Archive for June, 2010

Wireless Plastic Surgery and Medical Care

Tuesday, June 22nd, 2010

While my parents, and their parents, have lived much of their lives with fairly similar methods of doing business, the present world has seen a near total transformation in just the past decade. The merging of two initially unrelated technologies, electronic communication (now wireless) and social networking, have created a paradigm shift in societal thinking and strategies. While most who will read this have felt the impact on their business and personal lives, health care is one area where an equal transformation is rapidly occurring.

Plastic surgery has been one of the early adopters of both social networking and digital communication in the medical world. Part of this is because so much of plastic surgery is visual. Almost all of what we do can be seen and easily imaged. This is a double edged-sword as assessment is easy but with that can come an equal opportunity for criticism. Plastic surgeons rely on imaging only less than that of radiologists, whose entire practice is essentially the analysis of complex three-dimensional arrays of pixels. While a plastic surgery patient can provide great verbal detail and descriptions of their concerns, a good picture or two can leapfrog hundreds (or is it thousands?) of words.

Because of the need to market fee-for-service elective surgery, social networking sites have become a popular medium for plastic surgeons and numerous other practitioners of cosmetic services. In the old days (2000?), one would rent a hotel conference room  and put on an evening program for the public. Advertising by word of mouth or newpaper ads might get an audience of 50 to 75 people. Post  a blog or a promo on Facebook or Twitter and the potential exposure is to thousands.

I could pontificate on the medical impacts of these technologies, and there are too many to mention here, but one recent story makes the point. Driving home one evening after a day of surgery, I received a call from an emergency room halfway across the city. They had a five year-old boy that had a laceration on his forehead after his older brother  yelled, fore!, and swung. These type of calls are common in plastic surgery and despite that I would have liked to fix this child’s problem, being up since 4AM and driving 35 miles was not beyond what I could muster. I asked the emergency room doctor to pass along my regrets and asked them to call another plastic surgeon. As I was settling down for the evening and just put my feet up, I received an unrecognized e-mail on my iphone with a one sentence message and a picture attachment. The message said, ‘My son is in need of your skills.’  signed by a mother’s name I had never heard of. The picture showed a close-up of a child’s face with a laceration down the center of the forehead between the eyebrows and the scalp…right down to the bone.

I don’t need to tell you what happened later that evening.  With estimates that at least two-thirds of American physicians have smart-phones, doctors are prime targets for access from multiple wireless methods. With nimble technologies, from smart phones to  health-monitoring devices, patients as well as doctors are becoming more empowered. Will this make health care better and reduce costs? Who knows but interactive health and wellness programs already surround us. Apple alone  has thousands of health-related applications. Cell phone services using the Droid are not far behind.

Medical care is becoming more wireless at a brisk pace. While receiving the actual care still requires an in-person visit, the day may not be too far away when all you need to do is hold your cell phone next to what hurts.

Dr. Barry Eppley

Indianapolis, Indiana

Can You Cut Out Scar Tissue From The Labiomental Sulcus and Chin?

Monday, June 21st, 2010

Q: I had a chin surgery in the past with a silicone implant  placed from inside my mouth. I didn’t like it so the doctor removed it two weeks later. Within a few days after its removal, I could feel fluid inside. The doctor removed it by a needle and it looked fine. But five days later I had a hard ball in my chin and the doctor told me that it was scar tissue. He assured me that I would return to the profile I had before my surgery. But it did not go back and I went to see another doctor who also told me it was scar tissue and injected me with steroids. The steroid helped a little but the labiomental sulcus is still much fuller than it was before the chin implant was placed. It now feels soft but is still fat. I think that the majority of the problem is in the upper part of the chin in the mentolabial sulcus. I don’t have the normal S  curve that divides the chin and the lips. When you touch it you can feel something soft inside and the doctors here have told me it is scar tissue but they only want to fix the problem with more steroid injections. But I am afraid now because I have a dent from the steroids. Do you think it is possible to take out the scar tissue in the labiomental sulcus ?

