Your Questions
Your Questions
Q: I am writing you because I need information on gynecomastia reduction. I have been battling with fat around my chest ever since I was young. I am now 28 and not the least bit out of shape. Actually I am a certified personal trainer and have participated in body building contests. Even when dieting down to as little as 4% body fat I still have this fat on my chest. It is very humiliating and I have never been comfortable with my body because of this reason. I am completely happy with my body except for this part. Being a trainer and a single man my appearance is important. Can you help me?
A: Male breast enlargement, known medically as gynecomastia, comes in all forms. How it appears in different men is as variable as breasts are in women. While many people may think that gynecomastia presents as an actual breast, that is only partially true. About half the men I see today in my Indianapolis plastic surgery practice have what I call ‘minimal gynecomastia’. Their stories are all very similar. They are younger (under age 40) men who are in extremely good shape (many are trainers and body builders) who just can’t get off that little bit of fat on their chest. While a lot of other people may not think it significant, they are extremely bothered by it due to their understandable sensitivity to their body shape. I suspect in some patients their extraordinary focus on conditioning and body shaping may be a compensatory response to their self-image issues with it.
Such smaller amounts of gynecomastia are easily treated and resolved with simple liposuction techniques. This leaves essentially no significant scarring, can be done in one hour of surgery, and there is minimal recovery. Because of its effectiveness and skin tightening potential, I prefer to use laser or Smartlipo as the liposuction method. Men can return to full chest exercises in two weeks.
Dr. Barry Eppley
Q: I had a car accident in February 2009 that resulted in the need for big operation on my stomach. This has left me with a long big scar. I want to know what percent of it can be removed? I want to remove this scar for me because don’t want to get naked in front of my husband or any person because of the scar. It is so bad that I cry a lot about it as I picture how good my stomach looked before the accident. I am 23 years old, been married two years and have no kids.
A: Scar revision is about scar reduction, not scar elimination. While I wish as a plastic surgeon I could wipe them away for patients, that is not currently possible. Therefore, the judgment about the merits of scar revision are about the degree of improvement. Is the result worthy of the efforts is the consistent question about scar revision.
The answer as to whether scar revision is meritorious for any patient lies in the physical characteristics of the particular scar. There are several features of scars that can be consistently improved by surgical methods. Scars that have surface texture problems such as being wide, raised (hypertrophic), or depressed (indented) are good candidates. These type scars can be cut out and reclosed in a variety of ways whose objective is to make them flatter and narrower. Scar features that are difficult or impossible to improve include lack of pigment (normal skin color) and visible flat narrow scars.
Without even seeing a picture of the scar on this patient, one can be fairly certain that it is a wide vertical scar running down the middle of her stomach area. Such scars often get quite wide and indented as they have healed. Scar reduction can most certainly be done with the goal of making a much narrower and flatter scar. While that will not make it invisible, it will provide at least a 50% or greater degree of improvement.
Dr. Barry Eppley
Q: I am a male and am interested in the direct neck lift and want to know more about it. I don’t want a complete lift and think this may be my answer. How much of a scar remains visible and will it last a long time. Also, do you tighten the muscles and remove some of the fat?
A: The direct necklift is an alternative to a facelift for a select number of men and women that are interested in getting rid of their neck wattle. A facelift works out excess neck and jowl tissues by chasing them back towards the ears and placing the scars there. A direct necklift cuts out the neck wattle directly, placing the scar right down the middle of the neck. It is a highly effective procedure that produces neck results that are just as good, if not better, than what a facelift can do particularly in men.
In the direct necklift, not only is skin removed but fat and muscle tissues are changed as well. With the skin cutout, the underlying fat is removed as well right down to the muscle. The split platysma muscle is widely exposed with the overlying tissue removed. Because of the excellent visibility, it can be sewn together from under the chin right down to the thyroid cartilage with superb tightening achieved.
The direct necklift is not for everyone but for just a select few patients. In my Indianapolis plastic surgery practice, I reserve it primarily for older men (55 years and older) who either do not want to undergo a facelift or have a very poor hair pattern and density around their ears. The occasional woman is done but they are almost universally 65 years and older and are choosing the direct necklift vs a facelift because of its lower cost.
The obvious issue with a direct necklift is the scar. Generally these scars are quite thin and the only widening that occurs in them is in the middle of the neck where the tension is the highest. For this reason, I usually place a z-plasty scar orientation in this area to avoid hypertrophic scarring there. I have performed no scar revisions on them to date which speaks to patient acceptance of their final aesthetic appearance.
Dr. Barry Eppley
Q : I have a weak chin that has bothered me my whole life. I am so self-conscious that I turn away so people can not see me in profile. I also think my entire jawline is weak, it overall looks too small for the rest of my face. Can my jawline be improved with different types of implants?
A: Historically, most people think of jaw enhancement as that of the chin only. Chin implants have been around for over fifty years and have evolved today to include a wide variety of different chin styles and sizes. For horizontal jaw shortness, a chin implant can provide a simple, quick and permanent method of significant profile improvement.
Today, jaw enhancement has progressed to consider changes along the entire jawline from back to front. Besides chin implants, the use of implants to accentuate the jaw angle have become popular. Designed to increase the width of the jaw (and some designs will lower the jaw angle as well), they increase bigonial width and create a stronger and more masculine.
Chin implants are most commonly done as a stand alone facial augmentation procedure. Jaw angle implants can also be done by themselves if an adequately projecting chin already exists. For cases of an overall weak lower jaw, the combination of chin and jaw angle implants together can make for a more dramatic change in jawline appearance. This combination (the ‘jawline trifecta’) is increasingly popular for those men who have a congenitally shorter jaw or for those want to make a stronger jawline out of an otherwise normal sized one.
Dr. Barry Eppley
Q: I have a rib graft on the bridge of my nose which I would love to have removed. The surgery to place it was 12 years ago. At the time, the doctor thought my nose would be better off with the bridge higher. I liked my bridge before the rib graft. Is it possible to remove this graft? Is there any hope for me because I also dislike how it feels, not to mention how it looks which is not good?
