Your Questions
Your Questions
Q: Hello there… I was curious on whether you dabble in computer imaging for let’s say a jaw enhancement procedure. Thanks.
A: When considering structural facial alterations, as opposed to age-related changes, it is extremely important for the patient to have a reasonable idea as to what their face may look like. For this reason in my Indianapolis plastic surgery practice, I never do such facial surgery without computer imaging before surgery.
Several points about computer imaging, however, are important for patients to understand. First, facial computer imaging is a prediction but not a guarantee of results. It is the plastic surgeon’s best estimate of what he or she thinks may happen. But plastic surgery is not like Photoshop. How the body heals and responds to surgical manipulation of its tissues is not precisely predictable. Think of computer imaging as a communication tool primarily. It helps ensure that what the patient finds acceptable is surgically possible.
Secondly, the most predictable facial features to image are those that can be done in profile. With a contrast between flesh-colored skin and a solid color background, it is much easier to change the feature in a more precise manner. Therefore, procedures that change the brow (brow bone reduction), nose (rhinoplasty), chin (chin augmentation/reduction), and neck (liposuction, facelift, tracheal reduction) can be imaged with reasonable realistic accuracy. Certain frontal (face forward) structures can also be done, such as the ears and lips, but most of the face is this view do not have good color contrast between adjacent parts.
Last, if you can not get computer imaging for these types of facial plastic surgery procedures…go find another plastic surgeon.
Dr. Barry Eppley
Q: I have read about using my own fat as an injectable filler. This seems like a perfectly natural, and if I must say, an obvious thing to do to build up certain body areas. Is it not widely done however and several plastic surgeons that I have talked to either don’t do it or seem uncomfortable or unfamiliar with it. Is this because it doesn’t work well or is there something unsafe about it?
A: The concept of injectable fat grafting is in a state of development or evolution. Liposuction makes for an easy way to harvest an injectable natural material but its survival or retention after injection has been the issue. Using the fat suctioned from the body, technologies exist and are being developed to process the fat and extract and concentrate either the fat and/or the stem cells which naturally occur there. The concentrated fat with or without stem cell concentrate is then injected into the desired areas of the body or face.
Currently, more marketing than science exists about injectable fat grafting. Unfortunately, some surgeons actually tout that they have developed such a procedure and have ‘proprietary or special’ methods of their own to prepare an injectable fat concentrate. Multiple uses are being done from to facial or hand fillers. I have even read from some surgeon’s websites that their procedure ‘not only removes fat you don’t want, but it replaces it and changes multiple areas of your body, making for a more full-body change.’
The good news is that injecting your fat poses no harmful effects other than it may not work well. The less than good news is that some are claiming benefits that have yet to scientifically substantiated or proven. Injectable fat grafts holds great promise and, for small volume areas like the face and hands, does seem to be significantly retained. Good success has also been seen in the buttocks although multiple grafting sessions may be needed to get the best size result. Other areas, such as the breast, are purely investigational for now and are far from a replacement for implant augmentation.
Dr. Barry Eppley
Celebrities who undergo plastic surgery without question have a compelling influence on the general population, particularly those under the age of 40. One has to look no further than the checkout aisle in the grocery store to see how celebrity visibility is thrust upon us. From these consumer magazines to numerous television shows, anyone with a Hollywood connection is tracked and speculated upon about their cosmetic surgery, even if they have never had it. The media’s desire to push these cosmetic surgery tales of the stars fuels the public’s obsession with discovering the secrets to what keeps the beautiful and famous looking so.
While the star’s experiences may fascinate, they do little to actually educate. It is easy to confuse entertainment with reality because it is simply more interesting. Take the recent case of 23 year-old Heidi Mondag who had numerous cosmetic procedures done to satisfy her narcissistic and career agendas. While she may have had a lot of procedures, they were all quite small in scope. Most of her procedures were really ‘nip and tucks’ and not major overalls. After all, how many physical problems could a young person really have particularly given her appearance beforehand? But this is not how the media interpreted her surgery. Rather it was made to sound like it was a great undertaking and required supernormal surgical skills to complete.
These ‘tweakments’ are largely what is fueling the increasing visibility of plastic surgery. Botox, injectable fillers, lasers and minor skin lifts of the face have created a whole new set of treatment options that did not exist just a decade ago. While a 23 year-old partaking of this cosmetic menu does border on the overly self-indulgent, those in their late 30s and 40s have a more significant purpose. Fending back the early signs of aging is proving to be a more effective strategy than awaiting the day when major plastic surgery is needed. While my mother may have waited until retirement to wage the battle against the effects of time, today’s middle agers understandably what to look better and more rested now.
What is unique about these minimal procedures is that most of them are fueled and promoted by the cosmetic device and pharmaceutical industry. Plastic surgeons have taken a back seat to the promotions and marketing that billion-dollar-in-sales companies can do. The once retail approach to cosmetic and beauty products has expanded to include drugs and surgery. Targeting consumers through popular magazine and internet strategies, rebate coupons for Botox and eyelash stimulants are widely available as well as even franchise surgery for facelifts. Breast implant sizer kits are mailed to prospective patient’s homes with incentives for other procedures packed inside. Plastic surgeons collectively spend an insignificant fraction on marketing compared to that of the corporate world. This wave of industry’s promotion for profit and media attention for sales is why most people today know something about cosmetic enhancement and why it is now mainstream.
But like all entrepreneurial endeavors, making a profit and driving sales does produce some good byproducts that have wide benefit. Like the old commercial slogan from decades ago, there is ‘better living through modern chemistry’.
Dr. Barry Eppley
Q: Just wondering how common abdominal etching is amongst females. Most research online seems to be pointing to men only.
