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The internet continues to redefine our existence on a daily basis. From how we shop for everything from clothes to cars, to how we shop for information, it now influences and controls our culture. Even our English language is being affected.
This is best reflected in the Urban Dictionary. This is a web-based dictionary of slang words and phrases. The definitions on the website are meant to be those of slang or subculture words, phrasing phenomena not found in standard dictionaries. Most words have multiple definitions, often quite different than you think. It contains over five million definitions and is expanding rapidly with an average of over 2,000 new submissions per day. While it has tremendous web traffic, most of its users are younger than 25. For this reason you may not have heard about it…but eventually you probably will.
When it comes to ‘urban’ terminology, plastic surgery has many such terms. Used everyday with patients or in the operating room, these thinly veiled innuendos instantly describe the cosmetic problem. Let me share with you a few of the most common ones- some which you will know, and others which you may find enlightening.
Elevens– Not a number but a type of facial wrinkle. Popularized by the manufacturer of Botox in their advertisements, these vertical lines appear between the eyebrows when a person is scowling or frowning. Because they most commonly appear as paired lines, they are appropriately described as this number. The elevens are exactly what Botox injections were initially FDA-approved to treat.
Crow’s Feet – Long recognized as the wrinkles that radiate out from the corners of the eyes as we smile, a crow would probably be delighted to have its feet so described. Since wrinkles on our face always form perpendicular to the direction that the underlying muscles move, these naturally occur from eye squinting. Botox works well to reducing these also.
Dog Ears- Having nothing to do with a dog’s ear or anyone’s ear for that matter, this is the bunching of skin at the tail end of a scar. They commonly appear when skin areas are ellipitically removed, like the shape of a football, and the closure results in a straight-line scar. From procedures such as tummy tucks and breast reductions, dog ears may develop at the ends of the scars. They are a frequent source of minor scar revision.
Turkeyneck – Who doesn’t recognized this one, particularly if you are middle-aged or older. It needs no description and it often drives the desire for a necklift procedure.
Saddlebags – An older, urban plastic surgery term that many women recognize. That fat collection at the side of the thighs that resists every form of diet and exercise, but which liposuction can treat so well. If only they were as simple to get rid off as pulling their historic corollary off a horse.
Parentheses – Not an English quotation mark but those classic lines that develop from the sides of the nose down past the sides of the mouth. They are one of the major places for the use of the very popular injectable fillers (such as Juvederm) to make them look less deep and obvious.
Muffin Tops – While a tasty and crunchy part of a muffin, eating enough of those will put them on your waistline. These are the classic fat rolls that stick out from the side and back of your pants…and which are nearly impossible to get rid of. Liposuction machines love this part of the muffin, too.
Puff Daddy – Men won’t recognize this problem, but most women will. It is the fullness or puffiness of the pubic area just below the waistline. It can become evident after a tummy tuck when the waistline becomes narrower than what lies below. It can be an embarrassing bulge in pants that no slimwear can flatten.
If you recognize more than five of these terms, you can consider yourself to be both hip and plastic surgery savvy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very square jaw with a lot of fullness towards the front which has always bothered me and made me self conscious. I try to keep myself thin because any weight gain will make it even fuller. I am currently 43 and it seems to be feeling fuller, where I always felt when I got older the baby fat would decrease. My mother and father both had full faces with fairly square jaw lines as well. I am hoping the buccal fat procedure and would help my profile and thin my face from the front and side…like when I bring in my cheeks by sucking them in…it seems to show the angles more rather than looking chubby.
A: A square facial architecture is strongly influenced by the shape of the lower jaw and the cheek bones. To make a square face less full, the only area that can be changed is an inward movement of the submalar triangle facial zone. That is the area beneath the cheek bone done past the corner of the mouth in an inverted triangle shape. This is an area that is not supported by bone or muscle which is why you can suck it inward. Fat removal of this area is the only way to create some tapering in of this zone. The buccal fat pad occupies the upper region of the submalar triangle but not the area down by the mouth, known as the lower submalar triangle area. So a buccal lipectomy will help but needs another method of fat removal of the lower area also known as the perioral mounds. Microliposuction should be done from inside of the mouth to help this area in conjunction with the buccal lipectomies. The combination of both has the best chance to help achieve the look you are after.
Indianapolis Indiana
Q: I have a cyst like lump right in between the eyebrow. In stead of cutting the cyst off with the knife vertical to the skin, is it possible to make a cut right underneath the frown lines and slice the lump off from the cut? Is it possible to transfer some fat to that area if the area is dented after the lump is sliced off?
A: Those are two very good insights into how to remove your forehead (glabellar) cyst while leaving the most aesthetic outcome. Using a close wrinkle or frown line would be preferable to making an incision directly over the cyst. That would make for a far better scar. Even if the scar turned out less than ideal, it is more favorable area in which to perform scar revision. It may also be possible to remove it by an endoscopic technique, although I would have to see pictures of it to be sure that is a possibility.
