Your Questions
Your Questions
Q: Dr. Eppley, my goal is a harmonious and ideal ‘male model’ look profile via rhinoplasty and possibly horizontal and vertical chin augment if rhinoplasty is not enough. I want to have rhinoplasty done to correct my deviated septum, hanging columella, raise my tip slightly and smooth a slight nasal hump. I’m wondering if I can get away with rhinoplasty alone to enhance my profile? I feel my chin is a little weak (I have an overbite ~ class II). I did orthodontics/braces to correct my crooked teeth only, but not my bite. I don’t want jaw surgery because I’m OK with my bite function.
Concern: My deep labiomental fold that is between my lower lip and chin. Will a chin augmentation hurt, help or not effect this crease? I don’t want to make this crease worse, I either want it unchanged or improved.
Questions: Chin
Which procedure is recommended to produce an ideal result. Implant, genioplasty or doing nothing?
If implant, how big and what type should be used?
If genioplasty, what kind of cut would be done horizontal?
Will a chin augmentation hurt, help or not not effect labiomental crease??
A: In answer to your questions;
1) You absolutely can not get away with just a rhinoplasty alone to improve your profile. Your chin position is just too short. For your profile and overall facial aesthetics, chin correction is actually more important than the rhinoplasty.
2) Your chin correction should ideally be done by a sliding genioplasty because you have both a horizontal and a vertical chin deficiency.
3) The vertical component of the sliding genioplasty will allow the depth of the labiomental sulcus depth to remain unchanged as the chin comes forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is it possible during a tummy tuck to injure one’s bowels? I am afraid to have a tummy tuck because I don’t want to suffer a major medical problem just because I want a flatter stomach. How close are my bowels to where a tummy tuck is done?
A: While it is common to have some constipation after a tummy tuck, there is no risk of any long-term gastrointestinal tract issues. Only skin, fat and muscle is manipulated during a tummy tuck and there is no chance of inadvertent injury to the large or small intestines. The bowels lies on the opposite side of the abdominal muscles. Repairing a hernia at the time of a tummy tuck poses some risk for those concerns but it is no greater than any other hernia repair. Since pain medication will be needed after a tummy tuck, and that has a known slowing effect on gastrointestinal mobility, women should drink plenty of fluids during their recovery and take a daily stool softener starting a week before surgery as well as continue it afterwards. In short, a tummy tuck may require some significant recovery time but it is not a dangerous surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to deliver my third and final baby next month. I already have a c-section and will be getting another c-section for this final delivery. After the delivery of my second child, I saw how much loose skin and stretch marks I had and that never really went away afterwards. I am wondering if I can get a tummy tuck at the same time as my c-section. It just seems like a logical time to do it, kill two birds with one stone so to speak. Is the hardest part getting two doctors to do it at the same time or can my Ob-Gyn just do it?
A: While loose stomach skin can be removed at the same time as a c-section delivery, it is not the best time to do it. The uterus is swollen and prevents muscle tightening and there is still considerable water weight present. In addition, being under an epidural limits how much overall abdominal reshaping can be done. It is far better to wait six months after delivery and try to lose as much weight as possible before having a tummy tuck…the result will be so much better. While there is nothing wrong with having a little loose skin removed during the c-section but that shouldn’t be confused with a real tummy tuck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to have a tummy tuck but I have a question about how the belly button is made. Where does it come from? Is made from skin thrown away from the tummy tuck or is it somehow carved out from the stomach wall? Can you explain it to me how you do it?
A: The belly button is nothing more than a remnant or stalk of scar tissue from the skin down to the abdominal wall. It is never removed during a tummy tuck but rather the skin around it is. The stalk of the belly button is always preserved, it is the loose skin around it and any extra length of oys stalk that is removed. The shortened stalk of the belly button is simply put back by bringing it through the abdominal skin that has been brought down and tightened over it. Reshaping of the belly button is almost always done whether it is shortened or not. The key to a good looking belly button result in a tummy tuck is to shorten it so that the outer skin dips in, the surrounding scar is on the inside, and it has more of a vertical rather than a round shape.It is always better to have a smaller belly button than a larger one as a result of a tummy tuck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding chin and jaw implants. My question is: if a person plans to have both chin and jaw implants, do they have to be done in one procedure? In other words, is it possible to get jaw implants and then in a year get a chin implant? I’ve heard it’s easier when done together, but I just don’t have the resources to get both of them at once right now, so I’m wondering if it is possible to get a jaw implant this year and then next year a chin implant without complications?
