Your Questions
Your Questions
Q: I am wondering about reducing an area of my upper lip. Here is the problem. When I was younger, I had an incident that cut an area of my upper lip. My lip healed fine and the cut mark is no longer there. However, it appears that an excess of fat or tissue (not sure what it is) has collected in that part of my lip. I am guessing the procedure may be something like liposuction or something like that. It looks rather simple to do and perhaps could just be fluid in there. Please advise.
A: The bump on your lip that you are seeing is undoubtably scar tissue. It is not fluid or fat. This is an absolutely classic case of scar formation that occurs after a significant cut or laceration on the lip occurs.
While scar forms anywhere on the body after injury (this is how things heal), the lips are uniquely different from what occurs in skin…because they are not skin. Lips are a combination of wet and dry mucosa which is much thinner and more elastic than skin. It has to be so that the lips can be flexible. There is a reason that you can pull on your lips and really stretch them out without tearing them. (up to a point) Wet mucosa is more flexible than the dry mucosa which is the part of the upper and lower lips that we externally see.
The thinness of mucosa, particularly the dry mucosa, makes it very susceptible to forming a thicker scar. This can particularly occur with many lip lacerations which are often left to heal on their own. Such secondary healing almost always leads to a thicker area which disrupts the smoothness of the horizontal lip lines.
Lip scars can easily be re-excised and closed with successful smoothing of the lip line. Lip scar revisions can usually be done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had my face injected with fat and it was initially overfilled. The doctor that did it said it would go down and look more normal but it has not. Can anything be done to make the fat go away or at least become less full?
A: Fat injections to the face is a good and safe technique for adding soft tissue volume to specific areas. Its almost sole problem is that its volume retention (aka how much survives) is not completely predictable. Studies have shown that certain areas of the face do retain transplanted fat better than others. For example, the cheek and side of the face do much better than that of the lips. Thus, it is standard practice to overfill or add more volume than one thinks is really necessary. How much one should overfill has never been precisely defined. Some plastic surgeons may do it just a little, others may significantly overfill.
Despite overfilling, the most persistent fat injection problem is that not enough ultimately remains. It is rare, but I have seen it, that too much fat remains. One should wait at least 3 months after facial fat injections to judge the outcome. By then, one is most likely looking at how much fat volume will be maintained.
There are two basic methods for reducing overfilled fat facial areas. If the location permits, ‘micro-liposuction’ can be done if a small incision can be cosmetically tolerated. The other approach is using injection therapy. I have seen successful use of either a steroid (Kenalog or triamcinolone) or very dilute Lipodissolve solutions. (phosphatidylcholine) The two can be combined together to create a mild fat dissolving solution that does not cause a lot of facial swelling afterwards. Injection therapy as the advantage of a non-surgical approach in which the treatment can be done in very discrete spots. It is also a more gradual process that lowers the risk of removing too much fat and causing the reverse contour problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can you undo cheek dimple surgery I had done about 10 years ago? If so, how is it done?
A: The surgical making of cheek dimples is different from what causes natural cheek dimples. Anatomically, natural cheek dimples have been shown to be present from a split in the zygomaticus nuscle which runs from the upper lip to the cheek above. Because of this natural split in the muscle, the overlying soft tissues are pulled down or tethered into the split muscle, creating an overlying indentation in the cheek. Depending upon the size of the muscle split and the amount of tethering, this is why some dimples don’t appear until one is smiling or those that have them at facial rest get much deeper with smiling. The surgical creation of cheek dimples is done by going from inside the mouth, splitting between the zygomaticus muscle, and sewing the underside of the desired spot on the cheek down to the muscle.
Reversing cheek dimples is a matter of releasing the tethered skin and placing something between the skin and the muscle as a soft tissue filler or spacer. The best filler for that, in my opinion, is fat. The easiest and most convenient place to harvest fat is the buccal fat pad which is anatomically close to where one would be working for the cheek dimple release.
In natural cheek dimples, or in surgically created ones of long-standing, the result will be a softening or less prominent depth of the dimple. This is because some of the dimple presence is due to inverted or indented skin, which an intraoral approach alone will not solve. The skin also could be completely leveled but this would require a skin incision to do so. This creates a small scar in the skin as a replacement for the dimple which may or may not be a good trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am unhappy with what was done to my jaw angles. The procedure was done using a saw-like tool that was used to cut off bone from my jaw angles. I think they took too much bone. I don’t want to go back to exactly the way my jaw angle was before, however, I would like to get some prominence back. I think too much was shaved down and it looks too weak now. Also, both sides are uneven so my left and right profiles do not match which just shows how much my last surgeon was lacking in skill and technique. What can be done now to fix it?
A: Jaw angle reduction is done for prominent or flaring jaw angles which make the lower face too square. This is most commonly done in Asian populations due to their ethnically more square facial shapes. From inside the mouth, am oscillating saw is used to remove the tip of the jaw angle in an angulated bone. How much bone to remove and how steep to make the angle of the cut is a matter of intraoperative judgment and experience.