Also, placing a fat graft at the time of a facial cyst removal is almost a standard technique that I do since indentations may follow later due to a mass removal effect. An indentation may now appear initially, due to fluid fill of the cyst removal space, but will appear once that fluid is absorbed weeks to months after surgery. If the cyst is more than just the size of a pea, I would recommend that at the same time rather than waiting for it to appear later. It is just as simple to do it at the time of cyst excision.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 5’7″ and weigh 128 lbs. Even though I am relatively thin, I have always had a double chin for some reason. But I feel like it has gotten worse since I have given birth to two children and have gained over 40 lbs with each pregnancy. I am interested in knowing what could be done and how much improvement I could expect. Getting rid of this double chin would help me feel more confident. Thank you so much for your time.
A: The cause of a ‘double chin’ is a combination of three anatomic factors; neck fat, neck skin, and chin projection/prominence. Every double chin is made up of differing ratios of all three components. It is always about how much neck fat is there, how much extra neck skin there is, and how short one’s chin may be. While you didn’t state your age, that number also has an influence because it suggests how much neck skin you may have and, most importantly, how elastic it is.
Some double chins can be corrected by as simple a procedure as neck liposuction in someone who is young and with decent chin projection. On the flip side, an ‘older’ severe double chin may require everything including neck liposuction, chin augmentation, and some form of a necklift to help tighten the extra loose skin. Each patient must be assessed individually and a custom treatment plan devised as double chin correction is not a one size fits all procedure.
One surprising aspect to the ideal correction of double chin problems is that of the chin. Many people have short chins that are magnified by this problem. Lengthening the jawline with a chin implant while bringing the angle of the neck back (or making it more defined) is the classic ‘ying and yang’ approach which together makes a better result than either change alone.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting some facial implant work done and was wondering if I can have wisdom teeth extraction done at the same time? I want to get orbital rim implants with a possible midface lift. Is there any reason why these two can not be done together? Will one potentially cause problems with the other or is it better to have them done separately, like a decreased risk of infection?
A: I see no reason why these two facial bone procedures can not be done at the same time. It is quite common to do multiple hard and soft tissue procedures of the face together. The face is tremendously well vascularized and very resistant to infection. (I didn’t say impossible just very resistant) While such a combination (facial implants and 3rd molar extraction) is unusual, it is by no means contraindicated. The hardest part is not the operation, but finding someone who is well qualified to do both at the same time.
Orbital rim augmentation and a midface lift is done from the outside through a lower blepharoplasty incision. Wisdom tooth or 3rd molar extraction is done intraorally from inside the mouth. The two areas are not anatomically contiguous and would not connect, thus ensuring no risk of oral bacterial contamination coming in contact with any implanted material. Because of this risk, the orbital/midface procedure is done first so cross-contamination from instruments does not cause any inadvertent oral bacterial inoculation on the implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am considering getting involved in martial art training and was wondering if having a chin implant would pose a problem with that activity. I have a porex chin implant and I’m afraid it will shift if struck. Have you ever seen a porex implant shift from blunt trauma? Is there a difference in potential shifting between porex and silicone implants. Please let me know so I will know whether or not to proceed with martial arts training.
A: I would not personally refrain from martial arts training, or any other contact-related sports activity, if I had an indwelling chin implant. The risk is always there that a good blow to the chin could cause a problem such as shifting of the implant but that risk to me seems very low. There is an equal, if not greater risk, of breaking one’s nose or having a tooth knocked out. Such are the orofacial risks of any contact sport.
The potential advantage of a porex (medpor) chin implant over a silicone one in terms of shifting in the face of trauma is theoretical. Because the porex implant has greater tissue adherence and even some amount of tissue ingrowth, one would assume that it is more resistant to movement after surgery over a purely non-ingrown encapsulated silicone implant. But blunt trauma to the jaw with enough force can easily fracture the bone so the potential for implant movement, regardless of its composition, is always a low occurrence possibility.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in the Fat Injection Breast Augmentation surgery but have a few questions. What are the preop requirements and do you have to have multiple operations?
A: Breast augmentation with fat injections is in the early stage of technique development. While the appeal is enormous for some patients, it is a concept which has not been shown to be consistent in results just yet and the long-term outcome on breast health and cancer surveillance is unknown. Breast augmentation with implants remains a proven technique. Whether fat injections will one day be a comparative procedure remains to be seen.
What is known about fat injections for breast augmentation is that one has to select the patient for it very carefully. Several criteria are important. First, one has to have enough fat to transfer into the breast. If one is very thin or skinny, they will not be a candidate due to lack of adequate donor tissue. Secondly, one’s desired breast size increase must be modest. At best, only a 1/2 cup or maybe more can be gained in size. Desiring a bigger change than that is beyond what fat injections can yet achieve. Lastly, one must be prepared to accept the likely possibility that more than one fat transfer may be needed. Injecting too much fat in a single session will not work. It is better to incrementally increase the fat breast volume to ensure the best survival and decrease the risk of fat necrosis. Therefore, patients must be willing to accept, and have enough donor tissue, to do a second fat injection session in most cases.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I need your help. Three months ago I had a gynecomastia operation done and now I have a problem. The problem is that my nipples are folded in now and going inside. My skin is also very dry around nipples and my nipples have become cracked. This looks like a serious problem. How can I fix my nipples?