A: There is certainly no reason why chin and jaw angle implants they can not be done separately. Economics is a very good reason why some have to ‘stage’ their overall jawline enhancement. Which one you do first is a matter of personal preference and would depend on what you see as your biggest problem. For many patients that would be the chin because it is the most visible part of the jaw and often displays the most obvious deficiency. For others the chin has a more minor deficiency and the high and weak jaw angles is the most deficient part of the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wonder if my deep set eyes can be treated by the same procedure which is done for enophthalmos? I heard from a doctor that cartilage can be implanted behind the eyeball. Is that possible?
A: Building up the orbital floor with any form of a graft works in enophthalmos because there exists expanded intraorbital volume and the graft is merely returning the intraorbital space to normal. The eyeball can be oushed up and out because there is space for it to go. where it was once was. In a normal or non-enophthalmic eye, there is normal intraorbital space and lessening that with a graft runs the risk of putting pressure on the eyeball. In other words, you are not going to push the eye out by putting in a graft without the potential risk of visual impairment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe you are a real specialist in the matter of lips aesthetics and procedures and will greatly appreciate your advice if I should undergo a lip lift or fat transplant. Temporary fillers don’t work for me. I have attached some pictures from different angles for you to see the shape of my lips.
A: Thanks for sending your photos. I think they illustrate well your longer upper lip and you have always illustrated to some degree the effects of a subnasal lip lift. I think you are a good candidate for the procedure. I think with your vertical upper lip length that you are much better off with a lift rather than fat injections. Also the result from a lift will be more predictable than with fat injections. Fat injections also will not shorten your upper lip length nor will they create a more prominent cupid’s bow. This can be done under local anesthesia in the office as I do many isolated lip lifts that way. The biggest issue is the fine line scar along the base of the nose but if well placed it fades very nicely and quickly. (a few months)
Q: Dr. Eppley, I have some queries about Medpor implant surgery. One of my one friends, who is age 26, is looking for ear reshaping surgery. I have a concern about him, I am suggesting him to go for own body material surgery not with medpor implant surgery. Can you give us some guideline on this. Like as which one will be the best for his future.
A: While it is not clear from your inquiry as to the nature of your friend’s ear deformity, I will assume that it is either a subtotal or total ear reconstruction. (variations of congenital microtia or traumatic amputation) That would be the only consideration in which either a synthetic implant, like Medpor, or the use of a rib graft would be debated. There are arguments for the use of Medpor vs. rib grafts and I have done both successfully. (although many more rib grafts than medpor implants) I would agree that the use of rib cartilages are far safer and have much less risk of any long-term complications, in fact there would be few if any long-term issues with a natural material. But if one uses a Medpor implant in the ear it is absolutely critical that a temporalis fascial rotation flap is used to cover the implant to put more of a vascularized cover over most of the implant. This will substantially reduce the long-term risk of skin breakdown and implant exposure.
The reality is that while many patients and some surgeons think that using a synthetic implant is ‘easier’ than harvesting and carving rib grafts for ear reconstruction, it is not just as simple as pulling a preformed ear out of a box and sticking it under the skin. The success of synthetic ear reconstructions depends on the quality of the overlying ear skin and the surrounding tissues and getting good vascularized cover which means rotating a fascial flap. Successful long-term results from ear reconstruction, whether it is done by autologous or synthetic materials, requires experienced presurgical judgment and technical experience in performing them.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in more information on tummy tucks and mommy make-overs for my wife. I think she looks fine, but it would make her feel better about herself if she had a procedure done. So I am taking the first step for her. Please send us more information on the matter and costs. Thank you.
A: The term Mommy Makeover usually refers to a combination breast reshaping and tummy tuck procedure. You have only mentioned a tummy tuck so I am not sure if you mean a breast procedure as well. Knowing whether it is one or both procedures will have an obvious impact on the cost. If you can clarify that issue for me that would be helpful in answering your questions.
In addition, tummy tucks come in two basic varieties in being a more limited or full tummy tuck. Many tummy tucks, regardless of the type, may also include liposuction of the flanks to get a better effect around the waistline into the back. Where your wife falls in regards to these tummy tuck options would be helped be either seeing a picture of tummy or an actual in-office consultation. But for the sake of providing some price information, I will have my assistant forward you a cost quote for a full tummy tuck with flank liposuction so at least you can see the maximal cost that it would be.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am looking to have breast implants, rhinoplasty and mentoplasty. (no implant) Do you offer mentoplasty? If so would I be able to do these 3 procedures at once or if not I would wait to do the implants. I can send some detailed pictures if needed.