Restoring a now too obtuse and short jaw angle can be done with jaw angle implants. Placed from inside the mouth, the implants are inserted under the muscle back over where the bone had been cut out. The implant’s size and shape, like the original bone cut, is a matter of aesthetic judgment. While the jaw angle implant’s size should be small, positioning them to correct jaw angle asymmetry requires precise and secure placement. Using a panorex x-ray before surgery, measurements can be taken to get a good idea about the differences in bone shape around the jaw angle. This can be useful to appreciate when placing the implants as both sides can not be seen at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I don’t have a butt and my tail bone sticks out further then my butt. I have an pronounced tail bone and don’t have a butt. It hurts to sit long periods of time because of my tail bone and having no butt. My butt is really small and has no outside fat or butt to it. I can never find pants to fit because of having no butt to hold them up. I don’t wear bathing suits because of what little butt I have. I am 26 years old and would like to have a butt and not be embarrassed to wear tight jeans and/or a nice bathing suit in the summer time. I would like to see if you can help me with this. I had Ricket’s as a child and that is why I didn’t grow a butt. That is what the doctor’s told me and I would like to finally have a nice butt. Please help me if you can.
A: Buttock augmentation can be done by either injecting your own fat or using synthetic implants. While I usually prefer fat injections for buttock enlargement in my Indianapolis plastic surgery practice, there are certain limitations to its use. You have to have enough fat to harvest for transfer and there has to be some subcutaneous fat in your buttocks to put fat into. Fat grafts need an adequate fat bed to be implanted and grow. With absolutely no buttock substance at all (completely flat), fat injections are not a viable option. With such lack of buttock volume, the body habitus of such patients is that they would not have adequate fat to harvest anyway.
Buttock implants are the only option with such severe buttock hypoplasia. While the recovery and risks of buttock implants are important to consider, their submuscular placement is necessary if any significant buttock enlargement is to be obtained in a very thin patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 31yr old mother of two kids. I got out of a five year relationship where I got too comfortable and gained a lot of weight. About six months ago I started working out and lost over 30lbs along with a strict diet. I still have about 25lbs to go to reach my goal weight but I know that dieting alone will not give me the final results I want. I am interested in a tummy tuck, a monsplasty, and breast augmentation. I was born with one breast about 1 cup size bigger. I would like them to be equal in size along with a lift. Can all of these procedures be done in a single operation?
A: Congratulations on the results you have obtained so far. It is always surprising what effort and discipline can do for one’s weight. You should be proud that you have gotten this far. In pursuit of your goal weight, think of the plastic surgery as an incentive to get there.
The first step in body contouring is weight loss but this alone is often not enough to get the shape that one wants. There is no better combination than a combined breast and abdominal procedure to change a woman’s appearance between the shoulders and the waistline. In a few hours of surgery, some dramatic changes can be obtained. Putting these two operations together is very common and I have done it many times in my Indianapolis plastic surgery practice. Breast enhancement and tummy tucks together can still be done as an outpatient procedure.
Many larger tummy tucks require reduction of a large mons at the same time. It is done as part of the tummy tuck by modifying the location and orientation of the lower incision. Complete mons reduction may still require a secondary liposuction procedure for optimal flattening. Breast enhancement in most significant weight loss patients requires a combined lift with an implant, known as an augmentation mastopexy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Where to start? I had a chin reduction at a hospital overseas in 1992. I have never been happy with it. I have always been so self conscious that it looks odd to people when they see me from certain angles. I also felt that it was too extreme and not what I had pictured the result would look like. I also have a metalplate in my chin and too much fatty tissue in the front chin area. Is it possible to have the chin operation redone so it looks better? Or is a chin implant the answer for me?
A: Chin reductions can create unhappy results if not done properly. When you reduce bony support, you have to account for the overlying soft tissue. Reducing bone requires stripping off all of the chin pad tissues, there must be a way to satisfactorily reattach it and reduce or tighten these soft tissues. If not done, the chin bag will sag down and look like a lump of fatty tissue. Doing a chin reduction without simultaneous soft tissue management is akin to doing a breast reduction but without reducing and tightening the loose overlying skin.
There are three approaches to managing a sagging or ptotic chin pad. They include an intraoral muscle resuspension, a submental chin tuck-up, and the placement of a chin implant. Which approach is best depends on how on much the chin pad sags and one’s facial profile and appearance. If one is happy with their profile (chin not deficient), then either a muscle suspension or a submental tuck-up will work. The difference between the two depends on much tissue there is to tighten and whether one can accept a scar under the chin. If one feels that their horizontal chin position is short, then a chin implant would be preferable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to get my outie turned into an inne bellybutton. I don’t care for how it looks now, I think it looks weird. I have always wanted to get it fixed so I could look like everyone else. Can you tell me about how this is done and what is involved?
A: Belly buttons are nothing more the formation of scar and is actually the body’s first scar. The umbilical cord, which supplied precious nutrients to the unborn baby, is clamped off shortly after birth. It is clamped off an inch or two from where it exits from the baby’s stomach and the placenta and much of the cord is removed. The remaining stalk of the umbilical cord goes on to die and fall off, leaving a small scar we know as the belly button. For most people (90%), the scar is concave and is an innie. For the remaining 10%, the scar tissue protrudes slightly from the body creating an outie.
