Your Questions
Your Questions
Q: I am interested in Female Feminization Surgery which would encompass brow bossing reduction, hairline lowering, rhinoplasty, chin and jaw shaving and breast augmentation. I am considering doing the FFS either all at once or in two parts. I am male to female transgender. Can you provide me some details or specifics about what I need to consider for each of these procedures.
A: All of those Facial Feminization Surgery (FFS) procedures certainly can all be done as a single procedure and are not too excessive for one operation. If you were to do them in stages, I would separate them into the facial procedures as one set of procedure and the breast augmentation as a separate procedure.
A few comments about your proposed FFS procedures:
Hairline lowering – Whether that is possible would depend on your hairline now and where it is located. Some FFS patients have to consider hair transplants instead if their hair density is very thin or too far back.
Brow Bone Bossing – There are two methods based on the degree of bossing, burring reduction (tail of brow only) or frontal sinus wall setback (if the whole brow is very prominent) It is impossible to know which is best for you without seeing a picture. The relevance to this difference is prinarily a cost issue. Frontal sinus wall setback requires some tiny plates and screws to hold the reshaped bone and takes a little longer to do.
Rhinoplasty – There are two different types of rhinoplasty, limited and full. The full rhinoplasty requires more work and is almost always needed when there is a hump reduction needed. Limited rhinoplasty is where only the tip is manipulated/changed.
Chin and Jaw Shaving – For most FFS patients, this is largely burring reduction or saw shaving of the inferior border although sometimes the chin bone may need to be shortened vertically as well as setback.
Adam’s Apple – Any issues here? I am supposing not since you didn’t mention it.
Breast Augmentation – The only issue here is saline vs silicone gel breast implants. That is just a cost difference issue
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I’m 25 and have a really flat area at the back of my head. I’m very self-conscious about this since I was 15. Is there any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? You are my only hope now. If I can get the new round back of the head, I will also get a new life with your help. I have attached some of the pictures of my head taken on the side. Whenever I look at it, i just want to cry. And I’ve mentally suffered from this flat head shape since I was a teenager. If you could possibly please tell me, what needs to be done, and how long does it take to recover after the operation, I would appreciate your help and time so much.
A: Thank you for sending your pictures. I can see how flat the back of your head. The best and most economical way to augment and expand the back of your skull is through an onlay cranioplasty method. This involves putting a material on top of the bone to build it out. Given the amount of material needed, I would recommend acrylic or PMMA. Other materials exist but they are exponentially more expensive. There is even an injectable technique using Kryptonite Bone Cement, and that would be a good option for you, but that would be a cost issue.
To summarize, you can do an occipital cranioplasty by either:
1) An open cranioplasty approach with acrylic or PMMA, PMMA is a very firm material, is the least costly and must be put in through an open approach. (meaning a long fine line scar in the hairline) It would be a two hour procedure under general anesthesia.
2) The other option would be an injectable approach using Kryptonite cement. This would only need about a 2 inch incision. This procedure would take about an hour to do.
The fundamental difference between the two procedures, besides the incision/scar, is the cost of using the material.
Indianapolis Indiana
Q: I am 23 years old and am interested in breast augmentation. I know that there are different types of implants but I am most intrigued by the gummy bear implants that I have read about. They sound like the best type of breast implant to get but are there any real downsides to them? What do you think of them?
A: The term, gummy bear breast implant, is a layman’s term and not an actual name of a breast implant. I am not sure of the history of this name but I have heard the term was coined by a plastic surgeon. It is a new generationand innovation of a silicone breast implant, technically a third-generation gel filler material. Think of the original silicone filler material as a Type I which is more runny like thinner molasses syrup and existed up until 1991 when it was removed from the market, A type II gel implant filler is in newer and current breast implants, released commercially again in 2006, and is more cohesive like very thick molasses syrup. A gummy bear implant would be a Type III gel filler and is much more cohesive or stiffer like the gummy bear candy. (hence the name)
From a manufacturer’s standpoint, they have been known as the 410 implant (Allergan) and the CPG implant (Mentor) and have been in clinical trials for years. All manufacturer’s clinical trials with these implants are now closed and under FDA evaluation. It is possible that they may be commercially released by the FDA in 2011 but that is not a certainty.
The biggest advantage to the gummy bear implant is that the gel filler material is more cohesive and has no risk of leaking. It does feel more firm which some patients may feel is an advantage. It will be introduced initially as an anatomically-shaped (tear drop) shape with a textured surface. Because of these features, it must be placed through a lower breast fold incision to ensure proper positioning of the shaped breast implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had saline breast implants placed in 2003. Last week I developed some mild discomfort in my right breast which was just sort of achy. I thought my right breast was getting smaller right after but now I know for sure. My right breast looks much smaller than my left now so I think I have developed the dreaded deflation. I remember something about a warranty program in case this happens. What do I have to do now to get my breast implant replaced for free?
A: The risk of saline breast implant deflation is always a lifelong possibility. While most patients will enjoy the benefits of their saline breast implants for an average of 10 to 15 years, deflation can certainly occur much earlier. Since breast implant failure is one of the known complications of breast augmentation, patients need to be aware of the manufacturer’s warranties. There are two levels of implant manufacturer warranties; implant replacement and monetary contribution to the cost of replacement surgery. Over the years these two warranties have changed and it is important to contact the manufacturer (Mentor or Allergan) and find out what was in effect from that manufacturer in 2003.