A: Thank you for your inquiry. You certainly can do breast augmentation, rhinoplasty and chin augmentation all during the same surgery. When you refer to a non-implant mentoplasty, I assume you are referring to a sliding genioplasty in which the chin bone is moved forward. That accounts for about 25% of all chin procedures that I do so it is a chin augmentation technique in which I have great familiarity.
To help prepare accurate quoting, please send me some pictures of these areas so I can see exactly what needs to be done and the time it takes to do it. This is most relevant for the nose as there is great variability in rhinoplasty surgery depending upon how much of the nose structures need to be changed.
Once I have received the photos, I will do some computer imaging for the nose and chin and have my assistant send you a collective cost quote.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have deep set eyes and I don’t like them at all. What are the options for me? I have a very hollow appearance to my eyes and I want to improve it.
A: When it comes to trying to improve deep set eyes, there are few options. You can not move the eyeball forward by any method, all that can be done is to reduce the surrounding orbital bone along the brow ridge and the lateral orbital rim. Depending upon the prominence of the brow ridge, this can be particularly effective. It is important, however to separate the terms ‘deep set eyes’ and ‘hollow eyes’ for they represent different orbital morphologies. A deep set eye is when the globe (eyeball) sits far behind the surrounding orbital rims, particularly the superior and lateral orbital rims. Reducing the projection of the surrounding overprojecting bone is what can make the eye seem to come forward. Conversely, a hollow eye appearance implies that the relationship between the globe and the surrounding orbital rims is normal but that there is a lack of fat in the lid areas, having them retract posteriorly. The hollow eye or lid deficiency/retraction can be treated by fat injections.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a male with gynecomastia, I am wondering if you have any experience in gynecomastia removal. I have some bothersome buildups on my chest that I want removed. Here are two pictures of my chest, the tissue build up is most noticeable below and lateral to the nipples. Thank you for your time and help.
A: Thank you for sending your pictures. It appears that there is a fairly well defined mass below and to the side of the nipple-areolar complexes. I suspect that this may feel like a discrete mass. What you have a form of areolar gynecomastia where the breast tissue buildup is largely restricted to the periareolar area. These could be removed by a gynecomastia surgery technique in which the masses are excised through an inferior areolar technique. I can not tell whether any feathering of the chest beyond the masses is needed based on the angle of the pictures taken with the arms raised. This could be done as an outpatient procedure under IV sedation or general anesthesia. The recovery would be fairly quick with you only having to refrain from working out for several weeks after surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am 31 years old, 5’4” and weigh 162 lbs. I have had three children and my stomach certainly isn’t what it used to be. There is stretch marks and loose skin. I really need to get my body in better shape but I don’t want to undergo a tummy tuck even though I know that would probably be the best thing to do. I don’t need to look like a model but I don’t want to have loose hanging skin afterwards if I undergo liposuction. I know that I will not have perfectly smooth skin after liposuction but I am concerned if I will have loose hanging skin afterwards. Online I have seen stomachs just like mine that show good results afterwards with just liposuction. So do you think I will have wrinkled or hanging skin after liposuction?
A: While I don’t know what your stomach looks like, you have described several critical points about your abdominal liposuction concerns. Given that you don’t want a tummy tuck, your only abdominal contouring option is liposuction. With that decision you also recognize that the results will not be perfect. Skin irregularities are always a potential issue with any form of abdominal liposuction but that risk dramatically increases when loose skin is present. This is the issue to ponder when one is using liposuction as a substitute for a tummy tuck. As a general rule, if the abdominal skin does not overhang the waistline only irregular wrinkled skin will result. If there is an abdominal overhang, expect that removing fat will still leave you with a loose skin overhang.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I see you have posted blogs on removal of cephalohematoma on skulls and also filling in flat spots with a bone cement. My son was born with a cephalohematoma on the back left of his skull. He was also prone to sleep on the left side of his head and has caused a slight depression on that side. We have been doing head positioning every day and he is now 2.5 years old. If we were to consider plastic surgery, when is a good age to do this to fix both issues?
