My questions aside from obvious rhinoplasty and chin augmentation, can anything at all be done to address this “tilted” look to my face and eye area? It bothers the heck out of me . Your feedback would be highly appreciated. I think surgery is my real need and only true solution.

A: I do not have the advantage of seeing any x-rays so my comments can only relate to your photographs. The most significant component of your facial asymmetry is in the orbits with the one being lower than the other. That is potentially improveable through a brow shaving procedure through the upper eyelid and a lateral canthopexy corner of eye tightening procedure done on the lower orbit. That is relatively low risk and is an operation commensurate with the magnitude of the problem.

Straightening your nose through rhinoplasty is of obvious benefit as well as chin augmentation, via an implant or osteotomy, as you are already aware.

As for jaw surgery in terms of orthognathic repositioning…no. Your orthodontist is correct based on what I see in the photographs. I have no clue as to what your occlusion is but this would involve a major effort and years of orthodontic work. There would have to be a major malocclusion to justify that effort. You are far better off camouflaging the jaw asymmetry with chin augmentation and possibly a lower border shave/ostectomy on the elongated side.

Dr. Barry Eppley

Indianapolis, Indiana

A: Body changes that have occurred either from bariatric surgery, extreme weight loss or the impact of multiple pregnancies requires thoughtful consideration about the type and timing of surgical corrections. Sitting down with a plastic surgeon and going over all the surgical options is an obvious first place to start. Having had many of these discussions in my Indianapolis plastic surgery practice, most women will focus first on their tummy and waistline often combining it with another procedure such as an armlift.

These more substantative body problems are more substantial that the more traditional Mommy Makeover which is directly to two combined procedures, breast enhancement (implant with or without a lift) and some form of a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

A:  The three-dimensional shape or geometry of these scars is an important consideration. Are these scars wide and flat like chicken pox scars as you havhe described or are they wide and indented, having a central depressed component to them? Since they are old liposuction entrance scars, they are probably wide but the key question is are they indented or flat? That distinction is critical in choosing what type of scar revision to perform.

Excising small scars on the buttocks is easy to do and the intent of such an excision is to make the scar ultimately more narrow. While at the time of the procedure, they will be but in the long run they will likely widen again. The pressure of sitting on the buttocks will defeat most attempts at scar narrowing in this area if the scars are anywhere on the rounded portion of the buttocks. If they are around the perimeter or in the buttock crease, then such desired narrowing is more likely to be achieved.

If the scars are indented, however, cutting them and out and closing them make not make them smooth or flat. For this type of scar revision in this area, I would place small fat graft underneath them to prevent recurrent tethering or indentation.

Dr. Barry Eppley

Indianapolis Indiana

A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin.  Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.

Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.

When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?

Please send me some photos of your eyes for my further assessment.

Dr. Barry Eppley

Indianapolis Indiana

A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of  lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall  with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.

With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I would like your opinion on my nose condition. My history is that I have always had a big nose, it being very big and fat particularly at the tip. During my first rhinoplasty, they shortened the bridge between the tip of my nose and the upper lip but the size of my nose remained the same. During a second rhinoplasty,  another doctor took out all the cartilages. The nose subsequently increased in size on the top (created like a bump on the ridge). The doctor explained it to me that it was due to the internal scar and the thick texture of my skin. Then I had a third rhinoplasty with the same doctor as the second rhinoplasty. The nose has now increased to an unrecognizable condition. According to the doctor, it is the nature of my thick skin and inner scar. He advised me not to intervene any more, as no improvement is possible with my type of skin. Some time later, I had an injury to my nose and it became bent to the side a little with a hanging tip. The pictures I am sending you shows the nose after the third rhinoplasty and after the injury. After numerous consultations with various doctors, I decided to take a chance with injections of steroids. After 6 injections, my nose has decreased to what you can see in the pictures. But the doctor who has given me injections insists that my nose cannot be any smaller than it is right now. He says that since I need new cartilages to be inserted and the size of the nose will inevitably increase.

