Archive for October, 2010
Tuesday, October 26th, 2010
Q: I am unhappy with the mid- and lower cheek area of my face. My cheeks are sunken in below the cheek bone causing a hollow/gaunt appearance. I have smile lines that are becoming heavier and more visible all the time. I had fat injections in the area of the smile lines about 3 months ago. I would estimate that about half remains at this point. I saw your videos on Youtube and would like your opinion on whether a submalar implant would fully correct, partially correct, or have minimal effect in this area of my face. I would like to understand your recommendations on improving this area. My objective is to create a permanent and fuller looking face in the cheek area and pull out the smile lines without creating a chubby or fat face.
A: The key to answering your question is to understand the anatomy of the submalar triangle area. This is an inverted triangle facial zone that lies below the cheek bone in which the apex of the inverted triangle goes down below the corner of the mouth. Almost all of this area is not supported by bone, but by soft tissue only. As a result, a submalar implant will only help create fullness in the upper region of the submalar triangle. The smile lines lies in the lower end of this triangle and will not be changed by a submalar implant. Soft tissue augmentation must be done in the smile line area. Fat injections is one method but is fraught with unreliable take as you have experienced. But its simplicity remains its appeal and another effort at it may produce even better results. The other option, which I currently prefer due to its better effect and longevity, is interpositional dermal grafting. By placing layers of allogeneic dermal grafts in this area, the skin and the underlying tissues are released and separated by the grafts. They add an eventual well-vascularized tissue layer that can be from 2 to 5mms thick which is not unduly bulky. They must be placed through a limited facelift (preauricular) incision. Their longevity is much more assured than injectable fat grafts in this facial area.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dermal grafts to the face, dr barry eppley, indianapolis, plastic surgery, smile lines, submalar implants
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Monday, October 25th, 2010
Q: I live in New Jersey and loved reading your advice articles on injectable fillers. I am a 42 year-old female with dark circles under my eyes with hollowing, upper lip wrinkles, and horizontal forehead ceases. I would love to know if you could recommend a skilled Dr in my area who could do my eyes? Thank you for your time.
A: Injectable fillers can be used to create a variety of instantaneous facial effects by adding volume under the skin. While once limited only to lessening the depth of the nasolabial folds or increasing the size of one’s lips, their uses are being expanded. One of these newer areas is around the eyes, specifically for hollowing of the lower eyelids or treatment of the tear trough depression. This lack of volume can be one of the contributing factors to the appearance of dark circles under the eyes. Suborbital injection filling is one of the more technique sensitive (trickier) areas to inject well however. There is definitely much greater risk of bruising due to the many blood vessels in this area. Missing all of them can not always be predicted. Proper placement of the filler in the deeper tissue level down to the bone is important to not only get the best fill but to avoid lumps of the material if injected just under the skin. For those physician injectors that regularly perform blepharoplasty (eyelid) surgery, they will more likely feel comfortable placing the injectable filler into the proper tissue level. They will also be in better position to judge whether an injectable filler is the best treatment option and how it might compare to other methods of treatment such as fat grafting.
Dr. Barry Eppley
Tags: dr barry eppley, indianapolis, injectable fillers, injectable fillers for eye hollowing
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Monday, October 25th, 2010
Q: I am interested in what a limited facelift or lifestyle lift might do for me or if I can get away with fillers or something like that. What is the comparative recovery time? Costs? How long do they last?
A: One of the common misconceptions in management of the aging face is that injectable fillers and some form of a facelift treat the same problems. They do not and, as a result, are not comparable treatments. They are often companions (done together or in separate stages) but are never substitutes for each other. Injectable treatment are for the central part of the face and do things that surgery generally can not either achieve or do very well. These include Botox for forehead and eye wrinkles and fillers for nasolabial fold depth reduction and lip wrinkle reduction and lip size increase. Any form of a facelift deals only with the sagging skin and excess fat in the neck and jowls, lower third of the face sagging.
