Why Am I Numb After A Facelift?

Q: Dr. Eppley, I am 62 years old and I had a facelift done six weeks ago. I still have very dense numbness on both sides of my face which goes as far forward as my cheeks and straight down to and under my neck as far forward as my chin? Is this normal and, if so, when will it go away? 

A: When performing a facelift, the skin is raised up extensively to access the SMAS layer and well as to remove lax face and neck skin. Anytime the skin is undermined the tiny nerves that supply feeling to it are cut. This will result in numbness of the overlying skin that will persist for some time after surgery. Most if not all of the feeling will return but it will take time to do so. The return of feeling will begin in the most medial skin areas near the chin and nose and will work its way slowly back towards the ear. This is a process that will take months, often as long as six months to achieve maximal sensation return. In some patients they will be a small area of permanent numbness that may remain right in front of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Does Smartlipo Require Any Time Off Work?

Q: Dr. Eppley, I had a my first baby six months ago. Now I am not really happy with my belly. I have gained some weight that I never had before and can’t seem to get it off. What can I do that will not involve much time off work? I have read about Smartlip which seems like the best option and would not involve being off work.

A: Based on your pictures, you would be an excellent candidate for liposuction done under general anesthesia to really thin down your abdomen and waistline. There is always a misunderstanding that many patients are not aware that ‘Smartlipo’ is real surgery and is just another form of liposuction. While it can in the right patient be done under local or sedation anesthesia, it is still an invasive surgical procedure. It is not some external device that magically melts fat. The best results with Smartlipo are like any other method of liposuction…having it done under general anesthesia (if you want the most fat removed possible) and does involve some recovery.

For a treatment that requires recovery at all, you can consider a non-surgical approach like Vanquish. It will not produce the same result as any form of liposuction but does not involve surgery. It is done a series of office treatments, usually once a week for four to six weeks.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Midface Lift Do I Need?

Q: Dr. Eppley, I’m currently 26 and I had large silicone cheek implants placed two  years ago together with a buccal fat pad extraction. I had them removed two months ago as I just felt they were too big for my face. The issues I have now is that there seems to be a small degree of mid-facial sagging. I’m looking to get smaller malar implants later in the year, but I’m concerned that that will not be able to proper address this sag. Out of curiosity, since I’ll be undergoing a cheek implant procedure again, could a mini-lift help address this sag? I don’t think I’ll require anything too aggressive – do you know of any midface lifts that could help me out?

A: It is no surprise that once cheek implants are removed that some degree of midfacial sag will result. This is not just due to the stretched overlying tissues but because the soft tissue attachments to the bone have been permanently detached. Once the implants are out, the overlying midface soft tissue can not reattach to the bone (due to the slick surface of the residual capsule) and it thus slides ‘south’.

With your new cheek implants you consider a temporal suspension midface lift which can simply and easily pull back up the midface tissues over the new implants.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Technique For Successful Results with Buttock Implants?

Q: What is the best buttock implant augmentation technique? I have heard differing viewpoints about inside the muscle and on top of the muscle.

Buttock Implants Indianapolis Dr Barry EppleyA: Just like breast implants which can be placed under the muscle or on top of it, buttock implants share a similar two pocket location approach. (although intramuscular not under the muscle is where buttock implants are placed) Whenever there are two ways to do any surgery and different surgeons either approach, that indicates that neither method is perfect. You then have to look at the different advantages and disadvantages to either approach and figure out which one matches your needs the best and which risk profile is more tolerable.

The arguments for the subfascial location for buttock implants is the following. This pocket location allows placement of the biggest implants with sizes up to 700ccs. It creates a nice ‘S’ curve by making the pocket up to the posterior iliac spine, where the gluteal muscles actually attach. It also has a faster recovery because the muscle fibers are not disrupted deep into the belly of the muscle. Its disadvantages are that it has a higher incidence of seroma formation, potential implant visibility (if you have little subcutaneous fat between the skin and the muscle) and a greater chance of implant displacement/rotation. (since there is less tissue resistance)

The arguments for the intramuscular location for buttock implants is the following. It provides a thicker more vascularized tissue pocket which lessens the risk of seroma formation, potential implant displacement and has less risk of tissue thinning over time between the implant and the overlying skin. Its disadvantages are that it is somewhat more technically difficult to perform, has a limitation to implant size that can be placed (350cc or less) and has a longer recovery.

When you put all this together you can see that it is not so simple as just one implant location is better than the other. You have to look at each patient and make a decision based on their goals, tolerance for recovery and their tissue qualities. For thin or small women that have little subcutaneous fat tissue, an intramuscular implant location is usually best. For larger women with thicker subcutaneous fat layers that want a larger buttock augmentation result, a subfascial location would be preferable

Regardless of buttock implant location, a very important element that affects the result is the strict adherence to postoperative instructions to avoid too aggressive early activities. This can increase the risk of incisional wound separation, seroma formation and implant displacement.

