of lower eyelid skin and tighten the corners to reduce the risk of a drooping lower eyelid after surgery. Age is not an issue when it comes to having this eyelid procedure only one’s health is. Most lower blepharoplasty procedures need to be done under anesthesia as it is very difficult to keep the eyelid still when you can see what is happening right in front of your field of vision.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a couple of questions and I have included a photo of me now (right side) and when I was younger (left side). I’m currently overweight and intend to lose that weight but what interests me the most is if it is possible to look like my younger and fresher self again, like the left side of the picture. I have seen surgery that make people look at least 5 years younger. Is it realistically possible to make me look like that younger me again? And if so, what are my options? What procedure would suit me best? I would say that my cheekbones, used to be wider, the cheek pads were higher, there is a lot of sagging in my cheeks. Also the area around my eyes has become hollow. The bone is more visible and my eyes look deeper placed. If I would be my own surgeon I would probably suggest to lose that weight. And maybe then turn to possible cheek implants and fillers to reduce the hollow look. I’m not sure because I’m no expert. I could be totally wrong?

A: The first question you have to asked yourself is what has changed that makes you look older. By identifying the changes then you can see what may be able to be done. Thus I would first ask you what you see. I have my thoughts but what do you identify that you see has changed? What changes do you think would make you look more refreshed? You have done that and I feel that you are totally right. That is exactly what I would recommend and what I see as beneficial…small cheek implants and fat injections to the lower eyelid hollows.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in getting revision of my numerous arm scars. I have attached two photos of the scars on my left arm. The first one on my upper arm is an 8 year old scar. It is the largest of my scars. The second photo is of self inflicted wounds that are about 10 years old. These are the ones I am more insecure about. Let me know what you think of these.

A: Thank you for sending your pictures. I have seen many such scars as you have either from accidental or self-inflicted injury. The reality of your arm scar revisions is as follows:

1) The very large scar with the suture track marks can definitely be improved. But it would need to be done in two stages due to its width. First excise the inner scar portion, let it heal for six months and then go back in a second stage to include the area that has the suture track marks. This is the best way to get a much narrower scar. It is simply too wide the way it is now to get substantial narrowing in a complete one-stage excision. Staged serial scar excisions is the best approach in wide scars where the surrounding skin is not very lax. These are office procedures done under local anesthesia.

2) The ‘cutter’ scars are always problematic because there are so many and they go the whole way through the skin. That is why they appear white as they are a full-thickness skin jnjury/scar. This laser resurfacing will not simply ‘wipe’ them away. They really need to be cut out and reclosed which often does not make a real big improvement for what you are trying to achieve. (not to look like you cut yourself) I have done a few case of complete skin grafting but that is an extreme approach for those who seek another more palatable explanation for why they have a ‘patch’ of their arm.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to have rhinoplasty and otoplasty and, for a variety of reasons, will need to not do them together. I have some questions about the procedures:

1. How realistic is the imaged  “after” rhinoplasty result on the nasal profile? While the projection itself is noticeably smaller, I think half the effect comes from changing the slope of the upper lip. Is that something you could do along with the 1/3 to 1/2 reduction to avoid tip skin problems? 

2) I’m getting an otoplasty on March 11th. Is there a minimum time I need between the otoplasty and the rhinoplasty?

A: In answer to your questions:

1) The lip coming forward may have some impact on the perception of the dramatic change in tip projection. But, regardless of who did that imaging, you should know that is a ‘best case’ scenario and there is no guarantee you will ever get that much tip reduction. If you walk into surgery expecting that result and will be very unhappy if you do not get it, then you are setting yourself up for disappointment. Conversely, if you go into surgery hoping for that result but would still find it a big improvement to only halfway reach that amount of tip shortening then you will no doubt end up in a happy place.

