Your Questions
Your Questions
Q: I have been thinking about getting a rhinoplasty. I have never had any nose surgery before. I am filipino and my nose is short and too small for my face. What I would like to achieve is the following in my rhinoplasty; augment the dorsum, lengthen the columella, improve tip projection and definition, alar base reduction and show less nostril. I would like costal cartilage rhinoplasty, definitely no silicone or GoreTex implant for dorsum augmentation. Been thinking of rhinoplasty for a long time. I have attached some pictures for your review and imaging.
A: Thank you for sending the picture and your detailed analysis and goals. Given your smaller and short nose, you are absolutely correct in determining that only a rib graft rhinoplasty could achieve your goals. What you need is a combined dorso-columellar augmentation or the geometry of a L-strut configuration. Only a rib graft or a synthetic implant can possibly achieve that degree of augmentation. You have stated you want to avoid an implant and I assume you feel so because of their potential long-term problems, even though they are the ‘easiest’ to do. A rib graft would provide the best long-term graft retention without problems even though it has the short-term ‘problem’ of a donor site and resultant scar. I have attached some predictive imaging for your review. Please note that the increased columellar show in the side vie does not appear as it is not present at all in the original photo. (you can’t morph what is not there!)
Dr. Barry Eppley
Indianapolis Indiana
Q: I am looking to get my nose fixed after it has been traumatized in the past. I believe the problem is what is called the tip of the right-dorsal horn has separated or fractured from the left cartilage. In doing so, it is no longer held to symmetry as it extends away from the cartilage it separated from. Because of this it has created an appearance of a hook on the right side of my nose as well as a bumpy tip. I noticed that by pushing the cartilage in toward the fracture point the hook is no longer significant and the tip looks less bumpy. This is what my nose use to look like before the separation of the right cartilage from the left side. Is it possible to have a closed procedure where you stitch the right tip back to its natural foundation with the left tip. I am hoping to remedy this permanently with a less invasive procedure; hopefully removing the hook and smoothing out the tip of my nose. Thank you very much for your help.
A: Thank you for sending the pictures and clarifying exactly where the problem is. The problem is in the tip of the nose which is created by the union of two pieces of cartilage. It is a difference in the shape of the two domes or lower alar cartilages. They are separated and apparently the right dome or alar cartilage has been displaced to the right. You were correct in assuming that it can be fixed by a simple closed rhinoplasty using suture techniques. That is a relatively simple fix that is as close as it gets to minimally invasive for the nose.
Dr. Barry Eppley
Indianapolis Indiana
Q: My main questions are in regards to the permanent lip options available to me. I could send you my picture so you can get a better idea. I have tried a few injectables and am not really happy with results in terms of size and longevity. I understand there are also options for implants vs. v-y surgery. (most permanent?) What are the complications, risks and costs of these options. Also, do you use Alloderm or Gortex implants, or is it based on cases by case basis. What is the longevity of Allodem?
A: I choose which permanent lip enhancement option on a case to case basis. That could include lip advancement,lip lift, v-y advancement or Advanta lip implants. There are different reasons for using any of these based on the existing size and shape of one’s lip. Pictures would be of great help in determining what may be best for you. Alloderm has not proven to be a permanent lip implant material so it is no longer used.
If you have not had good success with injectable fillers, then the concept of putting in any permanent material will likewise be unsuccessful. Your lips are not big enough or have the right shape to merely be ‘inflated’. This would indicate that you need more vermilion exposure through some form of excisional procedure such as a lip advancement or possibly a tissue shifting approach with an internal V-Y advancement.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 33 year old adult who was born with a cleft lip and palate. I have had two rhinoplasties since the original surgeries I had as an infant. One nose surgery was at the age of 14 and the other one was at the age of 23. My nose is still not straight at all. I know that I do not normal tissue and the cartilage is very stubborn, but I want to know if there is any hope for a more symmetrical nose.
A: One of the most difficult of all rhinoplasties in which to get a good result is that of the cleft nose. As you have pointed out, the tissues on the side of the cleft (if it is unilateral) are not normal. This means that the lower alar cartilages are deficient and there is scar from the lip repair into the base of the nose as well as the scar tissue that you would have from your prior two rhinoplasties. But the most limiting factor, above all of that, is the skin at the tip of the nose and around the nostril. It is not only thicker than normal but it is both deficient and scarred. This is particularly true inside the nostril and in the soft triangle area near the tip. Having done many hundreds of cleft rhinoplasties, I find this issue to be the really problematic one that limits how good a cleft rhinoplasty result can be. To answer your question specifically, please send me some photos of your nose and I can provide a good answer if any further efforts at rhinoplasty are worth it.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr Eppley, I’m just writing to thank you for the great information you have posted on vertical chin reduction. I’ve always had a long chin and had liposuction on my neck 3 years ago. Afterwards it made my chin longer. I don’t know if it just looks that way or something was done to actually make my chin longer if that makes sense. In any event I’m too afraid to do anything about it, but thank you so very much for providing the great information on your site.