So my questions are:questions:

1) Is it indeed possible to make it smaller or at least a little thinner?

2) If new cartilages are inserted, can it still at least become thinner (doctors say that it will be only bigger)

3) Will it be noticeable that I had prior rhinoplasties?

4) How realistic is it to expect a smaller nose with my type of skin and inner scars?

I greatly appreciate you taking the time to look it over.

A: Thank you for sharing your rhinoplasty history and your pictures. While I have no idea what your nose looked like when you started, there is no question now that you have collapse of the lower 2/3s of your nose. Too much cartilage has been removed so the skin has no little support. This explains the nasal appearance after your second rhinoplasty and why it so easily got bent with the trauma. Ironically removing the cartilaginous support underneath the skin, if done excessively, actually makes the skin sleeve look bigger and sag more. A little cartilage tip cartilage removal and reshaping is one thing, a lot removed can turn into a disaster.

The question, of course, is what can you do now? If you are having any breathing problems (and I imagine you might) then rhinoplasty reconstruction with cartilage grafts (probably rib) can be beneficial. That will actually provide some midline nasal support, like a tentpost, and can possibly make the nose look somewhat thinner. When done through an open rhinoplasty, excess skin can be removed from the edges of the incisions which can also be helpful in creating less of a skin sleeve.

As you may have surmised, yours is a very difficult but not an impossible nose problem. All of your prior surgeries and steroids have definitely created scar but that is not a signficant problem in an open rhinoplasty approach. In conclusion, do I think you can be better than where you are right now…yes. You will never have a thin or small nose but it can be better shaped and supported to look less large than it does now.

Dr. Barry Eppley

Indianapolis Indiana

Breasts always seem to make the news and the more freaky seems to be better. Whether it is basketball-size implants of quadruple FFFF proportions, dancers subject to IRS scrutiny trying to write off their surgery, or breast augmentation as part of a marathon makeover (aka Heidi Montag), women who seek their ten minutes of fame marr the perception of an otherwise highly successful body contouring surgery. While the real breast augmentation news this coming year will be the introduction of a new form-stable (gummy bear) implants, this will likely be overshadowed by the media’s never-ending focus on celebrities, their breasts and Hollywood’s version of silicone valley.

There is always the continued incredulous news of patients suffering complications and even death at the hands of so-called cosmetic surgeons. This seems to be most evidenced with liposuction, largely due to its popularity and the larger body surface areas that it treats. There is an obvious difference in the size of the trauma to the body from abdominal and thigh liposuction from that of a nosejob or eyelid surgery for example. Liposuction attracts a large number of inexperienced and often unscrupulous practitioners because of the relative ‘simplicity’ of the procedure and easy access to new liposuction devices. It only takes a medical license and a credit card to buy the newer laser liposuction machines. Equipment manufacturers are more interested in sales than safety as evidenced by their marketing and selling behavior. Patients died last year from one coast to the other at the hands of doctors with dubious credentials. The public would think that better regulations would exist but they would be wrong. Doing your homework is your best protection.

Botox continues to show its fantastic benefits and those are not only in those worried about their frown lines or crow’s feet. Last year Botox was approved by the FDA for the treatment of migraines. For some migraine sufferers, Botox injections can be a miracle even if its effects are only temporary. The benefits of Botox have translated into an actual migraine surgery procedure developed by plastic surgeons. If Botox injections relieve one’s migraines, a relatively simple muscular decompression around the nerve trigger points can provide a more permanent amelioration of one’s migraine pain and frequency of attacks. It’s a rare example of a cosmetic treatment turning into a really useful medical or reconstructive surgery, usually that works in reverse.

One other piece of fantastic plastic surgery news from last year has been the emergence of face transplants. While once thought impossible and something more akin to a movie or science fiction, more and more partial or complete face transplants are being done around the world. While the patients who need them are last resort problems of massive facial deformities and tissue loss, that is the history also of all organ transplants which are commonplace today. From the extreme technical advances of today come spinoffs that will benefit many more facial reconstruction patients in the future.