A: Gynecomastia reduction procedures can be done two fundamental ways; liposuction or open excision (removal) of excess breast tissue. Sometimes the two techniques are done together to get the best result. With the open excision technique, breast tissue is removed through an incision on the underside of the nipple. (technically the areola) Removal of this breast tissue is largely an art form. How much to remove and how to shape what is left behind is more of matter of experience than an exact science.
One of the known complications of open gynecomastia removal is over-resection, removing too much breast tissue. This make look alright in the very beginning (or not) but as the swelling subsides and scarring sets in, the nipple gets pulled into the over-resected space where breast tissue once was. This is called nipple inversion or a retracted nipple. It most commonly appears underneath the nipple since this is closest to the incision but it can appear outside the diameter of the areola if the over-resection goes beyond just that area.
Correction of the inverted nipple after gynecomastia reduction requires replacement of the missing tissue to support the projection of the nipple. This is best done by a fat graft or a dermal-fat graft using the patient’s own tissues. This requires a donor site and a scar elsewhere on the body to do it.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was wondering if I could get a Botox procedure done in my masseter muscles to help with my teeth clenching. I have tried mouth guards and it doesn’t solve the problem because I’m also clenching my teeth a lot when I am awake. Please send me any information you can regarding this issue.
A: I have used Botox for masseter muscle injections for clenching and bruxism for the past five years. I have yet to see a patient who has not had some near immediate and significant improvement of their clenching afterwards. The duration of the pain relief will last as long as the Botox is effective, generally around four months or so. This makes perfect sense as the clenching is muscular in origin. While it can also involve the temporalis muscle, the large masseter muscles are certainly a major source of the clenching problem. While the simultaneous use of oral splints still has a role, particularly to prevent excessive tooth wear, the direct injection of a true ‘anti-spasm’ agent into the muscle is undoubtably more effective and immediate. (results within a week or less)
I have found that the starting dose of Botox is 25 units per side. Both sides are only done if the patient feels that the pain is on both sides. Many patients will have only a one-sided or unilateral source of masseter pain and clenching. The injections are placed in the lower half of the masseter. If a line is drawn from the earlobe to the corner of the mouth, the injections are placed in the part of the masseter muscle that lies below that imaginary line. This is a simple office procedure that is both quick and fairly painless. Compared to cosmetic Botox injections in the forehead, masseter muscle injections are surprisingly more comfortable.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I have a question about the cranioplasty operation. I had some frontal bone augmentation done two weeks ago with acrylic material. I had it done to get rid of some irregular areas that were quite prominent on my forehead. I had a craniosynostosis repair when I was one year old. I know that swelling is to be expected but I thought most of it would be gone by now. It appears asymmetric between the two sides of my forehead and doesn’t look quite even. Am I being too optimistic about the swelling?
A: It is normal that patients are generally quite overoptimistic as to how long it takes to see the final result of the cranioplasty procedure. While two weeks may seem like an eternity when you are the patient, six to eight weeks is the realistic time period to see about 90% of the final result…and 3 months after surgery before one can make a final critical analysis. That’s how long it takes for the scalp tissue swelling to go completely away and all areas to settle. The thicker the tissues are, the more swelling and the longer it takes for it to go away…and the scalp tissues are quite thick.
Another interesting note is the concept of bilateral (two-sided) surgery. Even though the same thing is done to both sides, the swelling that occurs is never, or rarely, the same. So any asymmetry at this point I would still judge to be swelling differences and not yet proven to be some differences in the degree of forehead symmetry from the augmentation.
Indianapolis Indiana
Q: I am unhappy with the mid- and lower cheek area of my face. My cheeks are sunken in below the cheek bone causing a hollow/gaunt appearance. I have smile lines that are becoming heavier and more visible all the time. I had fat injections in the area of the smile lines about 3 months ago. I would estimate that about half remains at this point. I saw your videos on Youtube and would like your opinion on whether a submalar implant would fully correct, partially correct, or have minimal effect in this area of my face. I would like to understand your recommendations on improving this area. My objective is to create a permanent and fuller looking face in the cheek area and pull out the smile lines without creating a chubby or fat face.
A: The key to answering your question is to understand the anatomy of the submalar triangle area. This is an inverted triangle facial zone that lies below the cheek bone in which the apex of the inverted triangle goes down below the corner of the mouth. Almost all of this area is not supported by bone, but by soft tissue only. As a result, a submalar implant will only help create fullness in the upper region of the submalar triangle. The smile lines lies in the lower end of this triangle and will not be changed by a submalar implant. Soft tissue augmentation must be done in the smile line area. Fat injections is one method but is fraught with unreliable take as you have experienced. But its simplicity remains its appeal and another effort at it may produce even better results. The other option, which I currently prefer due to its better effect and longevity, is interpositional dermal grafting. By placing layers of allogeneic dermal grafts in this area, the skin and the underlying tissues are released and separated by the grafts. They add an eventual well-vascularized tissue layer that can be from 2 to 5mms thick which is not unduly bulky. They must be placed through a limited facelift (preauricular) incision. Their longevity is much more assured than injectable fat grafts in this facial area.
Dr. Barry Eppley
Indianapolis Indiana
Q: I live in New Jersey and loved reading your advice articles on injectable fillers. I am a 42 year-old female with dark circles under my eyes with hollowing, upper lip wrinkles, and horizontal forehead ceases. I would love to know if you could recommend a skilled Dr in my area who could do my eyes? Thank you for your time.