In general, replacement of a failed breast implant is usually lifelong and never goes away. Money to be provided to help defray the cost of replacement surgery is usually time limited at 10 years currently. (less in 2003) That amount was $3500 in 2010 but likely was only $1200 in 2003. That money is not given up front to the patient but only months after the surgery is completed so patients have to wait to get their partial reimbursement. (the failed implant must be returned and evaluated first to determine the cause of failure)
One important point of confusion in replacement surgery is that the warranty is given by the breast implant manufacturer as it is a medical device. These warranties do not apply to the implanting plastic surgeon, operative facility or the anesthesiologist.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting my fatter face and neck thinned out if possible. I am sending pictures for your review (frontal and profile) so you can see what I mean. I am interested in a buccal lipectomy procedure and submental lipectomy. I have always thought my face has made me look, in pictures, 30-40 lbs heavier than I actually am. I have also looked at people that are obese or considerably heavier than I am in pictures, comparatively, and noticed that my face make me looks extremely heavy which I am not. I would like to have the procedures done if the changes are significant. I would also like to know if the procedures can be done under local anesthesia. Please advise.
A: Thank you for sending the pictures. I can see your concerns with the fuller tissues around the jawline and into the neck. Certainly fat reduction by neck liposuction and buccal lipectomy is all that is appropriate or should be done. The good question is how much improvement will be seen. That is a tough one to answer as the final result is determined by how well the skin adapts and shrinks down. The limiting factor in your result, and in other male patients who look just like you, would be controlled by the subplatysmal fat at the cervicomental angle (it is not all just above the platysma in the neck angle area) and the subcutaneous fat layer around the jaw angle and over the parotid. Subplatysmal neck fat can be removed by direct excision but the jaw angle fullness is more limited because it can not be treated neither by liposuction or direct excision because of the marginal mandibular branch of the facial nerve. While changes will clearly be seen, I would use the term moderate improvement rather than a dramatic change. Because of the variabiity of the result, you should only undergo the procedure if you can accept modest to moderate improvement. If it turns out to be significant or dramatic in your view then that would be a bonus.
To get the best result possible, doing the liposuction and lipectomy procedure under local anesthesia would not be my approach. That limits how much can be done as patient comfort then takes precedence over the extent of the result.
Dr. Barry Eppley
Indianapolis Indiana
Just when I thought I had seen every conceivable variation of a plastic surgery reality show, a new twisted version appears. If your entertainment schedule has not allowed you to catch E!’s newest reality television disaster, Bridalplasty, consider yourself fortunate. If you haven’t seen it, it a summary is that it is a bride-against-bride elimination-style show where 12 women compete to have various cosmetic plastic surgery prizes- ostensibly to turn them from ducklings to swans just in time for their weddings. Or, as E!’s tagline cleverly states, it’s the only competition show on television where “the winner gets cut.”
If you are thinking- as I was, You have got to be kidding me, seeing it will only make you feel worse. The household of brides-to-be initially compete in difficult wedding challenges that would test the mental limits of the average grade school child. These ‘prize’ for winning each of the competitive challenges is a surgical procedure intended to help transform the prospective bride closer to physical perfection. Each week one of the contestants gets eliminated while the others receive their dream plastic surgery procedures along the way. Eventually one bride-to-be will receive the wedding of her dreams…and will head down the aisle in a designer dress as a transformed woman ready to surprise her soon-to-be husband.
The concept of a show in which women compete for the grand prize of a plastic surgery makeover in order to be the perfect bride for her wedding day would normally be funny… if it weren’t so sad. At its most basic, the show is a societal commentary on our contemporary fairytale wedding culture where so much effort is spent in both time and money for just a few short hours. Maybe its greatest entertainment value is in seeing how the fully complicit contestants are willing to trade any dignity for some free plastic surgery and a little bit of fame. I suspect the show’s creators are well aware of this self-deprecation but the contestants are clearly completely oblivious to it.
While Bridalplasty may be the pinnacle of self-parody for reality TV, the participation of the plastic surgeon in the show violates some of the most stringent ethics of the American Society of Plastic Surgeons. The most egregious ethical violation is the very premise of the show – all ASPS members are prohibited from giving away free plastic surgery as a prize in any contest. To encourage any prospective patient to undergo surgery because it will be free encourages patients to cast aside any consideration of its risks and expectations. Part of what any ethical, well-trained plastic surgeon should do is to educate the patient about both the benefits and the risks of their procedure(s) of interest. Reaching for a little fame here seems to have affected more than just the brides-to-be.
‘Bridalplasty’ is cringe-worthy TV at its finest, and brings the practice of medicine and surgery to a whole new low point. What’s next, ‘Who wants to win a quadruple bypass’?
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like to have my Advanta lip implant removed – it has been in place for greater than 10 years. Do you have experience with this and how many have you removed? Any problems with lip asymmetry? Thank you.