2) There is not really a minimum time between two surgeries when they could be done either together or separately. The ears do not influence the nose or vice versa. It is more an issue of logistics for you such as work and other recovery issues. That being said, I would space an otoplasty and a rhinoplasty at least 6 weeks apart if the patient needed to separate them into two surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Sculptra and Artefill (at difference times) injected into both sides of my chin area a couple of years ago. Recently (January 2013), I had a series of lumps followed by this deep depression on one side. The discoloration on the other side has been there a while, but I usually cover it up with makeup. Juvederm will not fix the depression – when injected, it just moves to the other side of the depression. I don’t want to make things worse, so I’m trying to figure out how to fix this. Would 5-FU or Kenalog injections help or make things worse? From looking at my skin, does the problem appear to be from the Artefill/Sculptra? Is there anything that can be done? I had an endoscopic brow/mid-face lift in July 2010 that left my lower face looking worse, which is why I had the Artefill/Sculptra injected in the chin area in the first place. From what I’ve read, there is no way to remove the Artefill/Sculptra. I just want to try to get that area looking normal again and do everything I can to not make it worse and not end up with some kind of connective tissue disease. My chin area looked fine for a few years. The photo labeled August 2012 looked fine, but everything seemed to get worse in January of this year. Many dermatologists and plastic surgeons do not know how to treat this issue, so I am looking for someone experienced that can help with this.

A: To try and provide some insight, it is first important to look at why you have the lumps in your chin area. Certainly the use of the particulated semi-permanent fillers are the culprit. At this point in time Sculptra, which is a polymeric material which eventually absorbs and exert its effects by causing some collagenous scar formation, is now gone. The residual scar tissue left in its wake may even have faded at this point. This then points to Artefill which contains a percent of non-resorbable plastic spheres. These do have the risk years after placement of forming lumps due to scar contracture around the spheres. This is not an infection or dangerous reaction but a scar reaction to an implanted material, somewhat like a capsular contracture around a breast implant years or decades later. How to treat them? The standard treatment for scar contractures or granulomatous tissue reactions would be steroid (Kenalog) injections. While these may be effective they also have the potential of causing their own side effects such as fat atrophy and skin depressions. A very low dose of Kenalog would not likely cause these potential issues but is also unlikely to work either. 5-FU works best in the early phase of adverse scar reaction and not in well established scar tissue problems. I would not be too optimistic about either of these approaches. They will either not work or cause other problems. One newer treatment of which I would be more enthusiastic would be micro fat injections. The lumps could be broken up by needling them and then small quantities of fat injected into the subcised lump areas. Since fat is a natural material there are no risks of adverse effects. Fat contains healthy  adipocytes and stem cells of which by their incorporation may provide a softening of the scar tissue and some dispersion of the plastic spheres.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hello!  I have used unlimited number of eye creams and products in hope of trying to eliminate the dark circles around my eyes. Do you offer any surgical procedures to remove my dark circles/sunken eyes?

A: There are numerous causes of dark circles from hyperpigmentation to anatomic deficiencies such as retruded infraorbital rims and lower eyelid hollowing due to fat loss. Any surgical procedures for dark circles are based on treating the anatomic causes and could include injectable fillers, fat injections, dermal-fat grafts and infraorbital rim implants. I would have to see some pictures of your eyes to see what the cause of your dark circles are. Please send me some pictures of your face/eyes, particularly from the side view. It would be important to see the relationship of your eyeball to the surrounding eye socket bones.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have recently seen photos of myself at many different angles refereeing basketball games and in family pictures.  It made me come to the realization that I really do have rather large ears.  I attached 3 pictures of myself to this email to illustrate.  I looked on your webpage, and I see that you talk about a procedure that you do to pin ears back that stick out.  Mine don’t stick out, I would just like to make them a little smaller.  I did some research and found the procedure that I desire, which I copied below.  Is this something that you could do for me?

A: What you are referring to is known as vertical ear reduction, or truly making a large ear smaller. Unlike a setback otoplasty, which is done by an incision on the back of the ear and pins the ear back, an actual ear reduction removes a wedge of skin and cartilage from the center of the ear. This shortens the total ear height 10 to 15mms. This is an old well known ear reconstruction technique more commonly used for the removal of skin cancer simply applied for the cosmetic concern of a vertically long earl While very effective a scar along the line of excision. The key to getting a good scar is to not make it a straight line as it crosses from the concha (bowl) of the inner ear across the antihelical and helical folds. Much like a broken line scar closure technique for scar revision, the interrupted and irregular closure line scars better.

