Your Questions
Your Questions
Q: I have read that paranasal implants can be done in local anesthesia. Is this right? Is local anesthesia possible also with malar implants which are placed right next to paranasal implants? Does not the lifting of the periosteum from the bone hurt in spite of the local anesthesia? Thank you very much for your information.
A: Cheek and paranasal implants are placed from an incision inside the upper lip. Besides the mucosal incision, muscles and the periosteum covering the maxillary and zygomatic bone must be lifted up and a pocket made to place the implants. Given the proximity of the paranasal area to the upper lip compared to the cheek area, it would be ‘easier’ to position paranasal implants under local anesthesia as opposed to cheek implants where greater dissection is needed and the feeling in this area has more contributing nerve endings. You are correct in that it is the periosteum that is the most sensitive part of the surgical dissection. I also prefer to us screw fixation for the implants that I place in the midface which can cause more discomfort from the bone drilling.
While just about any surgery can be done under local anesthesia, I am not sure if I was a patient that I would ever do it that way. (particularly cheek implants) Unless there is some compelling medical reason why IV or general anesthesia could not be used, it would be more comfortable and slightly less costly to use some form of anesthesia for this type of facial implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have sleep apnea and a very thick fat neck. I was wondering if liposuction of the neck would help my sleep apnea? My thought is that if the fat was removed from my neck it would not be so heavy when I laid down. That way it would not push down on my neck and obstruct my throat as much when I was sleeping/ Does this make any sense? What are your thoughts?
A: While liposuction of the neck may help improve the shape and profile of it, I doubt very highly if it would make any improvement in your sleep apnea. Your logic seemingly makes sense but the flaws in it are that fat doesn’t weigh very much, the thyroid cartilage protects the voice box and lower area with a stout shield of protecive armour and the usual sites of anatomic obstruction are usually higher and are closer to the base of the tongue. While I don’t think liposuction of the neck will have any negative effects, it is not an acknowledged procedure in the surgical treatment of sleep apnea. Procedures such as septorhinoplasty and turbinate reductions to open the nasal airway, maxillary and mandibular advancements to open up the entire posterior oropharyngeal airway, shortening of the soft palate (fading in popularity) and bony chin advancement and genioglossus procedures to bring the base of the tongue forward are well recognized sleep apnea operations. Other non-surgical efforts include weight loss and various dental appliances. Before considering any of these options, one should be fully worked up by a sleep apnea specialist to search for the most effective solution.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in trying to get my face to look less fat. I want to make my face slimmer if possible. I have a small double chin and fatter cheeks and jowls. I have read about Lipodissolve injections and this seems like a good and easy solution for my small areas of facial fat as I know these injections are for small areas and not big ones. Do you think this will work for me?
A: While Lipodissolve injections can provide some minor benefit in fat reduction in the neck and jowl areas, they require three or more injection sessions (spaced 4 to 6 weeks apart) to get the best result. After each injection session, the treated areas will double or triple in size for one week as part of the inflammatory by which it breaks down the fat. . Because of this socially visible recovery, most patients will opt for a more effective set of procedures that actually has less total recovery even though it is surgery. I would recommend a combination of submental, jowl and lateral face liposuction and buccal lipectomies. This reduces all available fat compartments in the face that can easily and safely be treated. This is is the best way to get a slimmer face through fat reduction. It has less recovery than Lipodissolve injections because the swelling is only one time and is largely over after a few weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 30 yrs old and am tried of people telling me that I am in my mid to late 40s. Ugghhh! I usually just walk away and cry and I am tried of crying over this and want to get something done about it. I have had a brow lift and a neck liposuction about 2 yrs ago. I would like to see what it would look like with eyelid lift and filler. Would you also recommend something else? Maybe a chemical peel? Thank you for your help! I really appreciate it!
A: Thank you for sending your pictures. Unfortunately computer imaging is good at changing structures of the face but not very good at soft tissue manipulations such as those that you have asked for. An eye lift can not be done as it distorts the whole eyelid. However, I think there is no question you have upper eyelid hooding and you would clearly benefit by an upper blepharoplasty or eyelid lift. Putting in fillers along the nasolabial fold and lips is also not very accurate and often just distorts the lips in trying to image it. You have reasonable lip size so injectable fillers will make them nicely bigger. As you have suggested, a chemical peel is good for skin texture and brightening the glow of the skin and for fine wrinkles as well.
