Your Questions
Your Questions
Q: Hi there. I see that you list Evolence filler on your website and wondered if you are still offering this? Also, do you offer Selphyl (“filler” using patient’s own blood plasma)? I am interested in these options for superficial glabellar wrinkles. I prefer using natural, non-toxic products. Botox is not something I am interested in at this time. Thanks!
A: The injectable filler Evolence has been pulled from the market and discontinued from being manufactured by J & J in 2009.
Selphyl and Platelet-Rich-Plasma/Acell mixtures are procedures that I do but neither would be a good option for superficial facial wrinkles. That is not what they are intended to be used for as the needles for injections are bigger than that of the fine wrinkles.
For glabellar wrinkles, the use of any type of injectable filler, without prior treatment with Botox is a wasted effort and exactly the opposite of what should be done. You must first control the muscle activity first, otherwise the unchecked muscle motion will make the injectable filler disappear quite quickly. There are no permanent injectable fillers and muscle action working against them makes them dissipate much quicker than normal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in rhinoplasty and cheek implants and have had a consultation done which included computer imaging. The profile images show a nice improvement but in the front view I can see very little change around the cheeks and eyes. Will the actual surgery fill out these areas nicer than what I see in the imaging? What about the nasolabial folds, don’t they also diminish with cheek implants? Do you think larger cheek implants are better for me? (I heard small ones are unnoticeable)
A: While I have no idea as to the quality of the computer imaging that was done, it is difficult to show much cheek improvement from a front view. Computer imaging works best on facial structures that are not overlapped or in profile. That is the problem in the cheek area, it is not a profile structure unless it is imaged in the oblique or three-quarter view. Most likely, cheek implants will produce a much better result than what those images show…particularly if the cheek implants are a size beyond the very smallest. You are correct in that small cheek implants in most patients ones can barely be seen or are very subtle.
Cheek implants may create some lessening of the nasolabial folds but it will not be substantial. That is not an intended or known effect from cheek implants. However, paranasal implants can make a bigger difference as they are placed right behind the nasolabial folds so they create more of a push outward, thus lessening the deepest upper portion of the nasolabial fold.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had silicone breast augmentation last year in 2010. I just read that I am supposed to get MRI scans every couple years to make sure they are not ruptured. My doctor never mentioned that I needed to do this. Should I get them and who is going to pay for them?
A: With the release of silicone gel breast implants back onto the market in late 2006, the FDA recommended regular follow-up magnetic resonance imaging (MRI) scans for women so implanted to detect rupture. Silicone implant rupture is ‘silent’, meaning it can not be detected by sight or feel. This is quite different from saline breast implants which will spontaneously deflate or go flat should there be a problem with them.
The MRI evaluations was one of the conditions imposed upon the manufacturers and it is so stated on their websites, marketing materials, and in the package insert. Plastic surgeons are instructed to advise their patients about the MRI recommendations. With this MRI recommendation, however, there are no guidelines for tracking whom has this done, their compliance and most importantly from the patient’s standpoint whom is going to pay for these tests. It is clear from the FDA viewpoint that this cost is to be borne by the patient and/or their health insurance carrier.
But a recent article in the March 2011 issue of the journal Plastic and Reconstructive Surgery raises questions about the accuracy of such MRI scanning, especially in women without any breast symptoms such as pain or breast hardening. Beyond the issue of accuracy, the authors of this paper also point out that such screening tests are generally performed to detect diseases with serious health risks…and silicone breast implants are not known to have such significant risks
There is also a concern that there may be an overestimation of the ability of MRI to detect ruptured breast implants, particularly when scans are performed for screening purposes in symptom-free women.
This being said, your awareness of the recommendation of screening MRIs after silicone breast augmentation is important. What you do with this information is a matter of voluntary compliance and should be discussed with your plastic surgeon.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley. I would like to inquire about brow bone implant. Do you mind taking the mind to answer some of my questions? 1) Are there any limitations to brow bone implant? Can it stretch as much as we want? 2) Will the eyes change its expression after the implant? I tried pulling out the skin at my eye brown area and there seems to be a difference. 3) Will the eyes appear bigger or smaller after the implant? 4) Lastly, is lowering my eye browns accurate to determine how I would look like after the brow bone implant? Thank you for your attention. Hope to hear from you soon.