No telling what this coming year will bring, but if past history is any predictor of future events, plastic surgery will continue to make the headlines…let us hope it is largely in the fantastic category.

Dr. Barry Eppley

Indianapolis, Indiana

A: Thank your for your inquiry. Recovery after blepharoplasty surgery is largely social…meaning how do I look? (how much bruising and swelling will you get) That would depend on whether one is doing only upper eyelids, only lower eyelids, or all four eyelids.. When all four eyelids are done, most people will have noticeable bruising and swelling for up to 10 to 14 days after surgery. If only one set of eyelids is done, it will be less than that. Lower eyelids develop more welling and bruising than the upper eyelids after surgery. There are also different types of blepharoplasties done in which the overall swelling and bruising may well be less, what we call limited blepharoplasties which are either of the pinch type or lower eyelid which use only a transconjunctival (inside the eyelid incision) approach.

There are numerous strategies for keeping the amount of swelling and bruising as limited as possible. This includes pre-and postoperative oral Arnica, keeping one’s head elevated above one’s heart for the first few days and a good icing of the eyes the night after surgery. I also use gentle surgical technique with delicate amounts of cautery to keep down the amount of bruising that can develop.

Dr. Barry Eppley

Indianapolis Indiana

A: There is no question that pectoral implants will increase the perceived size of your pectoral muscles. Increasing the bulk of the muscle is what they do best from their subpectoral or under the muscle position as they push the muscle forward. Implants are not quite as good as improving pectoral muscle definition with the exception of the lower lateral pectoral border. The question you are really asking probably relates more to implant projection…or how big can the pectoral muscles be made to look.

Pectoral implants have, at most, up to 3 cms. of projection or forward push of the muscle. How significant that is depends on how thick the muscle is to start with. In other words, a flat chest with a thinner pectoralis muscle will show more but it will not be a ‘bodybuilder-like’ result. An already thicker pectoralis muscle in someone who is fairly developed will have a much more prominent result.

Dr. Barry Eppley

Indianapolis Indiana

A: Recurrent capsular contracture, although uncommon, can be a difficult breast implant problem. The conventional approach is total scar removal, with or without replacing the implants with those that have a textured surface. If the implant was originally above the muscle, relocating it to a submuscular position can also be tremendously helpful. These combined techniques are probably effective about half the time, maybe more. But when they fail, different strategies need to be explored.

One alternative approach is to wrap the new implant partially in a dermal graft after the repeat capsulectomy. This ‘out-of-the-box’ graft is intended to heal around the implant lessening the risk of new scar formation, essentially serving as a part of the new capsule rather than fresh new scar tissue which has a high propensity for contracture. PRP, also known as platelet-rich plasma, is a concentrate from the patient’s blood which can be sprayed onto the internal breast tissue surfaces. Its theoretical benefit is that it causes less scar tissue to form. The addition of a dermal graft is a more proven capsular contracture approach but the use of PRP has no downside and is simple to apply.

Fat injections as an alternative to the use of a breast implant for the treatment of capsular contracture may be novel but is both unproven and biologically flawed in my opinion. The survival of fat injections in breast augmentation is based on the graft being injected into the midst of healthy tissue where it can survive by revascularization. Injecting fat into a large empty open space would not only have it not survive but would likely become a liquefied pool of oil and fat that is prone to infection.    

Dr. Barry Eppley

Indianapolis Indiana

A: When it comes to chin implant size, there is a fine balance between too much vs too little. For a male, the chin position should ideally be even with the most protrusive part of the lips when see in a side view. While this is a classic anthropometric measurement, and one that is historically espoused in the concept of male beauty, that does not mean it is the most ideal aesthetically for any individual. Some men prefer their chin to be stronger than this measurement suggests while others prefer it to be a little shorter. When trying to decide between two chin implants sizes of a few millimeters difference ask yourself this question…would I prefer to ‘error’ on the side of having the chin turn out to be a little too strong or a little too weak? Obviously you want it perfect but knowing that choice will help make the decision between those two implant sizes.