A: Abdominal etching is a plastic surgery procedure for the artificial creation of a ‘six-pack’ appearance. This is done through liposuction techniques by removing linear strips of subcutaneous fat to highlight where the muscular inscriptions would be. This creates indentations in the overlying skin which looks like muscular definition. It should only be considered in a fit individual whose has a limited fat thickness over the abdominal area. It not only works better in this type of patient but will also look more natural. I currently use a Smartlipo technique which has a 3mm wide probe and metal cover which creates nice thin tunnels with very small entrance incisions. The heat from the laser helps the skin contract down as well.
You are correct in that it is much more commonly requested and done in men. That undoubtably reflects our current cultural fashion standards where men are defined by their muscle mass and definition while women are better appreciated for their curves. (history also shows that this is true through the ages) In my Indianapolis plastic surgery practice for every 10 abdominal etchings I have done, nine are done in men. But I have done a few in women.
The surgical technique is the same in women and is actually a little easier to do with more consistent definition in my observation. This is likely due to the thinner subcutanous fat layer that exists in most athletic women.
Dr. Barry Eppley
Q: Hello, I wonder if you can help my son (19 year of age) who suffers from low self esteem due to the appearance of his head size since he started school. He has seen four psychologists and therapists to help him deal with his concerns. The problem is his head size which is too big. I know that nothing can be done to reduce the overall size of his skull but he also has very prominent brow bones which draws attention to his face making him more self conscious. Can anything be done about this?
A: Skull shape and size is one of the features of our appearance that we take for granted…unless it is too big or small and out proportion to the rest of the face. When the skull is bigger, a form of cosmetic macrocephaly, the sheer thickness and surface area of the bone make any reduction not practical to surgically consider.
It is not surprising that another part of the skull (brow bones) is big given the overall size of the skull. Changing something on the face that is likewise bigger and out of proportion as an alternative is a form of ‘camouflage’ and can be psychologically empowering. When faced with a physical problem that is unchangeable, being able to positively modify something else can be a good diversion that can provide some self-image enhancement.
Prominent brow bones are the result of overgrowth or pneumatization of the frontal sinus. Reducing them involves takes off the front table of bone, which is quite thin, and putting it back in a reshaped and flatter form. That can soften the forehead and orbital appearance which is where most eye contact in conversation is directed.
Dr. Barry Eppley
Q: I have multiple lipomas along nerves in my arm and am interested in finding out how to get injections to decrease their size. These lipomas give me pain because they are up against my ulnar nerve. I have about 80 lipomas all over my body. I am female, fit, 35, and frustrated with surgeries to remove them.
A: While the benign fatty tumor, known as a lipoma, are common soft tissues masses seen, multiple or many lipomas that recur in a patient is uncommon. When large numbers occur, they are as familial lipomatosis. Throughout one’s life new ones continue to grow and develop. Modern medicine does not have an explanation for why they develop or what causes them.
While I have had positive experiences with Lipodissolve in the treatment of more superficial lipomas, I would have concerns about injecting near a motor nerve. There is the distinct possibility that permanent damage may occur to the nerve, causing forearm and hand dysfunction. That is a risk that would not be a good trade-off.
Lipodissolve remains a non-FDA approved treatment method for any type of fat removal or shrinkage. It is not even a pharmaceutical-grade chemical as it is made through compounding pharmacies. While widely used as a cosmetic treatment for ‘dissolving’ fat, its use as a lipoma injection treatment has never been scientifically evaluated in any clinical trial method although anectodal reports exist that attest to its effectiveness.
If these ‘lipomas’ in fact do involve or are connected to the nerves, they may well be neuromas or neurofibromas which would not be responsive to fat-dissolving injections anyway.
Dr. Barry Eppley
Q: I am interested in getting a portion of my skull reshaped. The top part is narrow and slopes off to the sides. As a man with shorter hair, it would look better if the top was rounder and didn’t slope so much. Can some material be added to build up these areas? There are also two smaller areas on the sides which need reduced. I have attached some photographs which show the areas that I am concerned about.
A: Thank for sending your detailed photographs. That is extremely helpful and you have clearly defined what your skull contouring needs are. There is no question that all of those contours issues can be done. Whether it is some side reduction by burring in the two spots you have indicated or adding a material (PMMA acrylic vs HA hydroxyapatite) to give it a more rounded shape and decrease the slope, that is very straightforward from my standpoint. This is fairly simple craniofacial plastic surgery as it is outer table cranial contouring.
The most relevant question is one of surgical access. While all of those can be done, it is most ideal to do that through an open scalp incision. While you have a wonderful head of hair, this would leave a fine line scar. Given that you wear your hair very closely cropped, I would be concerned that the trade-off of this scar versus the skull contour concerns may not be a good one. I would need your further input on that issue.
Otherwise, there are some more limited injection methods to place materials under the scalp onto the skull bone. This is best done with PMMA which hardens after being injected and can be molded while it hardens. Such limited approaches do not provide enough access for the side bone reductions though. The other injection option would be to place fat grafts instead of a synthetic material. This can be done with a few simple punctures using your own abdomen as the harvest site. The disadvantage of fat grafts is their unpredictability of survival however and how smooth and even the contours would be.
Dr. Barry Eppley
Q: I am interested in some form of gynecomastia surgery. At one time I was much heavier and have lost a lot of weight through the help of bariatric surgery several years ago. Since the weight loss, much of my chest has not only gone flat but it sags with nipples that are very stretched out. My chest needs to be reshaped. Help!
A: Chest changes after weight loss are common in men. Men suffer a deflation of the chest soft tissues after bariatric surgery which is magnified by the usual presence of weight-related gynecomastia. This results in a skin sag with enlarged nipples that is particularly unflattering in a man.
