Your Questions
Your Questions
Q: I have some questions about the lip lift. I know that this procedure is quite controversial in cosmetic medicine. The plastic surgeons in my area will not perform it. However, after doing some research I have found that there are ways for it to be done successfully without cutting the orbicularis muscle. What is your opinion and experience with this procedure?
A: When you say lip lift, I will assume you are referring to the subnasal lip lift. (aka bullhorn lip lift) This is where skin is removed from under the nose to lift up the central third of the upper lip and shorten the long upper lip. Despite a lot of hesitancy from plastic surgeons to perform this lip enhancement procedure, I have found it to be very straightforward and uncomplicated. There is no reason whatsoever to remove any orbicularis muscle when shortening the upper lip. This is fraught with problems if done including a tight upper lip and an abnormal smile. While muscle resection probably does prevent any vertical relapse, it causes irreversible lip problems. Relapse is a much more easily treatable ‘problem’ so only skin should be removed. As a general rule, no more than one-third the vertical distance along the length of the philtral columns should be removed. One can expect 1 to 2mms of relapse in the first few months after the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have scleroderma and there are quite a few things that bother me about my face. Because of the scleroderma, it has caused a lot of damage to my appearance and the whole left side of my body is smaller than the right. If I could change how I look, I would want to look as close to normal as possible. I know I won’t look perfect but just looking like I’m not sick is good enough for me. My main issues are my cheeks which are sunken in, my chin which is uneven, my lips in which the top and bottom left sides are smaller and my nose which I think is too pointy. There is also an indentation on my forehead and the area under my eyes seems very hollow, all these affected more on the left side. I would really like to hear your opinions are on what I mentioned and your recommendations. I have attached a series of pictures for you to review.
A: I have taken a look at your pictures and your overall problem which is two fold; a short lower face and a lot of soft tissue thinning and atrophy. (more on the left than the right) In making an effort to get you looking better, you need a two-level approach. First, it is necessary to change the bony foundation by making the chin longer, more even and further forward by a chin osteotomy as well as a rhinoplasty to bring the nose/middle part of the face back into better balance. (this is what is imaged in the side views) Cheek implants are also needed to add some fullness to the cheek area. (this is what is imaged in the front views) The soft tissue deficiencies, which are difficult to image, are addressed by the placement of multiple dermal grafts and/or fat injections (if you have any fat elsewhere on your body to harvest) in the forehead, lower eyes, side of the face below the cheeks and in the left upper and lower lips. All of these could be done in one single surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a question about jumping genioplasty. I am curious, if you have had previous chin surgery with indwelling plates and screws as well as possible internal scarring of the muscle that causes creases in your chin when you smile, can you still undertake a jumping genioplasty? Or would the scar tissue and plates and screws from the previous ostetomy prevent this? I understand this makes surgery more difficult to carry out. I was just wondering if it is still possible.
A: While you are correct in that it is more difficult, it is not impossible and sometimes is fairly uncomplicated. The only limiting factor is the plates and screws used from the first osteotomy and how easy they are to remove. The typical osteoplastic genioplasty, if the chin has been advanced, is a step titanium plate with 4 or 6 screws. As long as bone had not completely grown over these metal devices, they are often fairly easy to unscrew and pry out the step plate. But if bone has completely covered these devices, their removal can be very difficult and destructive. Fortunately, complete bony healing over the plate and screws is not common. Once the devices are removed, the osteotomy is straight forward and the prior chin surgery actually makes it easier to complete a secondary bone cut.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi there, I was interested in your lip lift procedure and wondering if you did fat transfer to the face for reshaping/volumizing, and a butt lift using fat transfer. I’ve been researching for several months and I’m ready to have it done, but I’m wanting to find the right surgeon for me.
A:I do a lot of fat injection surgery, most commonly to the face for volumetric enhancement and to the buttock for augmentation, otherwise known as the Brazilian Butt Lift. Fat transplantation by injection is a really exciting approach for numerous face and body contour problems even if its ultimate survival is not always assured. The exact technique for fat preparation varies by surgeon and there is no absolute agreement as to how it should be done. I use a fat concentration technique and then mix it with PRP and Acell Particles to enhance survival and volume retention. These are by far the most common recipient locations. The key is whether one has enough fat to harvest which is an issue for the buttocks and not the face.
