Your Questions

Q: Hi. As a baby/kid I had misaligned teeth due to sucking my thumb. I sucked my thumb pretty much up to 15 years old or so. At about 15 years old I went to the orthodontist to get braces. He decided along with the braces to install this thing in my mouth called a “herbst appliance”. Cant find anything about on Google. Maybe it was to push up my chin due to my some what recessed chin due to sucking my thumb? I finally got all the stuff out of my mouth removed last summer. I was always a little self conscious about my jaw line , but the past couple of months i’ve started to notice tremendous asymmetry between the right and left side of my jaw. The right side looks like I have a Brad Pitt Jaw and the left side is nothing, barely a jaw line showing. I’m tremendously discomforted inside due to the straight forward appearance of my face shich is crooked.  What can I do to address and fix this problem?

A: Undoubtably what you originally had was a short lower jaw or mandible. In an effort to help the lower jaw grow during your early teen years, the orthodontist put in a growth stimulting appliance for the lower jaw, known as the Herbst appliance to which you refer. It is a well known device that has been used for several decades now. Now that the device has been removed and you at are the end of your facial growth, the final position and shape of the mandible can now be seen.

When looking at facial symmetry from the front view, the important issues on the centric position of the chin and the amount of flare of the jaw angles.  These three points give the visual impression of the overall jawline appearance.  When one has jaw asymmetry, provided that the teeth are in a good bite relationship, manipulation of these three points can be surgically done.

The chin can be adjusted with an implant or an osteotomy. The jaw angles can be accentuated and lowered through implants. Any combination of these numerous options exist. Which one(s) or combinations can only be determined through photographs of your face, a panorex x-ray, and computer image manipulation of proposed changes.

Between chin and jaw angle surgery, a tremendous improvment can usually be obtained and a much more symmetric and pleasing jawline can be realized.

Dr. Barry Eppley

Q: Hello, I have a few questions.I’m interested in getting my leftover fat from my entire body put into my boobs. I’d like to get my bmi to be just at 18, although it is at a 20 right now. I was just wondering if anyone would be willing to even work with me since I weigh around 115 and am 5’3″.

A: Breast augmentation using injectable fat rather than a synthetic implant remains in an ‘experimental’ or an investigative phase currently. Since it does not involve an implant and uses your own natural tissue, it is understandable to think that it is  a safer and perhaps better procedure.

While fat may be natural, it is not a predictable implant material particularly in the volumes needed for breast augmentation. No standard techniques exist for fat preparation or injection methods and very different results can occur in various hands. At the least, much if not all of the fat can be absorbed rendering it a waste of time. At the worst, the fat may make the breast lumpy with cyst formations or develop sterile pools of liquid fat. What impact fat injections have on mammogram imaging and breast cancer detection remains unknown and not studied.

While much of this discussion sounds negative, the concept of using fat for breast augmentation has appeal and work is ongoing in this area. The only FDA-approved clinical trial that I know of is with the BRAVA system in which injectable fat is stimulated after surgery with an external low-level suction device.  Otherwise, any clinical work that is being done is occurring in an independent fashion as an individual-precribed surgery amongst a handful of practitioners.

With the low BMI and body fat that this patient has, she would not be a good candidate for the procedure even if it was proven and widely used. A simple breast implant is so much easier and more predictable that fat injections, which for now, remain as a more complicated and morbid approach for breast augmentation.

Dr. Barry Eppley

Q:  I have a fat nose and would like it to look slimmer. It doesn’t seem to fit the rest of my face which is actually very thin. But I don’t want to have my nose broken as I like the rest of it. Are there different types of rhinoplasty surgeries?

A: Like all operations in plastic surgery, it is important to tailor it to the specifics of the problem. Most plastic surgery procedures do  not use a ‘cookie-cutter’ approach but modify certain details of the operation to a patient’s specific needs. Rhinoplasty surgery is the pinnacle of this philosophy as every nose surgery is uniquely different.