Correction of this type of male chest wall change is not really gynecomastia surgery per se. There is usually not much fat or breast tissue to contend with. Rather it is more like a breast lift in a female. Skin needs to be removed and tightened and the nipple needs to be lifted and usually made smaller. If the skin sag is very minor, a circumareolar skin lift with nipple reduction can be made. This has the advantage of keeping the scar relegated to around the nipple area. More significant chest skin sag, however, needs a skin excision pattern that goes beyond the nipple. This is always problematic in men where scars are not well hidden in the more flat topography of the male chest.
Chest wall reshaping is usually the second most requested change (abdominoplasty is number one) in men who have had gastric bypass.
Dr. Barry Eppley
Q: I am inquiring about breast surgery for my son who is 14. He has developed small breasts and is quite conscious of it. He will not go swimming or even take his shirt off during gym class. (so I am told by his brother) My family doctor said it is gynecomastia and that it goes away in most teenage boys. He said we should wait until he is 18 years old before considering surgery. Given that it bothers him so much, and has made him very shy and reclusive, I was wondering what your thoughts were. Can surgery be done sooner rather than waiting? I am just desperate to help him and make him feel better.
A: While gynecomastia, male breast enlargement, does go away in some teenage boys, many times it does not. The historic teaching is to wait until the teenage male is near full development. In analyzing that approach further, its intent is to not subject a teenager to unnecessary surgery. In the spirit of such waiting, however, the teenage boy may (likely) develop self-image issues and psychosocial issues.
Given the exposure to potential social pressures and ridicule, I not think that such waiting is worth the trade-off. Gynecomastia surgery can be repeated (although I have never seen that necessary) but the emotional damage can be very difficult to get past. Therefore, in my Indianapolis plastic surgery practice I am an advocate of surgically treating gynecomastia early (age 14 is an acceptable age) provided that it is significant enough and one is certain that there is not a hormonal reason for it. While a hormonal cause (endocrine tumor) is a very rare cause of gynecomastia, they do occur. If the gynecomastia involves both sides of the chest and is not subtle, I would recommend getting him seen by an endocrinologist first.
Many cases of teenage gynecomastia that I seen today are less significant than they used to be. This is undoubtably a reflection of the changing cultural standards from decades ago.
Dr. Barry Eppley
Q: I have always wanted plastic surgery but can’t afford it. I have not aged well and I think it would make me feel better about myself. Do you know where I can get it for free? I would be willing to be a guinea pig to let someone learn on me. I would be willing to let them use an extra skin removed from me for help in reconstruction of burn victims.
A: Interest in cosmetic surgery continues to increase. While there are some people who say they wouldn’t subject themselves to something as vain or as drastic as plastic surgery, most people do not feel that way. In a recent online surgery of over 2,000 people done on behalf of theWeb community RealSelf.com, they reported that more than two-thirds (69 percent to be exact) said they would choose to undergo cosmetic surgery if they had the money. Perhaps to no surprise, a lot more people would have cosmetic surgery if money wasn’t the limiting step. I suspect in this group that some of those state opposition to plastic surgery would change their mind.
The bottom line is that there is no place where cosmetic surgery is done for free. There are costs involved, beyond the plastic surgeon’s time, that are incurred in surgery. In addition, there are medicolegal risks and exposure that one would not risk for no reimbursement. There was a time, years ago, when plastic surgery training programs did do cosmetic surgery for free for the educational experience of the residents and fellows. But that time has long passed and will not likely be seen again.
By the way, a patient can not use someone else’s skin for reconstruction. It would be rejected and cause infection. Skin can only be used from yourself.
Dr. Barry Eppley
Q: I am interested in corner-of-the-mouth lift surgery? I tried injections to turn up the corners of the mouth but that didn’t work. Then I went to a plastic surgeon who told me a facelift would make the corner of my mouth look better…and it didn’t! Since injectable fillers and a facelift didn’t work, I read about this procedure on the corner of the mouth. That seems like it would work. Can you tell me about the scars? Thanks!
A: For the downturned corner of the mouth (frowning or upside down U-shaped smile line), neither injectable fillers or a facelift will be successful. Either one may help a little but not generally for mouth corners that are more than just a little down.
The corner of the mouth lift is a simple but very effective procedure for leveling out the smile line. While it is a very small procedure, it can easily be overdone if the plastic surgeon is not careful and go the other way, up too high. (i.e., joker’s smile) By removing a small triangle or heart-shaped piece of skin just above the corners of the mouth, the tail of the smile line is brought. This does result in a small scar, about 7mms or so, off of the corner of the mouth that points up in the direction of the ear. But it is a very small scar that fades quite quickly.
A corner of the mouth lift can be done at the same time as a facelift or can be done as a stand alone procedure. When done by itself, it can be done under local anesthesia in the office. There is no recovery or any significant swelling or bruising. Tiny sutures are removed in a week or for out-of-town patients only small dissolveable sutures are used.
The corner of the mouth lift is a ‘cute’ little procedure that really can make quite a difference in one’s smile.
Dr. Barry Eppley
Q: I am interested in getting a tummy tuck. I have had two children and do not want any more. I can not get rid of this lower stomach pouch no matter what I do. A tummy tuck would do the trick but I am concerned about the scar. I am Hispanic and I am afraid I might scar badly. My c-section scar looks great so I seem to scar well. Will my tummy tuck scar look the same? I know it will be longer but will it look so fine and narrow?
A: While there are many factors that influence how a scar will ultimately look, one of the most important is that of tension. How tight is the wound on closure. A wound closed under tension will usually develop a scar that is somewhat wider than one that is not.
