Archive for March, 2011
Monday, March 28th, 2011
Q: I am an 18 year old looking to correct “witch’s chin” deformity or chin ptosis. I do not know of any doctors in my area who have experience with this procedure, so I am seeking your advice and hopefully you can educate me a bit more about my case. The problem is that I have a lot of extra soft tissue in my chin that folds under and looks very awkward when I smile. I had a consultation with a plastic surgeon who said he would scrape out some of the fat and pull the skin back. He also said that he would cut the muscle. I know he has not seen this case before and that is why I have not confirmed the surgery with him. How exactly is this surgery performed and what are the different ways to go about it? How complicated is the procedure? What are the risks of going to somebody who has not done it before and how high is the risk of causing a deformity? I have attached some photo of me smiling and not smiling from both a front and side views. Your insight is very much appreciated! Thank you.
A: Based on your photos, you are correct in that you do indeed have a witch’s chin deformity. The smiling view magnifies the redundancy of muscle and skin and pulls it down abnormally over a pointy bony chin. In the truest definition of a witch’s chin, it is a deformity that occurs after some form of bone chin manipulation. Your case is different in that this is a developmental/congenital problem and not an iatrogenic or surgically-caused one. In these non-surgical cases, the bony chin is also protrusive and that can be seen at rest in your profile view. So the actual anatomic proboem is one of ‘too much chin’ from all tissues involved.
Surgical correction is done from an incision underneath the chin, what is known as a submental approach and the overall procedure can be called a submental chin reduction. From below the chin bone is shaved down and excess muscle, fat and skin is removed. The chin is then reshaped by adapting the shortened soft tissues over the reduced bone. This is not a complex procedure but must be done carefully and all chin tissues musts be reduced and tightened. The trade-off is a scar under the chin. I have attached a patient example of the procedure for you to see the results and the scar.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, indianapolis, plastic surgery of the chin, submental chin reduction, witch's chin surgery
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Sunday, March 27th, 2011
Q: My 14 year-old son has developed breast enlargement that is quite troubling to him. Do you know if insurance will cover gynecomastia surgery?
A: There is no way to predict whether any insurance company will or will not cover an adolecent’s gynecomastia surgery. I have seen numerous cases over the years that has been covered (most before 2000) and many (since 2000) that has not. Regardless of what an insurance company may say in its declaration of coverages or what may be spoken on the phone by their representatives, nothing is certain unless it appears in writing. Therefore, pursuit of insurance coverage must be qualified with a predetermination process. This is essentially a letter from a plastic surgeon stating the diagnosis and intended surgery, complete with photographs of the patient’s chest. In addition for gynecomastia determination, it is important to have an endocrinologic work-up which demonstrates that there is not an hormonal basis for the gynecomastia which could be treated and reversed by medical treatments and thus not needing surgery. Even with this approach, there is at best a 50:50 chance. If the photographs do not show a significant breast mound (like a woman’s breast) those chances drop significantly. Only the most severe gynecomastias would be likely to be covered, anything less will be judged to be just a cosmetic gynecomastia surgery problem.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, insurance coverage for gynecomastia surgery, plastic surgery for gynecomastia
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Sunday, March 27th, 2011
Q: I am studying to become a radiology technologist at a local community college and I am preparing a powerpoint presentation on the skull. I’d like to play Dr. Eppley’s HTR/PMI Cranial Implant Reconstruction video as seen on YouTube during my classroom presentation to demonstrate current medical procedures to repair and reconstruct features of the skull. Can I please have Dr. Eppley’s permission to show his video to my class? Also, I’d like to inform my audience to what extent x-ray and fluoroscopy C-Arms are used in HTR/PMI cranial implant reconstruction cases since these are the devices we are learning to use. Does Dr. Eppley use fluoroscopy C-Arms during these surgical procedures to assess placement of the implant? Thank you for your consideration.
A: You may certainly feel free to use my HTR/PMI video for your classroom presentation. Hopefully it will add to the value of your presentation. This method of reconstruction of large cranial defects uses a custom implant (PMI = patient matched implant) fabricated from a polymeric bone substitute known as HTR. (Hard Tissue Replacement) The implant is fabricated from a 3-D model from a CT scan taken from the patient so it is an exact fit to the skull defect. The operation for implant placement is done in an open fashion, meaning the scalp is reflected and peel back for wide exposure. Since the implant is placed under direct vision, there is no need to use any radiographic method such as a C-arm to ensure a precision fit.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cranial implants, dr barry eppley, htr-pmi cranial reconstruction, indianapolis, plastic surgery of the skull
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Sunday, March 27th, 2011
Q: I want to thin out my face and am thinking of having a facelift to initially tighten my skin and then my cheekbones (zygomas) cut and narrowed. The reason I am considering zygomatic reduction and face lift is to first “trim” excess skin for maximum tightening of the jowls, nasolabial region, cheeks and neck. Then narrow my face with zygomatic reduction, perhaps including the arch and the zygomatic body itself. I was hoping to improve skin definition below zygomatic arch and angularity of the jaw first, than schedule second surgery afterwards. Do you think it is a good plan for my case? Thank you kindly.