An outie can be changed to an innie with an umbilicoplasty procedure. This is a small outpatient operation done under IV sedation or local anesthesia. A small incision is made on the inside of the belly button. Scar tissue between the underside of the bellybutton and the abdominal wall is removed. The underside of the outie is then swen down to the abdominal wall, changing its appearance to an innie. Dissolveable sutures are used and the only dressing is a band-aid. One can shower the next day and not worry about getting the area wet. One should avoid strenuous exercise for one week and no sit-ups or crunches for one month after the procedure.
In women who have had children, their outie could be an umbilical hernia particularly if it did not exist prior to pregnancies. This is a common finding during tummy tuck surgery. Since you are a male, your outie is unlikely to be a hernia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 65 years old and am extremely bothered by my turkey wattle. I do not look my age except this makes me very self conscious. I want to get rid of it with some type of neck procedure. What do you recommend?
A: Sagging or drooping of one’s neck is one of the most bothersome features of facial aging. While some people would never consider undergoing a ‘facelift’, they want some type of neck procedure to deal with their most troublesome age-related issue.
Aging necks are referred to many uncomplimentary names such as turkey neck and neck wattle. Some people become initially aware of it when they see themselves in profile in a photograph. Others notice it, particularly men, when wearing certain shirts and certainly in a shirt and tie. Others do not like, understandably, that it can be felt to move or flop when turning their head. (in more advanced aging)
Interestingly, some people would consider a necklift but wouldn’t dare undergo a facelift. This comes from a misunderstanding of the two procedures, not realizing that they are largely one and the same. I have found only a handful of patients in my Indianapolis plastic surgery practice who actually knew what a facelift really was.
A facelift is primarily a necklift. The type of facelift determines how much improvement in the neck is obtained. A limited facelift (aka Lifestyle Lift) has a minor effect on neck sagging and is best for just minor neck problems. It is primarily a jowl changing procedure. A full facelift is a powperful changer of the aging neck. The differerence between the two is the location and extent of the incisions around the ears. To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the occipital scalp. It is the pull from behind the ear that changes the neck. You can demonstrate this quite simply with your fingers in front of a mirror. A manuever that many patients with aging faces have done regularly.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a large bump on my nose and a long pointy nose to boot. My girlfriend tells me it looks ‘birdlike’. I also have trouble breathing through the right side of my nose. Can you help me get my health insurance to pay for my nose surgery?
A: Nose surgery can be divided into two areas, internal and external. Internal nasal surgery, often called septoplasty, is done to try and improve one’s breathing through the nose. This usually involves straightening of a crooked septum (septoplasty) and reduction of the size of the inferior turbinate bones. (turbinectomy) External nasal surgery, known as rhinoplasty, is done to change the shape of the visible external nose. When internal and external nasal surgery is done together, which is common, is called septorhinoplasty.
Internal nasal surgery is almost always covered by health insurance because its purpose is to improve a medical function, breathing through the nose. External or rhinoplasty surgery is not covered by insurance because it is changing appearance which is a cosmetic objective…unless the shape of the nose is the result of a traumatic injury, a birth defect (such as cleft lip and palate) or from removal of cancer.
Many patients are under the false belief that they can get their rhinoplasty covered by insurance because they have trouble breathing through their nose. While the breathing part may be covered, the rhinoplasty portion is the responsibility of the patient. The costs of that portion of the nose operation is given to patients in advance of the surgery date as it has to be paid prior to surgery being performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: have a older button style chin implant and would like to replace it with a new one. I want a chin implant that creates a more masculine look with lateral fullness in the mandible area and a more squared off appearance to the chin. I would also like to have a lip reduction to rebalance my facial proportions so that the jaw line is more prominent and the lips less so. Let me know if this is something you can do all at the same time.
A: Older style chin implants were much smaller in size and ‘non-anatomic’ in shape. They usually just fit over the central part or button of the chin, providing only central horizontal augmentation. While such chin augmentation shape can be acceptable in some patients (usually females), it does not provide the best chin shape in most males. It makes the frontal chin shape too triangular. In men, squaring of the chin shape produces a much more pleasing facial change. While profile views shows good horizontal advancement, patients do not usually see themselves that way and using that view as a judgment of the final result can be deceiving.
Today, chin implants come in a wide variety of styles and shapes that can achieve more than just a simple gain in profile lengthening. Men, in particular, often want a more masculine chin look which means a more square frontal shape and one that blends into the side of the jaw without an obvious transition. In addition, some increase in vertical length is often aesthetically desireable.
Chin implants can easily be exchanged in styles and size, regardless of whether they were placed from under the chin (my preference) or through the mouth. Pocket size and positioning may need to be altered but this does not usually involve the extent of dissection and postoperative discomfort that occurred from the first chin implant placement procedure.
Lip procedures can easily be done at the time of chin augmentation, particularly if the path of implant insertion is done from under the chin. (submental incision)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I was in a car accident several years ago and had some bad lacerations to my face. While they were sutured up by a plastic surgeon thaty same day, they have turned into some bad-looking scars. I would really like them to look a lot better. I know they can not be made to go completely away but do you think laser surgery would help? Thanks for your time.