A: Rib grafts to the nose are usually done for dorsal augmentation (building up the bridge, the distance between the top of the nose and the tip) secondary to prior trauma or rhinoplasty surgery or for altering certain ethnic noses. Whether dorsal augmentation is aesthetically beneficial, like all rhinoplasty changes, can be determined prior to surgery with computer imaging. The harvest of a rib graft and changing the dorsal line of the nose is not an insignificant adventure and everyone needs to be sure that it is a worthwhile procedure.
I have not found most rib grafts that hard to remove or manipulate in my experience, provided that they are completely composed of cartilage and are limited in location to the nasal bones and middle vault. Cartilage grafts to the dorsum, while wonderfully biocompatible, heal with a surrounding capsule and never truly integrate into the underlying structures like a bone graft would to bone. As a result, they can be usually be removed without as much difficulty as one would think.
The exceptions that make removal more difficult is if the rib graft was more bone than cartilage (which it usually isn’t) or if it was an L- strut configuration extending around the tip and down along the columella. It is not that the removal is that much more difficult, it is that it is more destructive to do. (more of the nose has to be taken apart to do it)
The description of a rib graft to the bridge of the nose done for aesthetic purposes suggests two things. The graft is small and probably all cartilage and that its location is just to the dorsal line of the nose. Both of these qualifiers would indicate that’s its removal is both possible and minimally destructive. Its removal, however, should be done through an open rhinoplasty approach even though it may have been placed initially through a closed or endonasal incision.
Dr. Barry Eppley
Q : Is umbilicoplasty recommended only after you’re done having children? I heard the procedure could be ruined during pregnancy.
A: As a general rule, changing the shape or form of the umbilicus (belly button) is a simple procedure that is usually permanent. However, pregnancy is well known to affect the umbilicus due to its expanding effects. The usual way it can change the umbilicus is to convert an ‘innie’ to an ‘outie’. This is the result of an actual hernia coming through where the umbilicus attaches to the abdominal muscle wall. One must remember that the umbilicus is really nothing more than a scar that goes all the way through to the underside of the muscle wall to the peritoneum. This can be appreciated during a mini-abdominoplasty where the umbilicus is often released and repositioned lower. Once it is cut off at the level of the abdominal wall, a small hernia is immediately apparent.
Because of the potential negative effects of pregnancy on the umbilicus, one should usually wait until after pregnancy for a female umbilicoplasty procedure. If you are converting an outie to an inner, it is possible with the increased abdominal pressure from pregnancy to have it change back to an outie after surgery. The one exception to this id if one is not planning to get pregnant for years. Adequate healing and scarring will then have occurred and it will be able to better resist stretching forces. But if one thinks it is possible to get pregnant within the first year after repair, then one is better to wait.
There are some umbilical changes that may be not be so adversely affected by pregnancy. Removal of skin tags, small scars, nevi, and a ‘pseudoinnie’ (looks like a partial outie but is just a lump of scar tissue) can be done with a low risk of post-pregnancy change.
Dr. Barry Eppley
Q: Hello sir, I did my first rhinoplasty for a minor problem. Initially I had a thin and pointed nose but overall it was not too bad looking. I went to this inexperienced surgeon because me or my parents didn’t know anything about surgery at that time. He made my nose shorter with a round tip and I got very bad dark circles under my eyes for a year. My nose is still short, fat and twisted. After three years, I have gotten the courage to consider another rhinoplasty surgery to make it look better. What do you recommend to be done?
A: Most likely what has happened is a fundamental problem that is reminiscent of rhinoplasty from days of old…removal of too much cartilage structure. This results in collapse of the nasal tip due to loss of support as well as wound contracture. Almost certainly, this rhinoplasty was done through an endonasal approach where removal is what can largely be achieved. Only the real masters of rhinoplasty can do significant restructuring that has predictable outcomes through the limited access of the endonasal approach.
For a revisional rhinoplasty such as this, the open approach needs to be done. The tip cartilages and nasal septum can be separated, cartilage grafts placed and reshaping done through suture techniques. It may also only require an onlay cartilage graft but that must be precisely placed. Only the open approach offers this degree of visibility. The cartilage grafts will likely come from the ear (conchal) due to the size and shape needed.
At three years from the initial surgery, the nasal tissues are more than soft enough to allow for good manipulation and healing.
Recovery from the short nose problem in revisional rhinoplasty is usually quite good, but access and cartilage grafting are the keys.
Dr. Barry Eppley
Q: I am interested in getting breast implants. I am 34 years old, have had three children and my breasts are just not what they used to be. They are smaller and now droop. They are disgusting to look at and are nothing like they used to be when they were nice C cups and round. I want to get implants so my breasts can look like they did before. Is this possible?
A: The concept of looking like you did before is an understandable one but may not always be possible. The reason is that the breast skin and breast tissue you now have is different than what it used to be.
Women considering breast augmentation almost always fall into two main types; those who have always had little breast tissue whether they have ever been pregnant or not (type 1)…and those women who have lost their natural breasts and have developed droopy smaller breasts due to childbearing and nursing. (type 2) The results of placing a breast implant will be different for each type of patient. Type 1 patients will do fine with a breast implant alone and will often get the more ideal breast shape result. Type 2 patients may need a breast lift in addition to an implant to get a better shape with a good nipple position. It is this consideration of a lift and breast mound scarring that will often catch the Type 2 patient by surprise.
It is important to appreciate what a breast implant can and can not do. Implants do a superb job of making the breast mound bigger. But they have very little ‘lifting’ ability. The only lift effect that can occur is from inflation of the breast mound and this will move the nipple up a little. The operative word here is…a little. Significant movement upward of the nipple for most breast ptosis patients is a matter of at least several centimeters, not millimiters.
Dr. Barry Eppley
Q : I am 52 years of age and my upper lip seems to be getting longer. When I was younger my upper lip didn’t seem to be as long. When I smile I barely show any upper teeth at all anymore. Is there some form of lip surgery that can help me?
