Should Cheek Bone Reduction Use Plates And Screws?

Q: Dr. Eppley, I did not know i could have cheekbone reduction in the U.S.. I had it done in Asia where my friend had that done too. I am of Asian descent and I have wide prominent cheekbones. I had the cheekbone reduction procedure without plates and screws and now I am afraid of non union of the bones, misalignment and dislocation of the fragments of the zygomatic arch. I hear a clicking sound. My surgeon in Korea says it’s normal and will disappear, but I wanted a second opinion from you. 

if you don’t use fixation how you make sure the bones stay in place how you prevent sagging and scleral show after the cheekbone is collapsed. Once you push the zygoma arches in and there are gaps and dents, does new bone is created in years to fill in those gaps or do they remain depressed?

A:  Cheek bone reduction surgery can be compared directly to have a facial fracture…albeit a surgically controlled one. The best way to ensure that the bones stay in the desired position and heal is to use some form of bone fixation. (plates and screws) The clicking you hear is the bone segments that are unstable and are moving with their edges rubbing together.

Since the zygomatic arches are not functionally loaded bones, like the lower jaw for example, one can argue that it is not critical that they are stabilized. They will eventually go on to heal even if it is by fibrous rather than bony union. When it comes to cheek bone reduction, however, the position of the bone is just as important as whether it heals. Sagging or dropping of the bone is associated with soft tissue sag and even potentially lower eyelid sag. This is why some form of bone fixation should be done.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Still Get Cheek Implants After Having Maxillary Sinusitis?

Q: Dr. Eppley, After perusing your blog extensively (thank you for it, it has been a tremendous help!), I’ve finally decided to get cheek implants. My issue is that I had a sinus infection 2 weeks ago,and my doctor put me on antibiotics for a week. It has since cleared up and I don’t have any symptoms of sinusitis anymore. As I will be getting my cheek implants in two weeks, will enough time have passed for me to get the implants safely, or will I be an increased risk of infection due to the prior sinusitis?

Cheek Implants and Maxillary Sinusitis Dr Barry Eppley IndianapolisA: It would be logical to assume that there could be a correlation between cheek implants and maxillary sinusitis. And certainly one should not undergo any elective cosmetic procedure if any active head and neck infection is ongoing. While they are anatomically very close, the placement of cheek implants on top of the zygomatic bones and the sinuses located below and behind the front wall of the maxilla are distinctly separate areas that do not connect. Even an active maxillary sinus infection does not contaminate the tissues where a cheek implant would be placed.

But having a two week period where the maxillary sinusitis is cleared would be prudent. But the typical antibiotics given for facial implants (usually Keflex) is not the type of antibiotics that should be prescribed for maxillary sinusitis since it does not provide adequate antimicrobial coverage.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Revision Rhinoplasty Do I Need?

Q: Dr. Eppley, I am in search of a very skilled revision rhinoplasty surgeon and am impressed by your work. 

I had my first septorhinoplasty with right inferior turbinectomy around 18 years ago.  My nose looked wide and had bulbous tip and pinched nostrils on birth and I had breathing problems. During first surgery the doctor took too much of my bridge away. My breathing problems got a bit better but my nose looked totally deformed.  I am of course very depressed due to that and am very much judged by people in life when they see me before I even open my mouth due to my appearance. 

I long to have a normal nose, I would like to have my bridge built up.  These pictures were taken in 2012 just before tip plasty.  I am sending the same pics to you for evaluation as the doctor did not even touch the bridge, only the nasal tip (hook) noted on left profile was made smooth, but everything is the same no difference at all. I did not want my bridge touched at that time as I thought things will get worst but am prepared now to take the plunge with the right surgeon. 

I was told that I did not have any septal cartilage left for grating but never had ear or other cartilage or implant used so far.  What do you think could be done to improve my nose? I do not want any synthetic implants in my nose, thus the only option is my ear or rib cartilage? 

I want to have an elegant nasal bridge, and have the pinched nostrils look better and start to live life better. I would be ever so grateful for your feedback.

A: In looking at your pictures, you do need a dorsal augmentation by a cartilage graft and a rib donor source would be the best and really only good choice in your revision rhinoplasty. This provides an adequate amount and shape of the dorsal augmentation that you need. You would also benefit by alar rim grafts to provide improved support to your nostril rims so they do not collapse downward. Slivers of rib cartilage graft would be an excellent source of the straight thin grafts that are needed here.

Dorsal augmentation would bring the upper two thirds of your nose in better balance/proportion to the tip.

Dr. Barry Eppley

Indianapolis, Indiana

Is There Surgery For Cutis Verticis Gyrata?

Q: Dr. Eppley, I was wondering if you have and do perform surgery on cutis verticis gyrata. If so I was wondering some of the details and and maybe some idea of the length and width of a post op scar.

A: I have performed surgery on this exact scalp condition in the past and can make the following comments about it.

