Archive for July, 2012
Tuesday, July 31st, 2012
Q: Dr. Eppley, am very unhappy with the right side of my face. My face is assymetrical; the right side looks smaller, there is less volume in the cheek, and my right eye and eyebrow are lower than the left. Also, the right side of my lower lip is smaller than the left. I feel that the left side of my face is the “good” side. I am very self-conscious of my appearance and avoid having my picture taken. I also feel that my nose is fairly wide from the front, although my profile is not that bad. Most surgeons in my area seem to focus on anti-aging procedures. I am too young (31 years old) that the right facial volume loss is due just to aging. The fact that I have always slept on my right side probably did not help. Please let me know what procedures you would suggest. I’ve attached a picture of my face straight on and also one of my right profile.
A: I would agree with you that you do have some degree of facial asymmetry. All features you have pointed out I can see and agree that it exists. The question is given the asymmetry what is reasonable to consider to do for improvement. I would also agree with youir three procedures of interest. A small right cheek implant with fat injections to the submalar (buccal space compartment) and the perioral mound area are very straightforward low risk procedures that can occur from visible improvement. While asymmetry issues exist in the eyebrow area, I would live with those for now. From a nose standpoint, a tip rhinoplasty to narrow the tip would work nicely. I would leave your profile and the upper portions of the nose alone.
The only point in which I disagree with you is that sleeping more on the right side of your face would not have caused the problem. This is a congenital ‘deformity’ and is a result of in utero development not from postnatal molding influences.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cheek implant, dr barry eppley, facial asymmetry, fat injections, indianapolis, rhinoplasty
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Tuesday, July 31st, 2012
Q: Dr. Eppley, I have a grandson who is only 3 months. He was born with a mishappen ear and I do not want him to go through surgery and I read online that there is a way to fix his ear with some sort of mold. Can you please help me and tell me where I can find this mold? Thank you for your time to read this and I hope to hear from you soon.
A: Neonatal ear molding can reshape an ear but it must be done within the first two months of life to be effective. There is a very narrow time window after birth when the cartilage remains ‘unstiffened’ and can be molded into a new shape. This is done using ear molds known as the Earwell System. It must be done by a plastic surgeon to apply the mold and change it as needed over a two to three treatment period. I am afraid at three months old your grandson has already passed the time when such non-surgical ear shaping is possible.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, Earwell ear reshaping, indianapolis, neonatal ear reshaping
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Monday, July 30th, 2012
Q: Dr. Eppley, I would like to get some facial cheek implants done and I have heard there is silicone and Gore tex. Do you have an idea of which one is better? And does Gore tex implants get smaller after time passes? Thanks alot.
A: What is commercially available as preformed off-the shelf cheek implants are the materials, silicone and Medpor. Each of these materials has advantages and disadvantages and neither one is perfect. So it is not an issue that one is better than the other. Both can work very successfully and they are non-resorbable so they are permanent and do not change in size with time. Goretex is available as a block material which can be carved into a cheek implant shape during surgery but is a softer material and more deformable than either silicone or Medpor. What matters a lot more than the material is the right shape and size for your desired cheek look and a surgeon who has both the artistic skill to make that selection and then insert them properly.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cheek implants, dr barry eppley, indianapolis
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Sunday, July 29th, 2012
Q: Dr. Eppley, I am interested in yourresults in treating facial asymmetry. I have a pronounced vertical orbital dystopia (I’m not sure if this is the result of plagiocephaly, though I highly suspect it is given the other imbalances in my face). I would like to know my options for treating this. I have attached pictures for your review.
A: Thank you for sending your pictures. I can clearly see that you have a mild to moderate case of right orbital dystopia. (5mms of horizontal pupillary discrepancy) The entire orbital box is situated lower than that of the left side, affecting every surrounding structure from a lower eyebrow/brow bone down to an orbital rim-malar deficiency.