A: The Advanta lip implant is composed of PTFE (Gore-Tex) and is a single tube in configuration. It is often confused with the original PTFE lip implants placed in the 1990s which were multiple strands in their geometry. That distinction is more than just in the name as Advanta is relatively easy to remove because it is a tube which can be easily extracted without much trauma. The stranded lip implants can be incredibly difficult to remove and very traumatic to do so. They are often best left alone.
It sounds like you are fairly certain that you have Advanta lip implants. Over the years, I occasionally have removed them without any great difficulty. As for resultant lip asymmetry I can not speak as to whether that will result or not. That depends on whether any lip asymmetrywas present to begin with and how the lip tissues contract and heal back down after the implant is removed. That outcome would be beyond the control of whomever removes the implant. In general, I would not think that is a common problem afterwards and have not seen it in those patients that I have removed. But whether that would be an issue for you afterwards can not be determined beforehand.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in buttocks injections and basically wanted to know a little more about the procedure. I would like fat removed from my waistline or abdomen area and injected into the buttocks. I would like a fuller bottom and a smaller waistline. I am an active member of the Indiana National Guard and also wanted to know more about the Patriot Program.
A: Thank you for your inquiry. How you have described the procedure is exactly how it is done. Fat is removed from the waistline and flanks and then transferred by injection to the buttocks. The issue with buttock augmentation with fat injections is how much fat will survive afterwards and how much of a size improvement will there be. The first part of the procedure, fat reduction, is assured in that you can be guaranteed your waistline and stomach areas will be less full and have less fat.
The other issue with the Brazilian Butt Lift, also known as fat injections to the buttocks, is whether enough fat can be transferred to create the size that you want. Unlike a buttock implant, where the size increase can be bigger and its postoperative volume increase stable, fat injections may or may not be be to reach your buttock size increase goal. However, the ‘ying anf yang’ effect of a smaller waistline helps the buttocks look bigger and more shapely regardless.
The Patriot Plastic Surgery program provides free consultations and surgery fee discounts to all those that quality.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am unhappy with the shape and length of my upper lip. It bulges out right under my nose. I would like to meet with a Doctor who has experience with lip lift surgery to see if my upper lip could be made to look better and to get rid of the bulge right under my nose. Here are some pictures of my face. My wife took the pictures and we were trying to show how my upper lip bulges out in the middle under my nose. All I want is to have the bulge removed or maybe even have it to where my lip would be more concave right under my nose. I really don’t even care if my lip is lifted or made shorter, just as long as the bulge is gone and made smooth or even hollowed out some. Thank You.
A: Thank you for your inquiry and sending the pictures. They illustrate well the bulge underneath your columellar area of the nose in the upper lip area. Interestingly that bulge is likely not just excess lip tissue alone. Undoubtably your anterior nasal spine is excessive in length and size as well. You may not be familiar with this small area of nasal bone that juts out undereneath the base of the nose. I have attached some anatomy pictures of where it is, and when it is excessively long in combination with the front of the nasal septum, how it can contribute to an upper lip bulge. I suspect that this small piece of bone and cartilage is making some contribution to that bulge along with some excessive lip soft tissue. That can be immediately confirmed by simply feeling under the upper lip as well as pushing down on the bulge at the same time.
Therefore, I would propose that he best solution for your upper lip bulge is a combination of a modified lip lift (use the incision to remove some soft tissue and muscle underneath bulge and only do a 2 -3 mm lift) and an anterior nasal spine resection. Anterior nasal spine reductions are commonly done in rhinoplasty surgery so its effects and benefits are well known.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am going to undergo orthognathic surgery in the coming year. My maxilla will be brought forward as well as my mandible. This will also help my sleep apnea problem. I was told with the advancement of my maxilla, my nose would move as well. That is why I am also having a rhinoplasty. It is supposed to be more of a tweak. To complement my mandible, a sliding genioplasty will be performed. I also have incompetent lips, so a v-y advancement of mu upper lip will also be done. What are your thoughts on the mandibular angle implant? I want more of that model look that I read about on your blog. Will it look right on me? Is my facial geometry even capable of changing with a mandibular angle implant to what I desire? Am I being too ambitious?
A: In answer to your questions, my overall statement is that you are being overly ambitious as you have already admitted. While jaw angle implants would be beneficial from a facial shape standpoint, it should never be done in conjunction with orthognathic surgery. That would require the implants to be placed directly on top of or next to the sagittal split mandibular osteotomies. That would be a recipe for infection and the potential to interfere with the healing of the mandibular osteotomy sites. In essence, a disaster from a jaw healing standpoint. While that may not happen, it is a real risk and one that isn’t worth it.
You need to go through the orthognathic surgery and adjust to your new face for a full year and allow everything to heal well. Only then should you reconsider jaw angle implants through computer imaging and further facial analysis.
Dr. Barry Eppley
Indianapolis Indiana
Q: Do you do forehead augmentation to make a flat forehead rounder using PMMA? If so how much does this cost and how is it done?
A: Forehead augmentation can be done with a variety of materials. The use of PMMA (acrylic) is historic for forehead augmentation and offers the most economical approach for the procedure. It generally costs in the range of $8500 to $9500, all surgical costs included.
Forehead augmentation with PMMA requires it to be done through an open scalp approach due to the working characteristics of the material.
There is a technique for forehead augmentation using Kryptonite Bone Cement which can be done through an injectable approach using very small incisions. Its cost is higher than that of a PMMA frontal cranioplasty.