A: A long upper lip can develop in some patients due to the natural process of aging. The upper lip can literally lengthen due to shrinkage of the vermilion (pink portion of the lip) which gets smaller and actually rolls inward. These age changes of the lip can be accentuated by tooth loss. Loss of lip volume combined with other falling facial features makes the skin portion (between the base of the nose and the vermilion) of the upper lip a bigger percentage of upper lip length.
There are two specific procedures for shortening the upper lip. Both involve removing skin in a horizontal fashion at either the top or bottom skin portion of the lip. The subnasal lip lift, also known as the bullhorn lip lift, removes skin from right under the nose and truly is a lifting procedure. Removing skin just above the pink lip line is known as a vermilion or lip advancement. This advances the pink part upward directly. Both result in fine line scars although the subnasal lip lift places the scar in a more hidden location in the crease under the nose.
While both of these procedures are effective at creating a slightly shorter upper lip, both will increase the amount of vermilion show. The subnasal lip lift is limited to increasing only the central pout of the upper lip with lip shortening. The vermilion advancement moves the entire pink portion upward from one corner of the mouth to the other.
Which procedure is best for any patient depends on the anatomy of their upper lip, specifically the shape and thickness of the vermilion.
Dr. Barry Eppley
Q: My boyfriend is concerned about the size of his areolas. Do you offer areola reduction surgery? He is very interested because he feels his nipples stick out too far and his areolas are too wide. They stick out when he is in t-shirts and some clothes.
A: The nipple and areola, known in plastic surgery as the nipple-areolar complex, is a two-tiered structure. Surrounding a central protruding and darker pigmented nipple, the areola is flat and much larger in diameter. The size of this complex can be quite variable with significant amounts of nipple protrusion and very wide areolas. But the extent of these variations is largely in women since this is a functioning gland that changes as a result of pregnancy. Men rarely show such variations in size as it serves no functional purpose.
Todays’ fashion and styles, however, have placed a little more focus on the nipple-areolar complex. Men do not like when their nipple protrudes through clothing and, rarely, a few men feel that their areola is too wide. Most wider areolar concerns are in patients with gynecomastia where the breast is also larger. But wide areolas can occur when gynecomastia is not present. In women, the typical areolar diameter measurement is around 38 to 45 mms. In men, those numbers are usually half those amounts.
Both nipple and areolar reductions are simple procedures. The nipple protrusion can be flattened by a simple wedge excision without any visible scarring. The areolar diameter can be narrowed by a circumareolar excision. This does leave a fine line scar at the junction of the areolar and skin. Both can be done under local anesthesia in an office setting.
Dr. Barry Eppley
Q: I had rhinoplasty over one year ago for a small bump on my nose and a tip that I thought was too wide. While it looked absolutely perfect for a few months, an indented area on the right side of the bridge of the nose appeared. When I brought this to the attention of the plastic surgeon, he told me to let it continue to heal and wait and see what it looks like at one year after surgery. I just saw him earlier this week and, although that indent is still there, he said it is not worth trying to improve it and I should just live with it since the rest of the nose looks fine. Do I have any other options at this point?
A: Like all forms of plastic surgery, the risk of a less than perfect result afterwards always exists. Rhinoplasty surgery is no exception and secondary aesthetic deformities are not uncommon. The risk of the need for revisional surgery in rhinoplasty is estimated by some to be 10% to 15%, although that risk varies based on the difficulty of the initial nose problem.
In my Indianapolis plastic surgery experience, I find that the dorsum or bridge of the nose is one of the most common areas where irregularities can eventually appear. It is the least precise area in rhinoplasty because it is the least visible and involves bone edges. Because of small amounts of persistent swelling and the months that it takes for the skin of the nose to shrink back down and adapt to the modified underlying bone and cartilage framework, any asymmetries of the bridge area will usually take three to six months after surgery until they become visible.
The recommendation to wait until one year after rhinoplasty before considering revision is generally a sound one. The reason is two-fold. First, you want to be sure that the area that needs to be improved is a ‘stable target’ so to speak. Because of the length of time it takes for all of the swelling of the nose to go away, operating too early may underestimate what needs to be done. Secondly, the nose needs to soften up so that dissection is easier once the scar tissue has settled down. While this is usually one year or so after surgery, a better estimate is how the nose feels. If it is still stiff, it is too early. It should feel soft and flexible again for the best revisional results.
Dorsal irregularities may only need to filed or rasped to smooth out a rough edge, but often indentations require some form of graft augmentation. Many graft options exist but I prefer diced cartilage because it is both a natural and easily moldeable augmentation material.
Dr. Barry Eppley
Q: I am a 23 year-old graduate student and former college athlete. My breasts are so large I am miserable all the time and can’t even run anymore. I wear a 36DDD bra and this puts too much strain on my body. My shoulders hurt all the time. I have been in physical therapy for my neck and back, have migraine headaches and asthma. I am 5’ 10 and weigh 190 lbs. Will insurance pay for my breast reduction?
A: Breast reduction surgery is commonly covered by insurance but not always. There are certain very specific qualifications that all health insurances require that a patient must meet to be eligible. These include being within 20% to 25% of their ideal body weight (not being too overweight), having a documented history of physical therapy or chiropractic treatments for three months that did not result in sustained pain relief (emphasis on being documented), failing other non-surgical therapies such as anti-inflammatory drugs and support bras (all patients meet these criteria), and having your plastic surgeon document the specific amount of grams that will be removed that meets the minimum amount based on your body surface area calculations. (estimated by your plastic surgeon) All of this information will be put in a letter by your consulting plastic surgeon and sent in with photographs of your breasts to your insurance carrier for their determination.
Generally, if all of these criteria are met a patient will be approved for breast reduction surgery. The most common reasons patients are rejected coverage is because they weight too much for their height, have not tried some form of physical therapy, or not enough grams of breast tissue are estimated to be removed. (in this patient based on height and weight, the BSA is 2.05 with a requirement of at least 1,000 grams removed per breast)
While any amount of breast reduction provides relief in all patients, and a patient’s weight or amount of breast tissue to be removed has not been proven to matter for pain symptom relief), these are the insurance criteria. Debating their merits with the insurance company is not a productive endeavor.
