Archive for December, 2010
Friday, December 24th, 2010
Q: Hello Dr. Eppley I am a 25 year old male who has been through several extensive surgeries due to craniosynostosis as a child. The last reconstruction surgery done was when I was 18. Unfortunately my Dr. wasn’t as concerned with the cosmetic outcome as I was. I feel that my head is to narrow both from ear to ear and back to the forehead. Additionally my forehead has irregularities and is not proportional. I feel that I need to widen my entire skull, giving it more girth. Augmenting the back of my skull, as well as the sides, starting in my temple regions, then along the front of the forehead so that my eyebrow line is defined rather than flat.
Also during surgery they left me with a 1.5″ wide scar from ear to ear. Towards the top of my head it actually creates a deep groove. Last but not least, I feel that my hairline is extremely close to my eyebrow line, and my left temple area of hair grows too far in towards the middle of my forehead. What would need to be done to improve all my skull imperfections and correct the proportions of it? Is there a way to make my scar smaller or vanish possibly by cutting along onside and folding my scalp over it? Finally, can I bring back my hairline and fix the side area as well? Since these are all things cause by a brith defect/disease what if any could possibly be covered under insurance?
A: Based on your concerns and objectives, I think it is possible to provide improvement for some but not all of them. Nor could whatever can be maximally done occur all in one surgery. Adding material to your skull (cranioplasty) is often best done for the forehead and front of the skull which is the most aesthetically visible. This should be your primary focus. While material can be added to the back of your skull, you can do not both front and back at the same time. Your coronal scalp scar may be able to be reduced depending upon how tight your scalp tissues are. It can certainly be narrowed, it is just a question of how much. Your concept of de-epithelization of the scar and advancing the other portions of the scalp over it for closure is the correct approach. Changing the position of your frontal and temporal hairlines, however, is not realistic as there is no procedure to really make that happen other than how the hairline may change slightly with the scalp scar excision and closure may cause.
Whether insurance will cover such a procedure must be determined by a process known as pre-determination.
Dr. Barry Eppley
Indianapolis Indiana
Tags: craniofacial reconstruction, cranioplasty, dr barry eppley, indianapolis, plastic surgery
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Friday, December 24th, 2010
Q: Hi Dr. Eppley I just had a combined breast lift with implants less than three days ago. I have several concerns at this point and want your opinion. My left breast seems to currently have a different shape than my right (more fullness to the top and more stiff on the top). I don’t know if it’s usual for them to have different shapes at the beginning of recovery if they were different sizes to begin with (my right was bigger than my left before surgery).
A: It is very common with any type of cosmetic breast surgery at this early postoperative period (48 hours) to have breasts that have some differences. This is a function of many factors including peak swelling that occurs 48 to 72 hours after surgery, the fact that no two breasts swell the same afterwards even if they had the identical operation, the fact that they are heavily taped which distorts them, and your pre-existing asymmetry (which will be improved but not cured).
For all of these reasons, I would not even try to look at them and come away with any assessment. It simply is way too early and substantial changes will take place over the next 4 to 6 weeks in both breasts as swelling subsides and the breast implants and tissues settles.The time to get more critical is 6 to 8 weeks after surgery but certainly not now.
In the end, I believe there will be some mild asymmetry in shape and the nipple position as this always occurs after major breast recontouring. (combined breast augmentation and breast lifts) But there is no way to get idea about that at this point. I know it is hard but my best advice is to stop looking at them for now.
Dr. Barry Eppley
Indianapolis Indiana
Tags: breast lifts with implants, combined breast augmentation and breast lifts, dr barry eppley, indianapolis, plastic surgery
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Thursday, December 23rd, 2010
It has been over a decade since a landmark study was published on identical twins and how their appearance changed as they aged. It showed how you live your life impacts how fast you age, and how old you look, more than the genes that are flowing through your bloodstream or camped out in your skin.
In this plastic surgery research that studied twins, it was observed that often one twin would look considerably older then the other. Since their gene make-up was obviously identical, how does one account for these differences? After studying hundreds of adult identical twins, the researchers discovered that how we nurture our skin has a huge influence on how well or poorly our skin ages. Three lifestyle factors came up consistently as accelerants of wrinkles and droopy skin; sun, smoking and stress.
So for this New Year if you want to slow down the clock on how you look as you age, here is another set of resolutions to consider. Limit the number of S’s in your lifestyle, adopt an S-free lifestyle as possible. Limit sun exposure, quit smoking and reduce the stress in your life as much as possible.