The concept of wound tension is what differentiates the c-section vs an abdominoplasty scar. C-sections are closed under absolutely no tension. They literally fall together loosely because of the expanded abdominal skin. This is why they usually look so good no matter how or by whom they were closed. A tummy tuck, however, is quite a different story. It is closed under considerable tension and requires the closure skills and training of a plastic surgeon to get a scar that may approximate that of a c-section. A good c-section scar is not necessarily a good predictor of what a tummy tuck may look like.
While scar outcomes are not always predictable, darker pigmented skin may widen and hyperpigment more than skin with less pigment. This is the risk of an abdominoplasty scar in one of Hispanic origin. Always remember that a tummy tuck is a trade-off, getting rid of that loose skin and fat with a better waistline for a scar. A scar is still an imperfection but, hopefully, one that is more tolerable.
Dr. Barry Eppley
Q : I had saline implants done three years ago in 2007. I had some left breast pain last night and woke up this morning with my left breast almost completely flat. I was mortified. How did this happen? I need to get my implant replaced as soon as possible. How quickly can we get this done?
A: Failure of a breast implant is a lifetime risk for anyone that undergoes breast augmentation. While everyone thinks it just happens to someone else, the statistics say that the risk is 1% per year of implantation. Failure of most breast implants occur spontaneously, meaning that there is no specific reason why or there is nothing that the patient has specifically done to cause it. It just happens from the fatigue of the implant folding back and forth.
Saline breast implants fail in a particularly dramatic fashion, known as deflation. Once the implant shell develops a hole or tear, the saline fluid comes rushing out and the breast goes partially or completely flat. This is one of the few cosmetic ‘emergencies’ that exist from a patient’s perspective.
If this should happen, contact your plastic surgeon immediately. Arrangements should be made to have replacement surgery within a few days. In my Indianapolis plastic surgery practice, we make every effort to get a patient’s deflated implant replaced no later than the next day if possible. If you have a copy of your implant size and serial numbers that is very helpful to get an exact size replacement. In the past ten years, most plastic surgeons provide a plastic card to the patient after surgery that has the lot and serial numbers from the manufacturer. This information is also very useful to find out what your warranty replacement is from the manufacturer, if the implants are not too old. (greater than 10 years)
The good news is that the breast implant replacement surgery is nothing like the original surgery. The pocket has already been made so the surgery is simpler and is comparatively painless from the initial breast augmentation surgery.
Dr. Barry Eppley
Q: I have read numerous blogs that talk about the value of facial exercises. With so many debates on this subject, I wonder if there is any benefit to doing facial exercises to tone up the face. Plastic surgery seems so drastic.
A: Much has been written over the past fifty years about using exercise to lift up a sagging aging face…or to prevent it from happening. This concept is not new. I have an original copy of a book entitled ‘Lifting Up Your Face’ from 1951. The more recent books that I have seen today in the book stores are beautifully done, and even have their own DVDs in the cover, but they are just modern re-inventions of this original concept.
It is certainly reasonable to do anything to avoid actual surgery, if it has some benefit. The problem that I have with facial exercising is three-fold. First, most of the signs of facial aging that are bothersome to people (appearance of jowls, loose skin in the neck, dropping brows, etc) are not muscular in origin. They did not occur because the muscles were loose and sagging. Anatomically, they are the result of the skin and the subcutaneous fat becoming loose and sliding off of the deeper tissues. That is not something that muscle tightening, even if it were possible with facial exercises, can really treat or prevent. Secondly, all facial wrinkles that develop are the result of muscle movement. That is why Botox is so popular, because it decreases this wrinkle-causing muscle movement. Moving those muscles a lot more through facial exercising will likely increase, not decrease the age signs of wrinkling. Lastly, I have yet to see adequate before and after photographs of believeable results from any facial exercising program. The photographs shown are never standardized. There are always some subtle changes in angle and lighting that can make a big difference in how the result looks. We know this very well in plastic surgery. It is very easy, intentional or not, to have an after result that appears to show a facial change that does not really exist.
For the sake of discussion, however, let’s us assume that there is some minor benefit to facial execising. In most patient cases, it is likely that the result would not be adequate…a lot of effort for a minor improvement. With todays’ minimally invasive and limited downtime facial procedures, they quickly surpass what exercising could do and require less effort. Plastic surgery does not have to be so drastic, one can get a few ‘tweakments’ that can make a real visible difference.
Dr. Barry Eppley
Q: I had breast implants done about 8 to 9 years ago and am looking to have them redone. Thr original size was 600cc implants. I am between D and DD cup size I think…but it depends on the bra. I want them increased but not sure if that is something you do? I know I would like to be DDD cup. I am a body builder as a hobby. I think it would balance my shape better.
A: Breast implant size is a personal choice and no one can really say what size someone should or should not be. Breast implants of 600cc size can be big or not so big depending upon whose chest they are on. For a small person this could be fairly large, for a bigger and broader-chested woman this may only be average looking in size. Most women are interested in having breasts that are in proportion to the size of their body but a few women want more than that.
Within reason, just about any breast implant size can be put in any patient. Whether that final size is in or out of proportion, or what someone really desires, is up to the patient to judge. In my Indianapolis plastic surgery practice, I try and accomodate a woman’s breast implant size desires. That being said, women should know that there are potential long-term consequences for having large breast implants. (i.e., extreme breast augmentation) Over time, the weight and size of the implant may cause tissues to stretch out and a ‘bottoming out’ of the implant may occur as the implant falls on the chest wall. This is known as loss of tissue support. This is why as a general rule it is wise to keep the base width size of the implant within the natural breast base width. Also remember, it is easy to go up in size without significant scar consequences. Should one day the desire arises to go smaller, there will be significant breast scars to remove and tighten the loose skin that the implant has created.
