Your Questions
Your Questions
Q: Dr. Eppley, I have consulted with various surgeons regarding my Medpor orbital rim implants as I would like to have them removed. However, these surgeons seem divided in thought – with some claiming that it’s impossible to remove as it causes too much damage, while others said that it would be possible but difficult. This has left me slightly confused as to what the actuality of Medpor removal is. Based on your experiences, do you think removing these Medpor implants with minimal soft tissue damage would be possible if the surgeon were meticulous about it?
A: In short, the removal of Medpor implants can be safely done. I have removed numerous Medpor implants over the years from the chin, jaw angles, cheeks and orbital rims. While it is true that there are much more adherent than silicone (which isn’t at all), there are far from impossible to remove. I have yet to see a Medpor implant that has any bone ingrowth for which they are touted to have. One very interesting feature about Medpor implant removal is that they are less hard after they have been implanted in the body and have had tissue ingrowth than when they are initially put in. This is undoubtably due to water absorption into the interstices of the implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a buried penis problem and was wondering if liposuction of the pubic mound would help. I have always been obese, my last 12 yrs I have been morbidly obese. I remember my penis has always been small I have had sex many times but is very uncomfortable. Normally I have to choose an small lady, but I can remember seeing it better when I was not as obese as I am now. I can feel the erections coming from way inside under the fat and if I push the fat back the penis will pop out .. I can only push so much that I am able to grab it with a full fist not including the head. But if I was to push more I can see that I have an average penis and of course if I don’t push that fat back it goes all the way in and can’t be seen.
A: The buried penis problem is usually multifactorial in what causes it. Certainly a large suprapubic fat pad is one easily identifiable cause and in the obese male can be the major factor. The shape of the suprapubic mound must be looked at carefully to see whether loose skin hanging down may also be a cause in addition to the fat content of the mound. These helps makes the determination as to whether liposuction alone or liposuction combined with a pubic lift may be needed. The other factor in the buried penis is that the penis itself may be part of the problem as well. It may be naturally small or may be tethered down by fibrosis. It may need to be released as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have reads that some doctors offer pain-free breast augmentations. How does that work and why isn’t that done for every braest augmentation surgery. Who would not want it?
A: The idea of a pain-free breast augmentation is more of a marketing concept that a reality. It is simply an impossibility to lift up the chest muscle (pectoralis muscle) and put an implant underneath it that is without pain anymore than it is to tear a muscle without any discomfort. What this so-called ‘pain-free’ procedures are is that they incorporate a new long-lasting local anesthetic. This new type of local numbing medicine, known as Exparel or Depofoam Bupivicaine, has been specifically studied in breast augmentations (as well as other plastic surgery procedures) and has shown showed good results with no complications. This local anesthetic when injected into the muscle during the breast augmentation does reduce pain after the procedure that has a lasting effect upt o three days afster surgery. While pain may be reduced, no study has ever shown that any method of breast augmentation can result in a ‘pain-free breast augmentation’. It may reduce the pain one may feel after surgery but will not eliminate it completely.
Exparel is a longer-acting form of an already long-acting local numbing medicine. (Bupivicaine or Marcaine) It is formulated in a liposome carrier that allows for slower absorption and lasting effects up to 3 days after surgery. This is a critical period for most cosmetic procedures as this is when the most severe discomfort occurs. This also reduces the need for oral narcotics and reduces the likelihood of nausea and vomiting and constipation, all common side effects of pain medication in women.
The one problem with Exparel injections is the cost. It adds at least $200 for the injections in a single patient, a significant expense when a patient is already paying $4,000 to $6,000 for their breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a Caucasian male in my mid-twenties. I had an unfortunate accident in my late teens in which I fractured my left parietal bone. At the time, I wasn’t particularly concerned about it – I don’t think I realized the severity of it. Now, a few years down the line, I’m balding and I have a dent in my head. Coupled with my hair-loss, it’s something that I’m very insecure about.
One of the first things that I did after I decided that I want to do something about it was to see a neurosurgeon. He sent me for CT scans, which showed that the parietal bone is indented and that the bone around it, towards the top of my skull, is raised. The dent is very obvious, as is the fact that the back of my skull, on the left side, seems to protrude further outwards than the right. I feel that it gives my skull a lopsided appearance. The neurosurgeon said that he could fix it, but that the scars that it would involve would not be a worthwhile trade-off; it may look just as bad, if not worse, than the dent. I also saw a plastic/reconstructive surgeon – one of the leading craniofacial surgery specialists in my country – about the dent. He gave me the option of injections using either fat or cosmetic fillers; neither of which would be permanent. He also advised me against surgery, due to the scars that it would leave. I don’t want to go the fat/filler injection route, since it is only temporary, and it will not do anything to fix the lumpy bone that surrounds the dent.