In patients where insurance coverage has been denied, breast reduction surgery can always be done on a fee-for-service basis. Your consulting plastic surgeon will be happy to provide you with a cost estimate.
Dr. Barry Eppley
Q: Hi. As a baby/kid I had misaligned teeth due to sucking my thumb. I sucked my thumb pretty much up to 15 years old or so. At about 15 years old I went to the orthodontist to get braces. He decided along with the braces to install this thing in my mouth called a “herbst appliance”. Cant find anything about on Google. Maybe it was to push up my chin due to my some what recessed chin due to sucking my thumb? I finally got all the stuff out of my mouth removed last summer. I was always a little self conscious about my jaw line , but the past couple of months i’ve started to notice tremendous asymmetry between the right and left side of my jaw. The right side looks like I have a Brad Pitt Jaw and the left side is nothing, barely a jaw line showing. I’m tremendously discomforted inside due to the straight forward appearance of my face shich is crooked. What can I do to address and fix this problem?
A: Undoubtably what you originally had was a short lower jaw or mandible. In an effort to help the lower jaw grow during your early teen years, the orthodontist put in a growth stimulting appliance for the lower jaw, known as the Herbst appliance to which you refer. It is a well known device that has been used for several decades now. Now that the device has been removed and you at are the end of your facial growth, the final position and shape of the mandible can now be seen.
When looking at facial symmetry from the front view, the important issues on the centric position of the chin and the amount of flare of the jaw angles. These three points give the visual impression of the overall jawline appearance. When one has jaw asymmetry, provided that the teeth are in a good bite relationship, manipulation of these three points can be surgically done.
The chin can be adjusted with an implant or an osteotomy. The jaw angles can be accentuated and lowered through implants. Any combination of these numerous options exist. Which one(s) or combinations can only be determined through photographs of your face, a panorex x-ray, and computer image manipulation of proposed changes.
Between chin and jaw angle surgery, a tremendous improvment can usually be obtained and a much more symmetric and pleasing jawline can be realized.
Dr. Barry Eppley
Q: Hello, I have a few questions.I’m interested in getting my leftover fat from my entire body put into my boobs. I’d like to get my bmi to be just at 18, although it is at a 20 right now. I was just wondering if anyone would be willing to even work with me since I weigh around 115 and am 5’3″.
A: Breast augmentation using injectable fat rather than a synthetic implant remains in an ‘experimental’ or an investigative phase currently. Since it does not involve an implant and uses your own natural tissue, it is understandable to think that it is a safer and perhaps better procedure.
While fat may be natural, it is not a predictable implant material particularly in the volumes needed for breast augmentation. No standard techniques exist for fat preparation or injection methods and very different results can occur in various hands. At the least, much if not all of the fat can be absorbed rendering it a waste of time. At the worst, the fat may make the breast lumpy with cyst formations or develop sterile pools of liquid fat. What impact fat injections have on mammogram imaging and breast cancer detection remains unknown and not studied.
While much of this discussion sounds negative, the concept of using fat for breast augmentation has appeal and work is ongoing in this area. The only FDA-approved clinical trial that I know of is with the BRAVA system in which injectable fat is stimulated after surgery with an external low-level suction device. Otherwise, any clinical work that is being done is occurring in an independent fashion as an individual-precribed surgery amongst a handful of practitioners.
With the low BMI and body fat that this patient has, she would not be a good candidate for the procedure even if it was proven and widely used. A simple breast implant is so much easier and more predictable that fat injections, which for now, remain as a more complicated and morbid approach for breast augmentation.
Dr. Barry Eppley
Identity theft is a growing problem that now threatens just about everyone, even if you don’t spend a lot of time online. It is a huge problem with risks that are estimated to place most Americans as having a 1 in 4 chance of being victimized in the next five years. With credit card and social security numbers flying around in cyberspace by the billions, it is a wonder that those risks are not even higher.
Plastic surgery faces its own identity theft problem but of a different nature. In the most noteworthy case of plastic surgery identity theft to date, an American in the Middle East was recently arrested posing as a renowned U.S. plastic surgeon. Shockingly, he had operated on scores of patients in his Dubai villa. There he allegedly performed numerous cosmetic surgery procedures with primitive surgical equipment and lack of any sterile conditions. To no surprise, several of his patients (victims) have suffered serious complications requiring additional surgery and medical care.
This former Oregon physician was impersonating and using the good reputation of a plastic surgeon in Washington, D.C. who performs several surgeries per year at the American Academy of Cosmetic Surgery Hospital in Dubai. Aside from facing legal charges in Dubai, this fake plastic surgeon is wanted in the U.S. by the FBI and Interpol on charges of drug trafficking and numerous other crimes from when he held a medical license in Oregon.
While this identity theft story seems remote and far from the American medical scene, plastic surgery identity theft occurs more regularly here…but it is of a more subtle and insidious nature. With the ongoing erosion of medical fee reimbursements and increasing practice revenues and regulation demands (which is only going to continue to worsen, particularly with the passage of the new Health Care Reform Act), some physicians search for methods of cash only services. No seemingly ‘riper fruit’ currently exists than that of cosmetic services. (although weight loss is a close second) Between public interest and the all-to-willing drug and device manufacturers to sell to anyone with a medical license and a credit card, there is a dearth of cosmetic surgery providers with quite dissimilar education and training backgrounds.
While many of these cosmetic surgery ‘adopters’ are largely involved in office-based injection and laser treatments, some perform invasive surgery which is within their legal right as a licensed physician. As long as you hold a valid medical license, you can do almost anything in your office which is largely unregulated unlike a hospital or surgery center. A great illustration of this phenomenon can be read in the April 7th issue of The New York Times where a California physician (non-plastic surgeon) was interviewed touting his breast augmentation surgery technique under local anesthesia. Claiming that patients can now have a say in the breast implant selection process, he teaches weekend courses to physicians of any background (the articles states mainly family practice and Ob-Gyn docs) who are willing to pay.