There are procedures touted as ‘liquid facelifts’ but these are a bit (or maybe a lot) misleading and are associated, in my opinion, with a relatively poor value. By using injectable fillers, the sides of the face and cheeks can be puffed up which does create a mild temporary lifting effect due to the expansion of the tissues. The operative word is temporary (six months or less) and, when one compares the cost of numerous syringes of injectable fillers, one could already be more than halfway to one of the variations of a facelift. This injectable approach will also do nothing for the neck area which is the primary target of facelift surgery.
For the patient with lesser amounts of facial aging, the combination of a limited facelift (aka Lifestyle Lift) and injectable fillers can create a very dynamic effect by being able to treat the entire face more effectively. There is a very definite role and benefit to injectable fillers but their results are not comparable to facelift surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, injectable fillers, lifestyle lift, limited facelift, plastic surgery
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Monday, October 25th, 2010
Q: I had a chin reduction just about two months ago. I still have not seen any results. If anything I feel that my chin seems longer then before. I spoke to the doctor about it and addressed my concerns. He said it takes up to 6 months for the final results. If by then I am not happy with it, he will then try something else. What to you suggest?
A: There is no question that any form of chin surgery takes time for the swelling to go down. In my experience in chin reduction, this is particularly true as swelling will mask a reduction longer than it will an augmentation. (the result from a chin augmentation will be seen immediately, the issue is that it initially looks too big due to the swelling) The initial soft tissue swelling from most forms of chin reduction will make it look longer or bigger initially and this is normal. Generally, however, the results start to become apparent within three to four weeks at most. By six weeks, patients should be able to say that they see a difference if not significantly so. It will take three to six months, however, for the true final result to be appreciated.
One important factor that controls the amount and duration of swelling is what type of chin reduction procedure was performed. There are two different types of chin bone reduction procedures, an osteotomy and a burring or shaving. One is done from inside the mouth (osteotomy) and the other is done from an incision underneath the chin. Knowing which one was done can help determine how long it may take to see the final results from the chin modification.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: chin reduction, chin reduction recovery, dr barry eppley, indianapolis, plastic surgery
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Monday, October 25th, 2010
Q: I am exploring cheek implants as a solution to my flat cheekbones which i was born with.sunken cheeks (genetic). I live in Pennsylvania and wanted to find out if Dr. Eppley would initially review emailed photos before making an appointment.
A: The concept of ’consults from afar’ in plastic surgery was once inconceivable and impractical. But the internet and the ease of photographic acquisition and transfer has changed that perception. Since almost all of plastic is external and very visible, physical and cosmetic issues can now be seen from great distances by simply sending pictures. In fact, the reach of the internet and its virtual no cost has made it possible to connect any two places in the world, at the very least by e-mail.
I regularly (daily ) do internet plastic surgery consultations. Many are from various U.S. states and provinces of Canada but some are from countries around the world ranging from the United Kingdom to China. There are two types of internet consultations. The first type is of an e-mail nature only. Inquiries are initially done by e-mail from which I request photographs for review and possible computer imaging. That may then proceed onto an actual phone call for the next level of more indepth discussion. The other type is a Skype video consultation. Its origin may be from an initial e-mail or from Skype itself. If a video Skype consultation is arranged, then photographs may be bypassed due to actually seeing the patient. However, due to the poorer resolution of many Skype video connections, photographs are recommended to be sent first.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cheek implants, dr barry eppley, indianapolis, skype plastic surgery consults
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Monday, October 25th, 2010
Q: Hi. I know I might be young to ask, age 19, but I was wondering what you called a plastic surgery that takes care of love handles. But I am not talking about the hip handles. I have some pretty good handles right under my breasts that wrap to my back. I believe it is some loose skin as I have managed to loose 25 pounds this past year. I am just wondering what you would call that specific body part and maybe an average of how much it would cost to fix it. Thanking you in advance for replying. From a discouraged yound girl.
