Archive for August, 2011
Wednesday, August 31st, 2011
Q: Dr. Eppley, I had a facelift several years ago that I am very happy with the results in the neck and jowls. However, it has resulted in my earlobes being pulled down which I believe is called a pixie ear deformity. I have spoken to the surgeon who did the facelift, and he has attempted to fix the ears by putting a suture behind the ear and pulling them up. At least that is what it felt and looked like. The ears came right back down. I understand that another way to correct them may leave a scar on my lateral face where they were attached and at this point I’m not to excited about that. Other than performing a facelift revision, is there another way to fix the ears that is not to extreme?
A: While the simplest and most effective way to correct the pixie ear deformity is a V-Y advancement, that will leave a fine line vertical scar in its wake as you have pointed out. It actually is very small, and one’s concern may be slightly overblown about it, but it is a scar nonetheless. The second best way is to advance the preauricular skin flap up slightly so the face skin can craddle under the earlobe after its release. This is also effective and uses the existing scars inside the ear up into the hairline. You might call this a revision of a facelift, albeit a minor one, but moving the pulled down skin up is the only way to truly correct the earlobe tethering. Just trying to ‘tuck’ the earlobe from behind will never work as it needs skin redistribution in an upward direction.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, earlobe reconstruction, facelift revision, indianapolis, pixie ear deformity
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Wednesday, August 31st, 2011
Q: Dr. Eppley, I had otoplasty done four years ago that was over done. I have just tried to live with it but it just makes my face look odd and unbalanced. I read an article that you were interested in correcting this issue. I have seen numerous plastic surgeons who have suggested a variety of surgical treatments. I want to know if there is any new non-surgical break throughs in this area? I wanted to ask you if you know of any devices, information or any experimentation in trying to stretch the ear cartilage, in cases where cartilage is still present, to increase ear projection? I mean can cartilage be stretched so if there was a stretching device you wore on your head, like a head brace with levers that have custom ear clamps molded to your ear, and you worn them at night set to pull your ears in the right angle, could this work?
A: The simple answer to your question is no. Cartilage, unlike skin, is not a tissue that is subject to elastic deformation or stretching. It does not have the right cellular composition for that phenomenon to work. Only a surgical approach has any chance to be successful. During an otoplasty, the curving and setback of the cartilage actually creates ‘less’ cartilage from a practical standpoint. Therefore, in attempting to bring the ears back out, the only plausible solution is a cartilage release and interpositional cartilage grafting. A release alone will only immediately relapse. Skin grafting of the postauricular sulcus or postauricular surface is also unlikely to work unless the problem is a direct fusion of the back of the ear to the mastoid skin or there is a prominent scar band between the two. While it is understandable why any patient would seek a non-surgical solution, the pursuit of that type of otoplasty revision is a mirage when it comes to changing the position of the ear cartilage.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, otoplasty revision
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Wednesday, August 31st, 2011
Q: Dr. Eppley, I am a 21 year old female that has very small breasts and would like to consider breast augmentation but would like to know my options. I also have inverted nipples and wasn’t sure if your specific practice in Indiana was able to help with that also. I would love to receive some information.
A: With breast augmentation there are numerous options to consider with the procedure, all which revolve around the implant. Implant choices include what type (saline vs silicone), what size (they range from 150cc to 800cc in volume), and what projection. (low, medium, high) Despite a tremendous amount of information that is easily accessible on the internet, I find that most women I see for breast augmentation consults are either confused or misinformed on many of these important decision points. Much of this information and how it applies to any particular patient can only be finally sorted out in an actual consultation with a plastic surgeon.
It is not uncommon to see a patient for breast implants who has an inverted nipple. In some cases, some or all of the nipple inversion may come out with the ‘push’ of the breast implant from behind. In most cases, however, it will not and it will require surgical correction. This can conveniently be done at the time of the breast augmentation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: breast augmentation and inverted nipple repair, dr barry eppley, indianapolis
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Wednesday, August 31st, 2011
Q: Dr. Eppley, my earlobe tore as a teen and it went on to heal on its own. While it did heal, it has left me with thick earlobes. The split closed up but it left me with an abnormally long lobe that makes me very self conscience. I would love to get it corrected.
A: All earlobe tears will heal on their own and one would normally be left with a crease or groove along the healed tear line. Otherwise the earlobe will not be significantly distorted. Occasionally, when an earlobe tear heals on its own it will develop thick scar tissue which may also make the earlobe look longer. Both issues can be solved through a procedure that is very similar to an earlobe reduction operation. The scar tissue and the surrounding elongated central earlobe tissues are removed and the earlobe is closed back together. This makes the earlobe vertically shorter and much softer. This earlobe reconstruction is an office procedure done under local anesthesia. The sutures are removed in one week. The earlobe can be re-pierced 8 weeks after the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, earlobe reconstruction, indianapolis, torn earlobe repair
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Wednesday, August 31st, 2011
Q: Dr. Eppley, I have a depressed skull fracture as a result of a head butt injury. What are my options for reconstruction?