The argument that women want to be awake and watch their surgery being performed is fundamentally flawed. I know of no female patients who want to sign up for that experience. But the underlying premise for such surgery under local anesthesia was not revealed in the article. Without proper training and credentials, an uunregulated office environment is the only place he could ever perform such procedures. And without an anesthesiologist, the only option is local anesthesia. Hardly good reasons for choosing a surgical method or even offering the procedure.
Dr. Barry Eppley
Q: I have a fat nose and would like it to look slimmer. It doesn’t seem to fit the rest of my face which is actually very thin. But I don’t want to have my nose broken as I like the rest of it. Are there different types of rhinoplasty surgeries?
A: Like all operations in plastic surgery, it is important to tailor it to the specifics of the problem. Most plastic surgery procedures do not use a ‘cookie-cutter’ approach but modify certain details of the operation to a patient’s specific needs. Rhinoplasty surgery is the pinnacle of this philosophy as every nose surgery is uniquely different.
Despite the many variations of rhinoplasty, they can be divided into two main types, a mini- or tip rhinoplasty and a full rhinoplasty. The fundamental difference between the two is that a full rhinoplasty treats all three sections of the nose, often breaking the nose bones (upper third) to narrow them. A tip rhinoplasty treats only the lower one-third which consists of a paired set of cartilages which meet in the middle to create the tip of the nose.
When one has a fat or wide nose, it is because the cartilages in the tip of the nose are big and protrusive and often don’t quite meet in the middle. Through a tip rhinoplasty, these cartilages can be reduced in size, reshaped and brought closer together. Using suture techniques, a remarkable change in the nose tip can be done making it thinner and more in proportion to the rest of the nose.
Dr. Barry Eppley
Everyone knows the phrase…’beauty is skin deep but ugly goes to the bone’. While commonly said, this phrase is only partially correct. Beauty is also bone deep as the outward appearance of the face begins down at this foundational level. How the face looks at the outside has a lot to do with how it is shaped on the inside. Any forensic scientist can attest to it. Many have seen on TV shows how an unidentified corpse’s face is ‘rebuilt’ with clay layers on top of the skull and facial bones based on established soft tissue measurements. Like a roof on a house, the outer appearance of the face is highly influenced by the shape of the bone underneath it.
Treating facial bone problems has a long history in plastic surgery. Since World War I, when trench warfare created a large number of severe facial injuries (sticking your head up out of a trench was usually not a good idea), plastic surgeons have been rebuilding, rearranging, and enhancing facial bones. Today’s plastic surgeons pay particular attention in cosmetic surgery to how the skin, fat and muscle of the face redrapes over the bones, knowing full well its influence on the final shape. Whether it is a facelift, nose job,or making one’s face more masculine, being aware of and changing the shape of the bone can lead to a better balanced and more attractive face.
Facial bone changes can be done by building the bone up with synthetic implants, or in some cases, actually moving select facial bones themselves. A remarkable array of changes in the forehead, nose, cheeks, midface, lower jaw and chin are now possible.
Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you down deep inside the face on a tour of its palpable architecture. Learn how many of the commonly known, and some less commonly known, cosmetic facial bone procedures work and help make for more beautiful faces.
INSIGHTS FROM ‘BEHIND THE NEEDLE’
In the past, plastic surgery was all about having operations to reverse the effects of aging on the face. Time was, once you could no longer stand to see yourself in the mirror or in pictures…facelifts, eye tucks and the like became appealing with all of the associated swelling and bruising, recovery, and expense.
Over the past ten years, non-surgical injectable treatments have become popular for men and women of all ages…and have become part of mainstream society in ways that rival Starbucks, energy drinks, and iPhones. The concepts of muscle paralysis, plumping fillers, and fat dissolving agents have made it possible to have smooth foreheads, fuller lips and softer laugh lines, and maybe some subtle tightening of the jowls and neck in a few simple visits to the doctor’s office. Unlike surgery, injectable facial treatments are as much about the prevention of the effects of aging as they are about reversing what has already taken place.
Along with this explosion of available injectable treatments have come the inevitable, unbelievable marketing claims, and so-called ‘expert’ injectors. But, like much of what you may read on the internet, in popular magazines, and hear in commercials , what can you really believe? How do you separate reality from marketing hype? How can you decide where-or if-injectable treatments are for you? And if so, which ones??
Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a broad tour of every injectable treatment option. Providing insight into Botox®, the many injectable fillers, and lipodissolve, Dr. Eppley provides the current science behind the treatments, and talks plainly about his experience and observations. These insights from ‘behind the needle’ about these incredibly popular injectable treatments are available nowhere else.
Whether you are just researching Botox® or fillers, or are a seasoned expert with an upcoming consultation about the next new option, Dr. Eppley gets you ready for Injecting Youth!
Q: I have developed brown spots on my legs and I hate them. They seem to be growing and getting more of them as I get older. What can be done for them?
A: When patients use the term, ‘brown spots’, that can be referring to a variety of colored or pigmented skin conditions. Most commonly, these can be sun or age spots where an excess pigment reaction develops in the upper most layer of the skin. These brown spots are flat in appearance. Other brown spot conditions could be keratoses or thickening of the outer skin layer which appear as raised and rough textured skin areas. These are known as keratoses. Occasionally patients may also be referring to more congenital light-colored brown areas known as cafe-au-lait spots or patches.
The success of brown spot removal depends on what type they are and what your ethnicity is. For flat brown spots as a result of sun and aging, broad band light (BBL) therapies (also known as intense pulsed light or IPL) can be very effective. This is a simple office that can significantly reduce them in or two visits. Raised brown areas like keratoses, however, do not respond to light therapies and require scalpel shaving. congenital birth marks such as café-au-laut spots can not be removed without leaving a lot of scarring and they are best left alone.
In dark-skinned patients (Asians, Hispanics, or African-Americans,) all such treatments could result in potential loss of pigment. This could create the look of white patches which may not be a good trade-off. The treatment of brown or dark patch areas should be approached with caution in darker pigmented patients and often are better left alone.
Q: I wrestled throughout high school and college and this has left me with both ears that are deformed. I am very interested in corrective surgery to both reduce their scarred appearance and gain better symmetry between them.