A: You have experienced one of the problems from intraoral chin implant placement. When the implant is removed, the muscles remain expanded and an ‘open’ pocket exists where the implant once was. While the implant removal was undoubtably done quickly and easily in the office, no effort was made to put the mentalis muscle back in place and re-tighten it. A technique well known in plastic surgery as eliminating the dead space. Since the body abhors dead space, it will fill it with serous fluid…a perfect nidus for the development of scar tissue.

My recommended approach for this type of chin scar revision is excise scar tissue and reposition the muscle back down to the bone. This would be done from inside the mouth through your old incision. This is the most assured way to get back your chin profile and re-establish the depth of the labiomental sulcus.

Dr. Barry Eppley

Indianapolis, Indiana

How Do I Get Rid Of This Bad Scar On My Nose?

Monday, June 21st, 2010

Q: I got the mole on my nasal bridge removed by elliptical excesion. The wound got infected (pus). The stitches were removed after five days of operation. Because the pus was still there the wound opened up. Now 15 days after the removal of stitches, I am left with 1mm deep large hole in place of mole, which is still pink. Please suggest a remedy, My doctor says I should wait for three months, If  the scar remaining is too big then I can go for another sugery. I dont want to wait for so long, as it is effecting my life . Please suggest something.

A: The strategy that your surgeon has suggested in this right one. It is better to let the wound heal and contract down in size. It is possible that it may heal to the point where you will find the scar acceptable. Most likely, however, this will not occur as the nose is one of the most unforgiving places to scar on the entire face. By letting it heal, the scar (like the original mole) can be excised again later. By this approach the size of the defect will be smaller and the tissue quality will be much better for handling and holding sutures. While this is certainly distressing to allow this process to evolve on a prominent area of your face, it is the wisest and will result in the best scar result long-term. 

A more immediate option is to re-excise the wound and close it now. While this can also work, it will result in a longer scar and a near 100% certainty that the scar will be wide and will need a secondary scar revision later. I would not recommend this approach.
Indianapolis, Indiana

How Do I Get Rid Of Rippling In My Breast Implants?

Monday, June 21st, 2010

Q:  I had saline breast implants placed three years ago. I went from a A to a C cup. While I like the results, there are ripples along the bottom and the sides of the implant. I know some people have them and can feel them, but in me you can actually see them. They are really evident when I bend over. Is there any way to fix these? Would a smaller implant be a fix? Would smooth implants be a fix? Would alloderm be a fix for rippling ?

A: By the way you have framed your question, I am assuming that you have textured saline implants. Whether they are above or below the muscle is another very relevant question. Either way, however, saline breast implants are well known to have this problem. Sometimes the rippling is relatively minor, other times it can be quite significant. It is a ‘natural’ feature of saline implants which reflects the differences in how water vs. a silicone gel coats the inside of the silicone shell or containment bag. While it is common and expected in saline breast augmentation, several things can make it more pronounced, such as using a textured implant, placing the implant above the muscle and underfilling the implant from its recommended minimum volume.

While there are still some unanswered questions about your breast implants, there are several known effective strategies. Changing to a silicone implant is one of the successful as these implants have much less rippling. If cost is an issue, a more economic approach is to simply fill your existing implants with more volume. (it would be important to know beforehand what base size implant you have and how much saline is in them) While alloderm can thicken the capsule and theoretically lessen the amount of rippling, it is the most expensive strategy and the least assured of making a significant difference.

Dr. Barry Eppley

Indianapolis, Indiana

How Do I Get Rid Of Hemosiderin Staining Under My Eyes From A Previous Rhinoplasty?

Monday, June 21st, 2010

Q: I have had quite noticeable under eye hemosiderin staining since a rhinoplasty nearly 20 years ago. I’ve had several laser treatments over the years and am currently applying a hydroquinone cream. Nothing has ever truly worked, but I still hold out hope. Any suggestions would be greatly appreciated.