Lip ‘lifts’ can be done as either a subnasal lip lift or a vermilion advancement depending upon the shape of the upper lip and the patient’s scar tolerance. Please send me some photos of your lip for my assessment. Both approaches can be very successful when properly done. Vermilion advancements produce the most dramatic change in lip size and shape. True subnasal lip lifts are more limited in how they change the shape of the upper lip.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 35 year old mother of two. I’m 5’4″ and 144 lbs. I have been planning my mommy makeover for a while now and have put a alot of thought and research into it. I need a breast makeover with a lift and implants and a tummy tuck. The other area that bothers me a lot is my inner thighs. I have very little fat just loose skin with a lot of stretch marks. I know an inner thigh lifts creates scars and I am not wild about that idea. I know that thse groin scars can move downward as they heal which could be a problem in a swimsuit. Would a body lift be a better option? I know the scar goes the whole way around but how well would it lift the inner thigh area? What are your thoughts?
A: Your thought process is a good one but you have an understandable misconception about what the the lower body lift or circumferential lipectomy procedure can do. By removing skin and fat all the way around (360 degrees), it will make significant changes to your abdomen, lower back, buttocks and outer thighs. But it will have little if any effect on the inner thigh area. You wouldn’t do a lower body lift if you thought one of its main advantages was improvement in the inner thighs. The only way to improve the inner thighs is to treat them directly with an inner thigh lift. This would be far easier and more effective than a lower body lift. With well-placed incisions, the scars should remain fairly hidden in the groin creases.
Dr. Barry Eppley
Indianapolis Indiana
Q: My forehead sticks out from the side is there anyway you could make it flat and look at least normal? I have attached s side view of my forehead so you can see how far it really sticks out.
A: Thank you for sending your picture. It does show a fair amount of convexity to your forehead. The amount of convexity could be reduced but it can not be made to be flat. The bone thickness will not support that much reduction.
Here is a computer image of what I think is the best that could be achieved with a burring reduction of the forehead bone. There is one way to know absolutely for sure how much reduction can be done and that is to get a simple lateral skull film x-ray. On that x-ray the thickness and, most importantly the thickness of the outer cranial table can be seen. The skull (forehead) is composed of three layers; an inner and outer hard cortical bone layer in between which exists a softer marrow diploic space. The amount of horizontal reduction of the forehead is limited by the thickness of the outer cranial table. It can only be reduced until one gets close to the diploic space. Measuring that on the x-ray could show how much the forehead could be reduced in thickness. A tracing of the before and after cranial contour could then show you the exact profile change that could be achieved.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is a cheek implant that is placed high (near the orbital rim) and lateral, that extends to the orbital rim and that provides a significant augmentation (5 mm or more), able to lift the portion between the iris and the lateral canthus (not the lateral canthus itself) of the lower eyelid a little bit? I noticed this feature of the lower eyelids in people who have naturally very high and prominent cheek bones.
A: The simple answer is that it is unlikely. While it seems logical that the lower eyelid can be pushed upwards, and it is easy to do with one’s finger, try it by pushing up on the cheek tissue. You will notice the lower eyelid does not really move upward but just creates bunching of tissue right beneath the lid line. This is because the lateral lid line is fixed by the lateral canthal tendon. The only way to change the lateral lid line is by repositioning or tightening the lateral canthus. I suspect that putting in a cheek implant as you have described may seem to work during surgery, only to be disappointed later when no change is seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very high jaw angle. My goal is to have a jaw implant that will lower my jaw angle as much as possible. The problem is that the biggest implant I have seen only has 35mms of vertical length and the inferior ridge is just under 10mms. Does a bigger jaw angle implant exist and I have just not seen it? If not, how can a bigger one be made if possible?
A: Your are correct in your assessment that no off-the-shelf jaw angle implant can drop one’s angle down anymore than 10mms at most. Anymore more than that requires a custom implant to be made which can bring it down closer to 20mms. Such exceptional jaw angle extensions are uncommonly requested or needed which is why no stock implant exists with that degree of accentuation. I have made custom jaw angle implants that do achieve what you are after. They require a jaw model to first be made which is done from a 3-D CT scan of the patient. The jaw model made is then the exact anatomy of the patient from which the design and model are created.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested, I think, in some fillers, Botox and perhaps a partial facelift. What I would like to achieve is a firmer jawline, reduce my crow;t feet and just have a refreshed look. I am attaching some pictures for you to review and give me your recommendations. Thanks!
A: Thank you for sending your pictures. I have done some imaging looking at firming up your jawline. You hve the typical jowling the comnes with aging and this also creates a prejowl indentation as the jowl sags. That is best corrected by a lower facelift (neck-jowl lift) and adding in a small chin-prejowl implant to bring the chin out slightly (yours is a little short) and filling in the prejowl deficiency. The combination of these two makes for a smooth jawline. At the same time, I would place some fat injections in the nasolabial folds (lip-cheek grooves, parentheses) as this is the best ‘filler’ to use when you have are doing a facelift as it is the only filler that potentially can be more permanent. Botox for the crow’s feet can be done either during a facelift or anytime in the office. Just for the sake of one additional suggestion, I have also imaged a rhinoplasty by doing some nose narrowing and lifting the tip a little as this can also have a rejuvenating effect as one gets older.