Dr. Barry Eppley
Indianapolis Indiana
Q: Have you heard of Cryoshape treatment for keloids and hypertrophic scars? I have read some favorable reviews on the internet about its success. What is your opinion of it?
A: I am familiar with the technology but must confess that I have never used it. Given the fact that keloids are the most difficult scar problem that exists, any potential treatment is welcome. Cryoshape is a method of delivering cold or freezing therapy via a probe that is inserted into the keloid. By freezing the keloid, it is hoped that it will not only stop growing but shrink down as well. This is another intralesional therapy for keloids of which the most commonly used is steroids and 5-FU injections.
I am certain that Cryoshape has its share of successful keloid reductions but it will have its failures also. Keloids are extremely refractory and difficult scar problems that no one treatment can be universally effective. Whether it is any more effective that steroid injections is unknown.
The value of Cryoshape, in my opinion, is as a pre-excisional treatment method like we currently use steroid injections. For those patients that want more than just a shrunken keloid, excision needs to be part of the keloid treatment approach.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I am located out of the United States. I am 42 years old and have a temporal artery on the left side of my head that has become very prominent over the last year and I am looking for someone to do a temporal artery ligation. I came across a forum where Doctor Eppley was commenting on the procedure saying that it was relatively straightforward. I would like to know if this is a surgery that he could do for me. I would be willing to travel to Indianapolis for it.
A: The superficial temporal artery (STA) branches off of the main trunk of the temporal artery just above the ear. It then courses forward until it crosses high in the forehead from the temporal hairline. It leaves the camouflage of the hairline at this point to cross into the forehead skin. For most people the STA is not usually seen although it can be palpated in the temple or forehead region. In a few people it becomes more noticeable. Whether this is because it is just simply more superficial or actually enlarges in size is unknown.
The STA can be ligated to eliminate its pulsatile visibility. However, it has to be done both high and low to prevent backflow. That may mean that the high ligation point may not be in the hair-bearing temporal scalp and require a small skin scar. Loss of the STA causes no known problems so it can be ligated without any vascular consequence.
Indianapolis Indiana
Q: I found your article fascinating on injectable rhinoplasty. I had a rib cartilage graft done 16 months ago but still have a depression to the left side of my mid bridge. I have banked rib cartilage left in my chest. Could the same technique be used with rib cartilage?
A: Any source of cartilage can be used in the injectable rhinoplasty technique. That is the very beauty of its use. Whether it be septum, ear, or rib, cartilage of any size or amount can be diced and injected. When an injectable rhinoplasty procedure is used, it is because only a small amount of cartilage is needed for the correction of a precise nasal defect.
Your banked rib cartilage would be a perfect donor source because it is likely more than adequate in the amount needed. It can be diced into a syringeable graft regardless of its present configuration.
Dr. Barry Eppley
Indianapolis Indiana
Q: Please tell me the procedure for the neck lift that is natural looking, no downtime and no bandages. I’ve done a lot of research into plastic surgery, worked with plastic surgery patients, so just want to know about the procedure and cost. I don’t want to make an appt to ask questions until I know what it is about and have done my research. Thanks so much.
A: Thank you for your inquiry. As you may know, there are a variety of limited neck and facial procedures for improving the signs of jowl and neck ptosis that occurs with age. In reality, these are all forms of more limited facelift type procedures although they are usually referred to by patients as ‘necklifts’. Many of these have branded and marketed names that imply rapid recoveries and minimal downtime. They are all based on the same structural premise which is neck liposuction (maybe with a little submental platysmal plication) and a preauricular-jowl skin flap with SMAS plication.
When the necklift procedure is done this way, there is virtually no downtime (very mild swelling and little bruising usually), no sutures to remove (all dissolveable sutures), no drains used, and no dressing. (sometimes only a head wrap for the first night only) This is quite a different early postoperative look than what one would be familiar with in the more traditional full facelift approach. The procedure generally takes about 90 minutes to do as an outpatient.
The success of this type of facial rejuvenation procedure is based on patient selection. It is not the best procedure for patients with substantial neck and jowl sagging where a fuller facelift version would be more appropriate. But for mild to moderate jowl and neck issues, and as a secondary tuck-up to freshen up an old facelift result, this approach can be very useful. Generally, the total costs of the procedure is going to be in the $4500 to $5500 range.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had an accident about a year ago in 2009 and got a stitch on my right chin to fix it. The scar is about 1 inch long. I got my real color and texture for the scar. But the skin above the scar had a slight swelling which is making the scar more evident. Is there any way to reduce this swelling? I would like to know the technique and cost of the treatment, which would help to improve the appearance of the scar.
A: The slight swelling to which you refer in your scar is no longer swelling. That would have resolved a long time ago given that this injury is more than a year old. What you undoubtably have is a residual mismatch in the skin edges with the upper edge being slightly higher than the lower one. This gives the illusion of swelling when it is really differences in tissue thickness between the two sides. This is a result of the original repair.