A: When fixing any cosmetic skull deformity in a child, there are two relevant issues. First, when is skull growth stable? In other words, when can you correct the asymmetry and have a reasonable expectation that the skull asymmetry will not recur or ‘regrow’? There is not an etched in stone answer and later is always safer in this regard than sooner. In general, when a child reaches 3 or 4 years of age, much of skull growth is completed and the risk of any recurrence is very small. Secondly, when is the best psychological time to intervene with surgery in a child who can not speak for themselves and may not know for a long time if their skull shape is even an issue for them in the future? This is only an issue that a parent can answer, and like many child-rearing decisions, has to be driven by what the parent thinks is best for them based on how they look now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have come across your website as you seem to be one of the few surgeons who offer chin cleft removal/reduction without the aid of implants or fillers. I am strongly interested in the procedure and I would like to know how it is done and understand how long the recovery time is. I would be willing to travel to undergo this surgery.
A: Chin cleft removal can be done without the use of implants or injectable fillers by treating the underlying muscle separation by muscle repair and a buccal fat graft. While an injectable filler is simpler, the lack of a permanent injectable material (short of fat) makes this a temporary fix. This is not to say that using a particulated filler (like Artecoll or Aquamid) with a series of treatments may not be a permanent solution.
This is done as an outpatient procedure under IV sedation. Expect chin swelling for a few weeks afterwards.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 19 years old and have developed a problem with my face. It looks crooked and I don’t know why. I saw pictures of me before about 6 years ago and my face wasn’t crooked. So I’m kind of worried about what made it crooked. So can it be fixed?
A: Thank you for sending your pictures. My assessment shows that your facial asymmetry is caused by a left-sided orbito-zygomatic deficiency. This is evident by a slightly lower eyebrow, a small amount of redundant upper eyelid skin, a lower globe (eyeball) position, a lower positioned lower eyelid and a small cheek bone on that side. This is caused by the underlying cheek and eye socket bones (orbito-zygomatic skeleton) being more underdeveloped than the right side. This makes the overlying soft tissues, including the eyeball, are positioned lower than the other side.
While this is a common facial skeletal deformity seen in cheek bone fractures, yours is clearly development and just grew that way. It has probably only become more evident as you are now nearing full facial skeletal development.
The facial asymmetry could be treated by a combination of procedures including a transpalpebral browlift through an upper eyelid incision (to lift the brow), orbital floor augmentation (to push the eyeball up), lateral canthoplasty (to reposition the outer corner of the lower eyelid) and a cheek implant. (to build up the smaller cheek area) I have attached some imaging which shows the predicted effect of those changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had large breasts as long as I can remember. While they were once more perky, they have fallen and are way out of proportion. They are just super saggy now and hang all the way down to my belly button. I think the reality is that I need a breast reduction although I am not super excited about the possibility of having scars. I am 32 years old and have never been married or had children. I am not sure whether I should wait to have surgery until I have had children or just do it now instead. I am also worried about having a breast reduction and ending up being too small. Being big-breasted is part of a body type that I am most comfortable with and it’s part of who I am and what I am known for. I want my breasts lifted but just don’t want to be flat-chested.
A: When one has breasts that are so big that they hang down to one’s belly button, they would be a good candidate for a breast reduction procedure. Breast reduction surgery combines a lift with breast tissue reduction to create smaller breasts that sit higher up on one’s chest wall. It is important to understand that there is a wide variability in the amount of breast tissue removal that can be done in any breast reduction. Thus you should not fear having a breast reduction because you think you will end up too small. That is a discussion you need to have with your plastic surgeon beforehand so there is an understanding as to how much smaller in breast size you find acceptable. Given your position, it is always better to end up with uplifted breasts that are still a little big rather than being too small. Whether you should have a breast reduction before or after having children depends on how much neck, back and shoulder pain you are in now. While pregnancy will ultimately affect the shape of your breasts, no matter if they had undergone surgical reshaping or not, the timing of the surgery should be based on musculoskeletal pain relief.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am thinking about using bone cement on my jawline. The mid-portion of my jawline goes up and then back down. Would you be able to attach bone cement there to lower it ? I like the way it looks when its straight, a good lower vector (jawline) I think compliments the upper vector (cheek line) and gives a very nice defined look. Also the advancement in projection I morphed for my chin augmnetation is about twice as far out as most sliding genioplasties I have seen. Would you be able to just cut the bone further back to slide to further forward ? I don’t know if you noticed but I pulled the upper part of my chin out a great amount and then really pulled out the bottom part because I don’t like the way it looks if you were to just pull the bottom out which is what I see most of the time. I know my teeth are there so you would have to put something almost on top of the sliding genioplasty that would give that area the projection I want, would that be bone cement or would you be able to use part of my chin bone?