These computer images will help you think more about what can be done for a refreshed look.
Dr. Barry Eppley
Indianapolis Indiana
Q: Six years ago I had a mandibular implant placed as well as malar implants. I am unhappy with the end result and do not feel the result was what I requested. I think, as I did then, that a geniomandibular groove implant with extended malar implants would provide my desired results.
A: I am assuming when you say mandibular implant you are referring to a chin implant. Since you feel that a geniomandibular groove implant is better, it appears that you feel that the transition between the chin and jowl area is not a smooth or confluent one or that the jowl area needs to be more enhanced as well. Do you know what type of chin implant you have in now?
From a cheek standpoint, the desire for further malar extension suggests that either you desire more fullness out across the zygoma to the zygomatioc arch or that your desire more fullness in the submalar area suggesting more of a malar shell design. Do you know what type of malar implants you have in now?
Please send me some photographs of your face and let me know, if you can, what type of implants you have in place. A copy of your original operative note can also be very helpful as often the type of implants used are described there. Once I have this information, I can offer a more qualified response as to the best replacement facial implants for you.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m planning on having a tummy tuck and have read that they can be done without using any drains. I don’t want a drain because it creeps me out thinking about a tube coming out of my body. I have also read that some plastic surgeons still use drains because they think it is better. What are your thoughts as to which way is best?
A: I have done tummy tucks both with and without drains. There are pluses and minuses each way which is why drain use is controversial and variable amongst different plastic surgeons. The purpose of a drain is to remove fluid that the body produces in the healing space of the tummy tuck area. When doing a tummy tuck without a drain, this open space is closed down with extra sutures which takes time and does add to the cost of the operation. Even though a drain might not be used, there is a small chance that fluid can still accumulate and have to be tapped later. When doing a tummy tuck with a drain, it will stay in for 7 to 10 days. There is about a 1/3 chance later that some fluid will still accumulate and have to be tapped.
Having done tummy tucks both ways, I have seen numerous cases where fluid still had to be tapped later whether a drain was placed or not. Unless a patient is possessed about not having a drain, I will use a drain most of the time. When a patien is opposed to a drain, I will use extensive plication sutures and extra OR time to perform it. That will add about a one-half hour to the cost of the operation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a 3 years old with mild plagiocephaly. I’m very interested in kyptonite injection to correct that problem in the future. Here’s my question about that technique: what is the method you are using to determine where (on the head) and how many (what quantity) kyptonite you will inject? Can we see a proposed “corrected headshape” before the procedure?
A: The determination of where to place the injectable cranioplasty material is determined before surgery by what everyone feels is the flattest area on the back of the head. That area is marked out prior to surgery. The location and size of the area to be filled in is a joint decision between the parents and myself. The amount of Kryptonite material needed is the greatest variable and the real guesswork in doing the procedure. What I know from experience is that 5 grams is inadequate and 20 grams would likely be too much. Usually 10 to 15 grams of material is needed. But the diameter of the defect is measured and then a benchtop test is done to determine whether 10 or 15 grams is best prior to surgery. Computer imaging is also done based on a superior view of the back of the head to get a prediction as to what may be obtained. It is important to realize that computer imaging is a prediction and not a guarantee of the exact outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I emailed you about a month ago about getting 5-FU injections for lumpy scar tissue underneath my nipple for a revision gynecomastia surgery I had about 4 1/2 months ago. I have been really busy at work and unable to get time off to make an appt. Last time you emailed me about a month ago you said I could schedule an appt. and possibly get a 5-FU or kenalog injection. I would really like to do this but an injection of kenalog makes me nervous due to the possibility of skin atrophy and other side effects I have heard about. I have heard that 5-FU mixed with a small amount of kenalog does not really carry these side effects and can work quite effectively. I have to travel about two hours or so to get there so I just want to make sure that 5-FU injections are a possibility before I make the trip. Also I have an issue about the scar I have from the surgery I had and I saw on your website that you deal with scar management. I know that the scar I have is only 4 1/2 months old but it does not seem to be getting any better and I was wondering if there are any non-surgical procedures or techniques, such as laser therapy, that you specialize in that could help to minimize this scar? Thank you for any help you may be able to give me.