Despite the many variations of rhinoplasty, they can be divided into two main types, a mini- or tip rhinoplasty and a full rhinoplasty. The fundamental difference between the two is that a full rhinoplasty treats all three sections of the nose, often breaking the nose bones  (upper third) to narrow them. A tip rhinoplasty treats only the lower one-third which consists of a paired set of cartilages which meet in the middle to create the tip of the nose.

When one has a fat or wide nose, it is because the cartilages in the tip of the nose are big and protrusive and often don’t quite meet in the middle. Through a tip rhinoplasty, these cartilages can be reduced in size, reshaped and brought closer together. Using suture techniques, a remarkable change in the nose tip can be done making it thinner and more in proportion to the rest of the nose.    

Dr. Barry Eppley

Q: I have developed brown spots on my legs and I hate them. They seem to be growing and getting more of them as I get older. What can be done for them?

A: When patients use the term, ‘brown spots’, that can be referring to a variety of colored or pigmented skin conditions. Most commonly, these can be sun or age spots where an excess pigment reaction develops in the upper most layer of the skin. These brown spots are flat in appearance.  Other brown spot conditions could be keratoses or thickening of the outer skin layer which appear as raised and rough textured skin areas.  These are known as keratoses. Occasionally patients may also be referring to more congenital light-colored brown areas known as cafe-au-lait spots or patches.

The success of brown spot removal depends on what type they are and what your ethnicity is. For flat brown spots as a result of sun and aging, broad band light (BBL) therapies (also known as intense pulsed light or IPL) can be very effective. This is a simple office that can significantly reduce them in or two visits. Raised brown areas like keratoses, however, do not respond to light therapies and require scalpel shaving. congenital birth marks such as café-au-laut spots can not be removed without leaving a lot of scarring and they are best left alone.

In dark-skinned patients (Asians, Hispanics, or African-Americans,) all such treatments could result in potential loss of pigment. This could create the look of white patches which may not be a good trade-off. The treatment of brown or dark patch areas should be approached with caution in darker pigmented patients and often are better left alone.

Q: I wrestled throughout high school and college and this has left me with both ears that are deformed. I am very interested in corrective surgery to both reduce their scarred appearance and gain better symmetry between them.

A: A very uncommon ear problem, while not unique to just wrestlers, is that of the ‘cauliflower ear’. So named because of its appearance, the cauliflower ear appears as raised hard irregular areas that cause the ear to become misshapen. Because these deformities can occur anywhere on the ear but the earlobe, it is the cartilage that is the source of the problem.

When the ear is traumatized, bleeding can occur under the covering of the ear cartilage known as perichondrium. This can particularly occur from shearing or severe rubbing forces on the ear. Blood is a stimulant for the perichondrium to form new cartilage. So wherever there is bleeding, cartilage nodules can form and grow distorting the very detailed hills and valleys that give the ear its form. When this occurs repeatedly (as in a wrestler), eventually the whole ear can become one knarled mass.

The cauliflower ear can be treated by cartilage removal and reshaping it as close as possible to its original form. To do this procedure, the skin must be carefully lifted off over the deformed areas. This requires an incision which can be placed on either side of the ear (front or back) depending upon the location of the excess cartilage. The key to the success of the operation is placing the skin back down and having it heal without forming new cartilage and allowing the new shape to be seen and maintained. This is done by placing a special dressing called bolsters onto the ear to keep pressure on the healing skin. These are removed one week after the ear reconstructive surgery.

Dr. Barry Eppley

Q: I am interested in the direct neck lift and want to know more about it. I dont want a complete lift and think this may be my answer. How much of a scar remains visable and will it last a long time? Do you tighten the musles and remove some of the fat during the procedure?

A: A low hanging neck, or wattle as it is sometimes unaffectionately called, is a concern for both male and female patients particularly as they get older than 55 or 60 years of age. The traditional and most method of treating these neck concerns is a conventional facelift. In this procedure, the loose neck skin is moved back from the central part of the neck up and backwards and then trimmed off, putting the scar in a near invisible location in and around the ears.