As for other recommendations, I have done some other changes just to look at how to soften your facial features and make your face more ‘youthful’. These have included the following:revisional browlift to lower hairline (reduce long forehead) and correct existing brow asymmetry, rhinoplasty to make nose look slimmer and more narrow and chin reduction to soften chin point and make softer looking.These are structural facial changes which are different than just anti-aging procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had severe migraines for years. My migraines start in the back of my head and shoot up into my scalp and down into my shoulders. It usually feels like there is a vise on the back of my head. I have been to a lot of doctors and have tried everything from every drug out there to chiropractors, acupuncturists, massage therapists and even Chinese oriental practitioners. A few things worked for several days or a week but nothing lasts. I went to the local university and saw a neurologist there who did an MRI and other blood tests and came up with nothing. His drugs didn’t work any better. I have read recently on the internet about some type of migraine surgery. While I am desparate to try anything, the thought of going through surgery and then not have it work would be disappointing to say the least. What is the success of this new migraine surgery?
A: Migraine surgery is based on the concept that there is a peripheral trigger or site of nerve compression which is the stimulus for the attack. One of the four recognized trigger zones is at the greater occipital nerve at the back of the head at the base of the skull which causes occipital migraines. Whether surgery would be effective can be predicted beforehand through the use of Botox injections into the area. A positive response to Botox, which includes a significant and sustained relief of the migraines, correlates highly with surgical success. While about 1/3 of patients will have a near complete elimination of their migraines, 2/3 s will have reduced frequency, intensity and duration of attacks. A recent clinical study reported that 90% of patients treated maintained good relief out to five years after surgery which as the time limit of the study.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would love to have breast augmentation before my 21th birthday which is later this spring. My preferred approach would be breast augmentation with an incision through armpit area But I also considering the option of an inframammary incision using Memory gel breast implants. Which do you think would be better for me? Thank you.
A: Breast augmentation poses multiple choices for prospective patients to consider. These options are driven by implant choice which can secondarily control the placement of the necessary incision. Saline breast implants are often placed through a small armpit incision because they are inserted deflated and then inflated once into position. Silicone gel breast implants, unless they are very small, can not be placed through the ampit because they are inserted pre-filled or fully inflated. Thus, they are usually placed through a lower breast crease or inframammary fold incision.
But the incision is not the most important part of the breast augmentation procedure, the implant is. All incisions heal really well and are rarely of any secondary cosmetic consequence. Therefore, it is important to understand fully the differences between saline and silicone gel implants. While both work well and do an equally good job at making a larger breast, there are some important minor differences in them that are relevant in the long-term. This is especially pertinent to you at your young age since you will live to see them. These include such risks as implant deflation (saline) and silent rupture. (silicone) You will be replacing these implants at least once on your long remaining lifetime so understanding these differences is important to you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am going to get a facelift and want the scars to heal to that no one will know that it was done. I have read about a Laser-Erase procedure that can get rid of the scars almost immediately. Does this really work? What are your thoughts?
A: Over 100,000 facelifts and an equal if not greater number of eyelid tucks (blepharoplasty) are performed each year in the United States. While the incisions in the eyelids and around the ears generally scar imperceptibly, patients are understandably motivated to get the best scar result as possible. Getting a more youthful appearance at the expense of poor scarring would not be a good trade-off.
Concerns about the possibility of less than ideal scarring, numerous plastic surgeons have touted an early laser scar treatment program. Laser-Erase is just one ‘branded’ name of this treatment approach. The concept is that about two weeks after facial surgery including facelifts, eyelid surgery or any other facial procedure that requires an incision, the incision line is then treated with a light laser resurfacing procedure. Some use high intensity light or IPL treatments as opposed to an actual laser. It is touted that the ‘incision is then erased with the laser’. The theory is that the laser disrupts a scar from forming in the very early stages of the healing process, thus to quote one treatment provider, ‘the incision line is banished from sight with a zap of the light.
While this early treatment of a scar sounds very appealing, there is no science to back up its touted benefits. Plus it goes directly contrary to how wounds heal in general. No scar can be prevented from occurring between two closed edges of skin. Scar formation is inevitable, and a little burning or heating of the upper part of the wound edges, will not make it disappear. Any scar benefits that subsequently occur are a result of a natural healing and scar fading process. Such early scar treatments are more about marketing and sales than they are about any form of a new revolutionary scar treatment approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: For my bulgy forehead, is it possible to burr down the forehead and then do a forehead/eyebrow lift at the same time, just removing the extra skin? The reason I ask is because my head is misshappen and my hairline is too high. I want my hairline to be lower so burring down some of the forehead and then making and eyebrow lift would help alot. After that is done I was going to get a hair transplant on my hairline to cover up the scar. Does this sound like it will work? Will it work if I get a hair transplant over the scar and can I do the eyebrow/forehead lift thing?