My questions, therefore, are as follows;
1.) Is there anything that can be done that would fix both issues (dent and lump) without significant scarring? I am hoping that one can remove some of the bone (it should be around 2 – 5 mm’s, by my estimates) to smooth out the lump and restore the normal contour of my skull. I can imagine that this would not be trivial since it involves that back of my head where the bone “rounds” down towards both the back and the left side of my skull.
2.) If surgery is an option, can bone by removed from the lumpy area and placed in the dent, or would a bone cement of some sort be used, regardless of whether or not bone is removed from the lumpy area?
3.) How bad will the scarring be, in the event of surgery? I found a blog (tracysigler . com/brain-surgery-experience / this-is-the-end) while I was doing my research. Does that image offer a good benchmark of what a healed scar would look like?
The attached images shows my issues.
Perhaps this question may also be of benefit to others visitors to your website.
Thank you kindly for your time.
A: Thank you for your inquiry and sending your pictures. While an open approach could obviously be done to create the optimal contour skull contour through a combined reduction of high areas and filling of the defect with bone cement, one has to be careful of the scar trade-off. I have done many open cranioplasty procedures through more limited incisions (5 cms.) in that very area and the scar can be acceptable. (ironically many of these have been done on men that actually shave their head. So I would not rule out that incisional approach. I think why other surgeons have not been enthusiastic is that they were envisioning a larger more traditional coronal incision which would obviously create an aesthetic trade-off that would not put you in a better position.
The other concept to consider is an injectable cranioplasty approach just for filling in the defect. Through a small 1 cm incision, the tissues can be lifted up over the defect (pocket creation) and a bone cement introduced through a tube into the defect space and molded from the outside until set. That would certainly fill in the defect in the most minimally invasive manner in regards to the scar.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 34 yrs old with a hidden penis problem I am uncircumcised too.. so I am getting a this surgery if suitable for me… please reply to me … I know below all that fat there a small but decent penis.
A: Thank you for your inquiry. Many buried penis problems are a combination of a suprapubic mound and a retracted penile length. Thus, suprapubic liposuction may not be completely effective for all buried penis patients as the penis may need to be released/lengthened as well. Do you develop a visible penis with an erection? Was the penis visible when you were younger before there was a significant suprapubic mound? To best answer your question I would need to see some pictures of the mound area, particularly from the side view to see what type of buried penis problem that it is you have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read a lot about the Vampre Facelift and wanted to know what you think about it. While the name sounds a little creepy, using your own blood to help make you look younger seems like it might work.
A:Platelets are ubiquitous cellular fragments in the blood stream that is most known for helping blood clot. But platelets also make a major contribution to wound healing as they contain a multitude of growth factors which are well known to help repair and regenerate connective tissues. Application of these growth factors in high concentrations through platelet-rich plasma (PRP) has been used as an adjunct to wound healing for almost 20 years.
Platelet-rich plasma (PRP) is blood plasma that has a high concentration of platelets due to processing techniques. A small amount of blood can be drawn from the patient and the platelets removed from it by centrifugation. This creates a platelet concentrate gel that can be added to a variety of plastic surgery procedures such as facelifts and fat grafts to theoretically improve their results through the delivery of its growth factors.
While PRP can be used alone, a variety of aesthetic facial procedures have been developed that combine it with different types of injectable fillers. Marketed brand names such as Selphyl and the Vampire Facelift create either a platelet-rich fibrin matrix or are used in conjunction with other well known fillers such as Juvederm and Restylane. The benefits of PRP in these facial rejuvenation techniques, while theoretically appealing, has not been fully substantiated in widespread clinical use and ongoing patient studies continue to evaluate this autologous therapy in aesthetic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read a lot recently about stem cells and their potential rejuvenative properties. It seems logical that if our body is full of them that they can be used to treat a lot of problems including the negative effects of aging. I see some plastic surgeons offer a stem cell facelift. Does this really work and, if not, how come some doctors do it?