A: Injectable fillers can be used to create a variety of instantaneous facial effects by adding volume under the skin. While once limited only to lessening the depth of the nasolabial folds or increasing the size of one’s lips, their uses are being expanded. One of these newer areas is around the eyes, specifically for hollowing of the lower eyelids or treatment of the tear trough depression. This lack of volume can be one of the contributing factors to the appearance of dark circles under the eyes. Suborbital injection filling is one of the more technique sensitive (trickier) areas to inject well however. There is definitely much greater risk of bruising due to the many blood vessels in this area. Missing all of them can not always be predicted. Proper placement of the filler in the deeper tissue level down to the bone is important to not only get the best fill but to avoid lumps of the material if injected just under the skin. For those physician injectors that regularly perform blepharoplasty (eyelid) surgery, they will more likely feel comfortable placing the injectable filler into the proper tissue level. They will also be in better position to judge whether an injectable filler is the best treatment option and how it might compare to other methods of treatment such as fat grafting.
Dr. Barry Eppley
Q: I am interested in what a limited facelift or lifestyle lift might do for me or if I can get away with fillers or something like that. What is the comparative recovery time? Costs? How long do they last?
A: One of the common misconceptions in management of the aging face is that injectable fillers and some form of a facelift treat the same problems. They do not and, as a result, are not comparable treatments. They are often companions (done together or in separate stages) but are never substitutes for each other. Injectable treatment are for the central part of the face and do things that surgery generally can not either achieve or do very well. These include Botox for forehead and eye wrinkles and fillers for nasolabial fold depth reduction and lip wrinkle reduction and lip size increase. Any form of a facelift deals only with the sagging skin and excess fat in the neck and jowls, lower third of the face sagging.
There are procedures touted as ‘liquid facelifts’ but these are a bit (or maybe a lot) misleading and are associated, in my opinion, with a relatively poor value. By using injectable fillers, the sides of the face and cheeks can be puffed up which does create a mild temporary lifting effect due to the expansion of the tissues. The operative word is temporary (six months or less) and, when one compares the cost of numerous syringes of injectable fillers, one could already be more than halfway to one of the variations of a facelift. This injectable approach will also do nothing for the neck area which is the primary target of facelift surgery.
For the patient with lesser amounts of facial aging, the combination of a limited facelift (aka Lifestyle Lift) and injectable fillers can create a very dynamic effect by being able to treat the entire face more effectively. There is a very definite role and benefit to injectable fillers but their results are not comparable to facelift surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin reduction just about two months ago. I still have not seen any results. If anything I feel that my chin seems longer then before. I spoke to the doctor about it and addressed my concerns. He said it takes up to 6 months for the final results. If by then I am not happy with it, he will then try something else. What to you suggest?
A: There is no question that any form of chin surgery takes time for the swelling to go down. In my experience in chin reduction, this is particularly true as swelling will mask a reduction longer than it will an augmentation. (the result from a chin augmentation will be seen immediately, the issue is that it initially looks too big due to the swelling) The initial soft tissue swelling from most forms of chin reduction will make it look longer or bigger initially and this is normal. Generally, however, the results start to become apparent within three to four weeks at most. By six weeks, patients should be able to say that they see a difference if not significantly so. It will take three to six months, however, for the true final result to be appreciated.
One important factor that controls the amount and duration of swelling is what type of chin reduction procedure was performed. There are two different types of chin bone reduction procedures, an osteotomy and a burring or shaving. One is done from inside the mouth (osteotomy) and the other is done from an incision underneath the chin. Knowing which one was done can help determine how long it may take to see the final results from the chin modification.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am exploring cheek implants as a solution to my flat cheekbones which i was born with.sunken cheeks (genetic). I live in Pennsylvania and wanted to find out if Dr. Eppley would initially review emailed photos before making an appointment.
A: The concept of ‘consults from afar’ in plastic surgery was once inconceivable and impractical. But the internet and the ease of photographic acquisition and transfer has changed that perception. Since almost all of plastic is external and very visible, physical and cosmetic issues can now be seen from great distances by simply sending pictures. In fact, the reach of the internet and its virtual no cost has made it possible to connect any two places in the world, at the very least by e-mail.
I regularly (daily ) do internet plastic surgery consultations. Many are from various U.S. states and provinces of Canada but some are from countries around the world ranging from the United Kingdom to China. There are two types of internet consultations. The first type is of an e-mail nature only. Inquiries are initially done by e-mail from which I request photographs for review and possible computer imaging. That may then proceed onto an actual phone call for the next level of more indepth discussion. The other type is a Skype video consultation. Its origin may be from an initial e-mail or from Skype itself. If a video Skype consultation is arranged, then photographs may be bypassed due to actually seeing the patient. However, due to the poorer resolution of many Skype video connections, photographs are recommended to be sent first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi. I know I might be young to ask, age 19, but I was wondering what you called a plastic surgery that takes care of love handles. But I am not talking about the hip handles. I have some pretty good handles right under my breasts that wrap to my back. I believe it is some loose skin as I have managed to loose 25 pounds this past year. I am just wondering what you would call that specific body part and maybe an average of how much it would cost to fix it. Thanking you in advance for replying. From a discouraged yound girl.