A: Your approach to a forehead or frontal contouring is conceptually correct. While I don’t know exactly where your exact hairline is now or what its shape is, making a scalp or coronal incision there allows one to access the forehead area. Probably about 5mms across the forehead bulge can be taken down. A browlift can then be performed and the redundant skin removed at the scalp incision line. This will shorten the perceived length or height of the forehead skin. Thereafter, no more than 3 to 6 months later, a hair transplant can then be done to put a camouflage to the scar. Such a scar in the scalp can often heal remarkably well due to the uniqueness of hair-bearing (or past hair-bearing) scalp skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I was wondering if it is possible to shave down certain parts of the skull. My forehead isn’t the way I want it to be shaped. I am trying to get my forehead to stick out a little less. Is it possible to shave the skull down? And if so how much can be taken off?
A: The thickness of one’s skull can be taken done by burring. How much it can be reduced is determined primarily by the thickness of one’s outer cortex. The skull has three bony layers, an outer hard cortex, an inner spongy marrow space and and an inner hard cortex. While the burring reduction can be taken down past the outer cortex into and through the marrow space, that causes a lot of bleeding and can make for an irregular surface. Therefore for practical reasons, the outer cortex is usually the only skull thickness reduced when done for cosmetic purposes. That can vary in different skull areas but in the forehead in a man, that may be up to 5mms or so.
The more significant rate-limiting step for male forehead reduction is the incision needed for access to do the procedure. A scalp incision is needed to turn down the scalp so the bony forehead is exposed for reduction. Given the unstable frontal hairlines and hair densities of most men, forehead surgery of any kind may not be worth the trade-off of a scalp scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin reduction a couple of years ago and although I am happy with the new shape of the bone, I now have hanging soft tissue. Needless to say I am not happy with these results. I have visited five plastic surgeons and none of them wanted to fix this problem saying that it was dangerous to cut or reattach the muscles and the ending results could be worse. I am very dissapointed and have attached some before and after pictures for your review. I hope you can help.
A: Your pictures show quite clearly some soft tissue sag or ptosis off of the chin bone. It is most pronounced centrally which is what one would expect given that your chin reduction was most likely an intraoral burring approach done to the central button. To improve this problem there are two approaches, intraoral muscle resuspension or a submental tuckup. The intraoral approach uses a suture anchor to the bone to reattach the muscle and tighten it back done. This is a scarless approach. The submental tuckup uses an incision under the chin where the loose skin and muscle is removed and tucked or tightened to the bone. Each has its own advantages and disadvantages. The intraoral approach avoids a scar under the chin but the submental tuckup is a more reliable method.
There is no danger to performing this procedure and there is no chance of making the problem worse. Whoever has said has either never treated the problem or is completely unaware that such surgical correction exists.
Dr. Barry Eppley
Indianapolis Indiana
Q: I wrote you a couple of months ago about the possibility of undergoing a forehead contouring surgery to address my possible forehead bulging, to which you asked me to provide you with pictures. This is want I would like to do now and i have attached some forehead pictures for you to review. I don’t know whether the bulge is created by my high hairline or if it is just the way my forehead is. Basically, as previously stated, I would like to know if the problem is a high hairline or a protruding forehead, or both. At any rate, I would like to hear your surgical recommendations, or lack thereof!
A: Thank you for sending your pictures. I think there is some degree of a mild amount of forehead bulging that is accentuated by a higher hairline. Given the mild problem and the resultant scalp scar to improve it, I would not recommend any surgical modification. While it can certainly be done, the scalp scar in a male is a major limiting factor. This would not be such a rate-limiting step for surgical treatment in a female. I have looked at hundreds of male candidates over the years for cosmetic forehead contouring and brow bone reductions and could only ever justify surgery on about 2% to 3% of them.The magnitude of the forehead problem has to justify the trade-off of the scar to do it.
Indianapolis Indiana
Q: I have a long and wide forehead scar that I would like to be made to look better. I have attached some pictures of it for you to review. I was wondering if you think that laser resurfacing will help. I have read that it can make scars go away. What is your opinion of it?