A: In answer to your questions about brow bone augmentation, let me clarify that building up with brow area is done using typical cranioplasty materuials and not just a carved or pre-shaped implant. With that being said: 1) The size of brow bone augmentation can be done to just about whatever size someone wants. 2) The muscle activity around the eyes will not change after brow bone augmentation. But a stronger brow appearance may make the eye area look different. 3) While the actual size of the eye will not change after brow bone augmentation, they may look little deeper set in some patients. 4) The horizontal position of the eyebrows does not change after brow bone augmentation. They are pushed outward and perhaps a millimeter or so downward but they do not shift downward to any significant degree.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I have severe facial wasting. I am not an HIV patient, I had a normal plump face as a young child and by about the third grade my cheeks had completely sunken in and has given me a much older and skull-like appearance. I am only eighteen years old. I would like to have a procedure to correct this done this summer before I begin college in the fall. I would like to know if you handle this sort of procedure and what you would suggest to be done. I have attached some pictures with this e-mail inquiry.
A: Thank you for your inquiry and sending your pictures. You have a classic case of facial lipatrophy, type IV (type V is more consistent with HIV related facial lipoatrophy) Your history is classic for it as most patients convert from the plump face of childhood to a thinner more gaunt facial look during grade or intermediate school. Of the augmentation methods for treatment (implants and fat injections), I think you need a combination approach. I would place submalar cheek implants that specifically builds up the area right under the cheekbone known as the buccal area. This implant is placed through the mouth under the upper lip. Then I would do fat injections with Acell collagen particles to the area below the implants out into the side of the face and down to opposite the corners of the mouth. The goal is to add some fullness to the sides of your face and help reduce your more skeletonized appearance.
Dr. Barry Eppley
Indianapolis, Indiana
When it comes to plastic surgery, women are perceived to make up the vast majority of patients. And for the entire last century as plastic surgery evolved, this was historically true. But a gender shift is occurring in whom now chooses to undergo the altering effects of the knife.
In a recent article entitled, ‘Men Fuel Rebound in Plastic Surgery: Sizeable Increases in Facelifts and Other Surgical Procedures for Men’ that appeared in the Science Daily, more men than ever before are having something ‘done’. Statistics released by the American Society of Plastic Surgeons (ASPS) show that cosmetic plastic surgery procedures were up about 2 percent in 2010 compared to 2009. However, male plastic surgery procedures increased significantly. Facelifts for men were up nearly 15 percent in 2010 while liposuction of the male chest, stomach and love handles increased almost 10 percent.
These same statistics show that men underwent more than 1 million cosmetic procedures last year, close to 20 percent of all plastic surgery that was done. While many of the cosmetic procedures that have accounted for the overall large increases in plastic surgery during the last decade have been non-surgical (e.g., Botox, injectable fillers), men buck this trend. Men actually do very little of these minimally-invasive treatments and choose surgery instead.
By the very nature of most men, they usually wait longer to consider having something done and have more significant age-related and weight issues. Because Botox and injectable fillers only work to a certain point, the more significant effects of age and gravity require surgical procedures that remove and lift skin or actually removes fat to show a significant improvement.
Another trend in male plastic surgery can be seen in whom shows up to request these procedures. While once thought of as just for celebrities and high profile men, the typical male cosmetic surgery patient is just the average guy who wants to look as good as he can. The most common reason I hear is that ‘I want to look as good as I feel’. Other underlying motivations can be a recent divorce or remarriage or is driven by job security or seeking new employment. In any case, looking vigorous, fit and well rested is the new norm for aging gracefully. These leads to the middle-aged or older male seeking procedures such as eyelid tucks (blepharoplasty), necklift, nose reshaping (rhinoplasty) and hair transplantation.
The newest burgeoning area is the young male plastic surgery patient. While not subject to aging concerns, they are interested in changing their facial look albeit to have a more balanced or masculine-looking face. Seeking more of a ‘male model’ look, structural changes of the face such as rhinoplasty and cheek, chin and jaw angle implants have the younger male driven by the desire to become better looking.
While you may never see a male patient on the TV shows, such as ‘Extreme Makeover’ and the new ‘Pretty Hurts’, more men are undergoing physical changes and adjustments than ever before…they just don’t talk about it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 27 years old and want to get Botox injections. I don’t want to get those lines in my forehead that my mother has and I think that this will be preventative. Am I too young for Botox?