A: Based on your projected imaging, I see no problem making the sliding genioplasty advance as much as you have shown. This is about a 10 to 12mm advancement which is well within the range of a genioplasty movement. Filling out the labiomental sulcus (upper part of the chin) does require that the step in the genioplasty be filled out with some material. Whether that is an hydroxyapatite cement, hydroxyapatite block or another material would depend on cost issues for you. When it comes to filling out/smoothing out the jawline behind the chin (other than the step-off in the back part of the osteomy cut), that can not be done with bone cement or any other intraoperatively fashioned material as that will simply not work. Short of making a whole chin-jawline implant from a 3-D model, which can certainly be done to accomplish all of these goals instead of a genioplasty, the jawline behind the chin can not be treated any other way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have angular cheilitis and have had it for over 8 years since I was 14. I have tried numerous steroid and anti-fungal creams however it does not go away permanently. I was made aware some surgery can be done on the lips, to solve this problem. If there was something to be done, I’d like to know what it might be?
A: While topical medication is the primary treatment for angular cheilitis, some patients have an anatomic arrangement at the corners of their mouth that predisposes them to chronic salivary wetness. If the corners of the mouth are turned down significantly, there is a natural spillway for salivary spill or to allow chronic wetness to occur at the mucosa of the mouth corners. In these cases, it may be beneficial to consider a corner of the mouth lift to relieve this spillway effect. The lift removes the overhanging tissues and eliminates a downslanting mouth corner. In other cases without a significant corner downturn, the chronically inflamed or irritated mucosa just inside the mouth corners may be simply excised. This removes the chronically infect mucosa and brings in new healthy mucosa that is not inoculated.
Dr. Barry Eppley
Indianaopolis, Indiana
Q: Dr. Eppley, Would like to have a more defined nose tip and thinner nostrils. My nose spreads and flairs. I have a bridge and a nice profile, would life the nostrils thinned and not rounded. Not interested in keeping a so called afrocentric ethnic nose.
A: As you know, you have many nasal features that are consistent with your ethnicity that you want to change. The typical African-American nose at its tip is reflective of the underlying cartilaginous structure. It is due to broad and widely-spaced lower alar cartilages that are inherently weak, a blunted and shorter caudal end of the septum, vertically-deficient columellar skin and a horizontally-ovoid wide nostril bases. The overlying tip skin is also very thick which blunts tip cartilage definition. Therefore, to make the change of more narrow nostrils and a better defined nasal tip, changes must be done to these structures. Through an open rhinoplasty, the lower alar cartilages need to be brought together and supported by both a septal extension and columellar strut cartilage grafts harvested from the septum. This is much like a tentpole effect raising up the tip and allowing it to push upward against the thick nasal skin for a more narrow and defined tip. The nostril width needs to be reduced by removing skin at the sides of the nostrils bringing them inward. Depending upon how much the nostrils need to be narrowed and the location of the scar determines what nostril reduction technique is used.
While seeing your pictures is helpful, only a non-smiling front view is useful for imaging. I have cropped the one such picture that you have sent but the image quality on magnfication is not great. But this rudimentary altered image helps illustrate the rhinoplasty objectives.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want a smaller, less frightening nose. I inherited this nose from my father. I’ve always been self conscious and I hate that I feel self conscious about my nose. Over the years my father’s nose has started to kind of go off to the side and developed one of those bumps and look even worse and I hope that same thing doesn’t happen to me. It’s not so bad from the front, but from the side, oh man. I just want it to not stick out quite so far, just a smaller slope and smoother point I suppose. I don’t know if that makes sense.
A: Your nose concerns make perfect sense when seeing your pictures. Your nasal tip is overprojected (too long) due to very strong and long lower alar cartilages. Your nasal tip needs to be shortened and lifted slightly to correct a tip that is too long for the rest of your nose. In addition, I would take down some of the dorsal septal height up to the nasal bones and add a crushed cartilage to the radix area. (these are all manuevers to match the dorsal line line better to the shortened and lifted nasal tip in profile) I have attached some images of these proposed changes in the side and front views based on this type of rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two c-sections over ten years ago and a tummy tuck with hernia repair five years ago. Then to my surprise I found out I am pregnant again. I am obviously going to need a c-section but am concerned as to whether the scar tissue from my tummy tuck will cause problems for this procedure.