Dr. Barry Eppley
Q : I have one ear that sticks out more than the other. My right ear is just fine and looks good. But the top of my left ear sticks out further than the right and it bothers me. This seems like it would be a simple thing to fix. How is it done? Does it require surgery to fix it?
A: The position of the ear and its angular relationship to the side of the head is the result of the shape of the ear cartilage. The ear cartilage has many folds and grooves. If one of these folds is not quite bent or shaped symmetrically, the ear will stick out further from the side of the head.
Otoplasty, or ear cartilage reshaping, is done but rebending the ear with sutures from an incision on the backside of the ear. With this technique, much of the ear can be brought back and made less prominent. When only one part of the ear is protruding out, a single suture can usually solve the problem. ‘Mini-otoplasties’ can be done under local anesthesia in the office in a short period of time. There are no dressings to wear afterwards. One does have to be careful not to pull on the ear or traumatize it in the first months after surgery to prevent dislodging the retaining suture as the ear heals.
Dr. Barry Eppley
Q: I am really curious about brow bone shaping. I am wondering if it is possible to lower the brow bone. My concern is that the distance between my eyes and brow bone is very large and therefore my mid face looks very long. I want to shorten this and I think one of the most effective ways would be to lower the brow bone. Is this possible? How is it done, etc?
A: The brow bone is traditionally reshaped because it is too prominent. The so-called Neanderthal look occurs due to excessive growth of the frontal sinus which causes the outer table of the brow bone to stick out. This can be reduced by setting back this outer table of brow bone.
The brow bone can also be built up by various materials should it be underdeveloped or deformed from a traumatic injury.
Lowering the brow bone is a very unusual request as the need to do it is very rare. But the lower edge of the brow bone, however, can be brought lower. This is not done by moving the bone though. The lower edge of the brow bone can be built up with an implant material that is secured to the bone with very tiny screws. The implant is custom-carved during surgery to make an exact as fit as possible. This would be done through an upper eyelid (blepharoplasty) incision. Whether this would actually make the eyebrows look lower or create the effect that one wants is uncertain.
Besides considering a build-up of the lower brow bone, there are other considerations such as dermal-fat grafting to the upper eyelid sulcus which may create the same desired effect. I would have to see photos to make a more educated opinion on what is possible.
Dr. Barry Eppley
Q : Hi Dr Eppley, I am inquiring about how to reduce a long forehead. My forehead is so long it is ridiculous. I have good hair but my hairline is so far back I can’t wear my hair pulled back. My forehead also has a bulge in it near the hairline which makes it look like it is even back further. I have heard that a plastic surgery procedure exists that can pull my hairline forward. Is this possible?
A: The typical distance for most people between their eyebrows and their hairline (forehead length) is up to 7 cms. When that distance is greater than that, most people would consider it to be a long forehead. In actuality, however, if one thinks that they have too much forehead skin then they do.
One’s forehead can be shortened through a skin excision procedure. The skin is removed in front of the hairline and the scalp hair brought forward in its place. In essence, this is a reverse browlift. The amount of scalp advancement can be up to 2 cms to 2.5 cms without any problem. More can sometimes be obtained by a very posterior scalp elevation at the subgaleal level the whole back to the occiput. Even more than that can be obtained by a two-stage procedure using a tissue expander although this is reserved only for the most severe cases.
The trade-off for a forehead reduction is a fine line scar along the hairline. As long as one has reasonable hair density and hair quality this is not a concern. With the forehead bone exposed, any bony contouring or reduction can be done at the same time.
Dr. Barry Eppley
Q : I would like perky and fuller breasts. I have had three children and my breasts have just lost everything. They are so saggy and droopy they are disgusting. I am so embarrassed about them I won’t even let my husband see them. My right breast is also different than the left. It is bigger and more saggy and the nipple is much bigger. I know I want implants but I think I may some sort of lift too. Can you tell me how bad the scars will be?
A: The need for a lift with the use of breast implants can be determined by one simple anatomic measurement…where does the nipple sit relative to the lower breast fold. (inframammary crease) If the nipple is above this level, an implant alone will give the breast a good shape with the nipple reasonably centered on the new larger mound. If the nipple sits at or below the fold, then an implant will make the breast bigger but the nipple will be on the ‘southside’ of the mound. (i.e., pointing downward)
There are essentially four types of breast lifts based on how much the nipple needs to move upward. They are with their resultant scars; type 1 superior nipple lift (scar on top part of nipple), type 2 circumareolar lift (scar 360 degrees around the nipple), type 3 vertical breast lift (scar around the nipple and vertically down to the fold) and type 4 full breast lift. (around the nipple and vertically down into the fold and then horizontally along the fold, an anchor scar pattern)
In general, breast lift scars usually turn out pretty well. The scars around the nipple and along the inframammary fold do the best. If a vertical breast scar is needed between the nipple and the fold, this is the one that has the most potential to widen due to the constant pulling by the weight of the breast against the scar. Most breast lift scars revisions involve that scar if needed.
Dr. Barry Eppley
Q : I would love to sign up for some free plastic surgery. I have never been happy with the way I look. My ex-boyfriends always told me I’m not good enough for them and they could do better. I always wanted plastic surgery but with no money and no time to work extra hours. I’m a single parent of three and try to give them the best. My time and money is for them, they are my life. I’m unable to save for surgery. Please contact me and let me know what I need to do.
A: The possibility of free plastic surgery is certainly appealing. Like a winning lottery ticket, the opportunity to be able to ‘afford’ something you could not previously is intriguing to say the least. But unfortunately, real life is not like a television show. Extreme makeovers for free really only do exist on the television screen. It simply is not provided by any plastic surgeon in any community.