A: The origin of your question is will any form of laser resurfacing make your forehead scar disappear. The simple answer to your question is no, no matter what type of laser resurfacing technique is used. And let me explain to you why. Your forehead scar is composed of abnormal tissue which is why it does not feel or look like normal skin. It is in fact abnormal tissue or scar but, most relevantly, that scar involves the entire thickness of your skin. In other words, the skin has been replaced by full-thickness scar. You can smooth of the surface of the scar out all you want with any form of laser resurfacing but it will always appear just as wide, just as discolored and just as obvious. Laser resurfacing only smooths out the surface of the scar, which is helpful if the scar’s main problem is surface irregularities, but it will get rid of the actual full-thickness of the scar. Only cutting it out (excision) can do that. When excision is combined with a geometric broken-line closure, the scar will become more narrow and less obvious. Secondary touch-up with laser resurfacing may be helpful but it is an ineffective treatment to do first. I realize that grasping out the hope of laser resurfacing seem appealing but it is but a treatment mirage. Formal surgical scar revision is what would benefit you the most.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.
A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.
Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.
While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.
The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am considering scar revision but need some direction. I basically have two small scars on my butt. They are small and they look like chicken pox scars However they are perfectly centered on each cheek. They are from a liposuction surgery I had many years ago. What is the best way to correct them? I hope you can help.
A: The three-dimensional shape or geometry of these scars is an important consideration. Are these scars wide and flat like chicken pox scars as you havhe described or are they wide and indented, having a central depressed component to them? Since they are old liposuction entrance scars, they are probably wide but the key question is are they indented or flat? That distinction is critical in choosing what type of scar revision to perform.
Excising small scars on the buttocks is easy to do and the intent of such an excision is to make the scar ultimately more narrow. While at the time of the procedure, they will be but in the long run they will likely widen again. The pressure of sitting on the buttocks will defeat most attempts at scar narrowing in this area if the scars are anywhere on the rounded portion of the buttocks. If they are around the perimeter or in the buttock crease, then such desired narrowing is more likely to be achieved.
If the scars are indented, however, cutting them and out and closing them make not make them smooth or flat. For this type of scar revision in this area, I would place small fat graft underneath them to prevent recurrent tethering or indentation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting a chin implant to make my weaker chin look better. It seems like a fairly simple procedure but this bone resorption underneath the implant sort of scares me. Why does this happen? Is there any way to avoid this bone reorption if I get a chin implant?
A: The phenomenon of bone resorption under a chin implant is a much talked about finding for many decades. One of the reasons that it occurs is due to a pressure issue with the implant sandwiched between the soft tissues and the bone. While the implant pushes the soft tissue out, causing more visible chin projection, the soft tissues do apply a small amount of pressure or recoil back over time. Since the implant is not going to resorb because it is an inorganic synthetic material, that leaves the underlying bone to accomodate and relieve this pressure.
This pressure situation is really magnified with implants that are placed too high on the chin bone. This happens when chin implants are placed from inside the mouth and are not secured down to the lower edge of the bone. It can also happen from a submental chin incision approach but is much less common because it it easer to keep the pocket of the implant low. The observation that it does not occur with more contemporary anatomical chin implants is because the wings of the implant keep them from riding up higher, acting like lateral stabilizing bars. From either approach, if the implant ends above the basal bone of the chin (which is thick cortical bone) it rests on bone with a much thinner cortex. This is where bone resorption will be seen with chin implants. It is a function of bone position and is not an actual feature or result of the implant or its material composition per se. This bone resorption phenomenon (which is largely benign and not of any great signfiicance) can be completely avoided by proper implant position on the lower edge of the chin bone. This will also maximize the benefits of the horizontal projection that the chin implant provides, some of which is lost if it gets malpositioned higher as it slides up and back.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have an unusual question. I’m half Chinese but my eyes are more Caucasian-looking. So I was wondering if there is a surgery to create an epicanthal fold at the medical canthus? ( the one that half covers/hides the tear duct). Some doctor once told it’s possible with a w-plasty or a jumping man flap to create a fold in the inner most part of the upper lid. And is it possible to lower the height of the eyelid? Like taking apart the previous fold and resetting it at a lower position? Many thanks and sorry for all the questions
A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin. Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.
Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.
When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?
Please send me some photos of your eyes for my further assessment.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with a nice shape ? Can it get warped and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.
A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.
In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.
The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.
Dr. Barry Eppley
Indianapolis Indiana
Q: My daughter has grown in the past two years a strange looking abdominal growth. It doesn’t look like any abdominal pannus picture I have ever seen. She is very obese but has a normal looking white abdomen which hangs down a little. However, directly under (and separate from) this normal looking abdomen is a huge purple/red hanging balloon which is ulcerated and infected. It grows out from under the abdomen right above the pubis. She is scheduled for surgery in a month and the surgeon is acting like he doesn’t know for sure what it is. It is estimated to weigh about 50 pounds. Have you ever run across anything like this in your plastic surgery practice?
A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.
With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.