A: The neck liposuction did its job by making the neck less full and improving the neck-chin (cervicomental) angle. But having a long chin to start with by your admission, the improved neck shape has unmasked the chin area and made it look longer. That is actually an optical illusion. But an illusion that aesthetically does not work in your favor. When considering neck changes, it is always important to not overlook the chin area as the two work together to contribute significantly to one’s facial profile. Doing computer imaging would have revealed what neck liposuction alone would look like. It likely would have shown that vertical chin reduction was just as important to an improved facial profile as was the neck fat removal.
Dr. Barry Eppley
Indianapolis Indiana
Q: All my life I have had depressions under my eyes. It’s a hereditary thing as I have no cheekbones at all. It makes me extremely self-conscious. Although I don’t need glasses, I wear them all the time to hide this problem. I have been thinking about getting cheek implants. Do you think that will help me? I have seen some cheek implant results and they look really fake to me. How do you avoid cheek implants from looking unnatural and even making my eyes look too sunken in?
A: There is no doubt that well-defined cheekbones are an important facial component of what can make a man or a women good looking. Cheekbones help define the face by highlighting the eyes, adding balance to the other facial prominences and contributing to a look of youth and vitality.
Cheek implants can really help those whose midface is deficient. But cheek implants come in different styles and sizes. There is more to cheek implants than just choosing a size. The cheekbone is a curved structure that has dimensions of a frontal, central, posterior and inferior considerations. Different styles of cheek implants highlight these areas differently. Patients have different types of cheekbone deficiencies and that is the reason so many cheek implant styles exist. In addition, how the implant is placed along the bone and what size is chosen will influence how it will look after surgery.
Probably the biggest consideration in avoiding an unnatural cheek implant result is to not use too big of an implant. The cheek area is very aesthetically sensitive and trying to make too big of a change or use the implant to lift sagging cheek tissues can quickly make for a peculiar looking result. There are some good celebrity illustrations of this exact problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi. I’m a male 34 years of age and am interested in getting liposuction done. I’m not obese, but am seriously overweight. I am around 250lbs at 6′ tall. I’m wanting to have a procedure done to have about 50 to 60 lbs removed. I’m not a professional, so I don’t even know if that’s possible. Looking forward to hearing back from you.
A: Liposuction is not a weight loss method but a body contouring procedure. While most patients do lose weight after liposuction, it is not in the order of magnitude to which you refer. For a man your size, abdominal and flank liposuction (the typical areas for male liposuction) will probably result in 10 to maybe 15 lbs of weight loss. This weight loss usually takes about 3 to 4 weeks to fully see once all the retained fluids from surgery are eliminated. Once can continue the weight loss further through their own efforts if they desire. While a weight loss of 50lbs may ultimately be achieveable, lipouction in this outome will have been the ‘kick start’ to the process. Much of the achieved weight loss will have been not from the actual procedure but from the efforts to protect and harvest the best results from their surgical investment afterwards.
In short, perceiving liposuction as a weight loss method is ill-conceived. It is better thought of as part of an overall body transformation program. Where in this process liposuction should be done requires a thoughtful discussion with a plastic surgeon.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a male to female transsexual and need some facial changes as part of the process. My chin is too male looking with a prominent chin cleft and it is very wide. It is too wide and prominent for my face which i am trying to make more feminine and slender. I need my chin cleft removed and the width of the chin corrected by burring it down from inside the mouth.
A: In trying to achieve a more feminine looking chin, your aesthetic goals are correct but the method to get there is not the best way. Simple intraoral burring of the chin can only make a minimal narrowing effect and, if done aggressively, will like result in soft tissue sagging problems. The best approach to really narrow and taper the bony chin is through the use of an osteotomy. By doing a horizontal chin osteotomy, the downfractured segmented can be split in the middle and a center segment of chin bone removed. It can then be put back together with the entire chin significantly narrowed and with a much better tapered look to it. The chin soft tissues can then be better suspended with no risk of soft tissue sag (witch’s chin deformity) afterwards. This will also provide a better means of muscle tightening and soft tissue fill of the chin cleft to create a better chin cleft soft tissue reduction. While this sounds complicated, it is just a simple variation of the traditional chin osteotomy technique. (genioplasty without the side)
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I have a son that is 3 and a half years old. He has plagiocephaly, the back right side of his head is flatter than the left. From a birds eye view his head appears somewhat crooked. I have read about injectable Kryptonite and was wondering if my son would be a candidate for this. At what age would he be able to have this procedure? Thank you so much for your time!
