Your Questions
Your Questions
Q: Dr. Eppley, I am interested in jaw wiring. I had a back injury about five years ago and then my weight was 130 lbs. Now it is 210 lbs. If I could get down about 30 to 40 lbs I think I could exercise and really make it work. Does this sound realistic?
A: The eternal question about weight loss is whether any method that provides an immediate and short term effect will provide a sustained weight loss change. The most effective long-term methods of weight loss are significant lifestyle changes in diet and exercise. But that issue aside it is well known that wiring one’s jaws together (e.g., orthognathic surgery) will cause weight loss by the limitations of what one can take in orally. (lack of solid food)
It is important to remember that while jaw wiring can certainly initiate weight loss while they are in place when they come off the onus will then be on the patient. But if you are confident that somewhere between a 20 to 30 lb weight loss over a several month period will help, there is no medical contraindication to doing so. The only question is how long to leave the jaw wiring in place which is usually between 6 to 8 weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, When placing a tear trough implant through the eyelid with internal scar and no stitches, are the tissues peeled off the bone as they are with cheek implant placement? I had cheek implants in and removed quickly which left me with mid face sagging and worse eye bags than before, minimal, but the tissues adhered a few millimetres lower than before the operation. Is this a risk with tear trough placement and or removal?, or is a mid face lift usually performed in conjunction with a tear trough implant? Which nerve functions are at risk with this implant?
A: A standard preformed tear trough implant can be placed through a transconjunctival (inside the eyelid) approach. Like all facial implants, it is necessary to make a pocket for the implant which is usually subperiosteal although is can be placed preperiosteal as well. Given the very thin nature of eyelid tissue over the orbital rim, it is best to placed it as deep under the tissues as possible. I would consider the tissue pocket locations between the orbital rim and cheek bones as different as well as the size of the implants that are placed. Cheek implants are placed from below with wide subperiosteal underming and dissection, releasing much of the midface tissues on the bone to place a moderately large implant. Thus it would not be surprising that removal of a cheek implant places one at risk for a subsequent midface sag of some degree. Conversely, the tissue pocket for a tear trough implant is much smaller and is over the medial orbital rim where the detachment of tissues will not cause a midface sag like that of the cheek area.
Tear trough implants pose no risk of nerve injury. The only close nerve is the infraorbital nerve which lies below the orbital rim and where the implant is placed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently looking to have a rhinoplasty later this year. I had a discussion with an anesthesiologist about my needle phobia who advised I speak to the anesthesiologist who will be taking care of me during the procedure. As much as I want to say I don’t have a problem with my needle phobia I do. The last time I had my blood drawn I panicked and passed out. Obviously I don’t want any of that to happen which would make my surgeon’s job harder. He suggested maybe a prescription of Valium before the procedure or something of that nature. I will let you give me your professional advise on this matter. Looking forward to hearing from you.
A: Needle phobia issues are not uncommon in surgery. Known as trypanophobia, it is estimated that about 10% of people have it. While having to get a needle sick is unavoidable since an IV will be needed for your rhinoplasty surgery, there are numerous ways to get past this fear. Your apprehension can be remedied by taking 10mgs of Valium and 25 mgs of Phenergan orally orally one hour before arriving for your surgery. (as there will be someone driving you to and from surgery) Your surgeon can write that prescription for you. Make sure that you have signed your operative consents and had all your questions answered days before the surgery as consent can not be obtained from a mildly sedated patient.
The other management issue that can be done is to apply a topical numbing cream prior to actually putting in the needle. This will minimize needle insertion discomfort.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost a lot of weight and the one area that bothers me the most is that of my buttocks. It hangs down with a lot of loose skin onto the back of my thighs. I don’t mind its size now but I can’t stand the loose skin at the bottom. And exercise will not get rid of it. What type of buttock lift do I need?
A: When it comes to large amounts of weight loss, the buttocks like every other area of the body is not spared from an overall deflation effect. The deflated buttocks loses both volume from fat loss and exaggerated amounts of sagging due to such volume loss. Buttock reshaping after weight loss can include either volume addition, tucking or lifting the sagging skin or some combination of both.
Buttock lifts can be separated into a true buttock lift (done from above as part of a circumferential body lift) or a lower buttock lift. (which is really a tuck after excision of overhanging skin.