Dr. Barry Eppley
Indianapolis Indiana
Q: I want to have breast implants done. I am not happy with the way my breasts look. But I have lupus and am not sure that I can have this procedure with this medical condition.
A: Whether breast augmentation with the medical history of lupus is a good idea would depend on what the extent and how symptomatic this autoimmune disease is in you. Do you have any known healing problems as a result of your lupus? Have you had surgery in the past and did you have any problems with healing or infections after surgery? Are you on any steroids or other immunosuppressive medications? What symptoms do you currently have from your lupus? What are your titer levels of ANA and other blood tests from your doctor?
Ultimately, what your doctor or rheumatologist would say about your lupus condition would have a lot to say about the adviseability of breast augmentation for you. Despite the past allegations that silicone breast implants cause autoimmune disease from the 1990s, that has now long been disproven.
The issue is are you more prone to breast implant complications from your lupus? Infection risk in the short term and capsular contracture in the longer term are the issues. If you have skin problems, such as banding and contractures, than you would be likely to get problematic breast implant capsules. If not and your lupus is stable and relatively asymptomatic, then breast augmentation may be a satisfactory procedure for you.
Dr. Barry Eppley
Indianapolis Indiana
Q: What do you think of hyaluronic acid for buttock augmentation? It seems like it would be a lot easier to do than using your own fat or putting a synthetic implant in your body.
A: While the family of hyaluronic acid fillers are commonly used for very small volume facial augmentation, they are very rarely or never used to try and fill other body areas which require much larger volumes. While it may be a biologically sound concept, it is an economically terrible idea. The volume of hyaluronic acid needed, if we use fat as an analogy, would be around 350cc per buttock or 700cc per procedure. If we use the cost factor in the U.S. of $375/1cc syringe for Restylane that would be a buttock augmentation at a cost of $262,500…all for a result that would last 3 to 4 months. Using Juvederm, which would last twice that long but at a cost of $550/1cc syringe, the procedure would cost $385,000.
While your own fat make not always be reliable in terms of volume survival, it is easy to see that it is a far more economical approach for buttock augmentation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I would like your opinion on my nose condition. My history is that I have always had a big nose, it being very big and fat particularly at the tip. During my first rhinoplasty, they shortened the bridge between the tip of my nose and the upper lip but the size of my nose remained the same. During a second rhinoplasty, another doctor took out all the cartilages. The nose subsequently increased in size on the top (created like a bump on the ridge). The doctor explained it to me that it was due to the internal scar and the thick texture of my skin. Then I had a third rhinoplasty with the same doctor as the second rhinoplasty. The nose has now increased to an unrecognizable condition. According to the doctor, it is the nature of my thick skin and inner scar. He advised me not to intervene any more, as no improvement is possible with my type of skin. Some time later, I had an injury to my nose and it became bent to the side a little with a hanging tip. The pictures I am sending you shows the nose after the third rhinoplasty and after the injury. After numerous consultations with various doctors, I decided to take a chance with injections of steroids. After 6 injections, my nose has decreased to what you can see in the pictures. But the doctor who has given me injections insists that my nose cannot be any smaller than it is right now. He says that since I need new cartilages to be inserted and the size of the nose will inevitably increase.
So my questions are:questions:
1) Is it indeed possible to make it smaller or at least a little thinner?
2) If new cartilages are inserted, can it still at least become thinner (doctors say that it will be only bigger)
3) Will it be noticeable that I had prior rhinoplasties?
4) How realistic is it to expect a smaller nose with my type of skin and inner scars?
I greatly appreciate you taking the time to look it over.
A: Thank you for sharing your rhinoplasty history and your pictures. While I have no idea what your nose looked like when you started, there is no question now that you have collapse of the lower 2/3s of your nose. Too much cartilage has been removed so the skin has no little support. This explains the nasal appearance after your second rhinoplasty and why it so easily got bent with the trauma. Ironically removing the cartilaginous support underneath the skin, if done excessively, actually makes the skin sleeve look bigger and sag more. A little cartilage tip cartilage removal and reshaping is one thing, a lot removed can turn into a disaster.
The question, of course, is what can you do now? If you are having any breathing problems (and I imagine you might) then rhinoplasty reconstruction with cartilage grafts (probably rib) can be beneficial. That will actually provide some midline nasal support, like a tentpost, and can possibly make the nose look somewhat thinner. When done through an open rhinoplasty, excess skin can be removed from the edges of the incisions which can also be helpful in creating less of a skin sleeve.
As you may have surmised, yours is a very difficult but not an impossible nose problem. All of your prior surgeries and steroids have definitely created scar but that is not a signficant problem in an open rhinoplasty approach. In conclusion, do I think you can be better than where you are right now…yes. You will never have a thin or small nose but it can be better shaped and supported to look less large than it does now.