Dr. Barry Eppley

Indianapolis, Indiana

How Does The Drainless Tummy Tuck Work?

Q: Dr. Eppley, Do you do the “drainless” tummy tuck surgery? Also, I have an umbilical hernia and am looking to have both procedures done simultaneously. Can this be done on the billing end so that insurance will cover the hernia repair, anesthesia, facility charges, etc and I self-pay the abdominoplasty procedure?

A: Thank you for your inquiry. Let me provide you with some clarification and additional insight in both your tummy tuck questions about a ‘drainless’ technique and the financial implications about doing combined medical necessary and cosmetic abdominal wall procedures.

I have done numerous drainless tummy tucks and there is an understandable appeal to it because of the absence of a drain. But there is more to it than just not putting in a drain. There has to be some additional steps done to close down the internal dead space and seal the wounds to prevent a seroma (fluid collection) after surgery. Drainless tummy tucks can be done by either using internal quilting sutures or a tissue glue prior to closure of the tummy tuck incision. These steps do take additional time (an extra 1/2 hour of operative time) and materials (tissue glues can cost up to $1,000) to do and thus the drainless tummy tuck is going to cost more than one in which a drain is used. A drain is a simple and quick method to manage potential seromas and also keeps the cost down. Thus one has to place a value on how much avoiding the drain is worth. And drainless tummy tucks do not have a complete absence of problematic serums afterwards, there is not a 100% guarantee that you would not get a seroma even with these maneuvers.

In what seems like a straightforward issue historically, the separation of a medical necessary procedure like a hernia repair and a cosmetic procedure like a tummy tuck should be simple. But in today’s health insurance world it is not. The first common erroneous perception is that somehow insurance is going to pay for the operative room and anesthesia charges for the tummy tuck portion of the procedure…and they will not. No facility will allow that to happen anymore so that all charges related to the tummy tuck portion of the combined procedure including operating room, anesthesia and any supplies used must be paid out of pocket and in advance of the procedure. While ‘sliding’ the operating room and anesthesia costs of the cosmetic portion of the procedure onto insurance was common practice 10 to 20 years ago, that is no longer permitted and is actually illegal today.

While there is no question that a hernia repair and a tummy tuck should be done together, and this is common practice, you have to look carefully at the cost issues to see what works in your best financial interest. Your insurance is going to require in almost all cases (with the exception of Anthem and a few other private carriers) that your hernia repair be done in a hospital or a hospital-owned facility. Such a facility may or may not have reasonable cosmetic fee usage costs. They will in most cases be higher than a private non-hospital owned surgical facility. Depending upon the difference in cosmetic costs between the two types of facilities will determine whether the combined hernia repair-tummy tuck is done through insurance using their required facility or whether it is just better to pay all of pocket for both procedures. (I have certainly seen that be the case many times) Each patient and what insurance carrier they have has to be considered on an individual basis.

Dr. Barry Eppley

Indianapolis, Indiana

 

Can Cleft Lip Revision Make An Improvement?

Q: Dr. Eppley, Would I be able to have any improvement on my cleft lip with a lip enhancement surgery (cleft lip revision) to make my lip more even?

A: Almost all cleft lip repairs, no matter how beautifully done as an infant, will end up needing some additional revisions to optimize the repair appearance. The one area of the the lip that almost always need adjustment is that of the vermilion. (pink part of the lip) It is frequently volume deficient on the cleft side and makes a major contribution to lip asymmetry.

I think there are several aspects of your cleft lip that can be improved and all of your cleft lip issues are common. There is a lack of vermilion fullness down at the lip line which needs to be augmented by a small dermal-fat graft. The cupid’s bow area is indented, again due to lack of volume which also needs to be grafted. The outer aspect of the cleft lip side along the vermilion-skin border is shorter in height than than the non-cleft side and that can could be improved by a lip advancement on that side. The actual philtral skin scar looks pretty good and I don’t think that scar could be improved with the exception of adding a few hair transplants into and along the scar line.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Custom Temporal Implants?

Q: Dr. Eppley, I am interested in making my forehead wider and more squarer to balance out the width of my new custom jaw implants that will be placed in about a months time. I have booked in for temporal implants at this stage but not forehead as I don’t think my doctor or any doctors here are quite familiar with the procedure. I wanted to know if it is ok to request to my doctor to use Medpor temporal implants? This is because I had a look at the Medpor catalogue and have found that the Medpor brand offered a significantly BIGGER size compared to the silicone ones offered my Implantech (which my doctor will use). Medpor ones go up to 20mm in augmentation. I’ve read your resource millions of times (very helpful) and want to know do temple implants sit only on top of the soft tissue or can the implant itself be placed higher if the implant overlaps onto the bone? Or is that something a custom made forehead implant would fix? If so are there any off the shelf forehead implants available on the market to widen the forehead? 