There are two fundamental strategies for dealing with these orbital discrepancies. The first is a complete orbital box change. Dealing with changing the fundamental problem through an orbital box osteotomy is too extreme is my opinion for the magnitude of your dystopia. Therefore, I would recommend an alternative approach of multiple camouflage procedures. At the minimum, I would use an orbital floor-rim implant with hydroxyapatite cement which could be extended out on to the lower cheek bone. One could also use other types of implants such as Medpor or Gore-Tex which can be custom carved to fit during surgery. Ideally I would get a skull model fabricated from a 3-D CT scan to make an exact implant that reconstructs the bone levels to the opposite side. The lower eyelid would then be resuspended/tightened which would move the lower lid level up, particulalry the outer half. One could also treat the upper orbit through either an endoscopic browlift approach with brow bone modification through an upper eyelid approach. You can see with this camouflage approach it is a function of how far you want to go in treating all components of your orbital dystopia.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, facial asymmetry surgery, indianapolis, orbital dystopia surgery
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Sunday, July 29th, 2012
Q: Dr. Eppley, I am considering getting a tummy tuck but am somewhat concerned about the scar. I know the scars can look quite good in some cases but not in everyone. Since I have a c-section scar I am wondering if this is a good ‘test’ as to what a tummy tuck scar would look like on me. I had a c-section about 3 years and the scar is still red, raised, and uneven. I remember right after my c-section I could feel my skin above and below the sutures overlapping. My question is will my tummy tuck scar be same way or will the scar be a thin line with no raised areas?
A: Your question is a good one and, in theory, how one incision on the body heals (particularly the same body area) should be an indicator of how the next one would heal. But the reality is that many factors go in to how an incision heals and they can dramatically affect how the final scar can look. C-section incisions, if closed well, should always look good because there is no tension on the wound closure. Lack of wound tension usually predicts a very narrow scar. Conversely, a tummy tuck incision is always under considerable tension which is why plastic surgeons use a meticulous multiple layer closure technique with most sutures under the skin to obtain a narrow scar. Tummy tuck scars are almost always a lot longer than that of a c-section. One of the key elements in this closure technique is to get a good leveling of the tissue layers so the skin edges are even across the scar line. Based on how you describe your c-section scar, I strongly suspect you will get a better looking tummy tuck scar.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: c-section scars, dr barry eppley, indianapolis, tummy tuck scar
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Sunday, July 29th, 2012
Q: Dr. Eppley, I would like to have temporal augmentation on both sides. I want a permanent solution which means no fat injections. I don’t want to have to do it every few years. I am ok with silicone implants. Because there are nerves in temporal area is temporal augmentation safe? I am scared of getting my nerves hurt. Can you please tell me what are the possible options for the implants.
A: The use of preformed synthetic implants is the only assured method of permanent temporal augmentation. There are several different designs from two manufacturers today. These implants are most commonly placed below the temporalis fascia on top of the muscle. The frontal branch of the facial nerve which runs through the temporal area lies above the deep temporal fascia, thus subfascial temporal implant placement poses no danger to this nerve which is responsible for movement of the forehead and eyebrow. There are some cases in severe temporal hollowing with a tight fascial lining in which the implants are better placed above the fascia to get the desired augmentation effect. This is usually necessary when there is a large step-off between the zygomatic arch and the temples. When above the fascia, it is important to place it right up against the deep fascia and avoid dissection in the more superficial fascial layers where the nerve runs. When done properly, temporal implants placed above the fascia are safe.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, temporal implants
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Sunday, July 29th, 2012
Q: Dr. Eppley, I have a question related to my paranasal implants. from Korea. Five months ago I had this augmentation but now I am disappointed with the result. I start to have awkward smile and a much longer upper lip. But because I have a sunken nose base, I do need the augmentation. In short, I am planning to remove the paranasal implant and change to a new one. I am wondering if I want to have an improved result whether I need to do these procedures separately (6months or so after removing current implant then add a new one) or can I do these two procedures together in one single surgery. It would be much easier for me to have only one surgery. But I am really worried that if I do so (removing and changing the implants at one time), that the swelling during the surgery might affect the doctor’s aesthetic decision for the new implant. Besides I am also worried that if I have only one surgery, whether it is possible the new implant would be much more likely to change its position on my face in future. Do you have any suggestion for my problem?