Everyone knows of the damaging effects caused by too much sun exposure on your skin. There are great examples that are not more than a person or two away most of the time. But not getting as burnt as toast at the beach is not what ages most people, it is the daily innocuous exposure that we don’t even feel. Lack of adequate daily UV protection in your moisturizer will add a few years and wrinkles than might otherwise have occurred.
The horrific effect of smoking on our heart and lungs is well chronicled since C Everett Koop was our Surgeon General. And most people recognize that it is not good for the skin either. Its impact is more than just those pesky lip lines from embracing that cylinder (and we have yet in plastic surgery come up with a good way to get rid of them), but it causes more and deeper wrinkles to occur, thins the skin, and creates a lot of dark spots and pigmentation irregularities. By reducing the blood supply to the skin, proper nutrients can not be delivered creating a state of skin malnutrition. A significant smoking habit can easily make a person look five to ten years older.
Stress is the wild card. It is bad for your skin and definitely causes more wrinkles. But treating stress is not as easy as applying a topical cream or not flicking a match or lighter. Maybe don’t sweat the small stuff (and it is all small stuff) approach is one antidote to adopt.
So if you’ve got wrinkled skin, age spots or a turkey neck, don’t blame your family tree. Blame those Ss in your life and make this the year you resolve to reduce them.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, new year's resolutions, plastic surgery
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Thursday, December 23rd, 2010
It has been over a decade since a landmark study was published on identical twins and how their appearance changed as they aged. It showed how you live your life impacts how fast you age, and how old you look, more than the genes that are flowing through your bloodstream or camped out in your skin.
In this plastic surgery research that studied twins, it was observed that often one twin would look considerably older then the other. Since their gene make-up was obviously identical, how does one account for these differences? After studying hundreds of adult identical twins, the researchers discovered that how we nurture our skin has a huge influence on how well or poorly our skin ages. Three lifestyle factors came up consistently as accelerants of wrinkles and droopy skin; sun, smoking and stress.
So for this New Year if you want to slow down the clock on how you look as you age, here is another set of resolutions to consider. Limit the number of S’s in your lifestyle, adopt an S-free lifestyle as possible. Limit sun exposure, quit smoking and reduce the stress in your life as much as possible.
Everyone knows of the damaging effects caused by too much sun exposure on your skin. There are great examples that are not more than a person or two away most of the time. But not getting as burnt as toast at the beach is not what ages most people, it is the daily innocuous exposure that we don’t even feel. Lack of adequate daily UV protection in your moisturizer will add a few years and wrinkles than might otherwise have occurred.
The horrific effect of smoking on our heart and lungs is well chronicled since C Everett Koop was our Surgeon General. And most people recognize that it is not good for the skin either. Its impact is more than just those pesky lip lines from embracing that cylinder (and we have yet in plastic surgery come up with a good way to get rid of them), but it causes more and deeper wrinkles to occur, thins the skin, and creates a lot of dark spots and pigmentation irregularities. By reducing the blood supply to the skin, proper nutrients can not be delivered creating a state of skin malnutrition. A significant smoking habit can easily make a person look five to ten years older.
Stress is the wild card. It is bad for your skin and definitely causes more wrinkles. But treating stress is not as easy as applying a topical cream or not flicking a match or lighter. Maybe don’t sweat the small stuff (and it is all small stuff) approach is one antidote to adopt.
So if you’ve got wrinkled skin, age spots or a turkey neck, don’t blame your family tree. Blame those Ss in your life and make this the year you resolve to reduce them.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, new year's resolutions, plastic surgery
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Wednesday, December 22nd, 2010
Q: I’m writing to you from after reading your article on temporal hollowing. I’ve been trying to find a recommendation on how to treat the temporal hollowing on the left side of my face that developed several years ago. I have yet to be satisfied that any surgeon I have seen truly understands the problem and how to treat it. Those that have seen it recommended some form of fat injection to mask it. Most of the surgeons wouldn’t speculate what might have happened that caused the hollowing, but I recently found out what it was. One surgeon asked for a CT scan and it was quite obvious that the temporalis muscle and the fat pad behind it was sitting around 1 inch lower, at the temple, on the left side than the right. In addition, the collapsed fat was bunching up behind the zygomatic arch causing the soft tissue to bulge above the zygomatic arch.