The best and only solution to improve this scar is excisional scar revision. The edges of the scar are opened up and the skin edges are realigned so they lay more flush and can heal back in a smoother fashion.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in removing acne scars. I am trying to decide between punch excision and dermabrasion. As I understand it with dermabrasion I will get minimal results on old and deep scars (however I am not sure what is meant by deep), but with punch excision I will be left with a small scar. As dermabrasion works best on newer scars, would a good option be to start with punch excision and then use dermabrasion to remove the resulting scar? or would dermabrasion or punch excision alone be the best option? or would there be another, better option. I am looking for the most promising option here, I have spend a lot of time and money on snake oil treatments and empty promises with no real results. Thank you for your time.
A: Thank you for your inquiry on acne scar revision. Punch excision is the only thing that will work for ice pick or deep acne scars. Dermabrasion works best on moderate-depth acne scars particularly of the saucer-shape variety. Laser resurfacing works best on more superficial or fine acne scars. The age of an acne scar is really irrelevant unless it is fairly new. The logic would be to work on the deepest scars first with punch excision and then use the skin resurfacing methods (dermabrasion or laser resurfacing) after.
Dr. Barry Eppley
Indianapolis Indiana
Q: Can my eyes be made more narrow with an outer tilt to them? How is that done and what is the downtime to do it?
A: One’s eye shape can usually be changed. Depending on your anatomy, that change can be very subtle or more obvious. The first thing I like to know is exactly what a patient’s means when they say ‘more narrow with an outer tilt’. I know what it means to me as a plastic surgeon but I have to be sure what it means to each patient so the changes are what the patient really wanted.
The concept of uptilted eyes, from a plastic surgery perspective, usually means that the outer corner is turned up. In other words, the outer corner of the eye is above the level of the inner corner of the eye. This gives the eyes an inward slant which is often described as being more exotic looking. Giving the eyes such a shape is done commonly with a procedure called a lateral canthoplasty or tendon repositioning. The corners of the eye are held in their position by a tendon that attaches to the bone inside the rim of the eye socket. There is both an inner (medial) tendon and an outer (lateral) tendon. This procedure repositions the lateral canthal tendon at the outer aspect of the eye. By turning up the outer corners this gives the eyes a more upward tilted appearance. Besides some temporary swelling, and some occasional bruising, there are no bandages or restrictions after surgery. The swelling and bruising will go away in a week or two. The result is immediately apparent.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I am 25 and have a really flat area at the back of my head. I’m very self-conscious about this since I was 15. Is there any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? You are my only hope I have. I almost cried of joy after reading your articles that it is possible to reshape the back of my head by some materials and that you have done this so many times. This really means so much to me if I can get a new round back of the head, I will also get a new life with your help. I have attached some opictures of my head taken on the side. Whenever I look at it, i just want to cry. And I’ve mentally suffered from this flat head shape since I was a teenager. What needs to be done, and how long does it take to recover after the operation? I would appreciate your help and time so much.
A: Thank you for sending your pictures. I can see how flat the back of your head. The best and most economical way to augment and expand the back of your skull is through an onlay cranioplasty method. This involves putting a material on top of the bone to build it out. Given the amount of material needed, I would recommend acrylic or PMMA. Other materials exist but they are exponentially more expensive. There is even an injectable technique using Kryptonite Bone Cement, and that would be a good option for you, but that would be a cost issue.
Recovery from this type of surgery is fairly quick, particularly if an injectable method was used. (since there is only a one inch incision to do it)
Indianapolis Indiana
Q: I am a healthy 55 yo female. Over the past year, I have lost 40lbs in an attempt to become healthier. After the weight loss, I had a bilateral breast reduction perfomed. The surgeon removed approximately 3lbs from each breast. The original surgery went very well, the drains were removed on post op day 3, and I thought I was on my way to complete healing. By day 10, the wounds started to separate and open, and subsequently, all the suture lines were involved. The surgeon treated my with prophylactic ATBs with no resolution. I was never sick and never ran a fever. I saw an Infectious Disease specialist who treated with with IV antibiotics but the cultures were negative. I was then referred to an allergist who patch tested me for the two types of suture material (Monocryl and Vicry) and the chemical coating (Triclosan); all of which were negative. I am going on 5 months post op and still have some areas of non-healing and draining. The drainage is sometimes a creamy, bloody fluid and is mainly from the areolar areas and the horizontal area. Could you please offer any insight into what may be causing this delay and how long this may last. The breast surgeon claims he has never seen a case like this and offers no answers to my questions. I will get hard nodules under the suture lines, which then pustule up, opens, and then drains.This has been an extremely frustrating experience, expecially since not one of the specialists can tell me exactly what caused this and how long to expect it to continue.
A: Your postoperative breast reduction course has been complicated, and is not a common experience, but it is not rare or unheard of. While I have never seen your wounds, your exact course and the time sequence by which it occurred is something that I have seen more than once from breast reduction surgery. It is not the result of an infection nor is it a reaction to the suture material. The origin lies in the nature and skin perfusion of how a breast reduction is done.