A: It is actually not rare that pregnancies happen after a woman has had a tummy tuck, even though they may have gotten the tummy tuck under the premise that they were done having children. I see at least one or two cases a year of the identical circumstances. A tummy tuck scar presents the incisional guideline for the c-section and provides the obstretician with unparalleled access for the c-section if they desire. The scar tissue from the tummy tuck poses no problem for the c-section and does not cause any more scar tissue than that which would normally exist from a prior c-section.
One of the interesting issues that a c-section poses after a tummy tuck is the potential for simultaneous excision of redundant skin during the closure of the c-section. Some women are curious about or desire a simultaneous tummy tuck at their c-section. A traditional tummy tuck that incorporates a muscle repair can not be done very well due to the enlarged uterus from the pregnancy, but the loose abdominal skin can be removed. The existing tummy tuck scar provides an opportunity, without adding additional scar, to remove any obvious skin overhang at that time. This combined c-section abdominoplasty adds nothing to the mother’s recovery and can also be done under the same epidural anesthetic.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a freelance writer working on an assignment for a medical aesthetics magazine and I could use your input. The topic is fat transfer procedures; specifically, techniques and longevity. Here are the questions I’d like to ask:
[1] In general, how is fat harvested? What type of equipment is used?
[2] How is fat then prepared for injection? Which components of it are used? What type of equipment is used?
[3] What specific injection techniques are used? Do any of the techniques pose greater risks to the patient? Do any of them generally produce better results?
[4] How long can patients expect the results to last? Does that vary by patient? By technique used?
[5] Are certain patients more likely to experience bad results? Are some patients riskier than others? How important is patient selection in ensuring best results and least risk?
[6] Any other comments?
A: Injectable fat grafting is both a reconstructive and cosmetic technique in plastic surgery that is undergoing widespread acceptance and use. While fat grafting has been around for 75 years, the ability to place it with an injectable approach and the generous amounts that most people have and its easy accessibility has made it into a standard modern-day plastic surgery technique. Just because fat is natural and most everyone would love to give some up, however, does not necessarily make injectable fat grafting a completely reliable treatment method. It is important to understand that the biologic behavior of fat cells and the concomitant stem cells that accompany them is not well understood. Fat grafting is equal art as science in current practice and that should be borne in mind when its techniques are discussed. They are based on what we know today…that will likely change significantly a decade from now.
- Fat is harvested using liposuction techniques. Most believe that low pressure vacuum extraction preserves fat cell structures and improves their viability after transfer. Whether this is syringe extraction or a traditional machine that generates less than -20cc of water pressure depends on how much fat is needed.
- The preparation of lipoaspirated-fat grafts has seen the greatest number of techniques currently used, all of which strive to separate the liquid fractions (blood, free lipids, injectate) from the cellular component. This include straining and washing, free-standing decanting, machine centrifugation, hand-held separation using centripetal force and low pressure forced straining using low micron filters. Much debate surrounds which, if any, of these offers a superior number of viable fat cells for transfer.
- Fat grafts are injected using small-bore blunt cannulas ranging in size from 16 gauge to 26 gauge size (comparative injection needle sizes) connected to luer-lok syringes of 1 to 3cc sizes for the face and 10cc to 60cc size for body areas. Placing the fat grafts in small aliquots (0.1cc for the face and .5cc to 2ccs for the body) is well shown to allow their best survival. Retention is all about how quickly the fat cells can be nourished by blood vessel ingrowth and the delivery of oxygen. Big globs of fat are hard to get perfused while small droplets interspersed about the tissues allows the best opportunity for nutrient perfusion.
- The retention of fat grafts, both short and long-term, is not a completely well-known issue. It is believed and considerable experience shows that what survives by three months after injection treatment is what will be ‘permanent’. (retained) Whether this same fat survives 5 or 10 years later is not precisely known and depends on what specific condition is being treated. Aging-related treatments are believed to be less permanent than those of structural rebuilding.