A:  Hemosiderin staining represents the deposition of residual iron oxide pigments from the breakdown of the hemoglobin molecule. While most hemosiderin staining problems resolve on their own, they do so within months due to macrophage activity. Once this problem exists beyond 6 to 12 months after surgery, the body is telling one that it will not remove it on its own.  It is faur to say after 20 years that your hemosiderin staining is fixed into the tissues.

This is a difficult problem and I think the chances of any treatment’s success is very unlikely. Certainly, no topical cream is going to work. Iron pigment in the subcutaneous tissue is not going to respond to any form of topical cream. Bleaching creams work on the skin for pigment, the iron oxide molecules lie much deeper.  I don’t know what type of laser treatments you have been receiving. The only type of laser treatment that makes any theoretical sense is the Q-switched laser, the type of laser used in the treatment of tattoos.  The residual iron oxide pigment must be viewed like a tattoo pigment being metallic in composition.  Like a tattoo, the age of the pigment in the tissues shouldn’t matter. No other type of laser or pulsed light therapy (i.e., IPL)  will work. A vascular laser will also not work since its focused light is for the oxygenated red hemoglobin, not the rusty brown color of hemosiderin.

Dr. Barry Eppley

Indianapolis, Indiana

Do You Perform Laser Blepharoplasty?

Saturday, June 19th, 2010

Q:  Dr. Eppley, do you perform the procedure, laser blepharoplasty? I have read about it and it seems the way to go if you want your eyes done.

A: The term or procedure, laser blepharoplasty, can mean several seemingly similar but different things. The use of the laser in blepharoplasty or eyelid surgery can mean that it is used to make the incisions, is used to remove the protruding fat pockets, or is used for resurfacing of the lower eyelid skin. Any or all of these can be defined as laser blepharoplasty. Knowing to which of these you may be referring to can answer your question better.

The use of the laser in blepharoplasty understandably captures a patient’s attention. Using the ‘Stars Wars’ effect of the laser and its seemingly magical properties, it is believed that its use would make any medical procedure better. But the laser is just a tool that can be used to cut or burn tissue and it is not a magical wand. It can not really do anything more than what a traditional scalpel or electrocautery can do. The real question is…can the laser make a blepharoplasty result or at least make the recovery quicker and better? (less bruising, swelling and pain)

Despite what many believe, there is no evidence that the use of the laser is a better way that traditional techniques for performing a blepharoplasty. While the laser can be used for a blepharoplasty for the making of incisions, vaporizing fat, and for skin resurfacing, it’s best benefit is it’s impact on marketing and the recruitment of patients for those that advertise and perform it.

Dr. Barry Eppley

Indianapolis, Indiana

How Can I Get Rid Of My Forehead Bumps?

Friday, June 18th, 2010

Q:  I have been self conscious about these bumps on my forehead ever since high school and that has been 8 years ago. It all started when I shaved my head and a friend asked me how I got the horns (bumps) on my forehead. Then my girlfriend  (ex-girlfriend now) said the same thing and then my cousin. So every morning I wake up since then I have been wearing a hat, every day all day. I constantly look at my head and notice these bumps. It’s really noticable when the light hits my forehead from certain angles. I have never heard of anyone having this problem before. What causes this and how do I get rid of it? I am so self-conscious about it.

A: Most likely what you have are known as osteomas. These are the development of a benign bony mass, much like a stalagmite. Why they develop is not well known although a history of trauma to the area can cause bleeding. When blood gets under the cover of the bone, known as periosteum, they will usually calcify creating a hard mass. Your forehead issue may well be osteomas and I have seen them on both sides of the foreheasd before, looking like horns.

Skull or foreheads osteomas are fairly easy to remove. They ‘chip’ off of the underlying skull bone with a chisel or sharp instrument. They can also be burred down. While they are easy to remove, you have to have an access point, i.e., an incision somewhere. Direct access by an incision over them is the easiest and if a forehead wrinkle is close by that is an opportune place to put a small incision. They can also be removed with an endoscopic approach with the small incision back in the hair-covered scalp. 

Dr. Barry Eppley

Indianapolis, Indiana

Is An Injectable Filler A Good Short Term Option for A Facial Bone Deficiency?