A breast reduction, and even a full breast lift, raises skin flaps whose blood supply is separated from the underlying breast tissue. Its perfusion largely relies on coming in through the skin along the sides. In addition to this vascular compromise, it is then put togther under considerable tension in the inverted T or anchor area on the lower pole of the breast. All of this stresses how well the incisions heal. While the vast majority of time healing is uneventful, the balance can occasionally tip and the wound comes apart. And it never comes apart until between 10 to 21 days after surgery when inflammation and healing really start. Before then the incisions are not really healing but just held together by the sutures. This begins by opening of the invert T and stop in that area for most patients. But rarely it will extend up the vertical incision to the nipple area and open up the whole way. When this occurs, one has to wait for secondary healing which can take several months if not longer until the wounds fill with granulation, contract, and then re-epitheliaze. As the wound is largely open in this process, suture spitting and extrusions become common even in those areas of the incisions that have remain closed.
This is a skin perfusion/vascular injury, not an infection or allergy. I assume you have closed downk considerably and are getting closer to closed wounds. It may take another month or so for the healing to be complete.
Dr. Barry Eppley
Indianapolis Indiana
Q: Please I need a second opinion. I have breast implants (saline) since August of last year and the left is still resting high. A few hours after surgery, my left breast implant moved all the way up close to my clavicle. It was a crazy experience. It seems like only after a month it stopped moving downward to settle in its right place. It feels and look stuck like if implant is glued or my skin is too tight to allow it to move naturally on its own. I fear and strongly believe that another surgery in my case is necessary. Please is there a non surgical way or is it mandatory for another surgery? Please need advice and thanks for your time.
A: What you have is a classic case of a highly-positioned implant that is reflective of an implant pocket that was not made low enough on that side or one that scarred down on the bottom too quickly. I suspect that your saline implants were placed through an armpit incision since you describe the pocket on the left side as being as high as your clavicle. It is not that the implant or skin is glued, there is just no pocket for it to settle down lower into. It is being restricted by tissue attachments from being lower.
There is no non-surgical solution. You will need a fairly simple surgery to make the pocket lower so the implant can settle down to match the other one. This can be done either through a nipple incision or a small incision in the lower breast fold. The implant pocket has now healed so additional time will not change its position. If you don’t make this implant adjustment, then the left-sided breast implant will always be where it is right now with an asymmetrical breast augmentation result.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have read on the internet an articlce that stated that Botox can cause permanent muscle weakening over time. Since I get Botox fairly regularly should I be concerned that it might eventually affect other facial muscles as well?
A: I think the article that you are referring to and has been reported in different internet venues was the one in the Journal of Biomechanics that appeared last year. I am familiar with that study and have read it. In this animal study, they examined the effects of Botox on not only the muscles that were injected but on the surrounding muscles as well. They found that Botox did lead to local muscle wasting as well as weakness of other untreated muscles in the region.
This study has caused a little bit of hullaboo about Botox but, in my opinion, it has no relevance to the cosmetic use of Botox. Beyond the fact that this was done in animals (rabbits), the doses were very high compared to what we use in humans. By my calculation, they were giving the equivalent of 200 to 300 units of Botox every six months. Given that the normal cosmetic dose of Botox is around 24 to 36 units, their dosing was nearly 10X that of a cosmetic facial treatment. The muscles that they injecting were voluntary motor muscles as opposed to involuntary muscles of facial expression. These are quite different types of muscles. Motor muscle are well known to atrophy from simple disuse, muscles of facial expression do not display this atrophy phenomenon. Most of our cosmetic patients would welcome that if it happened but there has been no evidence that it occurs.
This article is an interesting piece of science but its findings do not hold a candle to the 25 years of human Botox use in which this permanent muscle weakening effect has never been seen in a low-dose cosmetic application.
Dr. Barry Eppley
Indianapolis Indiana
Q: After having four children and breast feeding them all I am not happy with the way my breasts look. I am interested in getting breast implants. Do you think I will need a breast lift as well?
A: The combination of four children and breast feeding would take a toll on any women’s breasts. The effects of that repetitive expansion and then subsequent deflations will cause both skin excess and loss of breast tissue, known as breast involution. Undoubtably breast implants would be of great help in restoring breast volume and size.
The key issue is whether breast implants alone will be enough. If there is any significant sagging or ptosis, then some form of a breast lift may be needed. That can be determined by where the nipple now sits relative to the lower breast fold. If the nipple is above the breast fold, then implants alone will suffice. If the nipple is just at the lower breast fold, then a combination of breast implants and a small nipple lift will be needed. If the nipple sits below the lower breast fold, then implants with a more formal breast lift will be necessary.
What you don’t want are larger breasts with the nipples pointing downward or towards the floor. The nipples should be relatively centered on the implanted breast mound. Whether a breast lift is needed can be determined before surgery based on your nipple position on the deflated breast mound.
Dr. Barry Eppley
Indianapolis Indiana
Q: I read your very interesting article about lip lifts. I was wondering if it would be possible to do the same but on the inner side of the lip? My upper lip is quite thick and juts out a bit. The outward rotation and protrusion of the lip which he conventional procedure causes would not be a good thing for me. Would that be possible?
A: A subnasal lip lift is designed to shorten the skin distance between the base of the nose and the lip vermilion and lift the central portion of the upper lip giving it more of a pout. Doing the reverse, or the procedure on the inside of the lip, has another name known as a lip reduction.
In a lip reduction, a wedge of mucosa is taken internally to derotate the lip and give it less of a pout or fullness. Unlike the lip lift which is done high on the outer lip, a lip reduction is done closer to the vermilion or low on the inside of the upper lip. This is because the outer skin is different than the inner mucosa. Mucosa is more loose and stretches more than skin. Therefore, doing the resection way away from the lip margin in a lip reduction would cause no change in the visible lip shape.