Thus, it is not a question of whether it can be done but whether this fine line scar across the middle of the ear is a good trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had a consultation to receive chin liposuction as I rather dislike the definition of my jawline and chin angle. However, after studying myself more closely and researching the topic further online, I’m not sure liposuction will provide a significant result. From what I can perceive, my lack of jawline and chin angle definition is due more to the shape and size of my neck muscles (and perhaps my glands? and certainly my slightly recessed chin) then the little fat that is there. I’ve been reading about necklifts, in particular cervicoplasty, where an incision is made under the chin and excess fat is removed in conjunction with tightening of the platysma muscle. From my attached pictures, do you think this procedure might work for me best in an effort to define my jawline and improve my chin/neck angle? I realize you may suggest chin augmentation by implant to that effect, but I am not keen on that option (in my ideal examples, you will note that I have augmented the jawline only and not the chin). Could you please give me some information on the surgery and recovery time?

A: I would agree with your assessment that submental liposuction alone would be insufficient to achieve your ideal neck angle result. You will only end up about halfway there based on your imaging predictions. This is not just a fat issue as you have pointed out but a plastysmal issue as well..in conjunction with your shorter chin. A submentoplasty or isolated cervicoplasty would be a better approach. I don’t know if you can achieve your ideal goal as you have illustrated in the neck flexion image but it certainly would be better than liposuction alone. As you have mentioned, a submentoplasty or limited cervicoplasty is done by a small incision underneath the chin in which fat is suctioned and the platysmal muscles and overlapped and sewn together to tighten the neck angle. There is only moderate swelling and a very quick recovery. The biggest issue with cervicoplasties in young patients is to avoid any skin irregularities or ripples after it has healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am only just researching these procedures. I have lived my entire life with an asymmetrical face and flat head, being told that one half of my face looks young and the other like an old man. I’m 23 years old. This deformity is my biggest most unavoidable insecurity which has hindered my confidence since my teenage years. I don’t wear baseball caps or winter toques. I avoid having my picture taken as much as possible and I keep my hair long in front to cover my very uneven eyebrows. My question is will I ever be able to afford a surgery like this? How much generally is a surgery like this? Any support and advice on this would be so much appreciated.

A: Facial and skull asymmetry takes on many variations. It is impossible to say what procedures would be beneficial without seeing pictures and talking to the patient about their concerns. Every patient must create a priority list of their concerns and then a surgery plan is made around that list. Cost of surgery follows making that listyso it would be impossible to provide any estimates at this point.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about the laser scar removal and which would be best for my kind of scars. I have acne scars on my face and I am determined to do something about it before to much time goes by. Because its ruining my life to be honest. I have a family with my 2nd child on the way and I want to be able to be myself for them and be able to do things with them. Right now this issue holds me back from literally everything. I pretty much won’t go anywhere unless its an absolute must. Im only 24 years old. I may not have the worst kind of acne scars because they aren’t too big in actual size and stuff, but I kinda just have a lot of them. At least too many for me to really handle. Its really affecting my whole life like I said. Im pretty much scared to death to even be around people anymore. Even my own family sometimes. i just want to be able to look in the mirror everyday and be happy with myself.. mainly so that I can make my family happy, because It can be hard to do when I’m depressed all the time.. I sometimes go weeks without actually looking in the mirror, and then when I do, I will only do it in a certain dim lighting. I avoid it because I tend to beat myself up to hard over it, and its just beyond stressful. I’d probably even be too scared to send pictures because I’m scared to have to see the picture. Im sorry to go into so much detail, i just want to make sure that I’m dealing with a Doctor that understands what I’m going through, and how important it is for me to get something done. So, I guess I hope to hear back from you soon. I really appreciate any of your time and the fact that you are giving me the option to have a free consultation. Thats really cool and is a big reason why I picked to contact you over anyone else. 