A lower buttock lift is a lower excision/tuck procedure that is done along the infragluteal crease. (or makes a new one) It removes excess tissues and creates a new higher and more tucked in fold. It is not a difficult procedure to go through nor to recover from it. The biggest issue is to just not stress the incision lines (like bending over far) for a few weeks as the area heals. All sutures are under the skin and dissolvable so no suture removal is needed. The incision lines are heavily taped for support and serve as the only dressing. One can shower the next day and only strenuous activities need to be avoided for awhile until the incisions are more fully healed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am searching for a facelift opinion. I know you are an expert so I would value your opinion. Can a facelift correct this droopy mouth and marionette lines? I have lots of sag and volume loss. My skin seems firm with good elasticity but aging and gravity does take its toll. Is a long lasting correction possible? There are so many options for facelifts these days I don’t know which is the right one. Every doctor seems to have their way to do a facelift and they all claim their way is the best. I will only be able to financially do this once, so I’m looking for the best information to get the best outcome for me.
A: You are correct in that there seems to be many ways in which facelifts are done. And any time there are so many ways touted to do something you can be assured that there is no one single best way to do it. Nor does one facelift method work best for everyone as today’s facelift patients range anywhere from 35 to 85 years old…and simple logic would indicate that the facial aging concerns and anatomy amongst patients are quite different.
Facelifts fundamentally differ in three ways, extent (incisions and dissection), degree of SMAS manipulation and adjunctive procedures done at the same time. Putting together all these areas is what makes facelifts different and customized for each patient. But what does make them somewhat similar and serves as the basic elements of a facelift are the amount of skin flap dissection and SMAS redraping. With significant marionette lines and a droopy mouth, it is clear that you need a fuller type facelift with long skin flaps as opposed to a short scar or more limited type facelift. (e.g., Lifestyle Lift) SMAS manipulation is handled differently by various plastic surgeons but suffice it to say that extensive redraping of it is needed. Such manuevers are needed to help get rid of the marionette lines and improve the jawline and neck.
What a facelift will not do is correct droopy mouth corners. As a result, a separate small procedure will be needed with your facelift that directly treats this problem…a corner of a mouth lift.
When it comes to a ‘lasting correction’, it is important to understand that a facelift essentially buys time. It is not a permanent procedure and its effects will last years, perhaps 8 to 10 years, but eventually some or much of the correction will be lost. Facelifts help reverse the clock but they can not stop it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants recently and developed right after a weakness of my right upper lip and nostril. I was reading up on people that have had similar issues like mine and what other doctors have recommended and can across this (read below). I’ve also read the longer you wait to get the issue checked out the worse the outcome will be if your trying to fix it. So I’m torn on waiting if it lowers my chances of resolving the problem. I’m terrified this is permanent and was wondering if conducting a nerve test would be a smart thing to do. Maybe the nerve just needs to be decompressed, or if it was damaged or cut then nerve grafting would be the way to go. But the longer I wait the less my chances are to fully recuperate to the way I was before.
What do you think?
‘The usual risks have been well presented by the other physicians. However, based on observed cases, there is a risk for temporary weakness of a cheek or upper lip especially with the larger implants which have to be placed beneath a branch of the facial nerve which is stretched. When and if this happens , Botox therapy can be used for symmetry until the nerve function returns.’
A: Facial nerve injury is a very rare occurrence after cheek implants as the dissection is done under the muscle where the nerves supply them. But it can happen. In almost all cases complete nerve recovery would be expected.
I would be very careful about what you read and try to interpret about facial nerves injuries…as they are quite different based on where the injury to the nerve occurs and what type of injury that it is. Most of what you are reading refers to a proximal injury to a facial nerve branch, whereas what you have is a distal or terminal branch type of nerve injury. In essence if you draw a line between the corner of your eye and the corner of your mouth what lies towards the ear would be considered proximal and what lies on the nose side of that line is distal. Distal facial nerve injuries, where the nerve fibers are smaller than a human hair, are not treatable by any surgery or other therapy. Time and healing is all that can be done for them. This is particularly true for the distal branches of the buccal nerve which supply the upper lip and nostril. The buccal branch has a particular propensity to recover, unlike many other facial nerve branches, because there is considerable cross connections between these terminal nerve fibers. So even if one little branch is injured, the cross connections will allow other signals to supply what has been lost. This is particularly true in stretch injuries. (which is the only type of injury you could have) Thus it is not true that the longer you wait the worse the chances of recovery are. Waiting is the treatment and the longer you wait (there is nothing else to do) the better the chances of recovery will be. This is a process which is unknown as to how long it will take…it could be days, weeks or even months. Although I would guess some improvement will start within four to six weeks, it could take longer and complete nerve recoveries have been seen out to even a year after the event.
Botox injections can be done on the opposite side for facial symmetry, although if recovery on the affected side starts weeks later, the facial asymmetry will persist until the Botox wears off. (around 4 months) Since facial nerve recovery is usually progressive (starts working a little at a time), I would wait a few weeks or month to see if the nerve will slowly start coming to life. If not, then you can get Botox on the opposite to provide some temporary improvement in facial symmetry with smiling.
Dr. Barry Eppley
Indianapolis, Indiana