A: To provide a very specific answer, it would be helpful to know what type of paranasal implants these were, what was their shape and how were they placed. (through the mouth and and on the bone around the pyriform apertures or placed through the nose in the soft tissue of the nasal base) One of the advantages of having existing implants in place is now you know the result they create. That provides valuable information as to how to change them for an improved result. The existing problems with your current paranasal implants could be their size, shape, and/or anatomic location. The change should be predictable before surgery, not during the procedure. Therefore, there should be no problem removing and replacing them during the same procedure. I see no advantage to a staged procedure. In fact, I would find that actually counterproductive. Knowing what didn’t work well is a good guide to improving it.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, paranasal implants
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Friday, July 27th, 2012
Q: Dr. Eppley, I have some additional questions about thigh liposuction. I need a fair amount of fat removed frm my thighs and during our consult you estimated that it would be about 1.5 L per thigh. I know you are the expert but I’m wondering if I should get more removed (have you seen these thighs lately? Ha!). I believe your concern was that I have somewhat of ”cellulitic” thighs – nothing too severe but my legs aren’t perfect either (I’m 5’5, 165 lbs). How big of a factor is this when taking the amount of lipo into consideration? Would it be risky to remove a little more per thigh? Part of me would like more removed. However, the other part of me worries about skin elasticity and “lumpiness” or other skin irregularities produced from the procedure.
A: The key concept for your thigh reduction to consider is that the more aggressive you are with liposuction in someone who has pre-existing thigh cellulite, the more likely you are to worsen the appearance of the cellulite and create unevenness. Contrary to a common public misconception, liposuction is not a treat for thigh cellulite but a potential exacerbation of that problem. It is a delicate balance between improvement in thigh size and not worsening the overlying skin’s contour. The ‘price’ to be paid for aggressive liposuction (maximal fat removal) is increased skin irregularities. Removing anywhere near 1 liter of fat from the saddlebag area is a lot and is certainly aggressive. But almost assuredly, increased skin irregularities will be the trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, thigh liposuction
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Friday, July 27th, 2012
Q: Dr. Eppley, my 14 year-old son had his foreheasd bone fractured in an accident this past April 2012 . The bone was removed by the doctor then and he now now needs reconstruction of that part. The place is between both eyes with a size of size of 7cm length and 5.5 cms width. The doctor here is saying they will take out a piece of bone from the front table of head bone and put that on. Is it safe? I need your view.
A:What are you are referring to is reconstruction of the forehead with a split calvarial bone graft. That is certainly one accepted cranioplasty method to do the reconstruction and is the only natural or autologous method. It is a well known craniofacial surgical technique and is very safe if done in experienced hands. Given that it is a full thickness frontal bone defect, the size is not too big (7 x 5 cms) and he is only 14 years of age, this is probably the best approach. His skull should be thick enough that the outer table can be removed elsewhere on the skull in a single piece and moved to cover the forehead defect. There are numerous alternative methods that are technically easier such as titanium mesh and hydroxyapatite combinations as well as custom HTR cranial implants, which are also acceptable methods, but the cranial bone graft for his size defect should work well. This is particularly important of the frontal sinuses have been exposed in the defect, which I suspect that they have.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, forehead bone fracture, forehead reconstruction, frontal cranioplasty, indianapolis
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Wednesday, July 25th, 2012
Q: Dr. Eppley, regarding the skull augmentation will the bone cement be set beneath the periosteum. Could that involve any risk of “osteolysis”? Could the bone cement be put on the periosteum instead? Thanks!
A: Your question is an interesting one and is only relevant based on the type of cranioplasty material that may be used. When using any of the hydroxyapatite (HA) formulations, you definitely want to be under the periosteum for two good reasons. First, the material does bond directly to bone with no risk of osteolysis and you want to take advantage of this biologic benefit. Secondly, if HA materials do not bond to the bone they will ultimately be unstable and may likely shift position afterwards and develop fractures or fragmentation of the materials at their feather edges. When it comes to poly methylmethacrylate (PMMA) cranioplasty material, this can be placed on top of the periosteum and will set up and will likely not shift or fragment afterwards particularly if microscrew anchorage is used. PMMA materials, unlike HA, do have a known and low risk of settling into the bone a little bit and are what you refer to as ‘osteolysis’. But this is not a particularly progressive process and is self-limiting. Conversely, I have greater concerns for its effects on the overlying scalp and tissue thinning. Therefore I think it more important to provide as much barrier between the material and the overlying scalp tissues as possible and would recommend staying beneath the periosteum for this important long-term reason.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: cranioplasty, dr barry eppley, indianapolis, skull reshaping
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