A: The important question is whether the rolls underneath your breast that extend into your back are skin, fat or a combination of both. With weight loss, most loose skin is going to develop and be seen lower due to gravity. That being said, I would have no doubt that it is a combination of loose skin and fat. Whether one is more predominant over the other would require an actual physical examination to make that distinction. But given your young age, I would recommend a liposuction procedure for fat reduction first and see how the skin adapts. The fat in the upper abdomen and the back is more fibrous in nature than lower abdominal fat and a liposuction technique, such as Smartlipo, will be more effective than traditional liposuction. There are methods of skin and fat removal by excision in the upper abdomen, which do leave lower breast fold scars, but they are usually reserved for more extreme cases of weight loss where the sagging skin is the predominant problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey! I have large indentation on the right side of my frontal bone. It is becoming noticeable since I have started losing my hair. I am wondering if it is possible to correct it without any visible scars. Thanks and.hope to hear from you soon.
A: For select cranial defects, the use of the new Kryptonite bone cement may make it possible to fill out or augment deficient bony areas. Because of its flow characteristics, it can be injected through long small plastic catheters into cranial areas from a small incision placed in the most inconspicuous location as possible. Studies have shown that it is injectable through catheters as as small as a 12 or 14 French size. (roughly 4 to 5mms internal diameter) Once injected it can be molded through the skin from the outside until it steps up into a firm consistency.
When defects are present on the frontal bone, it is important to recognize the exact location if this injectable technique is to be used. Defects that exist between the anterior temporal lines are bone-based and can be augmented by onlay bone materials. If the forehead defect extends beyond the anterior temporal line, this area is covered by the upper edge of the temporalis muscle. While the temporal muscle can be lifted up and material added onto the bone, this is not possible with a limited incision injectable treatment method. Defects that extend into the temporal area require the more traditional open scalp incision for access and wider exposure.
Indianapolis Indiana
Advertising and marketing permeates our existence at every turn. It is so omnipresent that it takes outlandish claims and often near unbelieveable stories to even catch most people’s attention anymore. Nowhere is this more true than in anything connected to the pursuit of beauty and youth. From magical skin care creams that purport to make one look 10 years younger in just a fraction of that time to amazing non-prescription supplements that claim to grow body parts, it is hard to separate reality from just another pitch into your pocketbook.
The world of cosmetic surgery, even though it is done by medical doctors which should be more credible, frequently falls into these same marketing shenanigans. This has become rampant in the unregulated sphere of cyberspace where the only monitor is whomever is doing the posting. But when it comes to board-certified plastic surgeons, it is a completely different story. The American Society of Plastic Surgery provides it members with a clear set of ethical regulations and rules which clearly provides what can and cannot be marketed and claimed. Violation of these rules can result in Society expulsion. Here are a few of these highlights.
Plastic surgeons are not allowed to claim to be the ‘best’ without indicating where that claim comes from. No claim of superiority of skills or results of those skills can be stated compared to physicians of similar training unless it can be factually verified by the public. There are no rating methods provided by any legitimate plastic surgery society. Patients may have different experiences with various surgeons, and the internet provides countless means by which to report them (unregulated and one-sided), but plastic surgeons and their results are not something that can be quantitatively evaluated like a product by Consumer Reports.
The use of before and after photographs must be of the same patient and unaltered. Photographs that have been digitally altered, are of different people, or show results that are not typical for the average patient is forbidden. Before and after surgery pictures that use different lighting, angles and poses that misrepresent results from any plastic surgery procedure is prohibited.
American Society of Plastic Surgery members cannot participate in a raffle, fund raising event, contest or promotion in which the prize is free surgery. No method of inducement to encourage patients to undergo surgery for a financial reason can be done. When you see such a contest or someone who has won a free makeover, you can be assured it is not a board-certified plastic surgeon that is involved.
Claims can not be made of guaranteed surgical results. Predictions of any outcomes of surgery, including satisfaction or any degree of improvement, is likewise prohibited.
Procedure description or outcomes that are placed next to a picture (usually a model) whom has never had the procedure is another ethical violation. This would suggest that the accompanying picture is representative of results that the plastic surgeon can produce. While models in advertisements may be used, they must clearly state next to them that the person in the picture has not received the advertised procedures.
The need for such rules in advertising and marketing in plastic surgery runs counter to what is happening in the ever expanding world of the internet and social media. On the one hand, such rules seem both fair and obvious. But in the pursuit of the cash paying patient for elective surgery, it should be no surprise that the temptation for anything goes can be a powerful one. Plastic surgery is taking the high road in ‘truth in advertising’ and is holding its member’s feet to the fire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a male and would be interested in receiving a surgery in order to correct my bulging forehead. Do you perform that kind on procedure on men?
A: Forehead surgery or forehead reshaping can mean different things to various patient, both male and female. The two most common procedures performed on the forehead are brow bone reduction in the male and brow bone reduction/tapering in the transgender patient. (male to female) There are also a variety of other forehead reshaping procedures from defects and asymmetry caused by craniofacial birth defects and trauma and prior neurosurgical/craniotomy operations. Bu, by far, regardless of the diagnosis the vast majority of forehead surgeries are done in men.