A: A very uncommon ear problem, while not unique to just wrestlers, is that of the ‘cauliflower ear’. So named because of its appearance, the cauliflower ear appears as raised hard irregular areas that cause the ear to become misshapen. Because these deformities can occur anywhere on the ear but the earlobe, it is the cartilage that is the source of the problem.
When the ear is traumatized, bleeding can occur under the covering of the ear cartilage known as perichondrium. This can particularly occur from shearing or severe rubbing forces on the ear. Blood is a stimulant for the perichondrium to form new cartilage. So wherever there is bleeding, cartilage nodules can form and grow distorting the very detailed hills and valleys that give the ear its form. When this occurs repeatedly (as in a wrestler), eventually the whole ear can become one knarled mass.
The cauliflower ear can be treated by cartilage removal and reshaping it as close as possible to its original form. To do this procedure, the skin must be carefully lifted off over the deformed areas. This requires an incision which can be placed on either side of the ear (front or back) depending upon the location of the excess cartilage. The key to the success of the operation is placing the skin back down and having it heal without forming new cartilage and allowing the new shape to be seen and maintained. This is done by placing a special dressing called bolsters onto the ear to keep pressure on the healing skin. These are removed one week after the ear reconstructive surgery.
Dr. Barry Eppley
Q: I am interested in the direct neck lift and want to know more about it. I dont want a complete lift and think this may be my answer. How much of a scar remains visable and will it last a long time? Do you tighten the musles and remove some of the fat during the procedure?
A: A low hanging neck, or wattle as it is sometimes unaffectionately called, is a concern for both male and female patients particularly as they get older than 55 or 60 years of age. The traditional and most method of treating these neck concerns is a conventional facelift. In this procedure, the loose neck skin is moved back from the central part of the neck up and backwards and then trimmed off, putting the scar in a near invisible location in and around the ears.
When one doesn’t want to go through a facelift procedure, due to either lack of good hair around the ears or the expense and recovery, the direct necklift may be a reasonable alternative option. Because it cuts the wattle out directly, it leaves a vertical scar running down from under the chin to just below the adam’s apple. Both skin and underlying fat is removed and the platysma muscle is also tightened, which is both easy and very effective due to the wide open exposure. It is a simple operation with very little recovery, minimal swelling and bruising and virtually no pain other than some neck tightness.
The issue is the scar which is why it is not for everyone with a neck wattle, particularly younger patients and most women. It is largely an older male procedure as many men do not have good hairlines and are interested in going through a smaller less drastic procedure. Neck scars in men tend to do fairly well as they have thicker beard skin and do an unintentional but helpful scar treatment daily, known as shaving or microdermabrasion. But for the right older female who has less of a scar concern, it can make a dramatic neck difference.
The scar down the neck can be done several ways, either as a straight line, a straight line with a central Z, or a running w line. (like a pinking shear cut) I have used them all and the choice of which scar pattern is used is based on skin quality and the tightness of the closure. Most scars will become fine white lines that are very acceptable. Scar revision is always possible also but is not commonly needed in my experience.
Dr. Barry Eppley
Q: I am a transgender patient and I am looking for information regarding facial feminization surgery. I am interested in getting some work done. I think I may need full facial feminization surgery.
A: One of the most important transformations that a transgender patient needs to make is in facial appearance. The potential to be seen and accepted socially as a female is of major physical importance. There are numerous facial changes that can be done, most prominently brow reshaping, rhinoplasty, cheek enhancement, and jawline contouring. These are changes in the support structure of the face that can change the gestalt of sexual orientation. Soft tissues changes such as blepharoplasty, canthoplasty, lip augmentation and shaping, and facelifting are complements to structure changes but, in and of themselves, are not primary facial feminization changes. The prominent adam’s apple (thyroid cartilages) is the lone non-facial feature whose reduction makes for a softer more feminine neck profile.
In considering facial feminization surgery (FFS), there is no standard set of procedures that works for everyone. The total face must be taken into consideration and changes selected that will make for the greatest improvement in appearance. Some patients may benefit by only two or three while others may get half a dozen or more. In considering what changes may work, computer imaging can be very helpful. Such imaging is not a guarantee of outcome but a method of communication and education about useful possibilities.
Whatever changes are selected, it is best to do the whole package in a single operation. The recovery may be longer but a one-time commitment for ‘changing face’ is better psychologically.
Dr. Barry Eppley
Q: I had cancer in the parotid gland and it was removed with a neck dissection which left a deep horrible scar from the back of my right ear to the middle of my neck. The scar is mostly flat except when it gets close to the adam’s apple where it gets really wide. The scar is 4 years old and is still tender. I really hate it and it takes away from my appearance. One doctor did injections which didn’t really help it.
A: While any scar can be cut out and reclosed by different methods (scar revision), the question is always whether it would be beneficial or not. There are four features of scars that only surgical treatment can improve. Scars that are wide, depressed, raised (hypertrophic or keloid) or contracted (painful and movement restrictive) are very likely to be improved by getting rid of the bad (complete scar) and replacing it by moving your own unscarred tissue in its place. This neck scar has several of those features including being years old which means it is mature and no further improvement in its appearance or feeling can be expected.
Tumor excision in the neck with removal of lymph nodes (neck dissection) will leave a long scar that traverses the neck from around the ear to across the adam’s apple in many cases. While most of the scar should lie in a very favorable horizontal skin crease, portions of the scar may not. It is these areas in particular that often end up as a wide and distorted scar. Many patients with this type of surgery have also had radiation which may be another reason why it resulted in poor scarring.
Much of this scar can simply be cut out and reclosed along the skin line which it currently lies. But near and around the adam’s apple, re-orientation of the scar through a z-plasty will relieve the tension on it and allow it to heal with less distortion and be closer to a fine line in width.
Dr. Barry Eppley
Q: I want to get implants to have higher looking cheekbones. What is the difference between malar and submalar cheek implants? Which would be better for me?