I also wanted to know if I was certain that I need a forehead augmentation in future are temporal implants necessary? Or are they needed along WITH forehead augmentation. I just don’t want to waste my money on temple implants if a custom made forehead implant will fix both areas.

A: I would never use Medpor temporal implants myself. They are too big, are very difficult to modify and are very difficult to remove should that ever be desired. (and there should be a high probability that they would) No one ever needs a temporal augmentation that requires a 20mm thick implant. They are simply too big for most cases and were initially designed for patients that suffered significant temporal muscle atrophy from neurosurgical procedures not for patients that want a pure aesthetic augmentation with a normal tenporalis muscle.

If you are seeking a temporal augmentation that reaches the high temporal region to make the forehead wider as well, only a custom designed temporal-forehead implant can achieve that aesthetic change. No current implant style, Medpor or silicone, are made to create that look as a ‘catalog’ item.

Dr. Barry Eppley

Indianapolis, Indiana

How Is Ear Helical Rim Reconstruction Done?

Q: Dr. Eppley, I know that the two most common surgeries in cosmetic ear plastic surgery are to 1) remove cartilage from behind the ear and move the concha closer to the head and 2) reform the antihelix. In my case, the size of my concha and antihelical fold are OK. In my opinion my main problem is that the outer helical rim is short and dipped in. What I am asking is whether you have the ability and experience of building up the helical rim? In my self diagnosis, I think that we don’t have to fix the helical rim all over the ear, we can just fix something like a one centimeter area at the top of the ear. In my self diagnosis it gives me my ideal result.  Thank you very much.

A: What you are suggesting by self-diagnosis for your ear helical rim reconstruction makes sense and is possible. The helix exists as an outward curl of cartilage distinctly different than that of the anti helical fold. How to build out the helix at the top of the ear comes from knowledge of performing microtia, cryptotia and other congenital ear deformities. Based on the attached pictures of your ears, this is going to require the placement of a cartilage graft which could be harvested from the backside of the concha with no change in its appearance. The only question is whether this is best done by placing the graft on top of the existing helical rim or by placing it into a cut below the helical rim as an interpositional space to push the height of the helical rim higher. In my opinion this would best be done with the latter technique to prevent graft show through the very thin overlying helical rim skin.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Lip Advancement Create Less Tooth Show?

Q: Is the V-Y plasty the same thing as a lip advancement? If so, is that a procedure that can raise the height of the lower lip to have less tooth show? That is an option that I am exploring. 

A: A lip advancement and a V-Y advancement are two completely different operations with varying effects on the lower lip. A lower lip advancement removes a horizontal strip of skin on the outside so the vermilion can be rolled outward making the lower lip look bigger. It will not raise up the lower lip but is done to make the lip look fuller. (have more vermilion show) A V-Y advancement is a internal vertical mucosal procedure done on the inside of the lower lip. It is designed to try and lengthen the height of the lower lip and/or release any contracture or shortening of the anterior mandibular vestibule.

Raising the height of the lower lip is challenging and there is no one single procedure that can consistently do so. It usually require a combination of procedures through mucosal lengthening and vermilion augmentation to create such an effect.

Dr. Barry Eppley

Indianapolis, Indiana

How Do You Treat Cutis Verticis Gyrata?

Q: Dr. Eppley, These are a few pictures of my crown and a short video of my head. The hair on the ridges is sparse but in the furrows there is some. I’m not sure if I’m losing hair in this area due to mail pattern baldness or the cutis verticis gyrata. I just want to know my options for conceiving this. Wether it be a hair transplant over it or cutting it out.

A: Thank you for sending your pictures and the video. What you should do is based on how large of an area is involved in your scalp and how progressive or stable the cutis vertices gyrate is. If the area is small and stable and is not causing any other symptoms, it be left alone. I do not think it necessarily is causing hair loss but may just be spreading the follicles out further as it expands. (although I can not say for sure whether it is) The involved scalp area should only be excised if it can all be removed and should first have tissue expansion. The scalp is not very flexible and will leave a wide scar if it is all removed at once. If the scalp area is larger and it seems to be growing, then excision would not be advised. You may consider fat injections or PRP injections in an effort to treat it although such treatment is theoretically beneficial but not yet proven.

Dr. Barry Eppley

Indianapolis, Indiana