A: Thank you for your inquiry. Acne scars are very troubling for many people so afflicted and your story is not an uncommon one. While there are numerous acne scar treatments available, the most effective and commonly used is that of the laser…specifically fractional laser resurfacing. What notion that I have to dispel for everyone from the beginning is that there is no such thing as ‘laser scar removal’. It is currently impossible to get completely get rid of your acne scars. It is more realistic to use the terms ‘laser scar reduction’ or ‘laser scar treatments’ as this is what will actually happen. The amount of acne scar reduction possible may be very significant or the results more subtle. That will depend on the size and depth of your acne scars, your natural skin pigmentation, and their facial locations. Most fractional laser resurfacing for acne scars takes more than just one treatment, but how many would depend on how one responds to the first treatment.

You will have to be seen in the office for further evaluation to provide much more than this basic information about fractional laser treatment of acne scars.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently weigh 255. I would like to get down to 215.  I’ve improved my eating and exercise, but I’m not seeing results.  I would like 6 inches of fat removed from my waistline to help improve the fit of my clothes and my appearance.

A: I think it is important to put liposuction into proper perspective of what it can and cannot do. It is not a weight loss method nor can it remove a specific amount of fat in inches from anyone’s waistline. In some patients it may be possible to remove that much fat but in most cases that is not a realistic goal for what liposuction can do. While I have no idea as to what you look like, your height or your body frame, I do know you are a male who likely has a rounder more rotund belly. Much of men’s abdominal fat is not extraperitoneal (between the skin and the abdominal muscles) where it can be safely accessed and treated by liposuction. Most male abdominal fat is intraperitoneal, around the internal organs, behind the abdominal muscles and inaccessible to liposuction. There are two simple tests to tell where your abdominal fat is located. Is your belly hard or soft? (feel like a watermelon or like a firm pillow)  How much skin can you pinch between your fingers? (an inch or two or a whole handful) A soft belly in which one can grab a whole handful of tissue means that liposuction can make for a productive result.

The real question is whether liposuction can and should be done now or wait until you have lost more weight. (I know this is why you are asking for liposuction because the weight is not budging but there are other non-surgical means to pursue if needed) That is going to require an actual physical examination for me to see and discuss whether liposuction has a useful role in your abdominal contouring objectives.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, you are the first surgeon that has listed this on their site. I have been looking for a solution for my downturned mouth for years now and finally I have found it! My mouth has been troubling me for several years now and I keep having to sleep extra and drink extra coffee all the time so I dont feel tired so that my lips dont droop and mine have quite a severe droop. I just have a question and that is how long does the corner of mouth lift last for(how many years) before it starts to downturn again?

A: The downturning of the corner of the mouth is a result of either a natural shape of the mouth corners or skin pushing down on the corners of the mouth. This may be from a normal anatomic shape to one’s mouth or from aging as the descent of midfacial tissues pushes down around the mouth. Depending upon one’s age, it may be one or the other or often a combination of both factors. The corner of the mouth lift is the single most effective method for changing the mouth corners that I know. While there are some non-surgical options as well (Botox, injectabale fillers), its excision of skin makes it relatively long-lasting. The question of how long-lasting is an interesting one and that would depend on numnerous factors such as one’s age, the cause of the downturning and how the rest of the face is aging. For some patients it is a permanent change, for others its effects may last years but not necessarily permanent. I would need to see some pictures of your mouth/face to answer that question better for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 46 years of age and a runner in great health–I use to love my breasts, but now not so much.   Looking at either breast lift or augmentation and brazilian butt lift.  I have always had a flat butt, especially flat since I run…and sit all day–have great legs want the rest of my body to match.   Seeking cost of both surgeriess (I realize average is best you can estimate, not having seen me), all scenarios.   Would like to save an pay up front if possible, will not finance.   PS – I do have that baby belly fat still in there, so I’m sure it can be used to help my buttocks out!  🙂 Thank you!