A: Thank you for your inquiry. The use of an injectable cranioplasty technique using Kryptonite Bone Cement for improving the skull contours in children and adults with plagiocephaly is new and the first cases of it are just beginning to be done. It is a very simple procedure that, just like an open cranioplasty, adds material on top of the deficient skull bone to build it out. Its advantage is not only its simplicity but that it avoids a long scalp scar and a more extensive operation. The age at which it can be done is really determined like any cosmetic procedure, when the patient (pr parent) feels that it is warranted and the effort is worth it. It really could be done any age as long as the child is healthy and the parents feels the problem is significant enough that it would be in the child’s long-term interest. Given its simplicity, there really is no significant recovery afterwards. The material within a day becomes just as hard as the surrounding skull bone and can not be displaced or deformed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I want to augment my nose from the top down to the tip of my nose. I am of Asian decent. But my question is using cartilage, how can my nose be reshaped?? Since cartilage is kind of like meat can it have a form like silicone implant ? Also I heard that cartilage can shrink or warp?? THEN WHAT HAPPENS TO MY NOSE ???
A: What you are interested is a very common treatment for the Asian type nose, that of dorsal augmentation rhinoplasty. This can be done as either dorsal (alone the bridge) augmentation only or as dorso-columellar (done the bridge and then a 90 degree turn at the tip and then down underneath the columella which is the strip of skin between the nostrils) augmentation. By far, the most common method for this type of nasal augmentation is with the use of preformed silicone implants.
But the procedure can also be done using your own cartilage. This obviously requires a cartilage graft harvest, almost always from the rib. Because of the donor scar and the temporary after surgery discomfort, most patients choose an implant. (even though from a long-term standpoint your own rib cartilage is better) Your concepts about cartilage shape and how it feels, however, is not accurate. It is not like meat but more like the consistency of a carrot stick. (as a matter of fact one is trained on how to carve cartilage using a carrot stick!) The rib (carrot stick) can be carved and then placed into the nose just like an implant. One has to be careful in harvesting the graft so that as a straight a graft as possible is taken and it must also be carved straight so it does not look crooked in the nose after it is placed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am very unhappy with the appearence of my jaw and cheek areas. I had ptosis surgery and forehead lift ten years ago. The eyelids are not symmetric but that’s not why I refer to you now. The profile of my face is very long and in my opinion the middle of the face is too far backwards. I’m interested in what you would propose to make my appearance more harmonic.
A: In reviewing your pictures, you do indeed have a longer vertical length to our face. This is magnified by the short or more posteriorly (backward) position of your chin point and your midface. The cheek and nasal base is very flat and your chin is significantly behind the upper lip, giving your face a more convex profile.
While you can not really shorten the vertical length of your face, you can change how it appears. By bringing forward the midface and chin through bony augmentation, you can achieve better facial balance which will make it appear ‘shorter’. This can be done with cheek and paranasal implants to the midface as well as chin augmentation through either an implant or an osteotomy. I would also recommend comsidering a rhinoplasty as well. Very frequently, long faces have an increased nasal length with a small dorsal hump. This long nose contributes to making the face look longer as well. A small change in the shape of the nose through rhinoplasty can also help change the visual effect to a shorter and more balanced face.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had a couple of surgeries on my shoulder to revise an old scar I have. However, I am not quite satisfied with the results. In retrospect, while I believe my surgeon did a decent job and intended well, he did make some crucial mistakes. I fully understand that each scar is different, but do believe that my expectations are all-in-all reasonable, that is why I am looking for the right expert to perform a last try to improve the scar in a way that is satisfactory to me. I have been impressed with the scar revision results you have posted and would like to know if it would be a start to send you some pictures of the scar, maybe follow up with a call if that makes sense. It is not a problem for me come over to the states for the surgery in case we come to a consensus. Thanks.