The typical cosmetic reason for male forehead surgery is brow bone reduction. Large brow bones, caused by overgrowth of the underlying frontal sinus, can create very prominent bulges in the forehead bone above the eye. (supraorbital rims) While most patients think it is a thickening of the bone and a simple burring down will suffice, this is not so. Rather the frontal table of the frontal sinus (visible brow bone) must be removed, reshaped, and then put back in a more flatter or recessed position. While tremendously effective, the access to perform that procedure requires a long scalp incision. This cosmetic trade-off is a serious one to consider and is usually an issue which prevents most men from having the procedure. Until a more minimally invasive approach to brow bone reduction is developed, most men with prominent brow bones will have to live with them.
Q: I have a noticeable cleft in my chin and I was wondering what procedures can be done to remove the cleft and how invasive are they?
A: Soft tissue indentations of the chin can appear as either clefts or dimples. While both involve the chin soft tissues, they are anatomically different. Chin dimples are round depressions in the middle portion of the soft tissue pad of the chin and occur because of a central muscular and fat deficiency. There is no underlying bony abnormality. Chin clefts are vertical indentations that run from the middle part of the soft tissue pad down to the lower border of the chin. While they also have a muscle and fat deficiency (cleft of the soft tissues), they almost always have some notching of the lower border of the chin bone as well. (symphysis) Embryologically, it is easy to understand how a chin cleft occurs because of the union of the mandibular arches in the midline during development. It is harder to understand the origin of the central dimple although this likely represents an area of lack of epidermal cell adhesion during the final phase of merging.
Chin cleft surgery is best thought of as a reduction rather than a complete removal. There are two fundamental ways to perform the procedure based on the depth of the cleft and the tolerance for any outward scarring. An intraoral approach can be done where the the tissues under the skin are released from the bone, the cleft of the chin bone is filled in (if deep enough) and the muscles put back together to create more of an outward pout of the muscle. This works well for modest to moderate deep chin clefts. In very deeply grooved chin clefts, this will only provide partial depth reduction. Outward skin excision is more effective in these deeply grooved clefts but the creation of a vertical scar, even if the surrounding skin edges are smooth, may not be cosmetically acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I am trying to find an expert z plasty surgeon and I was wondering if you could help? Thank you.
A: Z-plasty is a common plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It has a long history of use in plastic surgery and is one of the original scar revision procedures. It can lengthen a contracted scar or change the direction of a scar’s tension line. It is conceptually done by initially drawing the he middle line of the Z-shaped incision along the line of greatest tension or contraction. Triangular-shaped flaps are then raised on opposite sides of the two ends and then switched or transposed. The transposition of these two triangular skin flaps creates the classic Z shape of the final scar lines. The angles at which the triangular flaps are cut will determine how much the scar is really lengthened. The traditional 60° angle Z-plasty will give a theoretical lengthening of the central limb of 75%. Different angles of the flaps will give variable amounts of lengthening. While the mathematics of these flap angles are interesting, the most important thing is that the z-plasty will always lengthen a scar. Single or multiple z-plasties can also be used in a variety of clever ways for longer scar problems.
The use of z-plasty scar revision and contracture releases is very common and every plastic surgeon is trained and knows how to use them. Therefore, ‘expert z-plasty’ surgeons would be any board-certified plastic surgeon in your local or regional community.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am about to undergo a third surgery for my short mandible. My first surgery consisted of bone grafts to the jaw angles with a sliding genioplasty for my chin. I then had a second surgery in which silastic jaw angle implants were placed as the bone grafts had resorbed. For my upcoming third surgery, a medpor chin implant is going to be used which will extend back to the jaw angle. My doctor is concerned, however, about placing the medpor implants over the indwelling silastic implants (to improve the angle still) because of issues with bonding medpor to silastic. I assume it will take some method to secure the two implants together. He is concerned with slippage of the two implants placed on top of each other. Do you have any suggestions as to how to fix these two implants together? Your comments will be very appreciated. Thanks.
A: Commenting on another surgeon’s operative plan or method of surgery is not really appropriate from my perspective. I am certain that your surgeon would not really appreciate it and, if he needed help in the planning, he would have his own reference sources to ask. In addition, the details of exactly what has been previously done and the specifics of this next proposed surgery are lacking in your brief description of the issues. I wish you the best in this upcoming surgery and hope that your desired final aesthetic goals from your jaw reconstruction will be successfully met.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I had a hair transplantation done about 6 years ago which left me with a terrible strip Scar on the back of my head. Because of the failure of the hair transplant, I now shave my head smooth and this scar is particularly noticeable. Getting the hair transplant was the worst decision I ever made in my life. I am trying to get to a scar revision to reduce the size and appearance of the scar.Is it possible to get good results? I have attached pictures of my scar. What is the best procedure available?
A: Thank you for sending pictures of your hair harvest scar. Admittedly it is not a good looking scar from this procedure as it is very long and wide and the suture or staple marks are quite evident. It is also unusual in that is obliquely oriented which was undoubtably done to get the most follicles for the transplant but poor orientation for good scar formation.