When one doesn’t want to go through a facelift procedure, due to either lack of good hair around the ears or the expense and recovery, the direct necklift may be a reasonable alternative option. Because it cuts the wattle out directly, it leaves a vertical scar running down from under the chin to just below the adam’s apple.  Both skin and underlying fat is removed and the platysma muscle is also tightened, which is both easy and very effective due to the wide open exposure.  It is a simple operation with very little recovery, minimal swelling and bruising and virtually no pain other than some neck tightness.

The issue is the scar which is why it is not for everyone with a neck wattle, particularly younger patients and most women. It is largely an older male procedure as many men do not have good hairlines and are interested in going through a smaller less drastic procedure. Neck scars in men tend to do fairly well as they have thicker beard skin and do an unintentional but helpful scar treatment daily, known as shaving or microdermabrasion. But for the right older female who has less of a scar concern, it can make a dramatic neck difference.

The scar down the neck can be done several ways, either as a straight line, a straight line with a central Z, or a running w line. (like a pinking shear cut) I have used them all and the choice of which scar pattern is used is based on skin quality and the tightness of the closure. Most scars will become fine white lines that are very acceptable. Scar revision is always possible also but is not commonly needed in my experience.

Dr. Barry Eppley

Q: I am a transgender patient and I am looking for information regarding facial feminization surgery. I am interested in getting some work done. I think I may need full facial feminization surgery.

A:  One of the most important transformations that a transgender patient needs to make is in facial appearance. The potential to be seen and accepted socially as a female is of major physical importance. There are numerous facial changes that can be done, most prominently brow reshaping, rhinoplasty, cheek enhancement, and jawline contouring. These are changes in the support structure of the face that can change the gestalt of sexual orientation. Soft tissues changes such as blepharoplasty, canthoplasty, lip augmentation and shaping, and facelifting are complements to structure changes but, in and of themselves, are not primary facial feminization changes. The prominent adam’s apple (thyroid cartilages) is the lone non-facial feature whose reduction makes for a softer more feminine neck profile.

In considering facial feminization surgery (FFS), there is no standard set of procedures that works for everyone. The total face must be taken into consideration and changes selected that will make for the greatest improvement in appearance. Some patients may benefit by only two or three while others may get half a dozen or more. In considering what changes may work, computer imaging can be very helpful. Such imaging is not a guarantee of outcome but a method of communication and education about useful possibilities.

Whatever changes are selected, it is best to do the whole package in a single operation. The recovery may be longer but a one-time commitment for ‘changing face’ is better psychologically.

Dr. Barry Eppley

Q: I had cancer in the parotid gland and it was removed with a neck dissection which left a deep horrible scar from the back of my right ear to the middle of my neck. The scar is mostly flat except when it gets close to the adam’s apple where it gets really wide. The scar is 4 years old and is still tender. I really hate it and it takes away from my appearance. One doctor did injections which didn’t really help it.

A:  While any scar can be cut out and reclosed by different methods (scar revision), the question is always whether it would be beneficial or not.  There are four features of scars that only surgical treatment can improve.  Scars that are wide, depressed, raised (hypertrophic or keloid) or contracted (painful and movement restrictive) are very likely to be improved by getting rid of the bad (complete scar) and replacing it by moving your own unscarred tissue in its place. This neck scar has several of those features including being years old which means it is mature and no further improvement in its appearance or feeling can be expected.

Tumor excision in the neck with removal of lymph nodes (neck dissection) will leave a long scar that traverses the neck from around the ear to across the adam’s apple in many cases. While most of the scar should lie in a very favorable horizontal skin crease, portions of the scar may not. It is these areas in particular that often end up as a wide and distorted scar. Many patients with this type of surgery have also had radiation which may be another reason why it resulted in poor scarring.

Much of this scar can simply be cut out and reclosed along the skin line which it currently lies. But near and around the adam’s apple, re-orientation of the scar through a z-plasty will relieve the tension on it and allow it to heal with less distortion  and be closer to a fine line in width.

Dr. Barry Eppley

Q: I want to get implants to have higher looking cheekbones. What is the difference between malar and submalar cheek implants? Which would be better for me?