- All other factors being equal, there are no ‘bad’ patients for fat injections. Some of the historic predisposing factors for plastic surgery treatments that bode poorly for healing, such as radiation and even diabetes, are exactly what some of the indications are for fat imjections. Age is an interesting potential issue because one would assume that older fat cells are less hardy, survive the transfer process with less viability and would take after transfer more poorly. This assumption, however, has yet to be shown to be true. This may more of a reflection that older patients (> 65 years old) make up a minority of the fat injected population.
- What was once thought to be a useless and unwanted tissue has ironically turned out to be a depot of regenerative material. Plastic surgery has just scratched the surface of what injection fat grafting has to offer and a whole new generation of research and clinical experience will take us much further than what we know today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty revision a year ago which has ultimately resulted in a much longer appearance of my upper lip. Since you’re an OMFS and a plastic surgeon, I’d really be interested in consulting with you about a lip lift +/- autologous fat grafting. I’m definitely interested in the subnasal approach, and since I talk to people all day long and occasionally engaging in public speaking, I’m also looking to leave the orbircularis oris alone as well. I would greatly appreciate your expertise and evaluation.
A: The long upper lip implies too much vertical skin between the base of the nose and the upper lip, a small or diminished vermilion show at the cupid’s bow area, lack of adequate upper tooth show or any combination of these three effects. For most patients, the subnasal lip lift is almost always preferred because of the less visible location of the resultant scar in a natural skin groove. There never is any reason to manipulate the orbicularis muscle in a subnasal lip lift as that only causes animation problems and accomplishes no positive effect. Injectable fat grafting can be done in a lip lift if an enhanced cupid’s bow or the lateral vermilion down to the corners of the mouth is desired to be enhanced. Micrografting of fat in 0.1cc aliquots is the best method of injection in an area where fat retention is notoriously difficult.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I find my nose too wide. I would like to narrow it a bit. I was also interested in having a cleft chin and anything else you suggest. Thank you so much.
A: Thank you for your inquiry. Your picture shows many of the features of the African-American nose, which is largely a broad and wide tip with lower alar cartilage flaccidity, flared nostrils and a low dorsum. Rhinoplasty changes would include dorsal augmentation, columellar strut graft, tip lifting and narrowing and lateral nostril flare reduction. Unfortunately the one picture that you have provided is not of good enough quality for computer imaging to show how these changes might look on you. Pictures should be better quality (not fuzzy), taken from the front and side view and be non-smiling.
Chin dimples are central round indentations on the central of the soft tissue chin pad. Chin clefts are vertical grooves that run from the center of the chin pad down to the lower border of the jaw. Either one made from an incision inside the mouth where a core of soft tissue (muscle and fat) is removed below the desired location of the external location of the chin dimple or a wedge of tissue removed along the underlying location of the desired chin cleft.. The underside of the chin skin is then sutured down inward to make the dimple or cleft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your commentary on another website about ‘shrink wrap lipo’. I appreciated your honesty in regards to that liposuction technique. The issue about it on the Dr.Oz show claiming that it tightens the skin had me wondering the validity of that statement…nice to see that a plastic surgeon gave an honest opinion. What do you think of the benefit of Sculptra versus a filler such as Juvederm for facial aging?
A: In regards to the use of injectable fillers in the treatment of facing aging, they do have a role to play for some patients. However, it is very important to differentiate the various ways in which injectable fillers are used to treat the symptoms of facial aging. That distinction makes a big difference in what type of injectable filler would be most appropriate. I divide injectable facial rejuvenation into two categories; spot and global facial rejuvenation. Spot rejuvenation includes such areas as lip enhancement, softening nasolabial folds, or filling in orbital tear troughs. Given the low volumes of filler needed and sensitivity of the tissues injected, any of the hyaluronic fillers (such as Juvederm) may be used. They are soft, have little risk of any tissue reaction and are completely reversible. There only real differences are in how long they last and how much they cost. Global or volumetric facial rejuvenation is different because it is about adding soft tissue volume to fill out the face, reinflate it to some degree, and create a little bit of a ‘lift’. Given the volumes needed, the hyaluronic fillers are a bit prohibitive because of cost considerations. This is where the role of Sculptra comes in because it is a better ‘volumizer’ based on the way it is administered, works and persists…even though it takes a series of injections to create the desired enhancement effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I am trying to find out pricing on getting implants and to see about payment. Most offices require full payment, however, I have heard of a few that will do payment plans. I didn’t know if this office was one of them?