A: We can certainly do 5-FU injections for scar therapy as that is an item I keep stocked her for injection treatments. While it is uncertain whether 5-FU is really better than Kenalog, it does have a higher safety profile. Kenalog done judiciously (low dose), however, can be done without significant side effects as well. As for scar management, there are numerous options regarding non-surgical approaches depending upon the scar issue such as hypertrophy or redness. Most commonly we do pulsed light therapy (Broad Band Light, BBL) or laser treatments. That decision would have to be made at the time of examination.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a rhinoplasty six months ago. My main goal was to make my nose larger in the middle. I have breathing problems and when I use nasal strips it makes me breathe better. I didn’t want to change my nose very much but just add support and width to the middle part. My rhinoplasty surgeon said he would put in spreader grafts and a columellar strut. After surgery when the splint was removed, he said he had also put in an onlay dorsal graft to make my nose look more balanced and masculine. My problem is that I didn’t want the dorsal graft. Now that I have more support in the middle vault, the dorsal graft makes my nose higher which I do not like. Can this dorsal graft be removed?
A: Dorsal grafts are onlay materials, usually cartilage, that is simply put on top of the bridge of the nose. How long it is and its size is largely irrelevant when it comes to removing it. The graft should be fairly easy to remove through a closed endonasal rhinoplasty approach. Unlike a bone graft, a cartilage graft never really becomes part of or truly incorporated into the underlying cartilage and bone but simply sits there with a surrounding capsule. This makes its secondary removal fairly easy. Since you are six months out, it is fair to say that you have a good idea of what your nose looks like and are certain that the dorsal graft does not fit into the desired aesthetic shape of your nose.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am interested in both malar and paranasal implants and I have learned a lot about facial implants on your homepage! In one article you stated that some areas in the face are more sensitive to implant size than others. For example, the orbital rim is one of these areas where the size of implants have to be chosen very carefully because 1 mm can make a huge difference. I guess it is the opposite with paranasal implants because (although they can be tailored) they are only available in such big sizes like 4.5 mm and 7 mm. I am not sure if I should choose the 4.5 mm or the 7 mm implant, but I am sure that I want rather a more dramatic look than a very subtle outcome. Do you think 2 mm difference in the paranasal area can make such a huge difference? Is the paranasal area more tolerant towards a slight overcorrection? Is my assumption, that paranasal implants are less sensitive to size, right? The worst thing that could happen to me after the implantation of the paranasal implants would be an increase of my nose tip projection, an increase of my nasolabial angle and a lengthening of my upper lip. Of course I know that paranasal implants usually don´t do this, but I am a little bit afraid that this could be different with the large 7 mm implants. Have you ever implanted the 7 mm paranasal implants and what are your experience with patient´s satisfaction? Did they rather wish to have more or less projection after they saw their final paranasal implant result?
A: The paranasal area is less sensitive to implant size for a variety of reasons. The first is that the skin around the base of the nose is thick so implant thicknesses are easily masked. A paranasal implant also has to push the base of the nose (nostrils) outward so it takes a bigger implant to do that. Lastly the surface into which the implant is placed is curved inward and not outward, further decreasing its influence. In general, small paranasal implants placed at the bone level has little effect so thinking bigger (7mms or more) will have a more visible effect. I don’t recall using a paranasal implant that was ever smaller than 7mms at its thickest portion.
A paranasal implant has no influence on the projection of the nasal tip, regardless of size. Only when a premaxillary implant is placed across the anterior nasal spine will it change the nasolabial angle with a small influence on the nasal tip.
Dr. Barry Eppley
Indianapolis, Indiana
The large number of stem cells in fat has led to a new wave of treatments in plastic surgery that hopes to harness the potential of this ‘wonder’ cell. Since a stem cell can turn into any type of cell if properly stimulated, it is not hard to see why any treatment attached to it is being hyped as a rejuvenative or regenerative therapy. These R words translate to anti-aging or make me look younger.
Given the ease from which fat can be extracted through liposuction, fat is being reprocessed and injected all over the body by plastic surgeons mainly because it is easy to do and perfectly safe. You might say it is the ultimate form of recycling, a green procedure if you will that is most certainly organic. Injected fat can be used from body contouring to facial rejuvenation. For the body, buttock augmentation and breast reconstruction (lumpectomy defects) are being widely done. Breast augmentation using fat instead of implants is being approached more cautiously. The other good body use is in the aging hands, using injected fat to make the hand look more plump and have a less bony appearance.The face, however, is the most common area for fat injections. Research has now shown that we loss fat in our face as we age. This facial deflation is one of the reasons that we look old and contributes to skin sagging. This has led to younger people getting fat injections at an early age and fat injections being used as part of a facelift procedure for more advanced degrees of facial aging. For the aging gaunt-looking face (or even a younger gaunt face), fat injections can be a good complement to traditional skin removal and tightening procedures.
In the most contemporary spin of fat grafting to the face comes the Stem Cell Face Lift. The concept is that stem cell-rich fat grafts combined with skin tightening makes for a better facelift result. Proponents claim that the stem cells provide a regenerative effect that makes the fat take better and helps the quality of the overlying skin as well. By mixing the fat with a little of your own blood, a theoretical youthful elixir is created.