A: In considering cheek augmentation, or enhancement of the midface, there are a wide variety of cheek implant styles from which to choose. Gone are the days when only a single design of a cheek implant existed. One of the different style designs is between malar and submalar implants. Malar is another word meaning cheek. So a malar implant sits on top of the existing cheekbone, providing more cheek projection. A submalar implant, however, sites on the cheekbone’s bottom edge providing increased fullness to the area below the cheekbone.
Submalar cheek implants have actually been around for some time and were developed to help with midface sagging from aging. As we age, cheek tissue slides or falls off of the cheekbone. One way to help lift it and restore more youthful fullness is with the submalar implant. The other option would be a midface lift, a more extensive operation with an increased risk of complications.
When most patients are considering cheek enhancement, they are usually thinking of higher cheekbones and more fullness to the bone right beneath the eye. Cheek implants come in a variety of designs to achieve this fullness and they differ in whether the most fullness in the implant is anterior, central, or posterior along the cheekbone. To choose the best implant style for you, you need to go over carefully with your plastic surgeon your exact concerns and what areas of the cheek you would like to be bigger. Most dissatisfaction with cheek implants occur because of style and size selections.
Dr. Barry Eppley
The eyes may be the window to the soul, but they also create a strong impression of how we look. So many people comment to and about others based on how their eyes look. We all have had the experience of someone asking us if we are tired or have been up late. You can be certain their question is not probably based on how we were dressed or what we were eating.
But it is not the eyes per se that give these impressions, it is what is around them. The drapes of the eyes, the lids or window shades, are largely responsible for their appearance. Too much skin, deepening wrinkles, and bulging fat creates a tired and aging appearance. When combined with falling eyebrows, the amount of eye we see gets smaller and one really does look older. All this excess lid tissue is also prone to collect and retain fluid, hence those swollen eyes in the morning.
Because of the impact of how our eye area looks, eyelid surgery (blepharoplasty) is the best value in all of facial rejuvenation surgery. This is certainly true based on the size of the treated surface area. But more importantly, changing the look of the eyes does exactly what one is after…to look more refreshed. Few want to look different, but all want to look like themselves, only better.
While there are some non-surgical treatments that can make some areas around the eyes look better, none of them can improve the way the eyelids look. Botox can decrease wrinkling between the eyebrows and around the sides of the eyes, and that can be a great benefit for sure, but that affects expression only. If you look in the mirror without your face smiling or moving and your eyes still look tired, eyelid surgery is the only option.
By the way, forget about some magical cream making your eyelids look better. Amongst the many hundreds that exist, a few can make some minor reduction in fine wrinkles and puffiness. But really visible differences require removal of what makes them look that way, too much skin and fat.
While blepharoplasty surgery works on the lid skin, there are differences between what is done on the upper versus the lowers. The upper eyelids are largely about skin removal and re-creating an upper eyelid crease. Having a well defined eyelid crease is more important than trying to remove all excess skin. In the lower eyelid, more focus is on fat removal and skin tightening and making it as smooth as possible. There is no lower eyelid crease that needs to be made.
Many potential patients fear that blepharoplasty surgery will make them look unnatural. While this is possible if too much skin is removed from the eyelids, most overdone results come from browlifting not blepharoplasty. While browlifting can be a valuable addition to eyelid tucks, it is a procedure that is easily overdone. High eyebrows can easily change the appearance of the eye area and not favorably. Consider browlifting very carefully. It is not a cavalier addition to eyelid surgery.
If you are tired of looking tired, blepharoplasty may be a good choice to get a more youthful look back.
Dr. Barry Eppley
Plastic surgery continues to grow in popularity as evidenced by the statistics from the American Society of Plastic Surgery over the past decade. Surgical procedures as well as non-surgical cosmetic office treatments have increased every year since 2000. With the explosion of the internet and other communication mediums, a tremendous amount of information about plastic surgery is available at the click of a mouse from anywhere in the world.
But like much on the internet, news magazines, and product brochures, what can you believe? How do you separate reality from the marketing hype? How can you decide what are the best treatment options for your facial concerns?
Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a tour of facial plastic surgery. Covering dozens of the most popular cosmetic surgeries and treatments of the face, Dr. Eppley talks plainly about his experience and observations. From facelifts and nosejobs to injectable fillers, Dr. Eppley writes from his own extensive plastic surgery experience of the face, and provides insights into what many cosmetic procedures are, and what they actually do.
The desire to feel beautifully confident at any age is a natural one. Seeking plastic surgery ‘assistance’ is not vain or trivial. It is a major decision that requires forethought and preparation. Whether you are still considering if plastic surgery is right for your face, have an upcoming consultation with a plastic surgeon, or are planning a procedure in the future, Dr. Eppley prepares you to ask better questions and Face The Facts!
This book has been written to provide a basic education and awareness of the surgical specialty of Maxillofacial Surgery. It is not designed to be an all- inclusive text, but an outline of the terminology, anatomy, diagnosis, and treatment of the broad and complex array of maxillofacial and craniofacial problems. It is intended to serve as a pocket guide that is visually- oriented, can be quickly used as a reference, and read from cover to cover in a short period of time.
Maxillofacial surgery, a long-standing subspecialty of Plastic Surgery, had its beginnings in the early part of the 20th century during World War I when trench warfare created a large number of severe facial injuries. Their treatment required the development of an integrated approach of reconstructive surgery and dentistry which remains the guiding principles of Maxillofacial Surgery today. It has grown from its beginnings in facial trauma to include congenital cleft and craniofacial deformities, jaw surgery, reconstruction of extirpated tumor defects, to aesthetic facial surgery.
Maxillofacial surgery requires an understanding and assimilation of medical and dental principles involving anatomy, biomaterials, and manual dexterity. Surgical manipulation of facial anatomy is unforegiving in its visible outcome to the patient and society.
The specialty of Maxillofacial Surgery combines a knowledge base and techniques drawn from all of the head and neck disciplines with particular emphasis coming from plastic surgery. The field has expanded greatly over the latter half of the 20th century, led primarily by the interest and innovations established by the tenets of contemporary craniofacial surgery where maxillofacial surgery was expanded to the orbits, forehead, and the cranial cavity to make a better life possible for many congenitally deformed but intelligent human beings.