A: When it comes to elective cosmetic surgery, including breast augmentation, you will find virtually no plastic surgery practices that take payment plans. A plastic surgery practice is not a bank or a credit agency that has any ability to finance and ensure that payments are received over time on a non-returnable service like surgery once it is provided. Full payment is required in advance of the actual surgery date. However, every plastic surgery practice recognizes that many patients can’t pay the full fee up front and work with independent loan agencies that do provide financing. One of the most common cosmetic surgery financing companies is Care Credit. You can go online with the amount you need to finance and apply and qualify. You can choose from a wide variety of terms up to 36 to 48 months. Many patients opt for the interest-free financing which extends out to 6 or 12 months. Our office has worked with many lending institutions over time but have found none that are as easy to work for our patients as Care Credit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have very large temporal muscles that I want reduced. They stick out significantly from the side of my head. It is not normal to look like this with such bulges. What is involved in reducing the temporal muscles. I have attached some pictures for you to see what I mean when I say these muscles are big. They might be great if they were biceps on my arms but not the side of my head!
A: Thank you for sending your pictures. That is one of the larger temporalis muscle hypertrophies that I have seen given the muscle size and the shape of the surrounding skull and orbital bones. It is no doubt all muscle and not caused by enlargement of the underlying temporal skull bone. You can confirm that by clenching your jaws and seeing the muscle striations and how much it bulges.
To reduce a temporalis muscle that is this large, a central wedge resection of the muscle must be done. This is accomplished through a vertical incision in the hairline on each side. The temporalis muscle fascia is opened and electrocautery is used to cut a large vertical wedge of muscle that parallels the muscle fibers out. The fascia is then reclosed. This will produce some immediate reduction in its size, not withstanding the temporary muscle swelling that will ensure right after surgery, but further reduction occurs up to six months after surgery as the muscle undergoes further atrophy. This is an outpatient procedure done under general anesthesia. Other than some temporal swelling and some stiffness on wide jaw opening, there is no significant recovery or restrictions after surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to improve the appearance of my eyes. My upper eyelids (just below my brow) have excess skin that hangs down, often pushing against my eyelashes. Also, I would like the canthopexy in order to make my eyes look more feminine. My eyes are very round, showing a significant amount of my sclera, and are angled down slightly at the outer corners.
A: The description of upper lid skin pushing on the eyelashes certainly indicates that an upper blepharoplasty would be needed to recreate an upper lid sulcus again. That is very straightforward and a standard periorbital rejuvenation procedure. Changing the position of the lateral canthus at the corners of the eyes can be done at the same time as the upper blepharoplasty. This is better known as a lateral canthoplasty as opposed to a canthopexy. In a canthopexy procedure the existing tendon is tightened by maintains its current position on the inner aspect of the lateral orbital wall. As a result, it tightens the lid margins but will not change their vertical orientation. Thus a lateral canthopexy will not correct a downward eye slant. A lateral canthoplasty, which relocates the insertion of the lateral canthal tendon up into a higher position on the bone is what you actually need to achieve your eyelid reshaping goals. That is done through the tail end of the upper blepharoplasty incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have bump on my upper ear that has been there as long as I can remember. My dad and sister have it also so it must be in my family genes. It feels firm but I can’t tell if it is skin or extra cartilage.While it doesn’t bother my other family members, I do not like it and want it removed so the rim of my ear is smooth. How easy is it to remove and will it leave any scar? It would not be worth removing if it left a scar which might be worse looking than the bump.
A: The bump on your ear to which you refer is incredibly common and is known as Darwin’s tubercle. It is a congenital thickening of the rim (helix) of the ear usually near the top at the junction of the upper and middle third of the ear. It is present in about 10% of all people and is inherited in an autosomal dominant fashion, hence your father and sister having it. It carries this name from the naturalist Charles Darwin who wrote about it in his book the Descent Of Man. He described it as a vestigial feature of man that serves as ‘proof’ of the link between man and primates. (check out a monkey’s ear)
A Darwin’s tubercle is an excess of cartilage that can be removed through a simple otoplasty procedure done from an incision on the underside of the bump. (inside of the helical rim) It can also be removed by direct excision of the skin and cartilage on the edge of the helix under local anesthesia. Either way, it can be removed without any significant or visible scarring. So scar concerns should not be a deterrent to having it removed.
Dr. Barry Eppley
Indianapolis, Indiana