There are a variety of reasons plastic surgeon do not provide cosmetic surgery for free. First and foremost, cosmetic surgery does not usually improve any medical function. Yes it is true it will make one feel a whole lot better about themselves but that is different than reconstructive surgery where the origin of the problem is from a birth defect, cancer, or a traumatic injury. Patients in need of reconstructive surgery are more in need than that of any cosmetic concern. Plastic surgeons have a long history of being very benevolent with their services for reconstructive surgery. Secondly, there are more costs involved than just the plastic surgeon’s time or expertise. The use of the operating room and an anesthesiologist (if needed) must be accounted for. Those providing these costs do not feel or have any obligation to give away their materials and labor. Lastly, free cosmetic surgery does not waive the plastic surgeon from medicolegal liability and exposure. Why should a plastic surgeon assume those financial and professional risks without compensation?
Board-certified plastic surgeons also cannot provide cosmetic surgery as a prize from a contest or giveaway. This is an ethical violation as a member of the American Society of Plastic Surgeons. While many cosmetic surgeons from different specialities freely do promote such contest prizes, board-certified plastic surgeons can not do so.
Dr. Barry Eppley
As people age, two of the most noteworthy and bothersome facial changes is what occurs along the jaw line and neck. These two changes are usually progressive, first comes the jowls then goes the neck. Like wax melting off of a candle, cheek skin and fat begins to slide off of the face creating those fleshy droopy folds at the jaw line known as the jowls. Recent research also indicates that it is more than just gravity that causes jowls, it is the shrinking of facial fat as well.
The appearance of jowls will eventually occur in everyone with enough time. Jowling creates an undesireable change in facial shape, making it wider and more rectangular in the lower face which is characteristic of an older person. It also causes a distinct disruption of a smooth jaw line from the chin on back, which is characteristic of a more youthful appearance.
Jowl correction is generally part of a facelift procedure. This is done during a facelift by either trimming the jowl fat, suturing the jowl fat back up to a higher level, or some combination of both of these manuevers. Facelifting is a relatively common procedure as evidenced by the 95,000 performed in the U.S. in 2009 according to the American Society of Plastic Surgery.
When only jowls are present and the neck has minimal loose skin, a different variation of a facelift can be done. Scaling back the ‘size’ of the facelift procedure can very effectively eliminate those troublesome jowls. Known by a wide variety of different names, the limited or downsized facelift tucks up the hanging loose jowls with very minimal recovery. Unlike a traditional facelift where incisions are made in front of and on the back of the ears, the jowl facelift only uses a fine incision in the front. The lack of any significant recovery is noted by the different names that are used to describe it, such as Lifestyle Lift, Swiftlift and EZ Lift. Expect one week for the significant recovery period of some mild swelling and bruising.
One of the great advantages of a jowl lift or ‘short scar facelift’ is that it also addresses a common facelift fear, that of looking unnatural. Few patients that I have ever met want to look like they have had a facelift. These procedures have no risk of that ever happening as they deliver a more subtle and less dramatic result. One will never look have that windwept or overdone look as, by definition, the procedure is more limited.
Q: Hi Dr. Eppley. I am a 56 yr old female and I am interested in liposuction for my arms. I am currently losing weight and have lost just about 25 pounds. My current weight is 186 and my question is… do I need to wait till I have lost all the weight I want to lose or could I have liposuction on my arms now? I am exercising on a regular basis, but I am seeing very little if any progress on my arms. I am having to cover my arms as much as possible and I so want to wear sleeveless tops. I have researched this subject and have read where liposuction of the arms produces “only modest improvement”. Would I even benefit from such a procedure?
A: Like all liposuction, but particularly in the arms, patient selection is key for a satisfactory result. The real question is what is making your arms big? Is it fat alone, extra skin or a combination of both? Conversely, a good question is how much improvement is needed to make a visible difference? How much change is necessary to be able for you to comfortably wear sleeveless tops again? That is the bottom line question and objective.
While I can not obviously see your arms, I have never seen any patient at a weight of 186 lbs where fat removal alone with liposuction will produce a significant arm contour change, particularly in someone losing weight. Significant arm changes at this size require both skin and fat removal, otherwise known as an armlift or brachioplasty. That procedure can make a dramatic arm change at the price of a scar running down the backside of the arms. More likely your decision is whether an arm scar is a good trade-off for a noticeable arm improvement.
Dr. Barry Eppley
There are many reasons why people undergo plastic surgery. The desire for self-improvement is the most compelling but the underlying motivation for such an emotional decision is never quite that simple. In a recent study in a prestigious plastic surgery journal, it was reported that nearly 80 percent of patients surveyed said that part of their decision to have plastic surgery was triggered by television and other media exposures. One television influence prominently noted was that of reality programming. The influence in the last decade of the reality TV concept is undeniable and has focused on everything from cake baking to child rearing..
The early success of ‘Doctor 90210’ and the now defunct ‘Extreme Makeover’ has fueled many copycats and there does not appear to be an end to the public’s desire for this form of reality plastic surgery. Whether the appeal is similar to the transformations seen on ‘Yard Crashers’ and ‘Rock Solid’ or the fascination of watching others subject themselves to an extensive makeover is undoubtedly part of it. I am all for increasing the public’s awareness of the benefits of plastic surgery but the ‘reality’ shown in the little bit of these programs that I have seen doesn’t really reflect the real life experience of the plastic surgery process.