Dr. Barry Eppley
Indianapolis Indiana
Plastic surgery, unlike some medical specialties, seems to always find its way into the news. 2010 was no exception in this regard. As a plastic surgeon, most of the items that become newsworthy were an incredible mix of the freaky, incredulous and even fantastic events.
Breasts always seem to make the news and the more freaky seems to be better. Whether it is basketball-size implants of quadruple FFFF proportions, dancers subject to IRS scrutiny trying to write off their surgery, or breast augmentation as part of a marathon makeover (aka Heidi Montag), women who seek their ten minutes of fame marr the perception of an otherwise highly successful body contouring surgery. While the real breast augmentation news this coming year will be the introduction of a new form-stable (gummy bear) implants, this will likely be overshadowed by the media’s never-ending focus on celebrities, their breasts and Hollywood’s version of silicone valley.
There is always the continued incredulous news of patients suffering complications and even death at the hands of so-called cosmetic surgeons. This seems to be most evidenced with liposuction, largely due to its popularity and the larger body surface areas that it treats. There is an obvious difference in the size of the trauma to the body from abdominal and thigh liposuction from that of a nosejob or eyelid surgery for example. Liposuction attracts a large number of inexperienced and often unscrupulous practitioners because of the relative ‘simplicity’ of the procedure and easy access to new liposuction devices. It only takes a medical license and a credit card to buy the newer laser liposuction machines. Equipment manufacturers are more interested in sales than safety as evidenced by their marketing and selling behavior. Patients died last year from one coast to the other at the hands of doctors with dubious credentials. The public would think that better regulations would exist but they would be wrong. Doing your homework is your best protection.
Botox continues to show its fantastic benefits and those are not only in those worried about their frown lines or crow’s feet. Last year Botox was approved by the FDA for the treatment of migraines. For some migraine sufferers, Botox injections can be a miracle even if its effects are only temporary. The benefits of Botox have translated into an actual migraine surgery procedure developed by plastic surgeons. If Botox injections relieve one’s migraines, a relatively simple muscular decompression around the nerve trigger points can provide a more permanent amelioration of one’s migraine pain and frequency of attacks. It’s a rare example of a cosmetic treatment turning into a really useful medical or reconstructive surgery, usually that works in reverse.
One other piece of fantastic plastic surgery news from last year has been the emergence of face transplants. While once thought impossible and something more akin to a movie or science fiction, more and more partial or complete face transplants are being done around the world. While the patients who need them are last resort problems of massive facial deformities and tissue loss, that is the history also of all organ transplants which are commonplace today. From the extreme technical advances of today come spinoffs that will benefit many more facial reconstruction patients in the future.
No telling what this coming year will bring, but if past history is any predictor of future events, plastic surgery will continue to make the headlines…let us hope it is largely in the fantastic category.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to get my eyelids done as they are very heavy looking and make me look bad. People tell me all the time that I look tired even though I am not. I am sick of hearing that! My only real concern about the surgery is recovery. How long is the recovery and what will I look like?
A: Thank your for your inquiry. Recovery after blepharoplasty surgery is largely social…meaning how do I look? (how much bruising and swelling will you get) That would depend on whether one is doing only upper eyelids, only lower eyelids, or all four eyelids.. When all four eyelids are done, most people will have noticeable bruising and swelling for up to 10 to 14 days after surgery. If only one set of eyelids is done, it will be less than that. Lower eyelids develop more welling and bruising than the upper eyelids after surgery. There are also different types of blepharoplasties done in which the overall swelling and bruising may well be less, what we call limited blepharoplasties which are either of the pinch type or lower eyelid which use only a transconjunctival (inside the eyelid incision) approach.
There are numerous strategies for keeping the amount of swelling and bruising as limited as possible. This includes pre-and postoperative oral Arnica, keeping one’s head elevated above one’s heart for the first few days and a good icing of the eyes the night after surgery. I also use gentle surgical technique with delicate amounts of cautery to keep down the amount of bruising that can develop.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting pec implants. I have always had a very flat chest with little muscle definition at all. I have done a lot of chest exercises but I have not seen a lot of improvement or at least the amount that I want. I have tried protein supplements, testosterone and even some human growth hormone but I just can’t get the size of pecs that I want. This has brought me to the conclusion that the only way I am going to get there is with an implant. Do you think pec implants will finally help me get what I want?