Basically, you are talking about a lip reduction procedure which is well known, successful, and fairly easy to do.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, After I was born, a hematoma appeared on the back top right corner of my skull (either trauma on the way out of my mom, or trauma suffered after being born…we’re not sure.). It ended up calcifying after being left untreated (at least that’s what doctors have said in the past), and to this day, the lump is still there. It’s about 1.5 inches in diameter and sticks up about 1/2 inch from my skull. This wasn’t necessarily a problem growing up, because hair could cover it up. But unfortunately, genetics have brought on the beginning stages of male pattern baldness. I’m thinning quickly, and a hair transplant seems unlikely at my age of just 23. Therefore, I would like to get used to shaving my hair down, but as we all know, people need a good head shape to pull it off properly. Another side note, but not necessarily as important: I have a prominent forehead that sticks out a bit further than the ridge of my browbone, and my temples are a bit hollowed out. I wear bangs to cover this stuff up as well, but with hair loss, this isn’t feasible in the long run. I’m not sure if these things are fixable, but hopefully I can begin to get some information on what should be done. This stuff is killing my self esteem! I’m a good lookin’ guy! I’m in college! This shouldn’t be happening right now! Looking forward to your response.
A: What you had an birth was a cephalohematoma, a blood collection under the skin and more pertinently under the periosteum of the bone. This is a well known stimulant to bone formation and they are well know to calcify. It can certainly be rather easily burred down which is a simple procedure. The key is to be able to do it with a fairly minimal resultant scar. (incisional access) Given its relatively small size, that should be able to be done with a very minimal scar of about an inch placed vertically on the back of the head at its lower end.
The forehead issues can be similarly treated through burring reduction but the problem is one of hidden surgical access. In the forehead with an unstable hair pattern in a male this is not very feasible. A long scar placed across the top of the head is not a good trade-off. Having a smoother and less bulgy forehead at the expense of a long scalp scar may not be a good aesthetic alternative.
Your temporal hollowing, however, can rather easily be improved through a temporal augmentation procedure. Dermal grafts can be placed under the muscle fascia through small vertical incisions in the temporal scalp. Rounding out the temporal area will help blend in with the forehead shape better.
Indianapolis Indiana
Q: Hi Dr Eppley, I read a article that you have used a long-lasting injectable filler to lessen the deepness of the chin lip fold? I had a sliding genioplasty and there is a mild stepoff and a bit of a deeper sulcus afetr surgery. I was wondering if you would be able to blend the chin into the jawline like the stepoffs and also lessen the labiomental chin lip sulcus? How long after genioplasty am I able to have the injectabale treatment? Also what complications have you seen with such injectable treatments? Thanks.
A: The first thing to appreciate is the anatomy of the labiomental sulcus (chin-lip groove) and how that has been changed from your bony genioplasty. The depth of the labiomental sulcus is a reflection of your anterior mandibular vestibule. If you put your thumb in the labiomental sulcus and your index finger inside your mouth, you will see the correlation between the two. The fold represents the level of the vestibule but, more pertinently, it is the upper or superior attachments of the mentalis muscle. Once the chin bone has been slide forward, the labiomental sulcus deepens because the chin point moves forward with the bulk of the mentalis muscle with it. That will deepen thue sulcus because the vestibule has not moved but the chin bone has.
How to treat the deep labiomental sulcus can be done several ways. If one is looking for a permanent solution to the depth of the fold, treat the exact anatomic problem and place a dermal graft and build it up from underneath in the bony step-off. That would be my preferred approach. The other option is to use injectable fillers but understand that they will onlu be temporary and are not long-term solutions.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr Eppley. I wonder if there is a way to remove bumps on the temporal area just above my ears. They aren’t related to any medical problem but I want to have flat temporal sides. So is there a procedure to remove them or make them flatter? The other thing I want to learn is whether it is possible to increase length of lips. I’m not talking about lip augmentation, is there a way to increase horizontal length of lips? Thank you.
A: Temporal bulging above the ears, in most cases, is a reflection of the combined muscle and bone mass. The tail or back end of the temporalis muscle is what lies above the ear. I have done temporal narrowing (bitemporal reduction) through muscle resection and superficial cranial bone burring. That has worked quite well and is fairly easy to go through. You don’t really need the posterior attachments of the temporalis so it can be removed. The amount of temporal narrowing would be about 7 to 8mms per side.
The horizontal distance of the mouth (commssiure to commissure) can be surgical increased. It is done by a Y-V lengthening of the corners of the mouth. In essence, it is a lateral vermilion advancement through skin excision. While it can be technically done and is virtually painless afterwards, it does leave fine line scars at the edge of the vermilion. Whether that is an acceptable trade-off would depend on the nature of your skin and the amount of mouth widening that one would desire.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in getting my nose done. My main reason is that I don’t like this bump on my nose. The rest of my nose I am really fine with. What I want to know is how can this bump be taken down. Can it be shaved or does it have be cut off? Will I need to have my nose broken? What type of rhinoplasty needs to be done? Will this in any way affect my breathing?