A: The use of lasers in scar revision is useful but largely over rated. Lasers are not a magic tool for erasing scars or other skin imperfections. The public’s perception of that highly desirous quality is a function of adventurous marketing and the ‘Star Wars’ effect which still persists even today.
Most scars are a full-thickness skin injury, meaning what you see on the outside exists the whole way through the skin. Lasers are a partial-thickness skin removing tool. As a result, it is easy to see why a laser can not remove a scar. The problem and the solution are not well-matched.
Lasers have a role is scar revision but it is more for creating a smoothing effect and often is used after other scar treatments are done. The most common scar treatment is surgical excision, cutting out the scar (full-thickness) and making the scar line thinner or changing the way the scar line runs.
Because of their more superficial effect, lasers are better at removing or lessening wrinkles and other more minor skin imperfections.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am tired of looking older. My jowls are getting bigger and my neck is starting to really sag. I hate to consider the thought of a plastic surgery procedure like a necklift but I am going to have to do something in the near future. I don’t mind getting old per se, I just don’t want to look old! I have read that there are different types of facelifting procedures. How do I know which one will work for me?
A: A facelift is a plastic surgery operation that changes the lower third of the face, the neck and jowls only. So it is a good match for the jowl and neck issues which bother you. Like many plastic surgery procedures, there are different ways to do them and they come in different ‘varieties’. No one type of facelift is right for everyone. Your plastic surgeon must ‘match the solution to the problem.’
Fundamentally, a full facelift changes both the neck and jowls and is best for someone whose primary problem is their neck. The jowls get improved as well and get swept alone in the changes that occur far away in the neck. The mini-facelift, aka Lifestyle Lift as called by some, changes the jowls primarily and a little bit of the neck. Any limited improvement in the neck is the result of the changes that have occurred in the jowls. The mini- or limited facelift is best for someone whose primary concern is in their jowls. Since jowling proceeds any significant changes in the neck, one can appreciate why a limited facelift is for younger people who have less signs of facial aging.
Another way to think about it is by looking at the incisional pattern around the ears. Mini-facelifts have use an incision that runs into and around the front the ear. Pulling upward from there only impacts the jowls primarily. A full facelift uses incisions in front of and behind the ear. By moving tissue upward from behind the ear, excess neck skin can be worked out to be cut off behind the ear.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in making my nipples less prominent. I think they stick out too far and it can be embarrassing sometimes with different types of clothes and in colder weather. How big of a deal is it to go through and what is the recovery?
A: Nipple reduction surgery is really a very simple procedure. While nipples are undoubtably very sensitive, they can easily be made numb with a little injection of local anesthetic. The actual size of the nipple is quite small so the procedure is appropriately a minor operation. When done by itself, it is an office procedure that takes less than one hour for both nipples.
There are two basic nipple reduction techniques. Which one is best for any patient is determined by how much nipple reduction is needed and how much nipple sensation one wants to preserve. Either way, small dissolveable sutures are used so there is no need for a follow-up suture removal appointment. A small band-aid is used for the dressing. One can shower the next day and not be concerned about getting the area wet. A little dab of antibiotic ointment and a daily band-aid change is all that is needed for one week after surgery. There are no physical restrictions and one can return to running and working out the very next day. I would not, however, immerse the breast in a hot tub or swimming pool for at least one week after the procedure is done.
Nipple reduction surgery creates an immediate change. Even with the little bit of swelling that occurs, the change is readily apparent. Complete settling of the nipple takes about three weeks until its final shape and amount of residual projection is seen.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting my cheekbones slimmer or smaller. Is there any way to apply pressure to them everyday or put something on them to make them gradually get smaller without the need to undergo plastic surgery?
A: The concept of making facial bones smaller is a surgical one. No amount of pressure or any form of outward manuevers will change the shape of a facial bone. Outward pressure, even if it were possible to do, would only make the overlying soft tissues thinner (pressure resorption) but would not change the shape of the underlying bone.
Cheek bone reduction requires cutting the ‘legs’ of the bone and allowing it to sit down or inward. In some cases, only the front legs of the bone need to be cut (body of the zygoma).In other cases, the back legs (zygomatic arch attachment to the temporal bone) need to be cut as well. By inward positioning of the cheek bone and its backward bony arch, the width of the face is narrowed. When done on both sides of the face, the narrowing effect can be quite noticeable.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I am in the military and am unable to make tape or weigh ins. I had two c-sections and my stomach looks like I am still pregnant. I am also having trouble passing my sit ups. I will not be able to be promoted until I am able to make at least tape and pass my fitness test. I have tried everything to lose the weight from my tummy but I haven’t had any luck. Not even basic training has helped slim my tummy. I am desperate to do something and I think a tummy tuck may be the only answer. How long does it take to recover from this procedure?
A: This is a tummy story that I have heard quite often in my Indianapolis plastic surgery practice. Women often come in for a tummy tuck (abdominoplasty) when they have exhausted all of the conventional options for trying to make it look better. Most women do view a tummy tuck as a last ditch effort.