Several years ago, I was involved in a cycling accident that left me with facial fractures on the left. One bicoronal scalp incision and multple plates and screws later I was quite well put back together. Within a year though, I had developed a droop in my brow, one of the plates was loose along my left orbit and I had developed a minor protrusion on the zygomatic arch. The surgeon I saw opened the bicoronal scar up, lifted the brow a bit, remove the loose plate and burred the left zygomatic arch a bit. When I saw him a month later with hollowing in the temporal fascia, he had no idea what might have caused it.
You’re the first surgeon anywhere in the world that I’ve found who has experience in treating this problem. As you’ve mentioned that different filler materials may be used depending on the case, I’d be really interested from hearing from you about what you believe to be the best treatment in my case. Also I am interested in reducing the bulge over the zygomatic arch. To date, only the surgeon has made any recommendation in that regard. He suggested that a small amount of Lipodissolve might be used along the top of the arch in order to reduce the fat along it prior to applying the filler treatment. The same doctor suggested Aquamid as the filler, but after researching this, I have decided against it as there are a large number of reports on the Internet referring to negative side effects.
A: Thank you for sending me your photos and providing your history. I think it is quite clear as to what the origin of the temporal hollowing is. In your first bicoronal craniofacial fracture repair, little or no temporalis muscle was lifted up to do the primary fracture fixation. But in the second procedure, the zygomatic arch was burred down. The only way to safely approach the zygomatic arch to do any burring, without risking injury to the frontal branch of the facial nerve, would be to do some elevation of the temporalis fascia near the zygomatic arch and come at it from underneath the fascia. With this approach, some temporalis atrophy (aka temporal hollowing) can be one of the side effects to doing so. Your temporal hollowing is not major compared to many other patients, but it is noticeable.
The correction of your temporal hollowing could be done by subfascial implant placement. While there are a variety of materials to use, I would place a allogeneic dermal graft if it was an isolated procedure. However, that approach MAY change if you are trying to get the arch prominence reduced. I do not think (until proven otherwise) that the prominent area over the zygomatic arch is fat. More likely, it is bowing of the zygomatic arch bone. Fat does not cause that bulge unless the zygomatic arch is no longer present. If it is indeed the arch, burring will not work for it. The bone is too thin. A more effective approach would be to osteotomize the arch’s front and posterior attachments and let the entire arch complex settle in a bit. This is a modification of a technique that I use for cheekbone reduction.
The combination of temporal augmentation and arch reduction should get you close to your intended aesthetic temporal/cheek goals.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, indianapolis, plastic surgery, temporal hollowing correction, zygomatic arch reduction
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Wednesday, December 22nd, 2010
Q: Please help me out. I’m so tired of being called Mrs Leno and hiding my lower face. I have been married for 6 years to a great man but to this day I cover my face when sleeping so he can’t see me and hide my face when we are in a car or at home. I can’t take this anymore. I just want to feel beautiful for once. Can my big chin be made smaller and more proportionate to the rest of my face? I have attached some photos for you to see my chin concerns.
A: Thank you for sending your photos. I can quite clearly see your concerns. You do indeed have a very large lower jaw which is most manifest in the strong chin protrusion. In studying your photos, I think the best method of chin reduction would be an intraoral vertical reduction osteotomy. That would give the greatest amount of vertical reduction and some horizontal reduction as well. There is always some concern about what will happen to the ‘extra’ skin under the chin area when the bone is reduced by this approach. Which is why I would think about doing a simultaneous submentoplasty (skin removal and tightening of the skin) at the same time. Normally this would not be necessary but your very large chin area poses an uncommon problem even in those who seek chin reduction.
Dr. Barry Eppley
Indianapolis Indiana
Tags: chin reduction, dr barry eppley, indianapolis, plastic surgery
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Wednesday, December 22nd, 2010
Q: Hi Dr. I have a large adam’s apple that I want reduced…I am not a transgender, just a regular guy who doesn’t want a big adams apple sticking out, I get tired of people mentioning it too. I was wondering what the approximate cost would be for this procedure! Thanks!
A: A prominent adam’s apple, medically known as a thyroid cartilage or voice box, causes a protrusion in the very visible central part of one’s neck. its size and shape can be very effectively changed through a procedure known as a reduction thyrochondroplasty or adam’s apple reduction. Using a small (one inch) incision overlying the thyroid prominence, the u-shaped protruberance can be shaved down. There is a limit as to how far it can be reduced because of the vocal cords that lie on the inside of the voice box. Most patients will not get a completely flat side neck profile but it is safe to say it can usually be reduced 50% to 75% in profile which is a significant difference.