Most certainly, this scar should be able to be substantially improved with scar revision. The length and orientation of it can not be changed but it can be made much thinner. In that regard, scar revision can offer improvement. The scar must be cut out completely but the key to a narrower result is what is done underneath. The galea deep to the follicles must be released and undermined so the scalp can come together without much if any tension. Tension is the enemy of any scar narrowing effort. The deep layers are put together to take tension off of the skin. The sutures to close the skin are merely put in help it heal quickly but will not ward off tension on the closure line. The skin must also be handed gently to avoid injuring any hair follicles. Loss of hair in the scalp equates to a wide and noticeable scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a very noticeable buffalo hump and I have tried the traditional liposuction and it didn’t work. I just recently tried smart lipo and the Doctor said the area was too fibrous and he could not get the laser probe in. He said that there was too much scar tissue. My neck is still swollen since this procedure was just attempted several weeks ago. Are there any other solutions to get this buffalo hump off of me?
A: When neither liposuction option will work, there is always the traditional method of excision for the buffalo hump neck deformity. This is actually more effective than liposuction in terms of the amount of reduction because the buffalo hump is a different form of fat that is not as easily removed due to its natural more fibrous composition. But there is the trade-off of a midline scar from the nape of the neck down into the upper back to do the procedure. The length of the scar would be no longer than the vertical height (length) of the buffalo hump. There will also be a need for a drain after surgery as the tendency to form fluid collections (seromas) after open excision is quite high.
While this approach may leave a scar, this may now be a good alternative given that two attempts at ‘non-scar’ liposuction has not worked. It is a matter of trading off one deformity for the other. You have to decide whether the scar is a better ‘problem’ than the buffalo hump.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am in need of a septoplasty and turbinate reduction for nasal obstruction and snoring. I am considering rhinoplasty at the same time as I have a larger nose which I want to make smaller. Do you perform turbinate reduction with radiofrequency ablation? Do you have an idea how much my insurance may cover due to breathing problems and what part I would have to pay for the rhinoplasty?
A: Contemporary turbinate reduction can be done by a variety of methods, all intended to shrink the size of the turbinates rather than by just cutting them out. Several methods exist including radiofrequency ablation. That is not a technique that I use. I use diathermy or cautery ablation and have done so for years. Whether one method over the other provides a better result is unknown as both approaches cause shrinking of the inferior turbinate by devascularization and some degree of mucosal necrosis.
Insurance almost always covers any form of internal functional nasal airway surgery and their willingness to do so has actually improved over the years unlike many elective medical procedures. Such allowed coverage is determined beforehand through the typical insurance pre-determination process.
Doing rhinoplasty at the same time as nasal airway surgery is obviously common and efficient from a nasal perspective. While insurance does not cover rhinoplasty, there is no question that it does help to lessen the cost of rhinoplasty as opposed to it being done as a stand alone procedure due to time efficiencies and many surgeon’s willingness to accept some reduced cosmetic fee for doing it.
The answer of the cost of rhinoplasty with internal nasal surgery would be based on what type of rhinoplasty is needed (partial vs. full) and what facility the procedure may be performed in. (different facilities have varying fees for operating room use and anesthesia charges) As a result of these variabilities, definitive cost estimates would require knowing what type of rhinoplasty you need and where it would be performed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a deviated septum. I am pretty sure my insurance covers surgery to fix a deviated septum. I was wondering whether would there be anyway of sliding in a rhinoplasty while fixing the deviated septum to cover majority of the costs. How would that work, thanks so much.
A: The premise of your question is…can I get insurance to pay for part or all of a cosmetic procedure? While the answer to that seems obvious, it is actually an understandable and common question that has historic precedence. In the past, many cosmetic procedures were done at the same time as medical or insurance-covered procedures…and the patient was never charged for the associated expenses of operating room charges and the anesthesiologist’s time. They were just ‘rolled into’ and considered part of what was billed to insurance. The hospital or surgery center never really knew or just looked the other way.
But such surgical behavior is now long gone and is viewed for exactly what it is…insurance fraud. Getting the insurance company to pay for part of a cosmetic procedure, just because a medical procedure is being done, is not what any patient’s health insurance is intended to cover. Nor are they obligated to do so. And the insurance companies understandably take a very dim view of such actions. As a result of such past behaviors, health insurance companies have gotten very vigilant of such behavior as well as hospitals and surgery centers. There are substantial fines and even criminal sanctions if such actions are discovered on the providing facility. Therefore, any operating facility is fully aware of whether a cosmetic procedure is going to be done and expects to be paid in advance for the time involved in performing the cosmetic part of the operation.
Similarly, expecting or asking your treating plastic surgeon to make an operation appears as if it were medically necessary, when it isn’t, is just a different form of fraud. Septoplasty, or internal nasal surgery, provides functional breathing benefits and is medically necessary. A rhinoplasty, unless done as a result of a birth defect (e.g., cleft lip and palate), accident, or as a result of tumor removal, is a cosmetic change that is not eligible for medical coverage.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting just a mini-armlift. I can’t seem to find any plastic surgeons that say they have actually done one. I don;t think my arms are bad enough for a full armlift and I don’t want that scar anyway. I just need a little tightening in the upepr part of my arm.