When you have suffered the ravages of pregnancy, no amount of dieting or exercise will improve stretch out loose skin and muscles. The protruding floppy stomach is not just a ‘fat’ problem. It is tissues that have been irreversibly damaged. While I think it is prudent to get in the best shape as possible before undergoing a tummy tuck, those efforts will not repair the tissue damage which exists.
While a tummy tuck is a wonderful body shaping operation, it should be considered major surgery. With major surgery comes a significant recovery. While recovery can be defined different ways, complete recovery that would allow one to perform strenuous activities will take six weeks for most people.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a tear trough and orbital deformity. One year ago I had surgery in which malar implants were placed. But it is too big and was the wrong choice for me. I only wanted to make my midface look healthy. I want make another surgery in 3 months and I now think an orbital rim implant is the right choice for me. Do you have experience with this type of facial implant and what are your feelings about it? Are the risks for an orbital rim implant surgery higher than a malar implant which I have now? Thank you very much.
A: The use of malar vs. orbital rim implants are for completely different facial problems or concerns. Even though they are anatomically close and contiguous, what effects they have on facial structure is completely different. If a malar implant was used in the treatment of a tear trough (orbital) deformity, it would have likely made it look even worse.
The midface has six structural components to it including the orbital rim, malar, lateral malar, submalar, paranasal and maxillary regions. The tear trough deformity represents a central and medial soft tissue recession even though the underlying bone deficiency may extend out into the malar area. Tear trough, also known as orbital rim, implants come in several different shapes and sizes which differ in the extent of the orbital rim that they cover and in how much projection they provide. It requires a careful assessment of the lower orbit and cheek to see which implant is best. Even with good implant selection, tailoring and shaping for fit is almost always required.
Unlike malar (cheek) implants, orbital rim implants must be placed through a lower eyelid (blepharoplasty) incision. This induces one potential risk that does not exist with an intraoral approach for malar implants, that of ectropion or lower eyelid retraction. Careful handling of the eyelid tissues and orbicularis muscle and canthal suspension are needed to avoid this potential problem.
Of all available facial implants, orbital rim implants are the most sensitive to size, placement and incisional access. To those with a lot of experience in maxillofacial trauma and craniofacial surgery, orbital manipulations is a comfortable place to work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Over a year ago, I had a medium-sized chin implant placed from inside my mouth and I HATED it. Last month I finally had it removed but I don’t look the same. My chin seems to droop a bit. I am going CRAZY over this! Please tell me what I can do!
A: To understand the problem and how to fix it, you must appreciate what any implant in the body does that changes the size of an area. Like a breast implant, a chin implant pushes off of the underlying bone stretching out the overlying soft tissues. As a result, you are gaining more soft tissue which the area needs to look bigger.
This soft tissue expansion can really be appreciated when and if the implant ever comes out. Without the implant’s support, the now extra soft tissue sags creating a classic chin ptosis condition. Some refer to it as a ‘witch’s chin’ deformity. There now is too much soft tissue for the amount of bone or underlying soft tissue support. Furthermore, the mentalis muscle has been detached from the chin bone and likely was not resuspended at the time of implant removal. This muscle problem can particularly arise when chin implants are placed from inside the mouth where the superior muscular attachments are completely separated.
Correction of chin ptosis can be done by two different approaches, based on the severity of the soft tissue sag. If the laxity is mild, then an intramural approach with muscle resuspension using bone anchors works very nicely. If the soft tissue sag is more severe, then an approach from the underside of the chin known as a submental tuck-up can be done for soft tissue removal and reattachment back to the bone.
Another option would be to replace the chin implant with another one (even if it is smaller), but that doesn’t sound like an option in your case.
Dr. Barry Eppley
Indianapolis Indiana
Q: My 12 year old daughter has had both ears repierced due to holes closing, but now the newer holes have closed due to infections and she now has unattractive scar tissue. Is there a surgery that she can have done to remove the scar tissue so she can wear earrings again? She has been very upset about this for a couple of years now. Thank you!
A: Despite the large number of earlobes (and ears) that get pierced, the number of infection and scar complications is remarkably low. This is a testament to the good blood supply to the ear and its relative resistance to typical skin bacteria. But minor complications to piercings do occasionally occur and, while they all resolve, they often end up with excessive scar tissue formation over and around the original ear hole.
Removal of earlobe scar tissue can easily be done with minimal to no visible deformity of the earlobe later. It is a simple ear plastic surgery procedure. Under local anesthesia, the scar tissue can be cut out and the earlobe defect closed. Because the earlobe has no cartilage framework, it is very elastic and flexible. This makes for closing most earlobe defects relatively easy without causing a visible deformity such as a notched earlobe or making it significantly smaller than the opposite earlobe.
There is one difficult type of earlobe scar, that of a keloid. While many earlobe scar patients think they have a keloid, they really have a hypertrophic or typical scar. A keloid is an abnormal form of scar tissue formation that will not stop growing, often causing a cauliflower-like appearance to the scar and distorting the entire earlobe. These have high rates of recurrence after being removed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in cheek bone reduction surgery. I want to know if there are any permanent side effects or can they develop years later.