Is the Stem Cell Facelift actual science or more science fiction? Is it hype or hope? At this point I would say a little of science and a lot of hype. The real scientists of stem cells would most certainly tell us that it just isn’t that simple. While stem cells have been extensively studied, how to make them work is far less clear. Conversely, the hopeful part of stem cells in facial rejuvenation is that it exemplifies the concept of ‘heal thyself’. Our tissues have a remarkable ability to heal themselves from injuries throughout our entire lives. It just seems that we should be able to use that to our advantage at some point.
One of the benefits of fat grafting to the face, whether the stem cells really make a contribution or not, is that it adds volume. And with our current appreciation of what happens as most faces age, becoming a little more cheeky might not be a bad thing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a corner of the mouth lift. I have checked in my area but have been unable to find anyone as of yet. How would it work if I was to choose to see you? How many trips would I need to make? Have you done many of the corner mouth lift procedures? I am 48 and do not feel I need, nor do I want at this point, a face lift as it is really only the beginning of slight mouth droop/marionette lines that really bothers me.
A: In answer to your questions, We have many patients how come from afar so we are very familiar with working with out-of-town patients. Ultimately, a corner of the mouth lift is done as an isolated procedure in the office done under local anesthesia. One only needs to come once, for the procedure only. An initial consult can be done by phone or Skype with photos of the mouth area sent in advance. Everything that needs to be discussed and determined can be done from afar. Once the procedure is done, there are no sutures to remove as they are just tiny dissolveable ones on the skin. There are no restrictions after surgery. Any follow-ups can be done like the initial consultation by phone or Skype with photos. A corner of the mouth lift is really a simpl;e proedure with the minor trade-off of a small scar. I have performed many of them either as a sstand alone procedure or often in conjunction with facelift surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 24 year old male who was born with a right cleft lip and palate and have been through five surgeries so far in my life. Besides my inital cleft lip and palate repairs, I underwent iliac crest bone grafting at age 11 and a Lefort 1 osteotomy combined with alveolar cleft bone grafting again at age 21. I have a fixed bridge across the alveolar cleft site. My current complaint is that I feels my upper jaw is collapsing again causing poor fitting of the bridge and thus pain. A CT shows a very small, but present, bridge of bone across the alveolar cleft. Also, the Lefort 1 plates appear in good position. I have no visible fistula but I can force air into my nose from the upper buccal sulcus. What, if anything would you recommend to try and solve my current orofacial problems? Thank you sincerely for your help.
A: It sounds to me like you still have a small oro-nasal fistula through the original alveolar cleft site with inadequate bone stock. I would look at repeating your alveolar cleft site grafting using a combination of some marrow and a cortical onlay graft screwed into place across the cleft site. It is very common to have resudal alveolar fistulae even though the site has been grafted more than once. If you can force air through it then there is a fistula. Plus if you have been grafted twice and it was done well, you should have more than just a small bridge of bone across the alveolus. I would wager you have a fistula going behind that bridge of alveolar bone. While alveolar cleft grafting seems simple, it actually is technically difficult and results can be less than ideal in many cases.
Indianapolis Indiana
Q: I am an 18 year old looking to correct “witch’s chin” deformity or chin ptosis. I do not know of any doctors in my area who have experience with this procedure, so I am seeking your advice and hopefully you can educate me a bit more about my case. The problem is that I have a lot of extra soft tissue in my chin that folds under and looks very awkward when I smile. I had a consultation with a plastic surgeon who said he would scrape out some of the fat and pull the skin back. He also said that he would cut the muscle. I know he has not seen this case before and that is why I have not confirmed the surgery with him. How exactly is this surgery performed and what are the different ways to go about it? How complicated is the procedure? What are the risks of going to somebody who has not done it before and how high is the risk of causing a deformity? I have attached some photo of me smiling and not smiling from both a front and side views. Your insight is very much appreciated! Thank you.
A: Based on your photos, you are correct in that you do indeed have a witch’s chin deformity. The smiling view magnifies the redundancy of muscle and skin and pulls it down abnormally over a pointy bony chin. In the truest definition of a witch’s chin, it is a deformity that occurs after some form of bone chin manipulation. Your case is different in that this is a developmental/congenital problem and not an iatrogenic or surgically-caused one. In these non-surgical cases, the bony chin is also protrusive and that can be seen at rest in your profile view. So the actual anatomic proboem is one of ‘too much chin’ from all tissues involved.