A: Armlifts, known in plastic surgery as brachioplasty or upper arm reductions, are traditionally thought of as a long excision of skin and fat between the armpit (axilla) and the elbow. While this is tremendously effective for ‘bat wings’ after a lot of weight loss, those women with more minor degrees of upper arm sagging on not good candidates because the scar would be worse than the sagging arm problem. This leaves the alternative arm strategy to either liposuction alone or liposuction combined with some limited upper arm skin removal, known as the limited brachioplasty or mini-armlift.
In the mini-armlift, the removal of skin for tightening is restricted to the upper 1/3 of the arm or just that of the armpit area only. (crescent-shaped excision) It can be removed staying inside the axillary skin folds or be extended somewhat further out onto the upper third of the arm. That scar can be placed on the inside of the upper arm or from the backside. The scars end up in different locations and there may be advantages either way for each patient. I have done the skin removal from both upper arm locations successfully and each patient must carefully consider their preference for scar location. While the skin removal adds an obvious tightening effect, the aggressive use of liposuction is really the mainstay of the procedure and is responsible for much of the result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I am a 16 year-old that is doing at school an assignment called the Research Project. It is where we have to choose a topic and learn about it and, in the end, we have to do a 10 minute oral presentation on it. I was wondering if you could help me with some questions. The question that I am focusing on is ‘How does craniofaical reconstruction change someone’s life?’. And also how would I write a survey for this type of question or topic. I hope that you can help me. I need all of this done in about three weeks so if you could email me that would be good.
A: Craniofacial surgery is a specialized area of plastic surgery that involves the reconstruction of deformities of the skull and face, whether they be from birth defects, traumatic injuries or from various benign or malignant tumors. Much of this work is about the rebuilding or moving of misplaced or missing bones of the face and skull. While not exclusively done in infants and children, much of craniofacial surgery is done early in life when possible to work with the growing face and to help children develop more normal social interactions. While there may be many functional problems that come with craniofacial deformities, creating a more normal looking skull and face helps provide a significant psychological benefit as well. While we may not always like it, how we look and are seen by others plays a tremendous role in one’s self-image and acceptance by society.
If one was constructing a survey on the topic, one would want to ask how the craniofacial reconstructive procedure made them feel after surgery and what specific impact it had on their lives.
Indianapolis, Indiana
Q: I’ve had a consultation and qouted prices for surgeries. However I wanted to know if Dr. Eppley particiapates in the Doctors Say Yes finance program. I am willing to do this however only if I’m able to use a good reputable plastic surgeon like Dr. Eppley. Please let me know if he is apart of this type of finance. Thank you for your time.
A: The use of financing for cosmetic surgery, whether it is done through separate financing companies or using one’s own credit cards, is common practice. I would estimate that up to 30% to 40% of cosmetic surgeries across the United States are now financed in some fashion. That is a far cry from what it was a mere decade ago where estimated numbers were around 5%. This obviously reflects the national trend toward financed luxury purchases in general as well as the greater demand for cosmetic surgery. Over the years, my practice has used a variety of financing programs which now number into the dozens. We have had both good and bad experiences with them in terms of ease of use, financing terms, and the ability to get patients actually financed. Currently we use Care Credit as our primary referral for cosmetic surgery financing. They have worked out to be the best in terms of approvals, finance terms, and ease of use for both our office and the patients to work with. I am not saying they are absolutely the best as we have not worked with every single financing agency out there. Just that in our financing experience, they have worked out the best for both the patient and ourselves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr Eppley. I have several issues about my face that I would like changed. I am a 21 year old female with prominent eyes along with an oblong face shape. My eyes are not bulging out but they are just prominent. I have no cheek bones. It must just come with having a longer face shape I guess and I lack fat below lower eyelids. I was considering a mini face lift to make my eyes less prominent and my face look less tired. But as I have researched it’s too early to get it done at my age. What options do I have? What would you recommend in order to make my eyes look less prominent and get some volume on my face to get rid of the tired look and make my face look fuller (rounder).
I’m sorry for the long question but I’m so excited to come across your site since I see that you are experienced in almost all areas of cosmetic surgeries.
A: By your description, it appears that you have a longer but flatter face. Flatter in the face refers to a recessed development of the midface, particularly the zygomatic-orbital skeletal areas. (midface, cheek and lower eye socket bones) This lack of anterior projection makes a face appear longer, particularly if the vertical height of the face is long to start with. This also accounts for the lack of fullness in the lower eyelids (sunken in appearance) and the apparent big size of the eyes.
While your eyes may be big in size and your face long, the lack of cheek and lower orbital rim bones can really accentuate that appearance. Improvement of midface deficiency at this level is done by the use of cheek and orbital implants, specifically a combined infraorbital rim-malar implant. This provides fullness across this deficient bony area and provides some horizontal projection. (fullness) This helps balance the face better, make it look a little shorter and can help make the eyes look a little less prominent. These implants are placed through a lower eyelid incision.
Any form of a facelift is exactly what you don’t want to do. This is not a skin problem but a bone-based issue.
Dr. Barry Eppley
Indianapolis Indiana