A: Reduction of prominent cheek bones is not nearly as common as augmentation or enhancement of deficient ones. Cheek bone reductions are almost always an ethnic request, usually commonly from patients with Asian or Pacific Rim heritages. Usually the concern is that the cheeks are too wide and the goal is to try and have a more narrow or ‘slimmer’ facial appearance.
Narrowing the cheek area is done by first understanding the shape of the bone. The zygoma (cheek bone per se) and the zygomatic arch (which extends back to attach to the temporal bone like a spanning bridge) together form the width of the middle part of the face back from the eye area. Reducing its width comes from cutting the bone (zygomatic osteotomies) at the two attachments of the bridge and allowing it to settle inward. Sometimes only the front part needs to be cut through the cheek bone itself. (done from inside the mouth) Other times the back part where the zygomatic arch attaches to the temple needs to be cut as well. (done from a small incision in the temple hair)
The biggest potential side effect or risk of the procedure is asymmetry, one side not being as far inward as the other. In theory, if the zygomatic arch goes in too far (unlikely), it may impinge on the masseter muscle causing some pain on oral opening and eating. (that I have never seen)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to have a consultation but live far away. Can I get some answers to my questions on the phone or by e-mail? I have read that some plastic surgeons consult with patients online. Is that possible?
A: The large amount of internet material on cosmetic surgery has helped to fuel the demand for these procedures. But access to the internet is not, unfortunately, always the best way to get accurate information. Prospective patients still need a professional to help them decipher what all they read means and how it applies to their individual needs. While an actual visit to a plastic surgeon and a face-face consultation is a necessary step before ever scheduling surgery, the accessibility and low expense of the internet provides a very convenient method to answer some basic questions from afar.
In my Indianapolis plastic surgery practice, I use the internet service, Skype, for webcam video conversations. For the first time in medical history, it is now possible to have an online video discussion with a plastic surgeon from anywhere in the world provided you have a webcam on your computer or laptop. (you can even do it from your smartphone)
To take advantage of this option, first find a plastic surgeon who offers Skype and performs the type of cosmetic procedures in which you are interested. Then go to the Skype website, download the application and register under your name. This process is free and takes less than five minutes to do. You will need to add the plastic surgeon to your contact list. That requires knowing how their name is registered and that should be available on their website. In my case, it is dr.barry.eppley. Add the name to your contact list and then send a message requesting a video conversation.Tell briefly in the message what your subject area or concerns are.
While this video conversation method is not a replacement for having an actual consultation in the plastic surgeon’s office, it provides a unique opportunity to ask questions directly to a plastic surgeon without leaving the comfort of your own home or city. It can be a great first step in your informational gathering process.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was wondering if you had any procedures that would reduce severe stretch marks. I just had a baby and my baby tummy is very loose and I have really bad stretch marks.
A: Stretch marks are a very common skin deformity that results from Ebook Creation Simplified tissue expansion(e.g., pregnancy, weight gain) followed by deflation thereafter. (e.g., delivery, weight loss) What stretch marks really represent is IRREVERSIBLE skin damage from partial tearing of the dermal component of the skin. The thicker collagen layers have been partially split due to the stretching of the skin. That is why when you run your fingers over them they feel rippled or indented over the stretch mark. There has been a loss of some of the skin’s thickness.
Why some women get them from pregnancy and others don’t is a result of numerous skin factors. These include their native thickness and elasticity of the skin and how much and how fast the skin was stretched. There probably is some merit to apply a topical emollient or moisturizer to the skin during the pregnancy process. Anything that can hydrate the collagen layers to allow it to stretch without deformation (irreversible breaking of the molecular bonds, like a broken spring) would be helpful.
Once the stretch marks exist, however, solving or eliminating them is virtually impossible. While many urban legends exist about ‘magical potions’ and patients who have completely gotten rid of them, there has never been any scientific or documented evidence that these often touted methods really work. It is simply not possible to thicken back up or repair the split dermis anymore than you can restore the tighten of a stretched out rubber band.
That being said, however, there are some treatments that may help reduce their final appearance if they are done early. Early means within less than 90 days after delivery or when they have appeared. The redness of the stretch mark can be reduced by pulsed light treatments (BBL) in my Indianapolis plastic surgery experience. Early treatment may help make the stretch mark do some collagen repair so it is less deep. The key, however, is EARLY treatment.
It is possible to lessen the appearance of new stretch marks if done early enough. In established stretch marks, there are no effective treatments. Stretch marks are not responsive to laser or skin resurfacing and any attempts to do so may result in a worse scar appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have breast implants originally placed in 2002. I got pregnant shortly afterwards and once I delivered my breasts changed afterwards and I developed some drooping. So I went back and had new implants placed in 2007 that were bigger and helped to fill out some loose and droopy skin. After having these implants for a while, I have decided that I want to go back to my original augmentation size. But I fear in doing so that I will get saggy breasts again. What do you recommend?