A: Scars on the shoulders are a particularly difficult problem. Between very thick skin and relatively constant motion, scars across the shoulders will often end up fairly wide and hypertrophic. This can occur even in well done scar revisions. I would be hesitant to state that your prior surgeon made ‘some crucial mistakes’ merely because the scar did not end up significantly improved. In considering any further efforts at shoulder scar revision, it would be extremely helpful to know what was done (surgically) to determine if a different surgical technique for scar revision can be used that might have a different outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in brow bone reduction surgery, flattening my prominent brows. I’m bald and was wondering if the incisions could be done via eye bows as I have no hairline. I was wondering a little about pricing and if there are payment options. Are there any tricks to have your health insurance assist paying for the procedure? Thanks.
A: Unfortunately, you are not a candidate for brow bone reduction surgery. You can not use your eyebrows for the incisions as this would cause unacceptable scarring, particularly across the bridge of the nose. This would also cause permanent loss of feeling of your forehead up to your scalp. The operation requires an approach from the scalp which is not possible given your lack of hair. In addition, there are not tricks for getting insurance to cover an operation that has no medical basis or symptoms.
Indianapolis Indiana
Q: I have a large pannus that hangs down to my knees. My insurance will not pay to have it removed even though my doctor and a specialist has written that it is medically necessary due to the health problems that it is causing me. How much would something like this cost or do you know any doctor that would do this probono. I have also lost a little over a 100lbs. (used to weight 550 lbs and now weigh 450 lbs) but my abdomen still keeps growing to the point it is down my knees. This has greatly affected my life to the point I have sores, I can’t bend, I have a hard time walking,and taking care of myself. I have to depend on my wife and daughter for the stuff I used to do for myself. I am desperate and need help and guidance.
A: What you are in need of is an abdominal panniculectomy. This should not be confused with a more simple tummy tuck or abdominoplasty in the cosmetic patient. Removing a large pannus in a man of your size is a complicated procedure with significant medical risks. In addition, that type of abdominal panniculectomy is associated with a 100% incidence of postoperative complications such as wound breakdowns, fluid collection, and infections This is not said to deter you from having this operation…as you need it…but it must be done in the right medical setting. This means in a hospital with good medical supervision afterwards and at least a few days of hospital time for recovery. This is why it should not be economically viewed as a cosmetic procedure. There are just too many potential expenses that are likely to occur that go beyond just the cost of the operation. Because of this operation’s complexity, there is not going to be any doctor who will do it for free…there is just too much work and risks to be taken for that approach.
For these reasons, you and your doctor should continue to work on getting it approved through your insurance carrier. This is your best bet to eventually getting this important operation for you done.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a tummy tuck about a year ago and I have been embarrassed about my pubic area since. Now it sticks out and it did not do this before the surgery. It is an embarrassing problem that makes me not want to show off my new figure. It is apparent in tight pants, underwear or a swim suit. I am so self-conscious about it. Is this normal after a tummy tuck and what can be done about it?
A: Because a tummy tuck has its greatest tightening effect around the waistline, it is not uncommon to have the suprapubic mound become more prominent. In reality, the suprapubic mound was always there and it has not gotten any bigger. It is just that what lies above it has now become less prominent, exposing what used to be an obscure and unobserved mound area. In my tummy tuck experience, this is not a rare development after surgery. The bigger the size of the tummy segment that is removed and the greater the waistline tightening is, the more likely a prominent suprapubic mound would be unmasked afterwards.
The suprapubic mound can be easily and very successfully reduced by liposuction. I have found it to be an area in which fat is easily extracted and the mound prominence reduced quite quickly. Because it is a small area, the liposuction procedure can even be done under local anesthesia with minimal recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I originally had breast augmentation three years ago and went from an A cup to a C cup. I got 375cc implant in now. I have decided that I would like to be bigger, at least another cup size. How do I know what next breast implant size to go to. My current plastic surgeon suggested 450cc but I am not sure. Is that enough of a size increase to get what I want?
A: There are a lot of variables that impact how a certain breast implant volume will look on any woman’s chest. There is no direct scale or measurement that can accurately predict for all women the correlation between breast implant volume and bra cup size.
That being said, you have one advantage over someone who is getting their initial breast augmentation. You know what cup size resulted from a specific volume. This does make it a little easier to predict what would happen with the next implant change as it is largely a matter of mathematics and proportionate relationships.
