Archive for January, 2011
Wednesday, January 26th, 2011
Q: I wrote you a couple of months ago about the possibility of undergoing a forehead contouring surgery to address my possible forehead bulging, to which you asked me to provide you with pictures. This is want I would like to do now and i have attached some forehead pictures for you to review. I don’t know whether the bulge is created by my high hairline or if it is just the way my forehead is. Basically, as previously stated, I would like to know if the problem is a high hairline or a protruding forehead, or both. At any rate, I would like to hear your surgical recommendations, or lack thereof!
A: Thank you for sending your pictures. I think there is some degree of a mild amount of forehead bulging that is accentuated by a higher hairline. Given the mild problem and the resultant scalp scar to improve it, I would not recommend any surgical modification. While it can certainly be done, the scalp scar in a male is a major limiting factor. This would not be such a rate-limiting step for surgical treatment in a female. I have looked at hundreds of male candidates over the years for cosmetic forehead contouring and brow bone reductions and could only ever justify surgery on about 2% to 3% of them.The magnitude of the forehead problem has to justify the trade-off of the scar to do it.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, forehead bulge, forehead contouring, indianapolis, plastic surgery of the forehead
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Wednesday, January 26th, 2011
Q: I have a long and wide forehead scar that I would like to be made to look better. I have attached some pictures of it for you to review. I was wondering if you think that laser resurfacing will help. I have read that it can make scars go away. What is your opinion of it?
A: The origin of your question is will any form of laser resurfacing make your forehead scar disappear. The simple answer to your question is no, no matter what type of laser resurfacing technique is used. And let me explain to you why. Your forehead scar is composed of abnormal tissue which is why it does not feel or look like normal skin. It is in fact abnormal tissue or scar but, most relevantly, that scar involves the entire thickness of your skin. In other words, the skin has been replaced by full-thickness scar. You can smooth of the surface of the scar out all you want with any form of laser resurfacing but it will always appear just as wide, just as discolored and just as obvious. Laser resurfacing only smooths out the surface of the scar, which is helpful if the scar’s main problem is surface irregularities, but it will get rid of the actual full-thickness of the scar. Only cutting it out (excision) can do that. When excision is combined with a geometric broken-line closure, the scar will become more narrow and less obvious. Secondary touch-up with laser resurfacing may be helpful but it is an ineffective treatment to do first. I realize that grasping out the hope of laser resurfacing seem appealing but it is but a treatment mirage. Formal surgical scar revision is what would benefit you the most.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, forehead scar revision, indianapolis, laser resurfacing, plastic surgery for scars
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Wednesday, January 26th, 2011
Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.
A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.
Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.
While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.
The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.
Dr. Barry Eppley
Indianapolis Indiana
Tags: cheek implants, dr barry eppley, indianapolis, lateral canthoplasties, orthognathic surgery, plastic surgery of the face, zygomatic osteotomies
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Wednesday, January 26th, 2011
Q: I am considering scar revision but need some direction. I basically have two small scars on my butt. They are small and they look like chicken pox scars However they are perfectly centered on each cheek. They are from a liposuction surgery I had many years ago. What is the best way to correct them? I hope you can help.
A: The three-dimensional shape or geometry of these scars is an important consideration. Are these scars wide and flat like chicken pox scars as you havhe described or are they wide and indented, having a central depressed component to them? Since they are old liposuction entrance scars, they are probably wide but the key question is are they indented or flat? That distinction is critical in choosing what type of scar revision to perform.
Excising small scars on the buttocks is easy to do and the intent of such an excision is to make the scar ultimately more narrow. While at the time of the procedure, they will be but in the long run they will likely widen again. The pressure of sitting on the buttocks will defeat most attempts at scar narrowing in this area if the scars are anywhere on the rounded portion of the buttocks. If they are around the perimeter or in the buttock crease, then such desired narrowing is more likely to be achieved.
If the scars are indented, however, cutting them and out and closing them make not make them smooth or flat. For this type of scar revision in this area, I would place small fat graft underneath them to prevent recurrent tethering or indentation.
Dr. Barry Eppley
Indianapolis Indiana
Tags: buttock scar revision, dr barry eppley, indianapolis, plastic surgery
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Tuesday, January 25th, 2011
Q: I am interested in getting a chin implant to make my weaker chin look better. It seems like a fairly simple procedure but this bone resorption underneath the implant sort of scares me. Why does this happen? Is there any way to avoid this bone reorption if I get a chin implant?
A: The phenomenon of bone resorption under a chin implant is a much talked about finding for many decades. One of the reasons that it occurs is due to a pressure issue with the implant sandwiched between the soft tissues and the bone. While the implant pushes the soft tissue out, causing more visible chin projection, the soft tissues do apply a small amount of pressure or recoil back over time. Since the implant is not going to resorb because it is an inorganic synthetic material, that leaves the underlying bone to accomodate and relieve this pressure.