A: Going up in breast implant size is always easy because loose skin is expanded and filled out. While breast implants alone are often not the sole solution to a really saggy breast, they do help tremendously and are very forgiving of less than ideal breast skin.
Going down in breast implant size, however, is not so forgiving. Even the smallest amount of loose or droopy breast skin will get much worse as the ‘balloon deflates’ so to speak. As a result, some form of breast lift is often needed in many breast implant downsizings. What makes this aesthetically difficult is that this will involve creating breast scars which is another form of a cosmetic breast deformity.
If the nipple is fairly centered on the breast mound, a smaller implant replacement may not involve any type of lift or only a very small one such as a nipple or circumareolar type lift. If the nipple is off-center or points any amount downward, then a more significant lift with breast skin scars may be necessary when the breast implants are down-sized.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m interested in learing more about dermabrasion or micropeeling. Can this be done on the eyelids? (above and below) Will this help reduce the beginnings of a fold in the top eye crease? I live two hours away. If you can answer these two questions about this procedure would help me determine if I should come in for a consultation.
A: By the way your question is phrased, it appears that you seek a non-surgical solution to the appearance of wrinkles on the eyelids. There are a variety of skin resurfacing methods that are commonly used on all other areas of the face so it is reasonable to ask about their use on the eyelids.
The eyelids represent skin that is very unique from that of the rest of the face. It is different primarily because it is so thin. Being thin makes it very sensitive with higher risks of scarring if the skin resurfacing method is not carefully selected and performed.
Microdermabrasion (superficial) and dermabrasion (deep) are not effective (microdermabrasion) or safe (dermabrasion) skin resiurfacing methods for use on the eyelids. Traditional laser resurfacing is not either for the same reason that dermabrasion should not be used, it penetrates too deep.
The use of laser micropeeling and chemical peels, however, are both effective and safe methods for the eyelids. Laser micropeeling at the depth of 20 microns or less, TCA (trichloroacetic acid) chemical peels of 15%, 25% and 35% as well as the newer Vi chemical peel are all potential choices. Which one of these is best for your eyelids will require an actual consultation to determine.
Another very effective option is the combination of ‘mini-blepharoplasties’ with chemical peeling. The actual removal of a small amount of excess skin and then tightening the rest can be a very effective eyelid wrinkle-reducer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m a 62 year old female interested in widening a narrow face with a chin/jaw widening implant that would also help with jaw lifting and mild jowls. Is this possible for someone my age?
A: It is unusual for a female at any age to desire a wider lower face. This is almost always a male procedure for the obvious reason of making the jaw line more prominent to create a masculinizing effect. It would be particularly rare, and the first time in my Indianapolis plastic surgery experience, to have an older woman make that request.
I suspect that the real reason for this request is to help improve the classic signs of facial aging which is that of jowling, loss of the jaw line, and neck sagging. While it is true that jaw line enhancement at the chin and even more posteriorly at the jaw angles can help fill out a lower face, I question whether the effect would be significant enough to achieve your goals.
While I will have to see your pictures, it is possible that chin and jaw widening in combination with a limited or tuck-up facelift may create a more ideal result. Widening and lifting along the jaw line is a diametric movement of soft tissues that will usually result in a better outcome than either procedure done alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I need help with my nose and lips. Four years ago I had a rhinoplasty. While no work was done on my lip it changed after surgery. My upper lip seems longer than before. My upper lip was long to begin with but now it covers my upper teeth and rests heavily on my lower lip when at rest. My nasolabial angle changed so that it is more of a 90 degree than tethered as it was before. I am a female 32 years old and was wondering if these problems can be fixed.
A: It is unusual for one’s upper lip to change after rhinoplasty but it is theoretically possible. If the base of the caudal septum, where there are muscular attachments at the anterior nasal spine, is resected to change the nasolabial angle, it is possible that there may be some release of the upper lip as well. If one had a longer upper lip to start with, then the risk of lip lengthening is greater.
Regardless of how it may have happened, a longer upper lip can be shortened by a procedure known as a subnasal lip lift. That can be very effective at reversing your lip lengthening that has occurred and can even make it shorter than were you were prior to your rhinoplasty. As a general rule, an upper lip lift can remove up to one-third of the skin length between the nasal base and the height of the cupid’s bow along the philtrum.
Changing of the nasolabial angle can also be done. While it is far more common to open up the nasolabial angle during rhinoplasty with caudal septal resection, the reverse can also be done. This would require a septal cartilage graft attached to the caudal septum which is so placed that it pushes back down on the nasal tip cartilages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have several old scars on my legs that really bother me. I had laser done on my scars over a year ago in a plastic surgeon’s office but I don’t see any improvement. How can I get rid of my scars?
A: When discussing possible scar treatments, one concept that needs to be eliminated from any patient’s vocabulary is the phrase, ‘getting rid of scars.’ A scar represents permanent damage to the skin layer that once had normal tissue (with good color and suppleness) replaced by abnormal tissue. (depigmented, less pliable) Therefore, the realistic goal is scar reduction not scar elimination. This is why the term ‘scar revision’ is fairly accurate, the scar may be improved but it is not completely eliminated.