Surgical correction is done from an incision underneath the chin, what is known as a submental approach and the overall procedure can be called a submental chin reduction. From below the chin bone is shaved down and excess muscle, fat and skin is removed. The chin is then reshaped by adapting the shortened soft tissues over the reduced bone. This is not a complex procedure but must be done carefully and all chin tissues musts be reduced and tightened. The trade-off is a scar under the chin. I have attached a patient example of the procedure for you to see the results and the scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: My 14 year-old son has developed breast enlargement that is quite troubling to him. Do you know if insurance will cover gynecomastia surgery?
A: There is no way to predict whether any insurance company will or will not cover an adolecent’s gynecomastia surgery. I have seen numerous cases over the years that has been covered (most before 2000) and many (since 2000) that has not. Regardless of what an insurance company may say in its declaration of coverages or what may be spoken on the phone by their representatives, nothing is certain unless it appears in writing. Therefore, pursuit of insurance coverage must be qualified with a predetermination process. This is essentially a letter from a plastic surgeon stating the diagnosis and intended surgery, complete with photographs of the patient’s chest. In addition for gynecomastia determination, it is important to have an endocrinologic work-up which demonstrates that there is not an hormonal basis for the gynecomastia which could be treated and reversed by medical treatments and thus not needing surgery. Even with this approach, there is at best a 50:50 chance. If the photographs do not show a significant breast mound (like a woman’s breast) those chances drop significantly. Only the most severe gynecomastias would be likely to be covered, anything less will be judged to be just a cosmetic gynecomastia surgery problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am studying to become a radiology technologist at a local community college and I am preparing a powerpoint presentation on the skull. I’d like to play Dr. Eppley’s HTR/PMI Cranial Implant Reconstruction video as seen on YouTube during my classroom presentation to demonstrate current medical procedures to repair and reconstruct features of the skull. Can I please have Dr. Eppley’s permission to show his video to my class? Also, I’d like to inform my audience to what extent x-ray and fluoroscopy C-Arms are used in HTR/PMI cranial implant reconstruction cases since these are the devices we are learning to use. Does Dr. Eppley use fluoroscopy C-Arms during these surgical procedures to assess placement of the implant? Thank you for your consideration.
A: You may certainly feel free to use my HTR/PMI video for your classroom presentation. Hopefully it will add to the value of your presentation. This method of reconstruction of large cranial defects uses a custom implant (PMI = patient matched implant) fabricated from a polymeric bone substitute known as HTR. (Hard Tissue Replacement) The implant is fabricated from a 3-D model from a CT scan taken from the patient so it is an exact fit to the skull defect. The operation for implant placement is done in an open fashion, meaning the scalp is reflected and peel back for wide exposure. Since the implant is placed under direct vision, there is no need to use any radiographic method such as a C-arm to ensure a precision fit.
Indianapolis, Indiana
Q: I want to thin out my face and am thinking of having a facelift to initially tighten my skin and then my cheekbones (zygomas) cut and narrowed. The reason I am considering zygomatic reduction and face lift is to first “trim” excess skin for maximum tightening of the jowls, nasolabial region, cheeks and neck. Then narrow my face with zygomatic reduction, perhaps including the arch and the zygomatic body itself. I was hoping to improve skin definition below zygomatic arch and angularity of the jaw first, than schedule second surgery afterwards. Do you think it is a good plan for my case? Thank you kindly.
A: While I don’t have the advantage of looking at your facial pictures, I think your plan is fundamentally fine but it is planned in reverse. You want to do any skeletal or underlying foundational surgery first. The reason being is that such surgery causes a fair amount of external swelling which will stretch any tightened skin, potentially reversing some of the effects of any skin tightening procedure. Maximum tightening of the jowls cheeks and neck (facelift) should, therefore, be done after the bone foundation has been treated.
When considering zygomatic reduction, it is important to know if it will produce much of effect. This can be assessed by locally at plain film x-rays, particularly a submental and/or a water’s view. These simple films give a visual assessment of how significant the curve is on the zygomatic arches. That will have to be ordered through a hospital or any free-standing x-ray facility where the appropriate equipment exists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in changing the shape of my neck. I want a visible Adams apple as my neck is too flat and feminine. Can it be done? How would it be done? Imperative to get an answer please!
A: When it comes to tracheal or thyroid cartilage (Adam’s apple) surgery, the standard operation is that of reduction. Known as Adam’s apple reduction (technically reduction chondrothyroplasty) it is done by shaving down the upper v-shaped edges of the thyroid cartilage through a small horizontal incision directly over the thyroid prominence.
Thyroid augmentation is a very rare request but can be just as easily done. Through the same type of horizontal incision, the upper edges of the thyroid cartilages are exposed and built up with a variety of potential materials. Then the strap muscles are closed over the augmentation and the skin closed. Essentially, the reverse of a thyroid cartilage reduction is done. This is a one hour operation done under general anesthesia as an outpatient. There is minimal discomfort and swelling afterwards. There are no restrictions after surgery.