A: One of your problems will be easy to solve and that is the breasts. Breast implants will provide an immediate and permanent solution to a larger breast mound, of a size of your choosing. Whether you would really need a breast lift I am not sure but as long as your nipple is above the lower breast fold you would not. I will assume that since you are a runner that you have breast deflation not breast sagging. The more difficult problem to solve is that of your buttocks for three specific reasons, none of them surgical per se. First, would a runner in great shape really have enough fat to harvest for an effective brazilian butt lift…in most cases usually not. Second, even if enough fat were transplanted the odds are high that being a runner will result in the fat being absorbed quickly…burning it off. Those who have less fat do so for a reason. Thirdly, like breast implants real buttock implants are the definitive permanent answer but in a runner the recovery might be longer than you want.

Expect silicone breast implants to be around $ 5,700, a brazilian butt lift to be around $ 4,500 since yours is small and buttock implants to be around $ 5,900.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an “apron” that hangs below my pelvic bone due to 3 c-sections. I have had this for 20 years. It is my dream to wear a wedding dress and not see the hang over through the dress. Would I have time to heal before wedding date of late October 2013?

A: Prepare to have your dream come true. One of the most rewarding of all tummy tucks is the removal of the abdominal apron, also known as a pannus. Its dramatic removal creates not only an instantaneous waistline change but a near lifestyle improvement without a floppy bag of tissue getting in the way of clothes, exercise, personal hygiene and intimate relations. Given that your wedding is over six months away, you will be in good shape for your wedding as long as you have the tummy tuck at least 3 months before the big day. The other good news is that after the tummy tuck there is no chance that this abdominal apron will ever come back unless one has more children (I am assuming after 3 that you are having no more) or unless you gain a tremendous amount of weight (greater than 50 lbs) and lose it again.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in increasing my breast size. I am 52 years old and would love to feel better about my body. I am a single woman, my children are grown. I am a 32A cup. The largest I have been was when I was pregnant. My breasts got smaller vs larger after childbirth. Really I think now I may be double A. I would like to have the under implants that lift and would appreciate a consultation with you. I finally have the nerve to inquire about this matter and am excited that I am researching my options.

A: Breast augmentation can do wonders for a woman’s self-esteem and confidence in her own body. While most people think that breast implants are just for younger women, I am seeing an increasing number of middle-aged women and older undergo the procedure today. It can provide a great boost for the post-pregnancy body no matter what one’s age is. This ‘bold’ move by you may well lead to a whole new era of your life…and some wardrobe changes along the way.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, have there been any new developments in the delivery of injectable fillers. I love what they do for my lips and have been doing them for years, getting Juvederm at least once a year. But getting injected is just something that I dread. I know beauty is painful but I am slowly reaching my limit of tolerance. I am due for another injection but have been putting it off for months now as I dread the process. I don’t care how it done and I have tried everyway from ice to dental blocks. Please tell me you have something new that makes it painless!

A: In case you didn’t know there has been a major advancement in the delivery of injectable fillers known as microcannula delivery. Unlike a needle which has beveled sharp edges and cuts the tissues as penetrates them, always causing some discomfort and potential bruising, a microcannula has a smooth rounded tip. It does not cut the tissues as it goes through causing no pain at all as it delivers the filler through a small side port just off the end of the cannula. This is a remarkable improvement over needles and only involves one small needle stick to make a tiny hole for the microcannula to get under the skin. For the very sensitive lips this will change your injection experience dramatically. In addition there will also be zero chance of any bruising. If your current injectable filler provider does not offer the microcannula method ask them to start doing it. If not, run to a provider that uses it. It will completely change your feeling about getting injectable fillers to your lips.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a slight asymmetry that affects most of my face, though the only place I noticed it was in my lower jaw. My chin grew too far to one side, and that side was under developed. I had implants put in to make the developed side fuller, my chin was filed down and capped to make it symmetrical. The problem was that after the surgery the side of my face didn’t have implants put in then looked very small. My dad said I looked like the “Janis” Roman coin with a different face on each side. I saw the same surgeon for a corrective procedure where he took out the chin piece almost entirely and only added a piece to make it symmetrical on that side. The result was a very odd look. I think because the jaw implant was designed to go with the chin implant, when the chin implant was gone it no longer worked. I look like I have constant swelling on one side of my face. This was all five years ago. I didn’t have the heart to ask my parents to pay for another surgery. I have been saving since then and I think that I can afford it now. I recently started orthodontics again and can send you current photos of my face and can send you x-rays that show the implants. 