Friday, June 18th, 2010

Q: I have a very asymmetrical jawline and am thinking about having a custom implant formed to the side of my jaw with the deficiency. For the rest of my face, I am hoping to achieve a balanced look, trying to get the best of both sides of my face, without exactly mirroring either side. One side is overly large, the other side is overly small. Both sides are appealing but different, except for the major sallowness to my face in my cheek area due to the smaller jawbone. I only want to have that filled in.

I was hoping to being treated with Radiesse or a facial filler to help even out the side with the deficiency without going through a drastic implant that might take away some of what I like about my face or compromising the way my muscle system has developed. Would it be a possibility to achieve some balance as a short term option?

A: One of the best benefits to injectable fillers is their immediate volume adding effects without having to undergo surgery to get it. For the soft tissue zone below the cheek bones but above the jaw line, only a filler material can add volume. This is not a facial area where a synthetic implant can be effective, there is no underlying bone to push off of.

The downside to facial fillers is that they do not last. And most will not last as long as the manufacturers claim in my experience. For this submalar facial area, good choices can be Juvaderm or Radiesse. One can expect about six to eight months of added volume before it dissipates.

Dr. Barry Eppley

Indianapolis, Indiana

Can You Give Me Some General Information About Facelifts?

Wednesday, June 16th, 2010

Q: I would like some information about facelifts.  Do you do lower face/neck lifts.? How much is the average facelift?  Do you have financing for facelift procedures?

A: Very detailed information on facelift surgery can be found on my blog, www.exploreplasticsurgery.com. Just search under facelift and more than 50 articles on various aspects of facelift surgery will come up on the topic. From what a facelift is and its different types, to how it affects the facial aging process and how long they last, and to recovery and postoperative instructions after a facelift are covered in detail in these articles.

The cost of a facelift can range from $5500 to $9500 depending on the type of facelift done. More limited facelifts, like Lifestyle Lifts cost less while more complex full facelifts cost more.

All facelifts are really neck-jowl lifts and affect only the lower third of the face. It is a common misconception that it is a procedure that treats the entire face, from the forehead down to the neck. Many facelifts are done at the samed time as other facial procedures such as blepharoplasty (eyelid surgery), browlift, rhinoplasty and chin augmentation.

The financing of cosmetic surgery is common and many companies offer this service. Plastic surgeons essentually act as referral sources to these companies as both a service and convenience to their patients. One of the most popular is Care Credit although there are many others. Plastic surgeons do not offer the financing directly but provide needed financial information so that you can apply.

Dr. Barry Eppley

Indianapolis, Indiana

Can You Use Fat To Inject Into The Nasolabial Folds?

Wednesday, June 16th, 2010

Q: Have you ever used a patient’s own fat to fill in the nasolabial folds?  I had it done in the past and it seems to last longer than other injectable fillers. Besides, I find it more appealling as it is completely natural.

A: The nasolabial folds have been injected with every conceivable form of injectable filler, including fat.  To date, there does not appear to be an ideal filler for this, or  any other, facial area. Off-the-shelf injectable fillers offer convenience but last less than one year at best. The use of fat injections is less convenient, as it must be done in the oeprating room in most cases, but does offer a natural material. Unfortunately, it has not proven to be permanent in most cases and has not been shown to last longer than commercial injectable fillers.

I do use fat as an injection material when one happens to be in the operating room anyway doing other procedures. This is a good time to take advantage of the natural or autogenous injection opportunity. This is particularly convenient when one is having some liposuction performed. In this case, some of the discard can be used for injection into the nasolabial folds.

Another fat option, not thought of very often, is that of the dermal-fat graft. Using a strip of skin with fat attached (and the top layer of epithelium removed), these grafts can be threaded into the nasolabial folds through small incisions above and below the folds. This type of fat graft provides very consistent survival. It does require a donor site, however, and that is a disadvantage if an excisional procedure (such as tummy tuck or breast reduction) is not being simultaneously performed. 

Dr. Barry Eppley

Indianapolis, Indiana