A: While I don’t have the advantage of looking at your facial pictures, I think your plan is fundamentally fine but it is planned in reverse. You want to do any skeletal or underlying foundational surgery first. The reason being is that such surgery causes a fair amount of external swelling which will stretch any tightened skin, potentially reversing some of the effects of any skin tightening procedure. Maximum tightening of the jowls cheeks and neck (facelift) should, therefore, be done after the bone foundation has been treated.
When considering zygomatic reduction, it is important to know if it will produce much of effect. This can be assessed by locally at plain film x-rays, particularly a submental and/or a water’s view. These simple films give a visual assessment of how significant the curve is on the zygomatic arches. That will have to be ordered through a hospital or any free-standing x-ray facility where the appropriate equipment exists.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cheekbone reduction, dr barry eppley, facelift, indianapolis, plastic surgery of the cheeks, zygomatic reduction
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Sunday, March 27th, 2011
Q: I am interested in changing the shape of my neck. I want a visible Adams apple as my neck is too flat and feminine. Can it be done? How would it be done? Imperative to get an answer please!
A: When it comes to tracheal or thyroid cartilage (Adam’s apple) surgery, the standard operation is that of reduction. Known as Adam’s apple reduction (technically reduction chondrothyroplasty) it is done by shaving down the upper v-shaped edges of the thyroid cartilage through a small horizontal incision directly over the thyroid prominence.
Thyroid augmentation is a very rare request but can be just as easily done. Through the same type of horizontal incision, the upper edges of the thyroid cartilages are exposed and built up with a variety of potential materials. Then the strap muscles are closed over the augmentation and the skin closed. Essentially, the reverse of a thyroid cartilage reduction is done. This is a one hour operation done under general anesthesia as an outpatient. There is minimal discomfort and swelling afterwards. There are no restrictions after surgery.
The key element of thyroid augmentation is what type of material to use. Ideally, cartilage is best and the loosely attached ninth rib at the subcostal margin has the right shape and size to be fashioned into a v-shape. But patients are unlikely to want the discomfort of its harvest and the small scar. This leaves a variety of synthetic material choices. Either a Gore-Tex or porous polyethylene (Medpor) block can be carved and secured by sutures to the existing thyroid cartilage framework.
Dr. Barry Eppley
Tags: adam's apple augmentation, dr barry eppley, indianapolis, plastic surgery of the neck, thyroid augmentation
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Sunday, March 27th, 2011
Q: I have a 14 year old boy with gynecomastia. It is hereditary. He is a thin boy but his chest is overdeveloped. If he has a liposuction done now, what are the chances he may need to do it again in the future?
A: The classic teaching in plastic surgery is to do gynecomastia surgery when growth is more complete. This is done with the concept in mind that there will be less chance of gynecomastia recurrence and the need for secondary surgery. While this does make sense from the perspective of decreasing the risk of further surgery, it does not take into account something that I think is more important…the psychosocial development of the young teenage male. Waiting until age 17 or 18 for gynecomastia surgery exposes the adolescent male to vital years of self-image development. For this reason, one should consider gynecomastia surgery when the problem clearly affects teenage behavior and a medical reason for the gynecomastia has been ruled out.
When undergoing early gynecomastia surgery, one accepts the trade-off that recurrence is more likely than when done at an older age. In my experience of doing gynecomastia surgery at age 14 or 15, however, I have not seen patients that have returned with recurrences. (although just because they have not returned does not mean that some have not had recurrences)
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, early gynecomastia surgery, indianapolis, plastic surgery of the male breast
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Saturday, March 26th, 2011
Q: I have very dark circles under my eyes that bothers me a great deal. I have tried all sorts of creams and lotions without any improvement. Are there any more result-oriented surgical approaches that will work?
A:Some of the best results for dark circles improvement is based on volume addition, either using injectable fillers or surgically done with orbital rim implants. (synthetic implants or dermal grafts) The cause for the appearance of dark circles in some patients is that the orbital rims (lower eyelid socket) is weak or underdeveloped. This causes the lower eyelid tissues to lack support so they fall inward, creating both a trough or depression whcih is also prone to looking darker due to shadowing. It is easy to see whom may have orbital rim hypoplasia by a side view. If the front part of the eye (cornea) sticks out further than the lower orbital rims one has lower eye socket hypoplasia.