Dr. Barry Eppley

Indianapolis Indiana

A: There is no question, even without seeing most patients, that the description of a lower belly pouch signifies that they have some excess fat there. So the use of liposuction for abdominal fat reduction is going to be useful. Whether liposuction would be of benefit, therefore, is not really in question. The issue is how much lower abdominal skin do you have and what will happen to it when the lower belly is deflated so to speak. In other words, do you need some type of a tummy tuck with the liposuction? The aesthetic outcome of liposuction is predicated, partially, on how well the skin contracts down once there is less volume. If there are a lot of stretch marks and you can pinch  more than an inch or two of skin, then it is likely than some skin removal (mini-tummy tuck) may be helpful also. If there is a question as to whether skin removal is really needed, you can always do the liposuction first and let that outcome make that decision for you. I would use Smartlipo (laser liposuction) for your abdominal liposuction as that has the best chance of shrinking down the skin you have the best.

Dr. Barry Eppley

Indianapolis Indiana

A: Your description of the left cheek/midface deformity is exactly what one would anticipate from an incomplete zygomatic or cheekbone fracture. As the zygomatic complex, when fractured, can only rotate downward and inward toward and into the maxillary sinus you will lose some cheek and underlying anterior maxillary projection. Because you have described no changes in the eye area or numbness of the cheek and teeth (infraorbital nerve impingement) your original zygomatic fracture is incomplete and less severe than a fully displaced fracture. Given the age of the injury and the now healed bone, a modified cheek implant placed across the anterior maxillary wall and up onto the anterior zygoma should do nicely to restore the bone fullness lost. Given the modified position of such a cheek implant, it would need to be secured by multiple screw fixation.

Dr. Barry Eppley

Indianapolis Indiana

A: The Mommy Makeover has become a popular plastic surgery procedure amongst mothers between the ages of around 25 to 45, although it can be done at any age. It has gotten this catchy name because the procedures involved help reverse the effects that pregnancy has ravaged on a woman’s body. These procedures have been commonly done for many decades so they are not new. They have just been put together and ‘packaged’ for this specific set of female body problems, that being the breasts and the stomach areas. Breasts frequently have lost volume (deflated) and sag and the tummy has loose skin and stretch marks. The combination of breast reshaping (implants with or without a lift) and some form of a tummy tuck (with or without liposuction) is the backbone of a Mommy Makeover. They are almost always done together if a patient’s economics permits. While this combination of a breast augmentation and tummy tuck will have a dramatic change on one’s body, you must tone down the concern about getting back to working out as soon as possible. This is a setup for after surgery problems. It is understandable that you have an addiction to working out as you would not have gotten this far without doing so.  But that same addiction, which you think is good, is not so good after this kind of surgery. You must mentally plan on 6 weeks before getting back to working out like you are now. Remember that in a span of a few hours you are going to make changes that you can’t do by working out for the rest of your life. The risk is not worth it for a few extra workouts that, in the big picture, will gain you nothing.

Dr. Barry Eppley

Indianapolis Indiana

A: What makes cheek implants different from other facial implants is their bony position. Sitting on the side of the cheek bone, with no bone support underneath them, makes them more prone than many other facial implants to shifting or malpositioning. This risk is magnified by their path of insertion from inside the mouth which opens up the southern avenue for shifting. While most cheek implants do not experience these problems, the risk is not zero. Because of this concern, it is my preference to almost always screw fixation for cheek implants. This makes me feel the most comfortable that the postoperative risk of implant shifting is virtually eliminated. the appeal to me of screw fixation is that it is also easy to do, involves no risk, is done at minimal extra cost, and adds essentially no extra time to complete the procedure.

Dr. Barry Eppley

Indianapolis Indiana