Contrary to popular opinion, the majority of people whom I have performed this procedure on in my Indianapolis plastic surgery practice are not transgender patients. Most are men who just want their neck bulge reduced. At one time the transgender patient may have made up the bulk of whom was requesting this procedure but not of recent times. More men are becoming increasingly sensitive to a large thyroid cartilage and want it reduced for cosmetic neck contouring purposes.
The typical overall cost estimate, all fees included, is in the range of $5,000 to $ 5,500. It is a one hour procedure that can be done under Iv sedation or general anesthesia.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, indianapolis, plastic surgery, reduction thyrochondroplasty, thyroid cartilage reduction adam's apple reduction
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Wednesday, December 22nd, 2010
Q: I have been thinking about getting a rhinoplasty. I have never had any nose surgery before. I am filipino and my nose is short and too small for my face. What I would like to achieve is the following in my rhinoplasty; augment the dorsum, lengthen the columella, improve tip projection and definition, alar base reduction and show less nostril. I would like costal cartilage rhinoplasty, definitely no silicone or GoreTex implant for dorsum augmentation. Been thinking of rhinoplasty for a long time. I have attached some pictures for your review and imaging.
A: Thank you for sending the picture and your detailed analysis and goals. Given your smaller and short nose, you are absolutely correct in determining that only a rib graft rhinoplasty could achieve your goals. What you need is a combined dorso-columellar augmentation or the geometry of a L-strut configuration. Only a rib graft or a synthetic implant can possibly achieve that degree of augmentation. You have stated you want to avoid an implant and I assume you feel so because of their potential long-term problems, even though they are the ‘easiest’ to do. A rib graft would provide the best long-term graft retention without problems even though it has the short-term ‘problem’ of a donor site and resultant scar. I have attached some predictive imaging for your review. Please note that the increased columellar show in the side vie does not appear as it is not present at all in the original photo. (you can’t morph what is not there!)
Dr. Barry Eppley
Indianapolis Indiana
Tags: costal cartilage rhinoplasty, dr barry eppley, indianapolis, plastic surgery, rib graft rhinoplasty
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Tuesday, December 21st, 2010
Q: I am looking to get my nose fixed after it has been traumatized in the past. I believe the problem is what is called the tip of the right-dorsal horn has separated or fractured from the left cartilage. In doing so, it is no longer held to symmetry as it extends away from the cartilage it separated from. Because of this it has created an appearance of a hook on the right side of my nose as well as a bumpy tip. I noticed that by pushing the cartilage in toward the fracture point the hook is no longer significant and the tip looks less bumpy. This is what my nose use to look like before the separation of the right cartilage from the left side. Is it possible to have a closed procedure where you stitch the right tip back to its natural foundation with the left tip. I am hoping to remedy this permanently with a less invasive procedure; hopefully removing the hook and smoothing out the tip of my nose. Thank you very much for your help.
A: Thank you for sending the pictures and clarifying exactly where the problem is. The problem is in the tip of the nose which is created by the union of two pieces of cartilage. It is a difference in the shape of the two domes or lower alar cartilages. They are separated and apparently the right dome or alar cartilage has been displaced to the right. You were correct in assuming that it can be fixed by a simple closed rhinoplasty using suture techniques. That is a relatively simple fix that is as close as it gets to minimally invasive for the nose.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, indianapolis, plastic surgery, rhinoplasty for nasal fracture repair
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Tuesday, December 21st, 2010
Q: My main questions are in regards to the permanent lip options available to me. I could send you my picture so you can get a better idea. I have tried a few injectables and am not really happy with results in terms of size and longevity. I understand there are also options for implants vs. v-y surgery. (most permanent?) What are the complications, risks and costs of these options. Also, do you use Alloderm or Gortex implants, or is it based on cases by case basis. What is the longevity of Allodem?
A: I choose which permanent lip enhancement option on a case to case basis. That could include lip advancement,lip lift, v-y advancement or Advanta lip implants. There are different reasons for using any of these based on the existing size and shape of one’s lip. Pictures would be of great help in determining what may be best for you. Alloderm has not proven to be a permanent lip implant material so it is no longer used.
If you have not had good success with injectable fillers, then the concept of putting in any permanent material will likewise be unsuccessful. Your lips are not big enough or have the right shape to merely be ‘inflated’. This would indicate that you need more vermilion exposure through some form of excisional procedure such as a lip advancement or possibly a tissue shifting approach with an internal V-Y advancement.
Dr. Barry Eppley
Indianapolis Indiana
Tags: advanta lip implants, dr barry eppley, indianapolis, lip advancement, lip lift, permanent lip enhancement, plastic surgery
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