The key element of thyroid augmentation is what type of material to use. Ideally, cartilage is best and the loosely attached ninth rib at the subcostal margin has the right shape and size to be fashioned into a v-shape. But patients are unlikely to want the discomfort of its harvest and the small scar. This leaves a variety of synthetic material choices. Either a Gore-Tex or porous polyethylene (Medpor) block can be carved and secured by sutures to the existing thyroid cartilage framework.
Q: I have a 14 year old boy with gynecomastia. It is hereditary. He is a thin boy but his chest is overdeveloped. If he has a liposuction done now, what are the chances he may need to do it again in the future?
A: The classic teaching in plastic surgery is to do gynecomastia surgery when growth is more complete. This is done with the concept in mind that there will be less chance of gynecomastia recurrence and the need for secondary surgery. While this does make sense from the perspective of decreasing the risk of further surgery, it does not take into account something that I think is more important…the psychosocial development of the young teenage male. Waiting until age 17 or 18 for gynecomastia surgery exposes the adolescent male to vital years of self-image development. For this reason, one should consider gynecomastia surgery when the problem clearly affects teenage behavior and a medical reason for the gynecomastia has been ruled out.
When undergoing early gynecomastia surgery, one accepts the trade-off that recurrence is more likely than when done at an older age. In my experience of doing gynecomastia surgery at age 14 or 15, however, I have not seen patients that have returned with recurrences. (although just because they have not returned does not mean that some have not had recurrences)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have very dark circles under my eyes that bothers me a great deal. I have tried all sorts of creams and lotions without any improvement. Are there any more result-oriented surgical approaches that will work?
A:Some of the best results for dark circles improvement is based on volume addition, either using injectable fillers or surgically done with orbital rim implants. (synthetic implants or dermal grafts) The cause for the appearance of dark circles in some patients is that the orbital rims (lower eyelid socket) is weak or underdeveloped. This causes the lower eyelid tissues to lack support so they fall inward, creating both a trough or depression whcih is also prone to looking darker due to shadowing. It is easy to see whom may have orbital rim hypoplasia by a side view. If the front part of the eye (cornea) sticks out further than the lower orbital rims one has lower eye socket hypoplasia.
The success of orbital rim implants can be predicted by initially using injectable fillers. Injectable fillers are both a diagnostic test and a treatment. Unlike the lips or nasolabial folds, which are exposed to a lot of muscle movement, the tear trough and lower eyelid area is not so injectable fillers can last a much longer time in this area.
Since any form of orbital rim implant must be put in through a lower eyelid incision, this also gives the opportunity to do a little skkin removal and tightening which can also help improve the dark circle appearance.
I would have to see pictures of one’s anatomy to determine if orbital rim hypoplasia is making a major contribution to one’s dark circle appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: I hate my deepening nasolabial folds that are developing. I was looking for something more long-lasting to treat them. I have read about the wire release method. At what age can you perform the new wire-release method for nasolabial folds?
A: Deepening nasolabial folds is a result of the cheek tissue above the lip falling down over the more fixed lip tissues. It is actually not a fold that is deepening in terms of indenting into the tissues but a rolling overhang of tissues. Injectable fillers are most commonly used to plump up the fold in an effort to get the top edge of the upper lip more even with the falling cheek tissues.
The concept of doing a release of the dermal attachments of the upper lip so that it ‘springs’ upward to be more even with the lower cheek tissues is not new. The wire release method is just a different way to do this older concept. It is clever but not original. Age is no determinant as to when it can be done. The timing of it is when the nasolabial folds are deep enough to justify more of a surgical approach or when one has tried injectable fillers and found them wanting in terms of a long-term result.
While the wire release method is clever, the nasolabial fold can be released just as easily with more simple pickle-fork instruments and large beveled needles. What we have learned with any method of doing nasolabial fold releases is that they require some interpositional material placed after the release to prevent the fold from re-forming over time. This can be done with with fat injections or allogeneic dermal grafts.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley ! My question to you is that I have a very short face. My midface is short and my ramus and lower jaw is also short which makes my face long horizontol and very short vertically. Also, my teeth of my upper jaw is way forward which is making my life miserable of having low self esteem. What type of surgery can correct this?
A: When there are jaw and teeth disharmony, one should look at the overall maxillomandibular and occlusal relatiopnships. Many times these require orthodontic and ultimately orthognathic surgical solutions. This is a path thaty should be pursued if one is young and this amount of effort can really be worth it over the long span of one’s life.