The success of orbital rim implants can be predicted by initially using injectable fillers. Injectable fillers are both a diagnostic test and a treatment. Unlike the lips or nasolabial folds, which are exposed to a lot of muscle movement, the tear trough and lower eyelid area is not so injectable fillers can last a much longer time in this area.
Since any form of orbital rim implant must be put in through a lower eyelid incision, this also gives the opportunity to do a little skkin removal and tightening which can also help improve the dark circle appearance.
I would have to see pictures of one’s anatomy to determine if orbital rim hypoplasia is making a major contribution to one’s dark circle appearance.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dark circle surgery, dr barry eppley, indianapolis, orbital rim implants, plastic surgery for dark circles
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Saturday, March 26th, 2011
Q: I hate my deepening nasolabial folds that are developing. I was looking for something more long-lasting to treat them. I have read about the wire release method. At what age can you perform the new wire-release method for nasolabial folds?
A: Deepening nasolabial folds is a result of the cheek tissue above the lip falling down over the more fixed lip tissues. It is actually not a fold that is deepening in terms of indenting into the tissues but a rolling overhang of tissues. Injectable fillers are most commonly used to plump up the fold in an effort to get the top edge of the upper lip more even with the falling cheek tissues.
The concept of doing a release of the dermal attachments of the upper lip so that it ‘springs’ upward to be more even with the lower cheek tissues is not new. The wire release method is just a different way to do this older concept. It is clever but not original. Age is no determinant as to when it can be done. The timing of it is when the nasolabial folds are deep enough to justify more of a surgical approach or when one has tried injectable fillers and found them wanting in terms of a long-term result.
While the wire release method is clever, the nasolabial fold can be released just as easily with more simple pickle-fork instruments and large beveled needles. What we have learned with any method of doing nasolabial fold releases is that they require some interpositional material placed after the release to prevent the fold from re-forming over time. This can be done with with fat injections or allogeneic dermal grafts.
Dr. Barry Eppley
Indianapolis Indiana
Tags: dr barry eppley, indianapolis, nasolabial fold treatment, wire release of nasolabial folds
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Saturday, March 26th, 2011
Q: Dr. Eppley ! My question to you is that I have a very short face. My midface is short and my ramus and lower jaw is also short which makes my face long horizontol and very short vertically. Also, my teeth of my upper jaw is way forward which is making my life miserable of having low self esteem. What type of surgery can correct this?
A: When there are jaw and teeth disharmony, one should look at the overall maxillomandibular and occlusal relatiopnships. Many times these require orthodontic and ultimately orthognathic surgical solutions. This is a path thaty should be pursued if one is young and this amount of effort can really be worth it over the long span of one’s life.
Short of major orthognathic surgery, there can be ‘camouflage’ solutions that can improve the facial skeletal balance. These are done using facial implants, usually off-the-shelf implants will work but sometimes it requires custom-designed implants. This is particularly useful in the vertically short face where the lower border of the lower jaw needs to be lengthened for which there is no way to do this without a custom implant design which is done off of a skull model made from the patient’s 3-D CT scan.
For the upper teeth protrusion, I would look into selective orthodontics. Even if you just pulled back the upper teeth only, that would make a cosmetic improvement for you and reduce the upper lip flaring.
Dr. Barry Eppley
Indianapolis Indiana
Tags: custom facial implants, dr barry eppley, facial implants, indianapolis
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Saturday, March 26th, 2011
Q: I desire to have cosmetic surgery next year with the wishes of making my forehead larger both in length and width. Can you inform me with what this procedure is called and also with all the information there is to know on this surgery (including risks, the type of implants used, how long it takes for the healing process, the cost of the surgery, how you go about customizing the implant and etc). Please respond as soon as you can with a detailed response. Thanks so much.
A: You are specifically asking about forehead augmentation. This is a procedure done through a scalp incision approach Augmentation of the forehead contour can be done using any of the cranioplasty materials, which include PMMA (acrylic), HA (hydroxyapatite cement) and calcium carbonate. (Kryptonite) Each of these materials has its own advantages and disadvantages. Large forehead augmentations (which you are referring to) is best done with PMMA due to cost considerations. These materials allow wide variability in adding to the brow ridges if desired and increasing the amount of frontal bone convexity, width and smoothness. These are liquid and powder mixtures that are put together and applied to the forehead in a putty form and then shaped by hand to the desired new forehead shape and allowed to harden. The operation takes about 2 hours and is done under general anesthesia as an outpatient procedure.
This is a highly successful procedure whose trade-off is a fine line scar in one’s scalp. The typical cost range for the procedure is $8500 – $9500. Healing is quite rapid and one can look fairly normal in about 10 days after the operation.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, forehead augmentation, frontal cranioplasty, indianapolis
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