Cutis verticis gyrate (CVG) is a most unusual although not rare scalp condition of which its cause is unknown. But how it presents with ridges and creases is well known and that the scalp tissue thickens to create it. Treatment options are very limited with the most common approach in limited scalp areas of excision. This may be satisfactory if the rolls are limited to the back of the scalp in a horizontal orientation. But for many cases of cutis verticis gyrata the scarring is likely prohibitive. A more innovative approach is the use of subcision (release) of the creases combined with fat injections. This ‘scarless’ approach has no real downside other than its effectiveness and would be the preferred approach in larger areas of scalp involvement in which excision is not an option.

I would need to see some pictures of your scalp CVG to see which, if any treatment options, may be worthwhile for you.

Dr. Barry Eppley

Indianapolis, Indiana

How Is Lower Eyelid Bag Removal Done?

Q: Dr. Eppley, I am interested in lower eyelid bag removal surgery. I have dreadful eyebags that won’t go away. I have tried all the home treatments and nothing works. I’m a young female at age 28 and the bags last all day. There are two bags under each eye. The past two years everyone has been asking if I’m exhausted or sick. It’s really affecting my self esteem. Can you help me? I am getting married next year and and I don’t want him to lift the veil and see my tired baggy eyes. Thank you for your time.

A: Lower eye bags are the result of fat that is sticking out from under the eyes and pushing out on the eyelids. Because there is a ligament of sorts that normally holds back this fat, when it protrudes it is known as herniated infraorbital fat. Usually it occurs as a result of aging but there are younger people who have it naturally. Known as congenital herniated infraorbital fat, I have seen and treated it as young as 14 years of age. Because you would be normally too young to have this as a result of aging, we can assume this is the result of a congenital weakness in the lower eyelid tissues that can not contain the fat.

This is a very correctable problem. There are two lower blepharoplasty techniques that can be used to eliminate the lower eyelid bags. The first is a transconjunctival (inside the eyelid incision) to just remove the protruding fat. (transconjunctival lower blepharoplasty) This is usually the best approach for younger patients or those that have no excess lower eyelid skin. The other approach is to reposition rather than remove the excess lower eyelid fat done through either internal or external incisions. The decision between the two depends the patient’s anatomy, age and their facial type.

Dr. Barry Eppley

Indianapolis, Indiana

Does Jaw Wiring For Weight Loss Work?

Q: Dr. Eppley, I am interested in jaw wiring. I had a back injury about five years ago and then my weight was 130 lbs. Now it is 210 lbs. If I could get down  about 30 to 40 lbs I think I could exercise and really make it work. Does this sound realistic?

A: The eternal question about weight loss is whether any method that provides an immediate and short term effect will provide a sustained weight loss change. The most effective long-term methods of weight loss are significant lifestyle changes in diet and exercise. But that issue aside it is well known that wiring one’s jaws together (e.g., orthognathic surgery) will cause weight loss by the limitations of what one can take in orally. (lack of solid food)

It is important to remember that while jaw wiring can certainly initiate weight loss while they are in place when they come off the onus will then be on the patient. But if you are confident that somewhere between a 20 to 30 lb weight loss over a several month period will help, there is no medical contraindication to doing so. The only question is how long to leave the jaw wiring in place which is usually between 6 to 8 weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Will Tear Trough Implants Cause Any Nerve Injury?

Q: Dr. Eppley, When placing a tear trough implant through the eyelid with internal scar and no stitches, are the tissues peeled off the bone as they are with cheek implant placement? I had cheek implants in and removed quickly which left me with mid face sagging and worse eye bags than before, minimal, but the tissues adhered a few millimetres lower than before the operation. Is this a risk with tear trough placement and or removal?, or is a mid face lift usually performed in conjunction with a tear trough implant? Which nerve functions are at risk with this implant?

Silicone Tear Trough Implants Dr Barry Eppley IndianapolisA: A standard preformed tear trough implant can be placed through a transconjunctival (inside the eyelid) approach. Like all facial implants, it is necessary to make a pocket for the implant which is usually subperiosteal although is can be placed preperiosteal as well. Given the very thin nature of eyelid tissue over the orbital rim, it is best to placed it as deep under the tissues as possible. I would consider the tissue pocket locations between the orbital rim and cheek bones as different as well as the size of the implants that are placed. Cheek implants are placed from below with wide subperiosteal underming and dissection, releasing much of the midface tissues on the bone to place a moderately large implant. Thus it would not be surprising that removal of a cheek implant places one at risk for a subsequent midface sag of some degree. Conversely, the tissue pocket for a tear trough implant is much smaller and is over the medial orbital rim where the detachment of tissues will not cause a midface sag like that of the cheek area.

Tear Trough Implants Dr Barry Eppley IndianapolisTear trough implants pose no risk of nerve injury. The only close nerve is the infraorbital nerve which lies below the orbital rim and where the implant is placed.