The specialty of Maxillofacial Surgery is designed to provide the highest standards of care for all surgery performed in the face and skull, whether it’s origin be of bone, soft tissue, or both. It can be difficult work in an anatomic area where many essential functional and aesthetic structures intermingle and proper training of the surgeon is paramount to achieve the desired end result, a patient with a more normal face and smile. It endeavors to achieve these aims through education, research, and awareness amongst the general public and medical field about the specialty. This handbook, in its own small way, is another brick for that building. May its reading provide insight into the astonishing work possible from Maxillofacial Surgery.
Dr. Barry Eppley
Q: I’ve lost about 90 lbs and now I have excess skin that hangs on my upper arms that I want to have fixed.
A: One of the many skin problems that develops after large amounts of weight loss is that of loose hanging arms. The skin on the back of the upper arm in the triceps area hangs down, creating what is often called ‘bat wings’. The excess skin frequently extends into the armpit (axillary) area and down into the side of the chest wall. Such large amounts of upper arm skin are a unique finding amongst extreme weight loss patients, particularly after bariatric surgery. Interestingly, this arm problem occurs overwhelmingly in women and not usually in men. (I have never performed an armlift in men) It may be that men’s skin shrinks down better after weight loss.
An armlift, known in plastic surgery as a brachioplasty, is an extremely effective procedure for reducing the size of the upper arms and getting rid of this loose floppy skin. While it accomplishes this result with the trade-off of a long arm scar, patients with this amount of loose arm skin consider that scar better than the excess skin. Armlifts are one of the most satisfying of all weight loss body contouring surgeries.
Armlifts traditionally have either placed the scar running down the middle of the inside of the arm or on the back of the arm. Recently, I am using a new technique during surgery that places the scar between the middle and the back of the arm with significantly better results. The scar is not only better hidden but the common postoperative wound healing problems that used to occur (particularly when using the inside of the arm location) have been largely eliminated.
Dr. Barry Eppley
Breast implants are a very common plastic surgery procedure that has not waned in popularity despite the recession. While they are unparalleled in making an instant body change, they have also make news for other interesting and unfortunate reasons. In the past year, these are the noteworthy breast implant stories you may not have read.
This week a California woman was sentenced to six months in jail and required to pay monetary reimbursement for ‘stealing’ breast implants as well as other cosmetic surgery back in 2008. Under an assumed name, the 30 year-old woman used a credit line in someone else’s name to obtain $12,000 in plastic surgery which included breast implants and liposuction at a plastic surgery center in Huntingdon Beach California. She pleaded guilty to burglary, grand theft and identity theft for using another woman’s personal information to obtain the surgery. How did she get caught you may ask? Police tracked her down using the serial numbers from her old implants, which she had removed when the new ones were put in.
In a similar scenario, but much more tragic, you may remember the murder of model Jasmine Fiore last August in California. The Playboy model mysteriously disappeared and was later found mutilated. With missing teeth and fingertips, she was initially unable to be identified as was the intent of the murderer. She was later identified by something her assailant had overlooked…literally…the serial numbers on her breast implants.
Proving that many criminals are dumb, most implantable medical devices today have serial numbers for tracking purposes as an FDA requirement. Usually the benefit of them on breast implants is for replacement and warranty reasons, but they also serve nicely as a human identification method that is more precise than fingerprints or dental records.
On a happier note, it was reported that a silicone breast implant saved the life of a California woman who was shot in the chest. A woman working in a Beverly Hills dental office last July was struck by a bullet after one of the employee’s estranged husband entered the office and killed her with a handgun. On exiting, the gunman ran into another employee and shot her in the chest. Unlike her co-worker, she miraculously survived. According to the Los Angeles Times, one of her breast implants stopped the bullet and prevented any fragments from getting as far as her heart. A physician who took care of her at the hospital stated that the bullet fragments were just millimeters from her heart.
A forearms expert was later quoted as saying that the breast implant probably slowed down the bullet enough that it caused it to stop short of the heart. While its an appealing story, that is not likely. A silicone gel or saline breast implant would not slow any bullet fired at close range. Breast implants have the stopping power similar to that of Jell-O. More likely her sternum or ribs was the reason that the bullet was deterred from going any deeper. The intervening breast implant, however, is happy no doubt to take the credit.
Breast augmentation and the implants needed to do them have weaved their way into the mainstream of American society, sometimes in ways not exactly as intended.
Dr. Barry Eppley
Published in 2003 with co-authors Dr. Peter Ward-Booth (United Kingdom) and Dr. Rainer Schmelzeisen (Germany), Dr. Eppley co-authored this now classic textbook entitled Maxillofacial Trauma and Esthetic Reconstruction. In a single volume, the comprehensive topic of the management of bone and soft tissue injuries to the face was done in just over 650 pages with 33 chapters and more than 500 color illustrations.
Bone and soft tissue facial trauma is one of the three major areas in the field of maxillofacial surgery. Having its origins in World War I and II from the last century where many facial injuries occurred, the need for specialized surgery methods for facial reconstruction began. It has now evolved into very sophisticated technologies for bone fixation and movement (plates and screws) as well as replacement of missing soft tissues. (pedicled and free flap transfers) The ‘high-rent’ district of the face allows the need for numerous medical specialities to participate including ophthalmology, neurosurgery, radiology, and dentistry in addition to the classic three surgical specialities of maxillofacial, plastic and otolaryngologic surgery. This book does an excellent job of bringing the knowledge base of all such disciplines together in a single concise volume.
One of the real strong points and emphasis in the book is what most facial trauma books historically lack, reconstruction of secondary facial defects. Despite the best surgical techniques and equipment, not all facial trauma patients end up with perfect results. Beyond simple lacerations and isolated bone fractures, the injury pattern of many facial trauma patients is complex and the best outcome will usually defy a single surgical effort. From scar revisions to occlusal discrepancies to soft tissue deficiences, secondary reconstruction of facial trauma is not rare and the book spends about as much time on those topics as that of primary repair.
This book is now undergoing a 2nd edition which should be forthcoming in the fall of 2011.