Going from 375cc to 450cc is a change of 75ccs or 20%. Based in your prior experience, it took 375cc to get a two cup size increase or roughly 175cc per each cup size increase. This would suggest then that a 75cc increase would only change your bra size by about a ½ cup size. To get a full cup size increase, it will take at least a volume increase of 125cc or a 33% increase in implant volume.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had gastric bypass surgery 2 years ago and am now bothered by a lot of belly skin that hangs down onto my legs. Besides giving me problems with the fitting of pants, I have trouble keeping it clean and it takes a lot of powder to keep the area underneath dry. Occasionally the area under this flop of belly skin will get really red and sore and my doctor puts me on a fungus powder to get rid of it. I know that plastic surgery can cut off this skin but what will happen to the extra skin that will still be there that wraps around the hips and across the back? Is there anything that can be done to get rid of this skin also or do I just have to live with it?
A: With a lot of weight loss, the skin on the trunk of the body falls like wax melting off a candle. This usually occurs in a 360 degree circumferential manner, but it is always worse in the front. This is particularly so in women due to their already existing loose skin and muscle of the abdominal area due to pregnancies.
What type of plastic surgery contouring procedure that is optimal depends on how much loose skin exists across the back. While an abdominoplasty or tummy tuck (also called an abdominal panniculectomy in the bariatric patient) is a good frontal procedure, it can be extended to go the whole around the back as well if needed. This is called a body lift or circumferental belt lipectomy. This may be a better reshaping for you based on the amount and location of excess skin around your waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley I am a 26 years old girl. Actually I have an oval face. I like all my features in my face except the shape of my face. This feeling destroyed my confidence, so I must do something about it. I like to make it more round and fuller. I would like to know which options do I have for that goal, fillers, fat injections, or what else? Do you think what is the best option for me, which has a reasonable price, is long lasting, with the least side effects and also look very natural. All your advices would be so valuable for me. I am looking forward to hearing from you. Thanks so much.
A: Increasing the fullness of your face involves expanding the ‘middle third’. This is the soft tissue area between the bony cheeks and the jawline on the sides of the face. The only practical approach would be the use of fat injections. While their survival and volume retention is always variable, they offer the best economic approach, virtually no complications, and the most natural looking result. For my facial fat injections, I now add Matristem collagen particles and platelet-rich plasma (PRP) to the fat for a ‘supercharging’ effect to try and get the best volume retention. That being said, it is still adviseable to overfill the injected facial areas to some degree. The fat needed to inject usually comes from the abdominal or waistline areas by liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a Lefort III osteotomy along with a genioplasty which was done 3 weeks ago to the day. My lower lip sticks out and sags to where I can see all of my lower teeth. My craniofacial surgeon says give it time, but from what I know he did not attach the mentalis muscle correctly.
Do you have experience fixing this deformity without removing any tissue, just relocating the muscle? Any help you could provide would be appreciated!
A: My first comment on your concerns are that you have just had major surgery just a few weeks ago. A LeFort III procedure is one of the most significant of all facial surgeries that can be done. There is going to be lots of swelling all over the face, including the chin area. When you combine a chin osteotomy with a LeFort III the amount of swelling will be extensive.
While I wouldn’t disagree with you that it is disconcerting to see your lower tooth exposure after a genioplasty, this does not necessarily mean it will stay that way completely. Certainly swelling accounts for some of the current visible problem and your mentalis muscles are not going to work properly for awhile. So it may look ‘bad’ now but there is a lot of time for improvement. I would work and be patient with your craniofacial surgeon as time and healing will more likely than not make his guidance correct.
For the sake of argument, however, let us suppose that is does not improve. Mentalis muscle repositioning can certainly be done as a method of correction. If that should be needed at some point, I am certain your craniofacial surgeon will know the right timing and method to get the lower lip problem resolved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have semi-thin calfs, and I will like to know if there is a common fat injection for calf augmentation without the need of surgery procedures. Thanks.
A: The traditional method of calf augmentation is the insertion of synthetic implants. A newer method is the use of fat injections instead of implants. Whether this will end up being as successful as an actual implant remains to be seen. But do not think that the use of fat injections is not surgery as it most certainly is. Fat has to harvested elsewhere on the body through liposuction to acquire the injection material and then it has to be injected into then calf region. While it may not be as invasive as the placement of a calf implant, it is still surgery.
The biggest risk of fat injection calf augmentation, like fat injections anywhere else on the body, is their survival after transplantation. Even with the best methods that we have today, the reliability of fat injection results remains unpredictable. Any patient considering fat injections must be willing to assume that risk.
One advantage that fat injections does have over implants to the calfs is the ability to augment areas that an implant can not traditionally do. Fat can be injected in a more ‘sculpting’ approach as opposed to the mass augmentation effect of an implant.