Dr. Barry Eppley

Indianapolis, Indiana

How Can I Handle My Needle Phobia Before My Rhinoplasty Surgery?

Q: Dr. Eppley, I am currently looking to have a rhinoplasty later this year. I had a discussion with an anesthesiologist about my needle phobia who advised I speak to the anesthesiologist who will be taking care of me during the procedure. As much as I want to say I don’t have a problem with my needle phobia I do. The last time I had my blood drawn I panicked and passed out. Obviously I don’t want any of that to happen which would make my surgeon’s job harder. He suggested maybe a prescription of Valium before the procedure or something of that nature. I will let you give me your professional advise on this matter. Looking forward to hearing from you.

Needle Phobia in Plastic Surgery Dr Barry Eppley IndianapolisA: Needle phobia issues are not uncommon in surgery. Known as trypanophobia, it is estimated that about 10% of people have it. While having to get a needle sick is unavoidable since an IV will be needed for your rhinoplasty surgery, there are numerous ways to get past this fear. Your apprehension can be remedied by taking 10mgs of Valium and 25 mgs of Phenergan orally orally one hour before arriving for your surgery. (as there will be someone driving you to and from surgery) Your surgeon can write that prescription for you. Make sure that you have signed your operative consents and had all your questions answered days before the surgery as consent can not be obtained from a mildly sedated patient.

The other management issue that can be done is to apply a topical numbing cream prior to actually putting in the needle. This will minimize needle insertion discomfort.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Buttock Lift Do I Need?

Q: Dr. Eppley, I have lost a lot of weight and the one area that bothers me the most is that of my buttocks. It hangs down with a lot of loose skin onto the back of my thighs. I don’t mind its size now but I can’t stand the loose skin at the bottom. And exercise will not get rid of it. What type of buttock lift do I need?

A: When it comes to large amounts of weight loss, the buttocks like every other area of the body is not spared from an overall deflation effect. The deflated buttocks loses both volume from fat loss and exaggerated amounts of sagging due to such volume loss. Buttock reshaping after weight loss can include either volume addition, tucking or lifting the sagging skin or some combination of both.

Buttock lifts can be separated into a true buttock lift (done from above as part of a circumferential body lift) or a lower buttock lift. (which is really a tuck after excision of overhanging skin.

Lower Buttock Lift result side view Dr Barry Eppley, IndianapolisA lower buttock lift is a lower excision/tuck procedure that is done along the infragluteal crease. (or makes a new one) It removes excess tissues and creates a new higher and more tucked in fold. It is not a difficult procedure to go through nor to recover from it. The biggest issue is to just not stress the incision lines (like bending over far) for a few weeks as the area heals. All sutures are under the skin and dissolvable so no suture removal is needed. The incision lines are heavily taped for support and serve as the only dressing. One can shower the next day and only strenuous activities need to be avoided for awhile until the incisions are more fully healed.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Right Type Of Facelift For Me?

Q: Dr. Eppley, I am searching for a facelift opinion. I know you are an expert so I would value your opinion. Can a facelift correct this droopy mouth and marionette lines? I have lots of sag and volume loss. My skin seems firm with good elasticity but aging and gravity does take its toll. Is a long lasting correction possible? There are so many options for facelifts these days I don’t know which is the right one. Every doctor seems to have their way to do a facelift and they all claim their way is the best. I will only be able to financially do this once, so I’m looking for the best information to get the best outcome for me.

A: You are correct in that there seems to be many ways in which facelifts are done. And any time there are so many ways touted to do something you can be assured that there is no one single best way to do it. Nor does one facelift method work best for everyone as today’s facelift patients range anywhere from 35 to 85 years old…and simple logic would indicate that the facial aging concerns and anatomy amongst patients are quite different.

Facelifts fundamentally differ in three ways, extent (incisions and dissection), degree of SMAS manipulation and adjunctive procedures done at the same time. Putting together all these areas is what makes facelifts different and customized for each patient. But what does make them somewhat similar and serves as the basic elements of a facelift are the amount of skin flap dissection and SMAS redraping. With significant marionette lines and a droopy mouth, it is clear that you need a fuller type facelift with long skin flaps as opposed to a short scar or more limited type facelift. (e.g., Lifestyle Lift) SMAS manipulation is handled differently by various plastic surgeons but suffice it to say that extensive redraping of it is needed.  Such manuevers are needed to help get rid of the marionette lines and improve the jawline and neck.

What a facelift will not do is correct droopy mouth corners. As a result, a separate small procedure will be needed with your facelift that directly treats this problem…a corner of a mouth lift.

When it comes to a ‘lasting correction’, it is important to understand that a facelift essentially buys time. It is not a permanent procedure and its effects will last years, perhaps 8 to 10 years, but eventually some or much of the correction will be lost. Facelifts help reverse the clock but they can not stop it.

Dr. Barry Eppley

Indianapolis, Indiana