A: A bump or hump on the nose is one of the most common reasons one seeks a rhinoplasty procedure. Reducing a hump and having a smoother bridge of the nose makes it appear more pleasing. A hump on the nose is not just bone but a combination of bone and cartilage most of the time. Very small bumps may be bone only but the midportion of larger humps, known as the rhinion, is at the junction of bone and cartilage. Reducing the nasal hump, therefore, must take down bone and cartilage in the vast majority of cases.
If a patient only needs a hump to be taken down for their rhinoplasty, I will do it through what is known as a closed approach. (incisions on the inside of the nose only) Most rhinoplasties, however, involve hump and other changes as well so an open approach with degloving of the nasal skin provides a much better view and more predictable results.
Breaking of the nasal bones is often a part of hump reduction but frequently not understood. When large humps of the nose are taken down, removal of that hump or ‘roofline’ (bone and cartilage) leaves a flat and open bridge area. The nasal bones are no longer attached to the apex of the roofline but are standing ‘open’. This is one reason why the nasal bones are broken (nasal osteotomies) so that they will fall back in towards the center, recreating the roofline and making the bridge of the nose smooth and more rounded. This may also make the upper part of the nose more narrow which is often desireable.
Small hump reductions do not require breaking the bones of the nose, but larger hump reductions almost always do. That is why some patients will get black and blue under the eyes after rhinoplasty while others do not.
The trend today, not only for aesthetic reasons but to preserve good breathing through the nose, is to keep a high dorsal nasal profile. Taking down the bridge of the nose too much, as was commonly done in the past with ‘scooped out’ or ‘ski-jump’ noses, is not acceptable today as it leads to breathing problems. Keep a high but smooth dorsal line helps not only to protect breathing through the nose but to prevent further collapse (known as a saddle nose deformity) later in life.
Dr. Barry Eppley
Indianapolis Indiana
A bump or hump on the nose is one of the most common reasons someone doesn’t like the way their nose looks. Removing a hump on the nose and having a smoother bridge down its length will make it appear more pleasing. That feeling about a nose hump is universal as people seem to intuitively know when the upper part of the nose is out of balance to the lower part of the nose…humps make the nose look too big and thick and sometimes even ages a face. Large nose humps can make one look older. (just like a downturned tip of the nose)
Hump reduction of the nose is one of the main reasons many people want nose-changing surgery or rhinoplasty. But removing a nasal hump is usually more than just simple shaving of the bone. What makes up most humps is a combination of bone and cartilage as the hump occurs where the bone of the nose stops and the cartilage of the nose begins. This means that both bone and cartilage must be taken down for a successful hump removal.
How big a nose hump is changes how it is done and what the recovery would be. Small hump reductions can be done by shaving or rasping and do not require breaking the bones of the nose, but larger hump reductions almost always do. That is why some patients will get black and blue under the eyes after a rhinoplasty while others do not.
Think of the bridge of the nose like the roof line on your house. Trimming off a little bit of the rooftop will not significantly change the inverted-V shape of the roof. (small hump) But taking more than just the very top of the roof line will leave the sides of the roof standing where they originally were….with an open top. To change that open roof back to an inverted-V shape requires moving the sides of the roof inward. To make them fall back to the middle, the base of the roof must be cut so they will fall back in together. This is what breaking or cutting the nose bones does. It is also the rhinoplasty maneuver that will leave you with black eyes afterward. The nasal bones are cut down low and then pushed in to close the open roof. This will also make the upper part of the nose more narrow and less thick.
Taking off a nasal hump, however, must not be done too far. Taking down the bridge of the nose too much, as was commonly done in the past, results in ‘scooped out’ or ‘ski-jump’ noses and leads to breathing problems. Keep a high but smooth and non-humped bridge of the nose helps to protect from breathing problems after rhinoplasty surgery.
Interestingly, taking down a hump also makes the nose look smaller and less long, an optical illusion that can easily be demonstrated by computer imaging.
The shape of one’s nose is said to reflect on one’s personality. I have no idea whether that is true but a well-shaped nose without a hump can definitely improve one’s facial balance and appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am HIV positive as well as a diabetic with deflated cheeks. Do you think transferring fat from my own body to my face will work?
A: Facial lipoatrophy is a common sequelae from the antiviral medications used in the treatment of HIV. Often this loss of fat is quite severe with the skin literally be right down on the bone with loss not only of the buccal fat but loss of the subcutaneous fat as well. When the condition is this severe, the concept of injectable fillers must be looked at very carefully. While fat injection transfer can clearly be done, the question is will it work long-term. How much of the injected fat will survive? The HIV patient on antivirals poses an additional variable to the biology of injected fat which is already challenged in the variability of its survival. Will the same medications that caused the fat atrophy to begin with do the same to the injected fat? No one knows with absolute certainity.
For these reasons, I prefer an additional approach to just injected fat for this cheek lipoatrophy. I like to place a submalar implant on the lower edge of the cheekbone and then cover this with an internally placed dermal-fat graft. Then injected fat can be placed subcutaneously throughout the cheek and lateral facial areas as an additional outer layer. This is a good way to hedge your bet so to speak by at least having some type of cheek augmentation that you can be assured will have stable volume preservation.
Dr. Barry Eppley
Indianapolis Indiana