Indianapolis, Indiana
Q: I have noticed that some fat has developed above the very top of the nose between my eyes. I have attached a picture of it. It seems to be getting thicker and heavier as I age. Is it possible that I am growing fat between my eyes? I have never heard of such a thing. Is there nyway of getting rid of this?
A: The ‘fat’ to which you refer between your eyebrows is not really fat. It is thick heavy skin and muscle, which over time and with age and continuing facial expression, has fallen downward into the glabella (area between the eyebrows). This creates a bunching of tissue and skin folds which looks like fat to you but is just sagging tissues from age and gravity. Its correction would require some form of a browlift to both thin out the overactive muscle in this area and to lift the sagging brows and forehead tissue which is pushing it downward.
Dr. Barry Eppley
Indianapolis Indiana
Q: Eight years ago I had a rhinoplasty that was overdone resulting in a more feminine look than I was looking for. Specifically the bridge is curved rather than straight and the bridge is lower on my face than I would like. The surgeon tried twice unsuccessfully to correct it. I’m not sure if correcting my nose could be done by straightening the cartilage and moving up the bridge bone or if it would require an implant of some kind. Can this be determined from an online consultation? Also if I do decide to go with an online consultation rather than an in person consultation will it be possible to conduct an image prediction of the results?
A: It appears that you have had an over-resected rhinoplasty with resultant dorsal line collapse, otherwise known as a saddle nose deformity. Rather than a straight dorsal line, yours is now curved inward. Correction of the saddle nose always require augmentation. This can be done by a variety of materials from synthetic implants to using your own cartilage. There are advocates for either approach. For a small saddle nose problem, using an allogeneic dermal graft (such as Dermacell) will work just fine. If it is a bigger saddle nose, then a cartilage graft is better. This often requires a rib graft for the donor site. I am not a fan of synthetic materials in the nose as they often come back to haunt one as future complications.
There is no such thing as computer imaging in a live online video consultation on Skype. But you send me some pictures of your face beforehand, computer imaging can be done and sent to you in preparation for an online consultation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am inquiring about fixing a scar on the back of my head. I had hair transplantation done on three separate occasions with the typical taking of the grafts from the back of my head. Unfortunately, the transplants did not take very well or look very good after (worse decision I have ever made in my life) and now I just shave my head. But the harvest scar looks terrible and is very wide. My hair doctor said it could not be made to look better but I am thinking (based on the way my transplants turned out) that he is not a very good doctor. I have about some material called Matristem that supposedly can heal wounds so there is no scar. Do you think this will work for my scalp scar revision? Is this a procedure that you do? Also, how does this material work, from a scientific standpoint?
A: The use of MatriStem from the Acell corporation to heal wounds and make incisions and scar revisions look better is a really intriguing concept. The material is novel and one of its preparations is in a powder form, which is a perfect way to incorporate it as part of any wound closure including scar revisions. My ear experience with it is very encouraging and I continue to use it for more and diverse applications in plastic surgery.
From a scientific standpoint, let me provide you with this explanation. The ACell MatriStem bioscaffold appears to provide signals to the host immune system that stimulate an adaptive or accommodative response that is ideal for both wound healing and three-dimensional growth of various cell types. The ACell MatriStem bioscaffold is distinguished from other ECM scaffold technology by its unique bimodal surface characteristics. One surface consists of an intact basement membrane which is especially conducive to epithelial and endothelial cell attachment, proliferation, and differentiation. (a key advantage in applications such as plastic surgery) The opposite surface consists of organized connective tissue comprised of the urinary bladder lamina propria. This surface is ideal for integration into wound bed and host connective tissues, and supports vascular ingrowth. MatriStem implants consist of a collection of both structural and functional proteins (such as Laminin, Collagen type IV and VII) that are arranged in a three-dimensional ultrastructure that is virtually impossible to reproduce in the laboratory. Growth factors native to the tissue layers comprising MatriStem implants, such as vascular endothelial growth factor (VEGF), transforming growth factor beta (TGFβ), platelet derived growth factor (PDGF), bone morphogenic protein 4 (BMP4), and basic fibroblast growth factor (BFGF), are present as the matrix resorbs, and support the growth of new blood vessels and the proliferation of connective tissue cells to facilitate the healing and tissue remodeling process. In the end, the wound or incision heals by making more natural tissue to knit it together rather than a jumbled bunch of scar tissue.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 72 years old and I had a facelift and chin implant some 20 years ago. (I remember waking up and hearing Sammy Davis Jr. and that Jim Henson Died) Today they say the chin implant is causing erosion of my bone. I am scared and don’t even know where to start. My days of plastic surgeons have passed me as they have all retired. HELP!!!!!!