A: The use of adult stem cells for their potential cosmetic and anti-aging effects is very controversial at present. While our fat is a large reservoir of stem cells (300X to 500X more than bone marrow), that does not necessarily mean that they work as we would like or hope. The popularity of stem cells is largely because of the ability to harvest fat through liposuction as a source for stem cells,. It is fairly easy to ‘recycle’ the liposuctioned fat and put it back into the patient as an injection with the assumption that tissues of the face can be rejuvenated, Numerous anectodal claims are made about such injections as creating youthfulness, adding permanent volume and improving the appearance of the skin. This has led to a number of touted procedures carrying such names as the stem cell facelifts. Despite their appeal, there is no medical evidence by published clinical studies that proves that it actually works.
Most of the time, such stem cell injections are really nothing more than fat injections that unavoidably contain some stem cells. It is the fat that creates any volumetric or lifting effect and not the stem cells that it may contain. While such ‘stem cell’ injections are unlikely to be harmful, they have not been proven to have anti-aging effects. But the hope that they might, and the lack of any adverse effects, provides plenty of motivation for marketing hype.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have the flat spot on the back of my head built up. I understand that various materials can be used to do it but don’t know which one would be better. What are my options?
A: Bone cements in cranioplasty can be either polymethylmethacrylate (PMMA) or various calcium-containing materials. All of these materials are joint powders and liquids that are mixed in surgery to create a self-curing putty that offers enough set times to create the desired shape on the bone. The most ‘natural’ bone cement is that of the synthetic calcium compositions, of which the most common ones used are calcium phosphate-based also known as hydroxyapatites. (HA) They are natural to the bone because the inorganic mineral content of human bone is hydroxyapatite. Another calcium-containing bone cement is that of calcium carbonate, known commercially as Kryptonite. It offers superior biomechanical properties (less prone to fracture) than the calcium phosphate-based masterials but is no longer commercially available. Whether PMMA or HA is better for any cranioplasty is based on a variety of factors (cost, inlay vs onlay, size of incision) and not necessarily because one is more natural or more synthetic. There are different material properties for each type of bone cement and these must be considered also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about getting liposuction. I am in the Military and am curious about the Patriot Plastic Surgery Program. Quick bit about me, I was injured a little bit ago, and was pretty much unable to work out for a little over a year; where I gained weight and loss quite a bit of muscle mass as well. I would like to get my abdomen and love handles sized down as much as possible (or that is possible).
A: The Patriot Plastic Surgery program offers some reduction in fees for any cosmetic surgery for those who are in or have been in military service. While I have no idea as to what your body looks like, you are obviously a young man who is probably in reasonable physical condition. (not obese) Because you are a male your abdominal and flank skin is likely in good condition (no stretch marks) and can shrink down nicely after the fat is extracted. Reducing your abdomen and flanks should, therefore, provide an effective and visible improvement with liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What’s the recovery time for a rhinoplasty? How soon could I return to work and look somewhat “normal”
A: The recovery time for a rhinoplasty is usually no more than 10 to 14 days at worst. This is not the total time that it takes for the nose to achieve its final shape, as that takes months, but until it really looks ‘non-surgical’. I have seen some patients who actually look pretty good when the tapes and splint is removed at one week but it would be safe to use the time period of 10 days for returning to work, etc. Normal is defined when one can walk around in public and not look like they have had surgery. Often the key determinant is when the bruising under the eyes will go away provided that one has had nasal bone osteotomies as part of their rhinoplasty. For those rhinoplasties in which the nasal bones do not need to be manipulated, the recovery in appearance is sooner.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In February 2012 I had a Mitrofanoff diversion done using small intestine. (appendicovesicostomy) Cathing thru the stoma has been a problem since day one. The hole keeps shrinking. Have to “punch thru” for each cath. Usually bleeds, plus painful. One stoma revision done last summer which lasted a few weeks. The urologist has suggested plastic surgery but I am skeptical and tired or surgeries. The total problem was radiation damage from prostate cancer treatment.
A: I think in the face of radiation, it is virtually impossible to keep a stoma open by any type of ‘simple’ scar revision around the stoma. As taking the same tissue that have been exposed to radiation and asking it to heal without shrinking by scar contracture will not work. These are not normal tissues. Any hope of sustained stoma enlargement must occur by altering the involved tissues to have improved vascularity. This could be done by injectable fat grafting around the stoma which adds healthy fat and stem cells and then secondarily performing an interpositional skin graft to the stoma opening. But this approach would be hard to get enthusiastic about when one has had repeated surgeries that did not work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read some articles online and some doctors said skin graft on eyelid looks horrible. Is that true? Have you done skin graft for your patients similar to my case? Will my eyes look uneven after the graft? And how to measure how much skin is needed for the graft? Will my eye shape change back to its original shape after the grafting? When the grafting is done, do I have to patch my eyes for few days? Is that mean I can’t open my eyes for few days? Do u think makeup can cover the unmatched color? I await your advice.