While scars on the face represent the best opportunity for maximal scar reduction, scars below the neck are not so forgiving. This is because trunk and extremity skin is thicker (thicker dermis creates more scar) and the healing wounds are exposed to more shear and frictional stresses which work to stretch out the scar. Therefore, non-face scars never (and I emphasize never) can look as good as facial scar work no matter how it is done or by whom.
Leg scars represent the least successful area for scar revision on the body in my Indianapolis plastic surgery experience. They are particularly refractory to any significant improvement for the reasons stated above, particularly below the knee. The thickness and tightness of the skin in this area makes scar revision work difficult.
Lasers are often touted and perceived as having some magical properties for scar improvement. While lasers do have a role in scar treatments, it is not a dominant one. They are best used as a finishing treatment for some minor skin resurfacing or retexturing. They are not like an eraser tool on Photoshop.
Dr. Barry Eppley
Indianapolis Indiana
Q : My jaw is asymmetrical. It is tilted and is also bigger on one side. I have read some of the articles you have written on facial asymmetry and wanted to ask you about how best to correct my problem?
A: Jaw or mandibular asymmetry is often a major cause of facial asymmetry. Often the entire side of one’s face is different if one looks for it carefully. Sometimes it is the lower face (jaw) that is the most significant part, other times the cheek, orbital, and forehead bones are equally involved and part of the problem. It is critically important to assess both sides of the face from top to bottom with photographs and measurements from different angles to get an accurate assessment.
In most cases of minor to moderate facial asymmetry, camouflage techniques are used. This means the use of facial implants to lengthen and broaden the smaller and flatter facial prominences. These are good options for jaw angles and cheeks. Chin asymmetry is often better done with osteotomies where the bone can be differentially lengthened between the vertically shorter and normal sides. Soft tissue deficiencies can be simultaneously improved by fat injections.
If significant facial asymmetry exists and one’s occlusion (bite) is very tilted, another consideration is orthognathic surgery. In younger patients this may be a better option if one is prepared to go through several years of preparatory orthodontics and then jaw surgery to directly treat the primary bone, differential bone growth.
Dr. Barry Eppley
Q : I would like information on the horizontal chin reduction procedure. My chin juts forward to a point (witches chin) and I think it being reduced would really help my appearance. Most interested in knowing how the procedure is done, down time needed for recovery, surgery location (outpatient in center or hospital, or in physician’s office), and rates of success.
A: A big chin (macrogenia) can be either too far forward (horizontal excess), too long (vertical excess) or a combination of both. Determining the 3-D dimensions of what makes the chin too big is important as it can change the method by which the chin is reduced.
Horizontal chin excess is best reduced through a submental (under the chin) incision rather than from inside the mouth. This is because it is important to properly manage the soft tissue excess which will result once some of the bone support is removed. If the soft tissues are not removed and tightened, one will end up with what is known as a witch’s chin deformity. (exactly the appearance of what you wanted to improve in the first place!)
The chin is horizontally reduced by burring down its prominence and tapering the bone into the sides of the chin. The mentalis muscle is brought down over the underside of the reshaped chin and any excess removed as it is re-attached to the its fellow muscle. Likewise, redundant skin and fat are removed so that the chin soft tissues are nice and tight.
Chin reduction surgery is done as an outpatient surgery under general anesthesia. It takes about an hour to perform. The chin is taped and will be sore but there are no restrictions after surgery. It takes about 3 weeks for the chin swelling to largely go away and it begins to feel normal again. The success rate is 100% in terms of having less horizontal projection. The usual amount of actual horizontal chin reduction that is achieved is from 5 to 8mms.
Dr. Barry Eppley
Q : I have broken my cheekbone 2 times and never had surgery. Now my face is assymetrical and I have frequent headaches and can’t breath thru one side of my nose. People close to me say that my face looks caved in. It also affects my vision and I sometimes have localized pain in my cheek. Do you think my insurance will pay for reconstructive surgery? How would this be fixed?
A: Cheekbone, or zyomatic or malar, fractures are common facial bone injuries. They are second in frequency to the most common facial fracture, that of the nose. When a cheek bone fractures, a classic set of problems results from the bone rotating downward into the maxillary sinus. The cheek prominence will become flatter (caved in), one may develop sinus congestion, and numbness or pain may occur from the infraorbital nerve being bruised or pinched. (the fracture line usually goes through the nerve foramen) It does not usually cause any vision problems.
If not repaired early, the secondary cosmetic deformity is that of an asymmetrical face with a flatter cheekbone prominence. There are two ways for its correction after the bone has healed. Building out the depressed cheekbone with a cheek implant is often very successful and is certainly the easiest. The other approach is to re-cut the cheekbone and move it back into its proper place. This is obviously more complicated with a longer recovery but can also be successfully done. Which approach is best is largely determined by the magnitude of the cheekbone depression and whether it extends into the surrounding orbital (eye) area.
Typically, reconstructive surgery from a facial bone fracture should be covered by one’s medical insurance. However, this must be determined by a written pre-determination process before proceeding to surgery.
Dr. Barry Eppley
