Do I Have Symmastia And Can It Be Corrected?

Q: Dr. Eppley, I was inquiring on if you have any experience with congenital symmastia? It’s something that I’m quite certain I have and something that has always bothered me. I do not think I need breast implants and my breasts are a good size. But I do not like this web of skin that crosses between my two breasts. In bras it looks even worse. How can this be corrected?

A: Symmastia presents in one two ways, either from a congenital basis (like yours) or iatrogenically created by breast augmentation surgery. In congenital symmastia, there is usually a web of tissue between the two breasts. In this web there is fat and therein lies the way to treat it…liposuction. By removing the fat in the web and with postoperative compression, the tissue between the breasts can be made to stick down to the sternum thus eliminating the web. This can be done as s stand alone procedure or combined with breast augmentation. (although by your pictures this is not something that you need)

The success of symmastia correction by liposuction depends on how well the skin will adhere down to the sternum. After liposuction compression is applied but this is a difficult area in which to keep good compression on the skin for any sustained amount of time.

Dr. Barry Eppley

Indianapolis, Indiana

Should I Have Breast Reduction Before Or After Bariatric Surgery?

Q: Dr. Eppley, I am interested in breast reduction surgery. Next month I am having barbaric surgery with a sleeve done. I have had a lot of female problems. I am having pain in my back and my chest from my large breasts. I do have Aetna Insurance so how does that process work to get a reduction on my breasts and having the insurance cover it?

Breast Reduction results right oblique view Dr Barry Eppley IndianapolisA: Breast reduction is often covered by insurance and the process to determine if they will pay for it is known as predetermination. This requires photos to be sent as well as documentation that efforts at physical therapy are done (I don’t make the rules, we just have to follow them) for the insurance company to consider coverage. However, if you are going to lose weight, particularly through bariatric surgery, breast reduction surgery should only be considered after the weight loss has occurred. Significant weight loss has been shown to affect breast volume. You may find out that you only need a lift and not a reduction as extreme amounts of weight loss can cause a lot of breast volume to be lost. Wait to consider breast reshaping/reduction surgery until your breasts are in a stable period where your weight is where you want it or the best that it can be.

Dr. Barry Eppley

Indianapolis, Indiana

Will I Need An Implant If I Get A Lower Buttock Lift?

Q: Dr. Eppley, I am interested in some form of a buttock lift. I I would like to have the extra skin/wrinkles removed from my butt. I have hoped to find a procedure that did not include implants. Do you feel I am I a candidate for this surgery procedure?

Lower Buttock Lift result back viewA: What you are demonstrating is a severe buttock sag with a lot of folds/rolls of skin around the bottom of the buttocks. This often occurs in  very thin women as they age and may also happen after a significant amount of weight loss. While it it true that buttock augmentation would help pick up some of this loose skin, it would take a massively large augmentation to do so. The better approach is to do a lower buttock lift or tuck which removes all the skin folds on the bottom half of the buttock. This places the scar along what should be the infragluteal fold or lower buttock crease. This will not increase the volume of the buttocks, which will still be very flat but it will get rid of a lot of that saggy skin which makes one’s buttocks look a lot older than they really are.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Chin Reduction Do I Need?

Q: Dr. Eppley, I am a 32 year old female interested in having chin reduction surgery. I underwent orthognathic surgery in 2011 to correct a class III malocclusion and to straighten my midline with a bilateral sagittal split mandibular setback osteotomy. I am pleased with the way my bite looks as a result of this surgery, but I am still unhappy with the extent to which my chin protrudes. I am very interested in learning what can be done to reduce the size of my chin and to improve my facial profile. I have attached some frnt and side view pictures for you to review.

A: Chin reduction surgery must take into account the extent of bone and soft tissue to determine what technique to use. What I see is a central button of bone on the chin which appears to be the primary culprit. It looks like it could be horizontally reduced by at least 5mms and the bone tapered backward along the jawline a few cms. The real question is whether this should be done by a submental or an intraoral approach. It is tempting to do it from inside the mouth but there is always the issue of what will happen with the overlying skin. As tempting as that seems with a smaller chin excess problem like yours, that is  probably a mistake. The submental approach has the added benefit of removing and tucking in any soft tissue excess which complements the bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Will My Mons Get Lifted With My Tummy Tuck?