A: Skin grafts on the eyelids will create somewhat of a patch look as it is impossible to match the exact color of skin on the eyelids from anywhere else on the body. I would not necessarily call them horrible-looking. Generally one does skin grafting to the eyelids for a very compelling reason and not for a minor aesthetic concern. Skin grafts are covered by a small sewn-on bolster after surgery for five days which does not prevent the eyes from opening or closing nor does it occlude them. The graft does take time to blend better into the surrounding skin and makeup can be worn in the interim.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve read online that you do infraorbital rim implants. I’m really sorry to trouble you, but I have a concern regarding my upcoming procedure with these implants. Basically, my doctor has informed me that he will be using an intraoral approach for the Medpor Extended Orbital Rim implants, but every resource I’ve seen has said that the implants are placed through an eyelid incision. Do you think an intraoral approach is possible, and will the results be affected by using it? Should I at all be concerned that he isn’t going to use the eyelid incision?
A: The placement of infraorbital rim implants can be done either through an eyelid or an intraoral approach. Both are acceptable approaches and which one is done is based on surgeon preference. It is a little easier to assure good implant position on the bone from above (eyelid incision) as one does not have to work around the large infraorbital nerve. But an infraorbital implant can be effectively placed from inside the mouth, it is just a little more technically challenging to do so and the risk of some protracted lip numbness from infraorbital nerve traction will occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a bad scar across the back of my head from two previous hair transplants. After the first procedure the scar looked pretty good and was narrow. But after the second time it has gotten wider and more noticeble and I can not wear my hair very short anymore. What is the nest way to improve this scar? Cab it just be cut out again and will it look better? Or should I just have hair transplants put into the scar? nd if hair transplant are done how would the grafts be taken and wouldn’t that just make another scar or risk making this on wider.
A: When it comes to hair transplant scalp scars, there are three approaches to consider. The first, as you have mentioned, is to simply re-excise the scar and reclose it. (scar revision) Whether this would make a successful improvement depends on how loose or lax your scalp now is. Given that you have had two hair transplants with the strip method, it is likely your scalp has lost much of its elasticity or natural stretch. Wide scalp undermining would need to be done from above but how successful that would be at reducing tension on the scar revision closure is unpredictable. Another scar revision approach would be to first do a few weeks of scalp tissue expansion. Going through the scar scar in a first stage, a small tissue expander is placed above the scar and expanded every few days for a few weeks. Then the scar revision is done and it could then be assured that there would be no tension on the wound closure and a very fine line scar achieved. The third approach would be hair transplantation. But this would not be done using a strip method. Rather a follicular unit extraction (FUE) method would be done using the Neograft system. This method harvests the hair (follicular units) by using 1mm punches spaced out over the occipital and temporal donor area. These small extraction sites heal imperceptibly and the hairs are then transplanted into the scar.
Whether a scar revision or hair transplantation approach is best for your strip scar would depend on how much laxity your scalp has (or doesn’t have), the width and location of the scar and what your hair donor site look like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very deep cleft on my chin. A surgeon suggested dermal filler, saying that a chin implant would move because (he said) the dimple was too small. But my cleft chin is very deep and I am very unhappy with it. A doctor injected a syringe of hyaluronic acid into last year but with no visible improvement. I have placed a link to an image of my chin cleft here.
A: Very deep chin clefts in men are not usually the result of any underlying bone deficiency but are rooted in the soft tissue with a lack of tissue between the skin and the underlying muscle. Often the mentalis muscle is clefted as well. In addition the skin is very indented almost like a scar band. Thus a chin implant on the bone is likely to be of little benefit as pushing out from the bone will make little change in the depth of the cleft. Injectable fillers, as has been demonstrated by your experience, do not have enough stiffness and volumetric push to change the cleft. The viable treatment options would be either fat injections done with a subcision release of the vertical skin indentation or an open approach using a dermal-fat graft. In some cases the placement of a small implant in a midline bony groove can be of adjunctive benefit if it exists.
When it comes to chin cleft surgery, it is best to think of it as a reduction rather than a complete removal.
Dr. Barry Eppley
Indianapolis, Indiana