I have several concerns, which you will probably need to see these pictures to answer. The first is, do I have unreasonably expectations. I think that I could expect to have symmetry, and a face I don’t try to grow a beard to hide, but I don’t have your experience. This is a tremendous amount of money for me and I won’t have the money to try again if this surgery is unsuccessful so I would rather not go for it if I can’t expect good results. I imagine the previous implants are grown in, I don’t know what that means for your surgery. 

Facing me, my right side is too full, my chin is too weak. I would ideally like to pull out the chin implant that is there now and create a new implant that wraps from (facing me) my left side to the implants on the right side. This would lengthen the chin so I wouldn’t have the fat face effect. It would also add filling to the left side so I wouldn’t have the janis effect. Hopefully, it would be symmetrical. Because my whole face is off slightly I worry that a 3d rendering of my jaw may allow for a perfectly symmetrical jaw, that does not look symmetrical. I am sure you could address that.

A: When you have a significant facial asymmetry that has failed previous attempts at ‘simplistic’ correction (estimating the amounts of augmentation), one can assume that this is partly a function of the planning stage. While one can never predict with absolute certainty as to how any bone surgery will create a change on the outside,  it is reasonable however to strive for optimal facial symmetry. This is best done with a 3-D CT scan and model fabricated to properly diagnose the problems and design/fabricate custom facial implants that would best correct them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here I’m sending you this picture to show you the degree of my facial problem. What can you please tell me about the procedure by looking at my picture now. What can be done to improve my facial asymmetry?

A: Thank you for sending your pictures. What I can see is that your facial asymmetry is caused by a near complete left facial hypoplasia or underdevelopment.  This can be seen over the entire left face by a lower eyebow position, left upper eyellid ptosis (2mms, smaller cheek bone and deficient jawline and jaw angle. Like all forms of facial asymmetry surgery, the patient must decide which side of their face they like more. Even though you have focused on bringing in the more protrusive right cheek/zygomatic area, that would be just one change that you could make. There are numerous other ones as I have illustrated in the attached computer prediction imaging such as an endoscopic left eyebrow elevation, left corner of the eye tightening, left cheek augmentation and left jaw angle augmentation. Your facial asymmetry is more than just one bigger cheek and a deviated jaw, it is the entire left face that is smaller.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions regarding cranioplasty, rhinoplasty, and septoplasty. I have a form of craniosyntosis and my skull has indentations that could be improved by a cranioplasty, I also have a severe deviated septum and crooked nose that needs correcting by having a combination of rhino/septoplasty. Insurance will cover the procedures for my nose to get corrected. I believe I have seen somewhere on your website where someone asked a question similar to this, and you said something along the lines of it is ideal to get the cranioplasty and rhino/septoplasty all done at once. That probably is not a possibility in my case, because getting my insurance to cover the cranioplasty is going to be difficult, so I am going to have to put that off for now until I have the money to get it done.  

My questions are:

1.Would it be OK to get rhinoplasty/septoplasty done before getting a cranioplasty? 

2.Or is it better to get the cranioplasty done first? 

3.Or does it not matter at all in which order I get these procedures done?

Thanks

A: In answer to your questions:

1) Insurance may cover the septoplasty portion of your nasal deformity but not the rhinoplasty portion.

2) Insurance will not cover any type of cranioplasty for skull recontouring. Indentations of the skull are not a medical condition but a cosmetic one.

3) The order of septorhinoplasty and cranioplasty is a matter of personal preference. There is no medical reason as to how they staged or in what order.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a cheek bone bigger that the other… due to a malocclusion and a deviated jaw. I was wondering if my jaw is place in position I will still have a cheekbone bigger that the other… where is the incision made  to reduce this zygomatic bone in my case. Thanks for your time.