A: The phenomenon of chin implant erosion or settling into the bone is well known. It can be a natural event that occurs over many years with some chin implant patients. While called an ‘erosion’, that descriptor makes it sound like some aggressive process (implant eating into the bone) and that it is a serious problem. In reality, this phenomenon is nothing more than a normal biologic process to implants in certain locations known as pressure resorption.
You have to think of your body’s tissues as active and flowing, not forever stable and never-changing likes bricks on a wall. Your own bone is that way. Bone is dynamic and it responds to stresses by changing its structure. Calcium constantly flows in and out of bone. But a synthetic implant in the body does not change its structure, its is stable. Therefore, when a chin implant is put on top of the chin bone, it represents a stable non-changing structure between the bone and the overlying muscle. If the chin augmentation is significant, over time, the pushback of the stretched out overlying muscle causes long-term pressure on the implant. Since the implant’s structure can not change, only one thing can…the bone underneath. The pressure is relieved by the bone underneath resorbing allowing the implant to settle somewhat into the bone. While called erosion, this is simple and benign biologic process.
Most likely this was seen and diagnosed on a dental film. Unless the chin is causing you pain or the bone resorption is affecting your lower teeth with pain and sensitivity (both very unlikely), there is no reason to do anything with the chin implant. (unless you want to change it for cosmetic reasons) It is not an active process and the resorption is not ongoing. Once the pressure from the muscle is relieved, the bone resorption is not progressive.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting deltoid implants. I realize this is a new procedure. What can you tell me about it? Thank You
A: Deltoid augmentation is a procedure for those that wish to have more bulk and definition in the area of the upper arm. Previously used in patients in need of shoulder reconstruction after trauma or cancer surgery, deltoid prostheses have been used to safely produce bulk in the shoulder region. Soft solid silicone implants can be fashioned (there is no established deltoid implant shape) to not only give bulk to the deltoid region, but also to give it more definition and shape. This is an example of a ‘muscle-building’ implant like that of the pectoral or gluteal muscles.
The deltoid is the muscle that forms the rounded contour of the shoulder. It covers both the front and back of the shoulder and has its name because it is in the shape of the Greek letter, Delta or triangle. It is a common injection site for injections and most people have probably had an injection there at least once in their life. It originates from the bones of the shoulder (clavicle and scapula) and crosses across the shoulder area to eventually be inserted by a thick tendon to the humerus bone of the upper arm.
The deltoid implant is placed through an incision on the back of the shoulder just above the armpit where the lower edge of the muscle is. The fascia (outer covering of muscles) that covers the muscle is then cut and a pocket made for the implant. The implant is then placed in the pocket just below the fascia of the muscle. The muscle lining is then sutured as well as that of the overlying skin. Once healed, the implant forms a permanent lining (capsule) which keeps it in place permanently. Recovery is largely one of swelling and muscle discomfort. One should not work out for a month after surgery.
Indianapolis Indiana
Q: Hi I had a breast reduction and then a scar revision over 15 years ago. Then last year I had a breast augmentation. Since then both nipples and parts of the breast are numb and I have no nipple sensation. Only when the nipples are pinched can I feel anything. Was having a breast reduction previously the reason that I have no nipple sensation now?
A: While breast reduction does decrease the amount of breast tissue, I am not aware that it would make one at more risk for nipple sensation later after a breast augmentation. I do not believe that the two are related other than both breast procedures were done on you.
The more likely explanation is that you have suffered nipple sensation loss exclusively because of the breast augmentation procedure. This is one of the know risks of the procedure although my experience is that it is very uncommon. While the nipple receives innervation from different nerve inputs, a major nerve supply comes from the side of the chest. The location of this nerve does place it at risk for a stretch injury during pocket development for a breast implant during the procedure. This is why I always only do blunt finger dissection when making the pocket to the side and to make sure it does not go too far too the side as well.
If you still have persistent numbness after a year after surgery, it is likely the loss of nipple and skin sensation will be permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: What method of bony cheek narrowing do you use to? Can you explain the procedure to me. Where do you cut the bone etc? How many cuts are made and what can be done to maximize the narrowing effect?
A: To properly understand the bone cuts, you need to know the anatomy of the zygomatic bone and how it articulates anteriorly with the maxillary and orbital bones and the temporal bone posteriorly. The width of the face in the cheek area is a reflection of the prominence of the cheek bone and its attached arch. Basically, cheek narrowing is done by shortening the attachments of the zygomatic process.