Q: Dr. Eppley, I am interested in some form of a tummy tuck. I am 42 years old, totally done with babies,  5’6” and my highest weight was 235 (pregnant) and I’m down to 150lbs and has been that weight for over a year. I’m trying to come down 10 more lbs. Should I get down 10lbs more before I have surgery?  If I do the surgery, will I be okay to lose 10 more and possibly work off that top fullness, or will it look lose again?  I go to the gym three to four days a week and I’ve been working really hard for a really long time.  It’s getting the point where I’m starting to get really discouraged, because the more I lose, the worst my stomach looks. :(   I have attached pictures of my stomach from all sides. I did try to get the  best photos possible (I am attaching a back view—just in case) since I’m not sure if I need an extended tummy tuck or the body lift.  Do you think I need it or will the extended TT will be sufficient?  I mean, obviously the hanging belly is the biggest issue, but I really want a good contour.  I am also very self-conscious about my mons area, and hope it will get pulled up (maybe a tiny bit of lipo on it?) in the process.  (It’s totally embarrassing!)  Will that happen?  I really like how your previous patient (2nd attachment–tummy tuck after) turned out—the scar symmetry, the low profile, and how the mons area looks.  I also have attached another photo from the web that I thought looked similar to me in the before photos.  Do you think I could achieve a result like that?

Tummy Tuck with Mons Lift (Dr Barry Eppley IndianapolisA: Your pictures were great and show exactly what you need. You definitely do not need a body lift and just a bit of an extend tummy tuck. Your mons will be liposuctioned and lift at the same time as the tummy tuck. Whether any patient can achieve the result that another patient obtained can not be precisely predicted. But if you look similar before surgery, then a similar result may be possible.

If you are within 10 to 15lbs of your weight goal, there is no reason to lose any more. The surgery process will take care of that weight. (what is removed during surgery and the weight loss after surgery during the recovery)

 

Dr. Barry Eppley

Indianapolis, Indiana

Does A Mini Tummy Tuck Move The Belly Button Lower?

Q: Dr. Eppley, I have loose skin around my belly button after having several children. I went to a plastic surgery consult and was given the option of a mini tummy tuck and moving the belly button lower from the ‘inside’.  I have some concern about the tummy tuck option for my belly. My only hesitation is the aesthetics of having my belly button one inch lower.  Most of my pants/jeans/swimsuits sit just below my bellybutton which, other than the puffy ring around my bellybutton, looks good (generally speaking). I attached a few pics with jeans and swimsuit bottom. I am thinking that it will look “odd” after a mini tummy tuck, such that the bellybutton will no longer be visible with these clothes on and my overall appearance will look “strange”.  Where my belly button sits is between my waist and hip; it seems that the belly button would be moved down around my hip which might appear “not quite right”. Are there any other alternatives for a better appearance of this area?

A: Unfortunately there are no other effective solutions for the excess skin around your belly button other than the mini tummy tuck approach. Unless one puts a horizontal scar across the belly button area (which would obviously be unacceptable) the only way to work out the extra skin is to translocate the belly button lower through a mini-tummy tuck approach

Like just about everything in aesthetic surgery, it is all about the tradeoffs…you usually tradeoff one problem for another. You just have to decide which problem you can live with the best…the skin the way it is around the belly button or less skin around a belly button which is positioned lower. There are no ideal solutions for your problem that don’t have their own drawbacks.

Dr. Barry Eppley

Indianapolis, Indiana

How Big Of A Lip Reduction Can I Get?

Q: Dr. Eppley, I had a lip reduction six months ago which, quite frankly, did very little. It may have resulted in a 10% reduction of my lip size. I am now considering further lip reduction surgery for better results but have a few questions.

1) I’m looking for very specific results so I need to be sure you are confident in your ability to perform a reduction of at least 1/2 of the size on each lip? I want results that are very significant and not subtle.

2) I would also like to reduce the bulkiness of each lip, in other words, less meaty.

3) In the technique you do will the scars be visible? What can I expect after everything is healed? Will there be any noticeable scars on the visible/dry part of my lips?

4) Will there be 2 scars, one from the prior surgery and one from this one, or can you remove the tissue from where the old scar is?

A:  In answer to your lip reduction questions:

1) Significant reduction can be obtained but there is a balance between reduction and the location of the scar. The only way to get significant lip reduction is to remove the DRY exposed vermilion not the wet invisible mucosa like you had the last time.

2) You really can reduce the thickness or meatiness of the lip per se. Right underneath the vermilion lies the labial artery which gives the blood supply to the lip as well as the orbicularis muscle which is responsible for some of its movement. Thus you can see that trying to debunk the lip by a deeper wedge excision is fraught with potential problems. All you can do is remove the surface vermilion to have less visible show but really thinning out the thickness of the lips is not surgically advised.