A: Without looking at any pictures of your face and x-rays, I can not answer how your cheekbone would look if your jaw is repositioned. Most likely, however, it will not look better and may likely look worse as the jaw is moved more into a more centric midline facial position. There are numerous types of cheekbone osteotomies, depending on what type of cheek bone reduction is needed. With facial asymmetry, most likely the bigger asymmetric cheek needs to be moved in medially towards the facial midline. This type of cheek osteotomy would be done through an incision inside the mouth. (vertical medial cheek ostectomy)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your prompt response and for clearing up the periareolar technique. I have heavy breasts so it sounds like the liposuction might not be enough for me. Do you perform the SPAIR technique? As you can see, I am trying not to have a lot of scarring. I know that it’s inevitable and I’m realistic just trying to avoid as much as I can. I have learned alot from your web site and appreciate it greatly.

A: What I was implying is that some scar must come off from around the areola to achieve a breast reduction/lift. However, no woman wants anymore breast scars that they have to have. There is where the SPAIR technique comes into play, a method which I am familiar and endorse. This is a combination of American and European breast reduction methods. The SPAIR acronym means a Short Scar Peri-areolar Inferior Pedicle Reduction technique. This methods reduces the breast scar load to about 50% of the traditional anchor method by eliminating the entire horizontal crease scar. While this is the least conspicuous of the three locations of the anchor breast reduction scar (peri-areolar, vertical and horizontal scars), any scar reduction is a benefit. As long as the amount of breast reduction stays in the range of about 500 to 1500 grams (where about 90% of all breast reduction weights are), I find that it works well.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m looking to get a revision rhinoplasty to fix facial asymmetry and improve appearance. My goals are to straighten my nose and decrease the amount of tip projection. Can you take a look at the attached document which shows some computer imaging and let me know what you think? Thanks!

A: Thank you for your inquiry and sending your goals. One of your nasal goals ia achievable, the other is not. Straightening a nose, particularly after a primary rhinoplasty, is always a challenge but potentially achieveable. Correcting the deviated nose would require a complete septoplasty and grafts to stabilize the realignment from an open rhinoplasty approach by separating the upper lateral cartilages from above for access. Shortening the nasal tip projection by the amount you have shown is not a realistic goal. While the cartilaginous framework can be shortened that much, the overlying skin is not going to contract down that far. And if one tries to reduce the support for the tip skin by that much, the tip skin is likely to end up with a ball-like deformity. It is far safer and more realistic to settle for a 1/3 or perhaps 1/2 that much reduction to avoid intractable tip skin problems.

I make these comments as general statements without knowledge of what was done during your primary rhinoplasty. Knowing those structural changes may change the aforementioned opinions.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hi, I’m interested in the periareolar breast reduction with lift and wondered if you perform this procedure? Also, I am interested in a tummy tuck at the same time if possible. Does you accept Tricare Prime insurance or Tricare and you a network or nonnetwork provider?

A: Thank you for your inquiry. For the sake of clarification, there is no such thing as a periareolar breast reduction procedure. Limiting the skin removed to the circumareolar area will not only not do any actual breast reduction but is a very poor method of breast lifting for most women with any degree of breast ptosis. (sagging) The only conceivable case in which a periareolar technique may be used successfully is where there is a very minimal amount of breast sagging and liposuction is be used for the removal of some breast tissue. Such a scenario would be most uncommon for most women who seek breast reduction surgery. I would have to see some picture of your breasts to see if this is a possibility for you. The reality about combined breast reduction/lifting is that it requires scars around the areola and downward to the lower breast fold and along the lower breast crease. (anchor scar pattern) This is the only method of breast reduction that actually really works.

It is certainly possible and very common to do any type of abdominal contouring in conjunction with any form of breast reshaping. When done together, these combined operations actually have a name….the Mommy Makeover.

Lastly, I am not a provider in the TriCare insurance program.

Dr. Barry Eppley

Indianapolis, Indiana