A: While I don’t know the location or exact extent of your depressed contour skull deformity, it is highly likely that an onlay cranioplasty procedure can completely restore the shape of the skull. Material can always be added to build the bone back to a normal contour and there are multiple options to do so including polymethylmethacrylate (PMMA) and a variety of hydroxyapatite formulations. This is actually a fairly simple procedure that is very effective. The only significant question is as to what incisional approach can be used to adequately perform the cranioplasty. Without knowing where the exact location and size of the skull issue i, I could not answer that question. I would be able to answer that question better if you could send me a picture of the depressed skull area.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, skull cranioplasty, skull reconstruction
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Wednesday, August 31st, 2011
Q: Dr. Eppley, I am interested in getting a tummy tuck but have a few questions about it. In reviewing the photos of other women whom have had the procedure, I noticed that the scars are up fairly high, is that necessary to achieve proper results? You see, in having two cesarean births, both incisions were very neat along the hairline, I really like the way it had healed. Do you cut through the muscle in this procedure? Oh, and the other thing, in viewing some post-op footage, there were these drainage apparatus, is that something always done? Sorry for all of the questions, I hope you don’t mind.
A: A full tummy tuck always pulls the incision up higher than a mini- or more limited tummy tuck. Only a min-tummy tuck can keep the incision as low as most women have their c-sections scars at. C-section scars should almost always heal beautifully because they are closed under no tension. (loose stretched out skin) Tummy tuck scars rarely look quite that good because they are close under considerable tension. (tight taut skin) Tension is the enemy of a narrow scar line.
No muscle is ever cut though in a tummy tuck of any form.
The use of a drainage tube is a necessary evil after tummy tuck surgery that stays in for about a week.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, tummy tuck surgery
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Wednesday, August 31st, 2011
Q: Dr. Eppley, I have a dermoid cyst in my forehead bone that needs to be removed. Because of its size, it will leave a significant bone defect after its removal so it will need to be reconstructed. One plastic surgeon told me that he has to take out too many bad products from people’s head’s so he now only uses a titanium mesh covering for these repairs. My question is which is a better method for reconstruction, metal mesh or a bone filler? Also, two different incisions have been discussed. Since the lesion is not too far from the hairline, is it possible to do a smaller incision, one that goes from the sideburns to the midline of the forehead and just very slightly into the hair line? I know that a bicoronal incision can be used but it is a more difficult recovery and some scalp numbness will result. Which incision would be better to perform the surgery with the least risk of problems?
A: It appears that you have an epideroid cyst in the diploic space of the frontal bone. I assume the reason for its removal is that it is slowly growing.
I have no picture of you to see where exactly the lesion is located in reference to your frontal hairline so it is impossible for me to comment on what incisional approach could be used. Certainly some variation of the bicoronal incision can be used. The only question is whether some other form of more limited incisionall approach could be used. Without knowing where on the forehead it is (seeing a picture with a mark on your forehead), I can comment no further.
In terms of reconstruction, I would disagree strongly with the idea that there are a lot of bad products for skull reconstruction. I have used all available materials and have never had a problem with any of them in hundreds of cases. They all work well when used with proper technique. For covering a ‘crater’ in the forehead after the cyst removal, I absolutely would go with an hydroxypatite cement. It can fill in the defect and make the forehead perfectly smooth. While covering the defect with low profile plates and screws is also acceptable, there is always the chance that you will be availble to feel the outline of the metal hardware and even some risk that it may leave a negative image on the forehead skin should it thin out after the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cranioplasty materials, dr barry eppley, indianapolis, skull reconstruction
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Monday, August 29th, 2011
While the neck is technically not part of the face, it does makes a very important contribution to one’s appearance. A sharp neckline helps highlight the jawline and makes a clear transition between the two. When the neck is too full or hangs downward, it may be the result of too much fat, loose or saggy skin or a combination of both.
How to reshape the unsightly neck requires an understanding of why it is that way. As a general rule, a younger patient’s neck has more fat than skin. Conversely, older patients usually have more loose skin than fat…and skin that may have lost much of its elasticity.
Many neck contouring treatments are touted that range from non-surgical energy therapies to actual surgery such as liposuction and necklifts. The degree of effectiveness of any of these neck procedures depends on how well the treatment changes the amount of fat in the neck, tightens the skin or preferably does some of both. When the patient’s problem matches what the treatment does best, an improved neck shape will occur. If not, results will be poor.
One effective neck contouring treatment is liposuction. As the only known treatment method that can remove fat, it is no surprise that it is a part of almost any surgical neck procedure. A basic principle of liposuction is that the skin must contract afterwards. Part of its reshaping effects relies on the skin shrinking down to the slimmed down neck. What is unique in neck liposuction is that the skin must actually shrink upward.
While traditional liposuction does not have any direct effects on creating skin tightening, that has changed with the use of Smartlipo or laser liposuction. The heat created by the melting of fat and the ability to directly treat the underside of the skin with the laser energy creates better skin retraction and some degree of actual skin tightening.