A: There is no question that pectoral implants will increase the perceived size of your pectoral muscles. Increasing the bulk of the muscle is what they do best from their subpectoral or under the muscle position as they push the muscle forward. Implants are not quite as good as improving pectoral muscle definition with the exception of the lower lateral pectoral border. The question you are really asking probably relates more to implant projection…or how big can the pectoral muscles be made to look.
Pectoral implants have, at most, up to 3 cms. of projection or forward push of the muscle. How significant that is depends on how thick the muscle is to start with. In other words, a flat chest with a thinner pectoralis muscle will show more but it will not be a ‘bodybuilder-like’ result. An already thicker pectoralis muscle in someone who is fairly developed will have a much more prominent result.
Indianapolis Indiana
Q: I currently have silicone breast implants that became hard and encapsulated. This was treated by having the scar tissue removed and new implants placed. Unfortunately, my implants became encapsulated again. In searching for what to do now, I have several consults with different plastic surgeons and have gotten differing opinions as to my options. One plastic surgeon suggested that I try the scar removal again with the use of dermal grafts and PRP. (??, not sure what this is) Another plastic surgeon suggested that I remove the implants and replace them with fat injections. Is this a reliable method? What would you recommend?
A: Recurrent capsular contracture, although uncommon, can be a difficult breast implant problem. The conventional approach is total scar removal, with or without replacing the implants with those that have a textured surface. If the implant was originally above the muscle, relocating it to a submuscular position can also be tremendously helpful. These combined techniques are probably effective about half the time, maybe more. But when they fail, different strategies need to be explored.
One alternative approach is to wrap the new implant partially in a dermal graft after the repeat capsulectomy. This ‘out-of-the-box’ graft is intended to heal around the implant lessening the risk of new scar formation, essentially serving as a part of the new capsule rather than fresh new scar tissue which has a high propensity for contracture. PRP, also known as platelet-rich plasma, is a concentrate from the patient’s blood which can be sprayed onto the internal breast tissue surfaces. Its theoretical benefit is that it causes less scar tissue to form. The addition of a dermal graft is a more proven capsular contracture approach but the use of PRP has no downside and is simple to apply.
Fat injections as an alternative to the use of a breast implant for the treatment of capsular contracture may be novel but is both unproven and biologically flawed in my opinion. The survival of fat injections in breast augmentation is based on the graft being injected into the midst of healthy tissue where it can survive by revascularization. Injecting fat into a large empty open space would not only have it not survive but would likely become a liquefied pool of oil and fat that is prone to infection.
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like a normal chin size without cutting or moving bone. Just with a chin implant or injectables. is it possible? I´m not interested in a major surgery such a sliding genioplasty. It seems that I have overbite but my dentist says that my bite is ok and I don’t need any orthognatic procedure. I ´d like to have neck liposuction too. I have a little extra fat below my chin and round the neck. The truth is that I don´t want to go under a major surgery but I also want a stronger chin. Can I achieve this result? I want it to look like a good male chin and not weaker or like a girls´s chin. I have looked at different projections of chin implants and I think that an 8 mm implant would work. I think that an implant with some little liposuction would be ok. I want it to be bigger but maybe more than 8mms kwill make my chin to look like very big. Please tell me what you think?
A: When it comes to chin implant size, there is a fine balance between too much vs too little. For a male, the chin position should ideally be even with the most protrusive part of the lips when see in a side view. While this is a classic anthropometric measurement, and one that is historically espoused in the concept of male beauty, that does not mean it is the most ideal aesthetically for any individual. Some men prefer their chin to be stronger than this measurement suggests while others prefer it to be a little shorter. When trying to decide between two chin implants sizes of a few millimeters difference ask yourself this question…would I prefer to ‘error’ on the side of having the chin turn out to be a little too strong or a little too weak? Obviously you want it perfect but knowing that choice will help make the decision between those two implant sizes.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 52 year old female that weighs 127 pounds. Several years ago I was down to 117 pounds and the lower belly pouch didn’t get much better. At that time I was exercising 4 days a week and doing everything I could to lose that belly. This seems to be a family trait as both my mom and her sisters had it. Do you think liposuction can remove this lower belly pouch?