Two vertical bone cuts are made, one anteriorly where the zygomatic arch joins the maxilla and orbit and the other small vertical cut is posterior where the thin sliver of the back end of the zygomatic arch joins the temporal bone just above and forward of the TMJ.
The front cut and bone removal (5 to 7mms) is made with a reciprocating saw from inside the mouth incision. It is narrowed and then held together with a small plate and two screws on each side. The back end cut is done with a small osteotome (chisel) from a small incision inside the temporal hairline. It is simply cut and it falls inward naturally on its own due to the pull of the attached muscles.
The facial narrowing effect through cheek osteotomies is maximized by doing both cuts and allowing the entire arch to move inward.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have already had three rhinoplasties. And at the moment, I have no cartilages, just a scar tissue. If a cartilage from the rib is inserted during my fourth rhinoplasty, does it mean that the size of my nose will increase? what effects can I expect for the fourth time? Can the size of the nose get bigger?
A: While your nose may have collapsed and cartilage has been removed from the three prior rhinoplasties, I am certain you have some cartilage left in your nose. The septum and the upper cartilages undoubtably persist but the most severe cartilage loss is in the lower alar or tip cartilages. This probably causes problems not only in its appearance but also in how well you can breathe through your nose.
When significant cartilage grafts are needed and the typical places for graft harvest have been previously used or can not offer enough, a rib or costal graft is the next and last harvest area. The rib(s) has more than an ample amount of cartilage for any single nasal reconstructive procedure. How the rib graft is harvest and used, however, is based on what is needed in the nose. Typically, a solid rib graft is used to built up the nose along the dorsum or as a combined dorso-columellar strut construct. This will make the nose bigger in terms of more projection and dorsal and tip height. Rhinoplasty with the use of a rib graft always means that the structure of the nose will be more built up or moved outward from the plane of the underlying face.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I am interested in information about hip implants. I have struggled throughout my adolescent and adult life with severe insecurities and embarrassment concerning my boyish figure. I have taken to fashioning shorts with layers of thick fabrics sewn into them to make myself feel better and more properly fit into clothing however, this method is flawed in many ways and the results are still less than desirable. I would very much like to have access to a permanent solution that allows for activities like swimming. I did see on your site that you have performed the procedure at least once and was wondering if I could get some information on it and if possible, before/after photos? Thank you very much!
A: Hip Implants are the rarest of all the body implants performed. They are so infrequently done that few plastic surgeons have ever done them, no specific style of hip implants is currently available, and there is no FDA-approved implant for this procedure. Any hip implants that have ever been done use implant styles for other body parts. It is not clear as to the best surgical technique for the procedure since so few have ever been done.
All of that being said, the placement of an implant into the hip area can be done. But this would involve a significant scar over the hip area and the placement of an implant in a very palpable area. While I have done one such procedure for the purposes of traumatic reconstruction, doing it bilaterally for purely cosmetic reasons must be very carefully considered. This is not like a breast or a buttock implant in that it ends up being placed in a subcutaneous rather than a submuscular position. This makes the risks of palpability, infection and migration much higher.
Before I would consider an actual hip implant, I would give more serious thought to injectable fat grafting. This would be far safer and has none of the potential complications of a synthetic implant in this more risky area. While the biggest problems with fat injections are survival of the injectate, that would be a better risk to take.
Indianapolis, Indiana
Q: I have been researching for the options to remove the silicone on my nose bridge. I saw some chat group people talking about Korean plastic surgeons removing injected silicons from the nose bridge from inside of the nostrtil and implanting a new bridge at the same time, supposedly leaving no visible scar left after the surgery. As far as I have seen, this approach seems like only available in South Korea, Thailand and Singapore so far. What is the feasibility of using this method in U.S? Will this be easier than accessing the injected silicon from behind the hair line? I will continue to search options. Hope I will not have to go overseas to remove the little piece of silicon. Thank you very much for your time and consideration.
A: What is not clear in your inquiry is whether the silicone that in on your nasal bridge is a solid implant or is from silicone injections. Furthermore, I am assuming when you say nasal bridge you are referring to the length of the nasal dorsum as opposed to just the nasal bone area at the upper one-third of the nose.
Regardless, a nasal approach to its removal would be certainly be preferable and easier. Whether this is best done through a closed or open rhinoplasty approach is not clear just based on the information you provided. I see no reason or benefit to using a superior or scalp approach for its removal.
Immediate replacement with another nasal dorsal implant, if desired, could also be done at the same time as well.
Dr. Barry Eppley
Indianapolis, Indiana