A: The important question is whether the rolls underneath your breast that extend into your back are skin, fat or a combination of both. With weight loss, most loose skin is going to develop and be seen lower due to gravity. That being said, I would have no doubt that it is a combination of loose skin and fat. Whether one is more predominant over the other would require an actual physical examination to make that distinction. But given your young age, I would recommend a liposuction procedure for fat reduction first and see how the skin adapts. The fat in the upper abdomen and the back is more fibrous in nature than lower abdominal fat and a liposuction technique, such as Smartlipo, will be more effective than traditional liposuction. There are methods of skin and fat removal by excision in the upper abdomen, which do leave lower breast fold scars, but they are usually reserved for more extreme cases of weight loss where the sagging skin is the predominant problem.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: back liposuction, dr barry eppley, indianapolis, plastic surgery, smartlipo, upper abdominal liposuction
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Monday, October 25th, 2010
Q: Hey! I have large indentation on the right side of my frontal bone. It is becoming noticeable since I have started losing my hair. I am wondering if it is possible to correct it without any visible scars. Thanks and.hope to hear from you soon.
A: For select cranial defects, the use of the new Kryptonite bone cement may make it possible to fill out or augment deficient bony areas. Because of its flow characteristics, it can be injected through long small plastic catheters into cranial areas from a small incision placed in the most inconspicuous location as possible. Studies have shown that it is injectable through catheters as as small as a 12 or 14 French size. (roughly 4 to 5mms internal diameter) Once injected it can be molded through the skin from the outside until it steps up into a firm consistency.
When defects are present on the frontal bone, it is important to recognize the exact location if this injectable technique is to be used. Defects that exist between the anterior temporal lines are bone-based and can be augmented by onlay bone materials. If the forehead defect extends beyond the anterior temporal line, this area is covered by the upper edge of the temporalis muscle. While the temporal muscle can be lifted up and material added onto the bone, this is not possible with a limited incision injectable treatment method. Defects that extend into the temporal area require the more traditional open scalp incision for access and wider exposure.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, forehead defects, indianapolis, injectable cranioplasty, kryptonite bone cement
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Monday, October 25th, 2010
Advertising and marketing permeates our existence at every turn. It is so omnipresent that it takes outlandish claims and often near unbelieveable stories to even catch most people’s attention anymore. Nowhere is this more true than in anything connected to the pursuit of beauty and youth. From magical skin care creams that purport to make one look 10 years younger in just a fraction of that time to amazing non-prescription supplements that claim to grow body parts, it is hard to separate reality from just another pitch into your pocketbook.
The world of cosmetic surgery, even though it is done by medical doctors which should be more credible, frequently falls into these same marketing shenanigans. This has become rampant in the unregulated sphere of cyberspace where the only monitor is whomever is doing the posting. But when it comes to board-certified plastic surgeons, it is a completely different story. The American Society of Plastic Surgery provides it members with a clear set of ethical regulations and rules which clearly provides what can and cannot be marketed and claimed. Violation of these rules can result in Society expulsion. Here are a few of these highlights.
Plastic surgeons are not allowed to claim to be the ‘best’ without indicating where that claim comes from. No claim of superiority of skills or results of those skills can be stated compared to physicians of similar training unless it can be factually verified by the public. There are no rating methods provided by any legitimate plastic surgery society. Patients may have different experiences with various surgeons, and the internet provides countless means by which to report them (unregulated and one-sided), but plastic surgeons and their results are not something that can be quantitatively evaluated like a product by Consumer Reports.
The use of before and after photographs must be of the same patient and unaltered. Photographs that have been digitally altered, are of different people, or show results that are not typical for the average patient is forbidden. Before and after surgery pictures that use different lighting, angles and poses that misrepresent results from any plastic surgery procedure is prohibited.
American Society of Plastic Surgery members cannot participate in a raffle, fund raising event, contest or promotion in which the prize is free surgery. No method of inducement to encourage patients to undergo surgery for a financial reason can be done. When you see such a contest or someone who has won a free makeover, you can be assured it is not a board-certified plastic surgeon that is involved.