A: In considering cheek augmentation, or enhancement of the midface, there are a wide variety of cheek implant styles from which to choose. Gone are the days when only a single design of a cheek implant existed. One of the different style designs is between malar and submalar implants. Malar is another word meaning cheek. So a malar implant sits on top of the existing cheekbone, providing more cheek projection. A submalar implant, however, sites on the cheekbone’s bottom edge providing increased fullness to the area below the cheekbone.

Submalar cheek implants have actually been around for some time and were developed to help with midface sagging from aging. As we age, cheek tissue slides or falls off of the cheekbone. One way to help lift it and restore more youthful fullness is with the submalar implant. The other option would be a midface lift, a more extensive operation with an increased risk of complications.

When most patients are considering cheek enhancement, they are usually thinking of higher cheekbones and more fullness to the bone right beneath the eye. Cheek implants come in a variety of designs to achieve this fullness and they differ in whether the most fullness in the implant is anterior, central, or posterior along the cheekbone. To choose the best implant style for you, you need to go over carefully with your plastic surgeon your exact concerns and what areas of the cheek you would like to be bigger. Most dissatisfaction with cheek implants occur because of style and size selections.

Dr. Barry Eppley

Q: I’ve lost about 90 lbs and now I have excess skin that hangs on my upper arms that I want to have fixed.

A: One of the many skin problems that develops after large amounts of weight loss is that of loose hanging arms. The skin on the back of the upper arm in the triceps area hangs down, creating what is often called ‘bat wings’.  The excess skin frequently extends into the armpit (axillary) area and down into the side of the chest wall. Such large amounts of upper arm skin are a unique finding amongst extreme weight loss patients, particularly after bariatric surgery. Interestingly, this arm problem occurs overwhelmingly in women and not usually in men. (I have never performed an armlift in men) It may be that men’s skin shrinks down better after weight loss.

An armlift, known in plastic surgery as a brachioplasty, is an extremely effective procedure for reducing the size of the upper arms and getting rid of this loose floppy skin. While it accomplishes this result with the trade-off of a long arm scar, patients with this amount of loose arm skin consider that scar better than the excess skin. Armlifts are one of the most satisfying of all weight loss body contouring surgeries.

Armlifts traditionally have either placed the scar running down the middle of the inside of the arm or on the back of the arm. Recently, I am using a new technique during surgery that places the scar between the middle and the back of the arm with significantly better results.  The scar is not only better hidden but the common postoperative wound healing problems that used to occur (particularly when using the inside of the arm location) have been largely eliminated.

Dr. Barry Eppley

Q: I have been infected with HIV for nearly 15 years. While he medications have been invaluable and have saved my life I suffer from some of their cosmetic side effects including a very gaunt face and a  non-existant butt. For my face which is better, fillers or iimplants. Can anything be done to my butt bigger?

A: One of the well known side effects of the medications to treat HIV is lipoatrophy or fat loss. The fat loss is quite specific, however, and has a predilection for facial and buttock fat. Loss of the buccal fat pads and, in severe cases, much of the subcutaneous fat results in a sunken in or very gaunt look to the face. It is such a classic presentation that it can be socially stigmatizing has having the underlying medical problem. In the buttocks, fat is lost so they become very flat appearing. Other parts of the body, for unknown reasons, undergo fat hypertrophy (excessive growth) most commonly in the back of the neck (buffalo hump) and in the abdominal area.

Facial lipoatrophy can be successfully improved with a variety of approaches including synthetic cheek implants, fat injections, or synthetic fillers. (e.g., Sculptra) Which one is best must be determined on an individual basis considering the extent of the fat loss and whether one prefers to avoid actual surgery or not. Fat grafting is probably best avoided as its persistence in the face of the medications is unlikely.

Treatment of buttock lipoatrophy is a different matter with no good options. Fat injections are not adviseable due to likely complete resorption and a result which will be underwhelming. This leaves buttock implants as the only option which carries with it a significant recovery and risks of infection and seroma complications.

No type of plastic surgery should be performed in an HIV patient unless their cell counts have been normalized and medical clearance is obtained from their treating physician. According to recent studies, the infection rate for plastic surgery procedures is not different in HIV vs non-HIV patient populations if good cell counts exist.

Dr. Barry Eppley