Smartlipo has been and remains my preferred technique when liposuction of the neck is done as a stand alone procedure. When used in younger patients with fuller fatty necks, good skin retraction and reshaping can be seen. It is very common for the neck to feel very firm for weeks afterwards. This is a temporary skin effect that takes a month or two to soften and go away.
In older patients with significant skin sagging, the tightening effects of Smartlipo are limited due to the amount and quality of the skin. When requested to do it in a few patients who refused any other form of surgery, I have seen a few impressive neck reshaping results. But I do not consider it the treatment of choice in the older neck and patients should temper their expectations accordingly. Its benefits are also obviated when liposuction is done as part of a face or necklift where skin undermining and flap repositioning are far more effective methods for neck reshaping.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: indianapolis, smartlipo of the neck. dr barry eppley
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Monday, August 29th, 2011
When the subject of breast implants or breast enlargement surgery comes up, many people immediately think about size. Large breasts that create eye-catching cleavage are what comes to many minds, a concept that has not been helped over the past two decades from celebrities ranging from Pamela Anderson to Heidi Montag of more recent note.
The reality of breast implant surgery, however, is far from this image. There are certainly a minority of women who do want this look. But the vast majority of women who choose to have breast implants are much more interested in finding the right size for their body and not to have overpowering breasts that become the focal point of their appearance.
Most breast augmentation patients are average women who simply want to look good in clothes and sport attire. I have seen many women who have told me that they are embarrassed to wear a bathing and won’t go to the pool or beach with their family. While breast underdevelopment is the most common motivation for getting implants, there are numerous other reasons. These include such breast conditions as postpregnancy sagging, asymmetrical breasts, body proportioning, breast asymmetry and reconstruction after mastectomies.
Pregnancy and nursing can have an adverse effect on a woman’s breast shape and size causing sagging and, almost always, a change in the amount of breast tissue. Many women are unaware that it is completely normal to lose breast tissue after pregnancy, a phenomenon known as involution. For some women who have had multiple pregnancies, they lose all of the breast tissue they originally had. When combined with stretched out skin, the change in a woman’s breasts can be deflating for their self-image as well. These are women who simply want to return to their pre-baby size and shape.
There are many women who have breast asymmetry where one breast is larger or different in shape than the other. In some cases the breast size difference can be as much as a cup size, sometimes even more. For women so afflicted, finding a bra to fit comfortably and properly is not as easy as going to Victoria Secret’s and pulling a good fit off the rack. Often they are forced to add padding to create a more even look in their clothing.
One of the most recognized and easily understandable reasons for implants is in breast reconstruction. The physical and emotional devastation of going through any form of a lumpectomy or mastectomy procedure can be softened knowing that an immediate or even a delayed reconstruction can be done. While numerous forms of breast reconstruction exist, including flaps that form the breast mound out of your tissues, implants remain the backbone of how most breasts are recreated.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: breast augmentation, breast implants, dr barry eppley, indianapolis
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Saturday, August 27th, 2011
Rhinoplasty surgery can make many changes to the nose, from taking down a bump on the bridge to narrowing the tip. But in the end, the result that will be seen depends how the skin of the nose redrapes and adapts to the new changes that have occurred in the supporting framework underneath it. Given that removing skin from the nose or tightening it through incisions and creating external scars would be unacceptable, the wildcard in any rhinoplasty outcome is ultimately the patient’s nasal skin.
Thus, unlike any other piece of nasal anatomy, the skin is really a fixed and not a variable component of rhinoplasty. It is the one piece of nasal anatomy in which its surface area can not be reduced. It is a common principle in rhinoplasty teaching that the skin will shrink down and adapt to show the changes that have occurred in the bone and cartilage framework. But this is not always so and is not necessarily even always predictable.
How well the skin of the nose can shrink down is influenced by many variables. The two most important are the thickness of the skin and where on the nose it is located. Skin in the upper half of the nose seems to be better at adapting than the lower half of the skin. But that may be just a reflection of the complexity of the anatomy underneath it. The upper nose is like a saddle while the lower nose has a much more complex shape and is more similar to wrapping paper around one side of a ball. Thin skin is believed to shrink better than thick skin and probably reflects that it has less overall mass. In theory, thick skin should shrink more than thin skin due to a higher number of elastic fibers. But its thickness provides 50% more mass given any surface area so significant skin contraction does not occur.
When one has thick skin on the nose and is undergoing a rhinoplasty, it is important to temper one’s expectations and to have extreme patience in awaiting the final result. This is particularly relevant to many ethnic rhinoplasties including Africa-American, Hispanic, and Middle Eastern. Since one of the main objectives of these rhinoplasties is to have a more slim and refined nose, thick skin will have an influence on how achieveable that goal is. It is also important when performing these rhinoplasties to not attempt to slim the nose by removing too much underlying structure. That will cause the skin to ‘ball up’ particularly in the tip area since the now ‘excessive’ skin has nowhere to go but to contract onto itself.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, thick skin in rhinoplasty
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