Claims can not be made of guaranteed surgical results. Predictions of any outcomes of surgery, including satisfaction or any degree of improvement, is likewise prohibited.
Procedure description or outcomes that are placed next to a picture (usually a model) whom has never had the procedure is another ethical violation. This would suggest that the accompanying picture is representative of results that the plastic surgeon can produce. While models in advertisements may be used, they must clearly state next to them that the person in the picture has not received the advertised procedures.
The need for such rules in advertising and marketing in plastic surgery runs counter to what is happening in the ever expanding world of the internet and social media. On the one hand, such rules seem both fair and obvious. But in the pursuit of the cash paying patient for elective surgery, it should be no surprise that the temptation for anything goes can be a powerful one. Plastic surgery is taking the high road in ‘truth in advertising’ and is holding its member’s feet to the fire.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: advertising in plastic surgery, advertising rules for plastic surgeons, american society of plastic surgeons, dr barry eppley, indianapolis
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Saturday, October 23rd, 2010
Q: I am a male and would be interested in receiving a surgery in order to correct my bulging forehead. Do you perform that kind on procedure on men?
A: Forehead surgery or forehead reshaping can mean different things to various patient, both male and female. The two most common procedures performed on the forehead are brow bone reduction in the male and brow bone reduction/tapering in the transgender patient. (male to female) There are also a variety of other forehead reshaping procedures from defects and asymmetry caused by craniofacial birth defects and trauma and prior neurosurgical/craniotomy operations. Bu, by far, regardless of the diagnosis the vast majority of forehead surgeries are done in men.
The typical cosmetic reason for male forehead surgery is brow bone reduction. Large brow bones, caused by overgrowth of the underlying frontal sinus, can create very prominent bulges in the forehead bone above the eye. (supraorbital rims) While most patients think it is a thickening of the bone and a simple burring down will suffice, this is not so. Rather the frontal table of the frontal sinus (visible brow bone) must be removed, reshaped, and then put back in a more flatter or recessed position. While tremendously effective, the access to perform that procedure requires a long scalp incision. This cosmetic trade-off is a serious one to consider and is usually an issue which prevents most men from having the procedure. Until a more minimally invasive approach to brow bone reduction is developed, most men with prominent brow bones will have to live with them.
Dr. Barry Eppley
Tags: brow bone reduction, dr barry eppley, forehead reshaping, indianapolis, plastic surgery
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Saturday, October 23rd, 2010
Q: I have a noticeable cleft in my chin and I was wondering what procedures can be done to remove the cleft and how invasive are they?
A: Soft tissue indentations of the chin can appear as either clefts or dimples. While both involve the chin soft tissues, they are anatomically different. Chin dimples are round depressions in the middle portion of the soft tissue pad of the chin and occur because of a central muscular and fat deficiency. There is no underlying bony abnormality. Chin clefts are vertical indentations that run from the middle part of the soft tissue pad down to the lower border of the chin. While they also have a muscle and fat deficiency (cleft of the soft tissues), they almost always have some notching of the lower border of the chin bone as well. (symphysis) Embryologically, it is easy to understand how a chin cleft occurs because of the union of the mandibular arches in the midline during development. It is harder to understand the origin of the central dimple although this likely represents an area of lack of epidermal cell adhesion during the final phase of merging.
Chin cleft surgery is best thought of as a reduction rather than a complete removal. There are two fundamental ways to perform the procedure based on the depth of the cleft and the tolerance for any outward scarring. An intraoral approach can be done where the the tissues under the skin are released from the bone, the cleft of the chin bone is filled in (if deep enough) and the muscles put back together to create more of an outward pout of the muscle. This works well for modest to moderate deep chin clefts. In very deeply grooved chin clefts, this will only provide partial depth reduction. Outward skin excision is more effective in these deeply grooved clefts but the creation of a vertical scar, even if the surrounding skin edges are smooth, may not be cosmetically acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: chin cleft removal, chin dimple removal, dr barry eppley, indianapolis, plastic surgery
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