3) as per #1. The key point is…the bigger the reduction the more likely the scar may be visible.

4) The old scar would be removed with the new excision.

Dr. Barry Eppley

Indianapolis, Indiana

 

Are Preformed Skull Implants For Augmentation Safe And Effective?

Q: Dr. Eppley, I’m considering getting the custom skull implant for skull augmentation to build up the back of my head. Can you please share your experience of this type of skull implant surgery you have performed?

A: When considering preformed silicone implants for occipital or any skull augmentation, there are two basic methods to do it. Here in the U.S., a custom fabricated implant is always used since there are no preformed skull implants that are commercially available. It is always hard to argue with a custom implant since that is the ideal way to get a perfect fit and have it made to correct any existing asymmetries. That is the approach I have used over eight forehead/temporal augmentations and one occipital augmentations in the past two years. That being said, I have placed a few preformed skull implants (top and back) on international patients who brought the implant with them from overseas manufacturers. (they are illegal to directly import into the U.S. since they are not FDA-approved)

I do think such silicone implants do have role to play in forehead and occipital augmentations for the reasons discussed even if there is a modest increase in the infection rate. (out of 9 such skull implants in the past two years, I have had two infections that necessitated their removal (22%). This is contrasted to over 100 PMMA skull augmentations with no infections seen even in three cases where the implants became exposed due to wound dehiscences. (0%)

That begin said, I am enthusiastic enough about using preformed implants that I am now working with a major manufacturer to create a set of three sizes for occipital skull implants. For many patients this simplifies the procedure, allows for a slightly small incision and creates a moth contour even if it does not have perfect adaptation to the underlying bone.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Skull Reshaping Do I Need?

Q: Dr. Eppley, I’m very interested in pursuing skull reshaping surgery to fix a congenital defect involving the right side of my skull. For as long as I can remember, it has been both a cosmetic concern and one of comfort. (causing pain/discomfort with prolonged lying on the right side or with wearing helmets of any sort). From reading your web-based article, I believe I may be a good candidate for your procedure. I’ve attached a few photos of the affected area for your review; of course it’s difficult to capture the magnitude and dimensions of the defect (a bulging, sharply angulated defect) with mere photos. I thank you in advance for your time and consideration.

A: As best I can tell from your pictures, the location you are referring to is the right parietal/posterior temporal region. You describe it as a congenital defect but also call it bulging. I suspect you mean a lifelong bulge in this area which is painful. This is very consistent in my experience with more of a temporalis muscle problem in that area. Most patients and even physicians have little appreciation of how thick the temporalis muscle is in that area and how far back it goes. It always feels like bone but there is a 5 to 7mm layer of muscle under exactly where you point. Having done a far number of temporalis muscle reductions/resections (temporal reduction) in this area for symptoms described just like yours, I can attest that your concerns are more likely muscular based than being a bone problem. A CT or MRI will show how thick the muscle is in this area. However, I often make the decision to do muscle resection/reduction based on the description and physical examination only.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Lip Lift Or A Lip Advancement?

Q: Dr. Eppley, I am interested in a lip lift. I have very thin lips and a long upper lip. I want them to have more shape and size although I don’t want them to be too big. I have read about lip lifts but am not sure what I really need. I would like your opinion. I have attached a front and side view of my lips for your recommendations.

Vermilion Lip AdvancementA: Thank you for sending the pictures. What they show to me is that unequivocally need a vermilion advancement and not a sub nasal lip lift. Your lips are very thing from corner to corner, has little cupid’s bow shape and there is a long distance between the base of the nose and the upper lip. This is a contraindication to a subnasal or bullhorn lip lift as it will only move up the central third of the upper lip but leave the rest of the lip behind, potentially creating an unusual and unpleasing shape. Only moving the physical location of the vermilion-cutaneous border, from corner to corner, of both lips can you make a significant improvement in the size and shape of your lips. I have attached an example of upper and lower lip vermilion advancements although this patient is older and she wanted a more dramatic change. The change from a lip advancement procedure is adjusted by the vertical size and shape of the skin excision and can be in any degree desired. The ‘test’ of the change a patient wants with a vermilion advancement is done by having them draw on the new border and shape of the lip with an eyeliner pencil. Then that becomes how much lip advancement is done.

Dr. Barry Eppley

Indianapolis, Indiana