A: There is no question, even without seeing most patients, that the description of a lower belly pouch signifies that they have some excess fat there. So the use of liposuction for abdominal fat reduction is going to be useful. Whether liposuction would be of benefit, therefore, is not really in question. The issue is how much lower abdominal skin do you have and what will happen to it when the lower belly is deflated so to speak. In other words, do you need some type of a tummy tuck with the liposuction? The aesthetic outcome of liposuction is predicated, partially, on how well the skin contracts down once there is less volume. If there are a lot of stretch marks and you can pinch more than an inch or two of skin, then it is likely than some skin removal (mini-tummy tuck) may be helpful also. If there is a question as to whether skin removal is really needed, you can always do the liposuction first and let that outcome make that decision for you. I would use Smartlipo (laser liposuction) for your abdominal liposuction as that has the best chance of shrinking down the skin you have the best.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley I need your help with my cheek. Several years ago I was involved in a fight and got struck on the left side of my face. At the hospital they diagnosed me with a cheekbone fracture but I never got it fixed since I didn’t have insurance at the time. The left side of my face is asymmetric now to the other side and I want to get it fixed. I will describe the problem as I see it. If you look at about an inch down from my left eye, that area from the middle of the top portion of the cheek toward the edge of my nose is flattened. It has no definition like my other cheek. The flatness extends down toward the middle portion of my ceek also. It appears to me as the complete area is shaped like a sideways triangle toward the rear. Also in the same area about an inch under my left eye, right on top of the upper portion of my cheek, it appears as if that area has dropped down. Do you think the bone needs to be rebroken to be fixed or can some type of implant be used to fix it? Thanks for your time.
A: Your description of the left cheek/midface deformity is exactly what one would anticipate from an incomplete zygomatic or cheekbone fracture. As the zygomatic complex, when fractured, can only rotate downward and inward toward and into the maxillary sinus you will lose some cheek and underlying anterior maxillary projection. Because you have described no changes in the eye area or numbness of the cheek and teeth (infraorbital nerve impingement) your original zygomatic fracture is incomplete and less severe than a fully displaced fracture. Given the age of the injury and the now healed bone, a modified cheek implant placed across the anterior maxillary wall and up onto the anterior zygoma should do nicely to restore the bone fullness lost. Given the modified position of such a cheek implant, it would need to be secured by multiple screw fixation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had two babies in three years and have lost nearly 50 lbs through an aggressive diet and execise program. While I have defnitely seen some body changes, I am not happy with the way my breasts and stomach look. I thought with all of this working out that my stomach would look better. I have loose skin and stretch amrks around my belly buttonm and my breasts droop and are floppy. I have read about a plastic surgery procedure called the Mommy Makeover. What is sone in this procedure and can it be done all in one surgery. I am worried about recovery time and getting back into the gym for my workouts. Thanks!
A: The Mommy Makeover has become a popular plastic surgery procedure amongst mothers between the ages of around 25 to 45, although it can be done at any age. It has gotten this catchy name because the procedures involved help reverse the effects that pregnancy has ravaged on a woman’s body. These procedures have been commonly done for many decades so they are not new. They have just been put together and ‘packaged’ for this specific set of female body problems, that being the breasts and the stomach areas. Breasts frequently have lost volume (deflated) and sag and the tummy has loose skin and stretch marks. The combination of breast reshaping (implants with or without a lift) and some form of a tummy tuck (with or without liposuction) is the backbone of a Mommy Makeover. They are almost always done together if a patient’s economics permits. While this combination of a breast augmentation and tummy tuck will have a dramatic change on one’s body, you must tone down the concern about getting back to working out as soon as possible. This is a setup for after surgery problems. It is understandable that you have an addiction to working out as you would not have gotten this far without doing so. But that same addiction, which you think is good, is not so good after this kind of surgery. You must mentally plan on 6 weeks before getting back to working out like you are now. Remember that in a span of a few hours you are going to make changes that you can’t do by working out for the rest of your life. The risk is not worth it for a few extra workouts that, in the big picture, will gain you nothing.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am going to get cheek implants but am concerned about them moving around afterwards. I am an extremely athletic person who works out a lot. This involves running and jumping around a lot. I do participate in conatct sports such as basketball and flag football. However, I don’t do boxing and am not planning to get punched in the face. (who does really?) My cheek implants will be the Conform malar shell type so they are not small. Do you think just suturing them in is enough or should they be secured with screws. Which method is best for me?
A: What makes cheek implants different from other facial implants is their bony position. Sitting on the side of the cheek bone, with no bone support underneath them, makes them more prone than many other facial implants to shifting or malpositioning. This risk is magnified by their path of insertion from inside the mouth which opens up the southern avenue for shifting. While most cheek implants do not experience these problems, the risk is not zero. Because of this concern, it is my preference to almost always screw fixation for cheek implants. This makes me feel the most comfortable that the postoperative risk of implant shifting is virtually eliminated. the appeal to me of screw fixation is that it is also easy to do, involves no risk, is done at minimal extra cost, and adds essentially no extra time to complete the procedure.
Dr. Barry Eppley
Indianapolis Indiana