Just like the entertaining but tragically distorted plastic surgery show, ‘Nip/Tuck’, television is all about entertainment and getting you to watch and rarely about truth. Only the highlighted moments of excitement and results is portrayed, leaving out all of what the producers consider dull filler material. This unshown filler, however, is really what plastic surgery is about. Boring accurate information, such as risks and complications and realistic outcomes, are never portrayed. What may happen when the plastic surgery doesn’t turn out so well is rarely if ever shown. In fact, some of these shows focus almost exclusively on the eccentricities of the plastic surgeons or their patients. While Dr. Ray may be entertaining, it is never revealed that he has never taken the effort to be board-certified.
Not all plastic surgery programs on TV, however, are badly done. There are some that are especially informative and insightful. This is the case with the Discovery Channel’s “Plastic Surgery: Before and After.” It is clear in this type of programming that their intent was educational, not a festive diversion to keep your eyes glued. Rather its intent is to teach, educate, and give us a greater explanation of what cosmetic surgery is all about. That is meaningful time spent about a serious TV subject.
In reality, most patients are not primarily driven to get plastic surgery because of these reality TV programs. They do it because they have physical imperfections that are bothersome to them. These TV programs are an extension of the often distorted Hollywood world where the pursuit of physical perfection and the fighting of father time is taken to sometimes ridiculous levels. They promote unhealthy desires such as teenage girls possessed about enlarging their breasts or changing their nose in the hope that this make them famous or get them noticed. Most people may be able to see through the façade of these shows and see them for the trivial entertainment that they are. But impressionable teenagers and insecure adults may not be so discerning. Just like the recently passed Health Care Reform bill, the devil is in the details. The real reality of plastic surgery is in that boring stuff that is hardly worth watching…but is really worth knowing.
Dr. Barry Eppley
Q: I have an inherited double chin that makes me look twice my 46 years of age. Can you make it disappear so I can look younger ??
A: A ‘disappearing’ act is what we do a lot of in plastic surgery. Whether it be liposuction, chin implant, facelift…or some combination….it certainly can be made to ‘vanish.’ I know that your double chin makes you look older….but I doubt if it makes you look 92!
When patients refer to a ‘double chin’, this means there are at least two and sometimes three rolls of skin if you include the chin as one of the rolls. The double chin is often the result of the combination problem of a full neck and a short chin. In the younger patient, this can be improved by doing chin augmentation and neck liposuction at the same time. When you move two different things in opposite directions, the result becomes greater than when only one is done alone. In an older patient with more loose skin, this diametric action may require chin augmentation and a facelift to get the neck going back and up as the chin comes forward.
If the forward position of the chin is adequate, then the neck alone can be treated. Again, age and the amount of loose skin determines whether liposuction (good skin) or some version of facelift (bad skin) is needed.
Correction of a double chin is highly effective plastic surgery adventure and can make for a dramatic difference in one’s appearance.
Dr. Barry Eppley
Q : I am bothered by the size of my nipples. They stick out too far. It is embarrassing in shirts. They are even noticeable in bras unless they are padded. I often wear nipple pads or ‘dimmers’ so they are not so obvious. I am interested in having them reduced but am afraid of losing all my feeling in them. Can you tell me how this procedure is done?
A: There is no standard size or length for what a nipple should be. But when its length becomes a socially embarrassing issue, then nipple reduction should be considered. Reducing the length of the nipple is a simple procedure that can be done under local anesthesia. It can be done alone or in combination with most forms of breast surgery, most commonly breast implant augmentation.
The nipple can be reduced two different ways depending upon its size, how much reduction one wants to achieve, and if as much feeling as possible wants to be maintained. A wedge excision of the nipple can be done which will reduce its length by at least half if not more. (depends on the size of the wedge) This will eliminate the possibility of breast feeding and some feeling will definitely be lost. (how much can not be predicted) The other option is a circular or donut reduction where a ring of nipple tissue is removed at its base. Breast feeding will still be possible and the least potential for feeling loss is the benefit of this approach.
Either method uses dissolveable sutures with only a band-aid for a dressing. One can shower the next day. There are no restrictions after nipple reduction surgery.
Dr. Barry Eppley
Q : What kind of headband or sweatband do you have your patients wear after otoplasty? Thanks! How long do you have them wear this?
A: Otoplasty, or pinning back ears, uses internal permanent sutures to reshape the cartilage. This is done from an incision on the backside of the ear. The security of the sutures are very critical until enough scar tissue between the folded ear cartilages forms to act as a ‘cement’ to hold them permanently together. This is usually about six to eight weeks after surgery.
Accidental folding of the ear forward could loosen the sutures or pull them through the cartilage, thus allowing the recoil of the ear cartilages to cause relapse. This risk is largely age and activity dependent and determines whether and how long any form of ear protection should be used. In teenagers and adults, I recommend such ear protection only at night for two weeks where inadvertent turning on one’s side could pop a stitch. In children, ear protection should be used more liberally given their propensity to accidental events. For two weeks after surgery, ear protection is worn round the clock and then only at night for another two weeks.
While plastic surgeons may use a variety of ear protection methods after otoplasty, the simplest and most comfortable is a sweatband or athletic headband. Its soft elastic is comfortable and it is inexpensive. Multiple headbands can be purchased for a few dollars. In addition, its width is only an inch or two which makes it not too hot to wear.
Dr. Barry Eppley
Q: I have been contemplating rhinoplasty for many years. Only now that I’m approaching my thirties have I decided it’s time to take that step. Please provide any information you can at your convenience and hopefully we will be in touch. Thanks.
A: Considering rhinoplasty is a big step given the very significant changes that it can make on your face. When beginning the initial step in the process, you must first consider what plastic surgeon you are going to see and prepare yourself for the initial consultation.