Short of major orthognathic surgery, there can be ‘camouflage’ solutions that can improve the facial skeletal balance. These are done using facial implants, usually off-the-shelf implants will work but sometimes it requires custom-designed implants. This is particularly useful in the vertically short face where the lower border of the lower jaw needs to be lengthened for which there is no way to do this without a custom implant design which is done off of a skull model made from the patient’s 3-D CT scan.
For the upper teeth protrusion, I would look into selective orthodontics. Even if you just pulled back the upper teeth only, that would make a cosmetic improvement for you and reduce the upper lip flaring.
Dr. Barry Eppley
Indianapolis Indiana
Q: I desire to have cosmetic surgery next year with the wishes of making my forehead larger both in length and width. Can you inform me with what this procedure is called and also with all the information there is to know on this surgery (including risks, the type of implants used, how long it takes for the healing process, the cost of the surgery, how you go about customizing the implant and etc). Please respond as soon as you can with a detailed response. Thanks so much.
A: You are specifically asking about forehead augmentation. This is a procedure done through a scalp incision approach Augmentation of the forehead contour can be done using any of the cranioplasty materials, which include PMMA (acrylic), HA (hydroxyapatite cement) and calcium carbonate. (Kryptonite) Each of these materials has its own advantages and disadvantages. Large forehead augmentations (which you are referring to) is best done with PMMA due to cost considerations. These materials allow wide variability in adding to the brow ridges if desired and increasing the amount of frontal bone convexity, width and smoothness. These are liquid and powder mixtures that are put together and applied to the forehead in a putty form and then shaped by hand to the desired new forehead shape and allowed to harden. The operation takes about 2 hours and is done under general anesthesia as an outpatient procedure.
This is a highly successful procedure whose trade-off is a fine line scar in one’s scalp. The typical cost range for the procedure is $8500 – $9500. Healing is quite rapid and one can look fairly normal in about 10 days after the operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My 13 year-old daughter was bitten by a bull mastiff just 4 days. She has a lot of jagged lacerations across the nose and just under the left eye. There were no lacerations on her left eyelid or any eyeball trauma. She was repaired in our hospital’s emergency room with a lot of stitches. It was not a fun experience for her to have it done that way with just local anesthesia. It will be time to get her stitches out shortly and I want to be on top of anything that can be done to minimize her scarring.
A: Like any patient that has gotten their face cut, but particularly for the parent of a child, there is always great concern about the eventual scarring that will occur. In the short-term, getting the stitches out and letting the initial healing take place for a few months is all one can do. There are no magical potions or lasers that can alter or make better the early phases of wound healing. Once the wounds have healed and scar tissue has formed (which is inevitable and absolutely necessary for healing) there are highly touted methods of scar treatment. These can include topical agents, such as silicone patches/tapes and paint-on products, as well as light and laser therapies. It is controversial as to how helpful these are as to the final scar appearance but they are not harmful and may have some benefit. Therefore, I would recommend any of them, or a combination, beginning several months after the injury up to six months after. Which one(s) to use will vary based on the opinion and expertise of your plastic surgeon as well as the scar’s appearance and location. After 6 months, actual surgical scar revision becomes more of a useful technique.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley, I was considering zygomatic reduction surgery to narrow the sides of my face. I am also considering SMAS facelift or modified SMAS like MACS-Face Lift to be done later this year. Could facelift interfere with zygomatic arch reduction surgery? Could you give me a second opinion if either or both procedures will take care of heaviness and fullness of my face? Would I esthetically benefit from these procedures and achieve better symmetry and balance to my facial features??? I have attached some photographs for you to see what I am talking about. Thank you.
A: In reviewing your two frontal photographs, I can see that you have a broad facial width across the cheeks and jaw angles. This skeletal base helps create more of a square face configuration which makes a significant contribution to your ‘heavy-looking’ face. Part of that appearance also has to do with your thicker soft tissues such as your skin, fat layers and muscles.
In considering how to make your face appear slimmer, I can clearly say that no form of a facelift will help in that regard. You are too young to have any significant sagging of your facial tissues (your pictures show none) and what any type of facelift accomplishes is cleaning up the jawline and neck of sagging tissues. In someone with your facial anatomy you are likely to end up making your face look a little wider by some type of a facelift, not thinner. You can’t make your tissues look thinner by lifting or tightening them. In making that statement, I am at a disadvantage since I can not examine you and am looking at only one view of your face.
Will zygomatic arch reduction help your face look somewhat slimmer? Quite possibly, it is just a question of how much. One helpful piece of information would be a simple submental view x-ray which could show how significant the arc is in your zygomatic arches. The more arched it is the more likely it will make a visible difference. The combination of zygomatic arch reduction and buccal lipectomies could likely be helpful.
Dr. Barry Eppley
Indianapolis, Indiana