This pressure situation is really magnified with implants that are placed too high on the chin bone. This happens when chin implants are placed from inside the mouth and are not secured down to the lower edge of the bone. It can also happen from a submental chin incision approach but is much less common because it it easer to keep the pocket of the implant low. The observation that it does not occur with more contemporary anatomical chin implants is because the wings of the implant keep them from riding up higher, acting like lateral stabilizing bars. From either approach, if the implant ends above the basal bone of the chin (which is thick cortical bone) it rests on bone with a much thinner cortex. This is where bone resorption will be seen with chin implants. It is a function of bone position and is not an actual feature or result of the implant or its material composition per se. This bone resorption phenomenon (which is largely benign and not of any great signfiicance) can be completely avoided by proper implant position on the lower edge of the chin bone. This will also maximize the benefits of the horizontal projection that the chin implant provides, some of which is lost if it gets malpositioned higher as it slides up and back.
Dr. Barry Eppley
Indianapolis Indiana
Tags: chin augmentation, chin implants, dr barry eppley, indianapolis, plastic surgery of the chin
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Tuesday, January 25th, 2011
Q: I have an unusual question. I’m half Chinese but my eyes are more Caucasian-looking. So I was wondering if there is a surgery to create an epicanthal fold at the medical canthus? ( the one that half covers/hides the tear duct). Some doctor once told it’s possible with a w-plasty or a jumping man flap to create a fold in the inner most part of the upper lid. And is it possible to lower the height of the eyelid? Like taking apart the previous fold and resetting it at a lower position? Many thanks and sorry for all the questions
A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin. Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.
Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.
When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?
Please send me some photos of your eyes for my further assessment.
Dr. Barry Eppley
Indianapolis Indiana
Tags: asian eyelid surgery, dr barry eppley, epicanthoplasty, indianapolis, plastic surgery
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Tuesday, January 25th, 2011
Q: I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with a nice shape ? Can it get warped and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.
A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.
In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.
The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.
Dr. Barry Eppley
Indianapolis Indiana
Tags: asian rhinoplasty, dr barry eppley, indianapolis, plastic surgery of the nose, rib graft rhinoplasty
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Monday, January 24th, 2011
Q: My daughter has grown in the past two years a strange looking abdominal growth. It doesn’t look like any abdominal pannus picture I have ever seen. She is very obese but has a normal looking white abdomen which hangs down a little. However, directly under (and separate from) this normal looking abdomen is a huge purple/red hanging balloon which is ulcerated and infected. It grows out from under the abdomen right above the pubis. She is scheduled for surgery in a month and the surgeon is acting like he doesn’t know for sure what it is. It is estimated to weigh about 50 pounds. Have you ever run across anything like this in your plastic surgery practice?
A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.
With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.
Dr. Barry Eppley
Indianapolis Indiana
Tags: abdominal panniculectomy, dr barry eppley, indianapolis, large abdominal mass, plastic surgery
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Monday, January 24th, 2011
Q: I want to have breast implants done. I am not happy with the way my breasts look. But I have lupus and am not sure that I can have this procedure with this medical condition.
A: Whether breast augmentation with the medical history of lupus is a good idea would depend on what the extent and how symptomatic this autoimmune disease is in you. Do you have any known healing problems as a result of your lupus? Have you had surgery in the past and did you have any problems with healing or infections after surgery? Are you on any steroids or other immunosuppressive medications? What symptoms do you currently have from your lupus? What are your titer levels of ANA and other blood tests from your doctor?
Ultimately, what your doctor or rheumatologist would say about your lupus condition would have a lot to say about the adviseability of breast augmentation for you. Despite the past allegations that silicone breast implants cause autoimmune disease from the 1990s, that has now long been disproven.
The issue is are you more prone to breast implant complications from your lupus? Infection risk in the short term and capsular contracture in the longer term are the issues. If you have skin problems, such as banding and contractures, than you would be likely to get problematic breast implant capsules. If not and your lupus is stable and relatively asymptomatic, then breast augmentation may be a satisfactory procedure for you.
Dr. Barry Eppley
Indianapolis Indiana
Tags: breast augmentation in lupus, breast implants, dr barry eppley, indianapolis
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Monday, January 24th, 2011
Q: What do you think of hyaluronic acid for buttock augmentation? It seems like it would be a lot easier to do than using your own fat or putting a synthetic implant in your body.
A: While the family of hyaluronic acid fillers are commonly used for very small volume facial augmentation, they are very rarely or never used to try and fill other body areas which require much larger volumes. While it may be a biologically sound concept, it is an economically terrible idea. The volume of hyaluronic acid needed, if we use fat as an analogy, would be around 350cc per buttock or 700cc per procedure. If we use the cost factor in the U.S. of $375/1cc syringe for Restylane that would be a buttock augmentation at a cost of $262,500…all for a result that would last 3 to 4 months. Using Juvederm, which would last twice that long but at a cost of $550/1cc syringe, the procedure would cost $385,000.
While your own fat make not always be reliable in terms of volume survival, it is easy to see that it is a far more economical approach for buttock augmentation.
Dr. Barry Eppley
Indianapolis Indiana
Tags: buttock augmentation with fat injections, dr barry eppley, indianapolis
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