In choosing a plastic surgeon for rhinoplasty, first use the internet as a resource. Look in your geographic area for those plastic surgeons that offer it and do it with regularity. That can usually be gleaned from their practice website. Look for specific photos of their patients and there should be a good number of them showing different types of noses and results. Also look for any articles (blogs) that they may have written about rhinoplasty. Between photos and writings you can gather how concerned and focused they are on rhinoplasty surgery and patients.
In preparation for the consult, write down exactly what you want to achieve from surgery. Saying that you want a better looking nose is obvious, be more specific. What parts of the nose do you not like and how would you like it changed. A written list is always good to see. You may bring pictures of noses that you like but remember those are just suggestions and ideas and can not be reproduced in surgery.You are not the person in the magazine, your face and nose is different. Anything else you do not like about your face can also be brought up as this is an opportune time for that discussion. Also, do you have any trouble breathing through your nose? Functional (internal) nasal surgery is commonly done with changing the appearance of the outside of the nose.
Expect during the consult to have photos taken for computer imaging. This assessment is critical and a review of the suggested changes and results may require a second consult to be sure everyone is on the same page so to speak.
For more detailed information on rhinoplasty, go to my blog, www.exploreplasticsurgery.com and search under rhinoplasty. You will find dozens of helpful articles there.
Dr. Barry Eppley
Q : I had liposuction in December and still have pain in my stomach. Also I have an ugly lump under my chin after my liposuction and facelift. Have you seen such chin lumps before?
A: While liposuction doesn’t look like much from the outside, what goes on inside is quite extensive and traumatic to the fatty tissues. While liposuction can be very effective at fat removal and contouring, full recovery is not quick and really takes time often as long as three months to four months.
As part of this prolonged recovery process, there are some very typical aches, pains, and irregularities which one will experience. While liposuction is not acutely painful, soreness and discomfort persist at different intensities over time. As one gets more active and moves about more, twinges of shooting pain and tightness will occur. This is the stretching out and breaking loose of scar tissue that has formed as a result of the procedure. The skin over any liposuction-treated area will also be numb. Full feeling will return but again will take months. Some of the those shooting pains may also be nerves that are healing and re-establishing feeling.
One of the very common sequealae of liposuction is the temporary areas of lumpiness or irregularities that will be felt. These are collections of dead fat, scar and blood that have accumulated in an area. These feel very firm and painful to manipulate or massage. They are extremely common in the neck area because of the thinner neck skin and being an easy place to accumulate in the center of the neck. With time, they will get softer and eventually go away. The neck can get quite indurated after liposuction and will create fullness that temporarily distorts the good result that was seen at the end of surgery. One can massage the neck area several times a day which will help soften it faster.
The recovery after liposuction is a prolonged process and patience is definitely needed. I would not judge the final outcome until you are six months out after your surgery.
Dr. Barry Eppley
Q: I am in the very early stages of looking into treatment for the area under my eyes. I believe the problem could be easily fixed by the right Dr. and this is my first attempt to find out what is involved and how much it would cost. The skin directly under each eye is all wrinkled and takes completely away from my appearance and has caused me to be completely self conscious for many years now and if I can do something about it, I would like to.
A: Aging around the eyes is often one of the first signs that many people notice as they get older. Changes in the lower eyelid are usually more obvious than that of the upper eyelids since they are not hidden or distracted by the eyebrow and are larger by surface area. Since so much of human conversation involves direct eye contact, how our eyes look is seen by all. It is no wonder then that many people seek plastic surgery for an improved and more youthful eye appearance.
While there are many topical creams out there, and they do have some anti-aging merits, they are no replacement for more invasive eyelid skin treatment methods. Depending upon the amount of loose skin that exists on the lower eyelid, some version of a lower blepharoplasty or eyelid tuck can be very helpful. Through a fine line incision along the lower eyelash line which extends slightly out from the corner of the eye, loose skin is removed and the lower eyelid is tightened.
Lower blepharoplasty will definitely help remove some but not all of the eyelid wrinkles. You never want to risk removing too much skin from the lower eyelid in an effort to work out every sinle wrinkle and then end up with a pulling down of the eyelid after. (ectropion) Lower blepharoplasty is an excellent wrinkle reducer but should not be thought of as a complete wrinkle remover.
Dr. Barry Eppley
Q : Hello Doctor, I had a chin implant in November 2008. It got infected and had to be removed two weeks later. Now after one and a half years later my chin is still loose and stretched, making my chin look like it is hanging and looks weirdly different. I like to find out if there is a way of fixing this by shrinking and tightening my chin that will hold my face together the way it was before. Thank you for your time and help, hope to hear from you very soon.
A: In placing a chin implant, it is necessary to lift the mentalis muscle off of the bone. Like placing a breast implant, this stretchs the overlying tissues out. As a result, if chin implants are ever removed there is a risk of the tissues not shrinking back down and become ptotic. (sagging off the bone) This is a well recognized chin problem whose occurrence is more likely the larger the chin implant that was used. The risk of chin sagging is also greater if the pathway in which the chin implant was originally placed and removed was done from inside the mouth. (this method separates a greater amount of mentalis muscle)
Chin ptosis, also known as a ‘witch’s chin’ deformity, can be corrected through two different methods. If you want to get the effect of greater chin prominence that you were originally after, replacement of a new chin implant or moving the chin bone forward (chin osteotomy) can be done. This will give more chin projection and pick up the sagging chin tissues. If you are not interested in any further chin projection, then the mentalis muscle must be shortened and tightened to readapt the soft tissues back on the chin bone. This can be done either from inside the mouth using resorbable bone anchors or from an incision on the underside of the chin. (submental tuckup)
Dr. Barry Eppley