A: In recently published statistics from the American Society of Plastic Surgeons, nearly 30% of the 5 million people that underwent some form of cosmetic surgery in the last year were under 30 years of age. There is no question that, while more aged patients are getting corrective treatments, younger patients are interested in aging prevention. This is both a reflection of the widespread availability of Botox in the past ten years and the shifting attitudes towards anti-aging of a younger generation. This is often also influenced by a relative, usually from a mom getting Botox and their daughters seeing this and thinking that they might be able to prevent wrinkles before they ever form. With the relatively low cost of Botox, such prevention is as affordable as many high-end topical creams and serums.
Is Botox wrinkle preventative? The answer is both yes and no. Botox will not alter the aging process but, at the first sign of seeing an undesired expression such as excessive frowning between the eyebrows, it can soften the appearance of the future location of wrinkle lines the earlier one starts to get the injections. The age of 27 would not be too young for Botox if…one has very strong forehead or crow’s feet expressions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr Eppley, I have read your article about chin reduction. I am a female and I have a long chin and my self-confidence is affected by it. I have attached some pictures for you to see what can be done about it. By the way, I wear a full lower dental denture (one original tooth left) and I have partial upper denture. Most of my remaining teeth has been root canaled. Thank you and looking forward to hear from you.
A: In reviewing your pictures, you undoubtably have a very long chin. But, equally relevant, is that your face has a great imbalance between your upper jaw (maxilla) and your lower jaw. Your midface is very flat and recessed, partly because of your ethnicity but also because it is underdeveloped. This is magnified by your loss of teeth which contributes to your maxillary atrophy from a horizontal projection standpoint. Your lower jaw is very long with a high jaw angle. This combination has created a significant maxillary-mandibular mismatch (short maxilla, long mandible) and is a major contributing factor to your appearance of a ‘long chin’. One of the missing pieces of information is what your bite (occlusion) is like. With these facial bone relationships, you may also have a Class III malocclusion or underbite.
From a corrective standpoint, the ideal approach is to move the entire lower jaw back and the upper jaw forward. This would ideally solve this long chin appearance. But that may be more than you want to do, although having most of your occlusion done by dentures, it is not so far fetched. Short of orthognathic surgery, the other combination would a vertical chin reduction osteotomy and possible paranasal augmentation of the midface. This would not make as big of a change as orthognathic surgery but it would be a noticeable difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a problem with the shape of one side of my jaw. I had a fibular free flap surgery done several years ago as a result of an osteosarcoma tumor that was removed from my right bottom mandible. I have since recovered nicely from surgery and I now have dental implants. However, one thing that bothers me from the surgery is that my right bottom mandible is not in alignment with my left bottom mandible. My left mandible is defined and square whereas my right mandible is “heart-shaped.” Side pictures of me are especially embarrassing as well as the stares I get from strangers. What can be done to give me a more normal shape to the reconstructed side of my mandible?
A: Having dental implants placed into a mandible reconstructed with a fibular free flap suggests that you have had a very successful outcome. It takes good bone stock and alignment of the reconstructed jaw segment to the upper jaw to be able to get such dental reconstruction. I suspect that the deformity to which you refer is that you have no defined angle of the mandible on the reconstructed side. This can happen due to the take-off of the fibular graft from the ramus of the mandible. The joining of the fibular bone flap and the remaining mandibular ramus forms a new jaw angle. If this is not done at a 75 to 90 degree angulation, the jaw angle will be blunted or more obtuse. This can be confirmed by a panorex dental film, which you undoubtably have from your dental implant reconstruction, which shows the entire mandible and its shape from side to side quite clearly. This could be improved by the simple placement of a jaw angle implant. This would be best done through your existing neck incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Will Radiation Help Shrink An Earlobe Keloid That Is Returning After Having Been Removed Previously?
Q: I want to know how much is radiation therapy after a keloid is removed from the earlobe? I had a large keloid removed several months ago and now it seems to be returning. I have read that radiation therapy can be very helpful after surgery.
A: For radiation to be beneficial in the management of keloids, it must be done immediately after the keloid is removed. This is low dose radiation that is done within days after the excisional procedure and continued daily for a very short period of time. The purpose of radiation is to disrupt the formation of collagen fibrils in the very earliest phase of wound healing. But decreasing the early and aggressive collagen response of keloid-prone tissues, it is hoped that the over-production of scar tissue would be halted and the keloid would not return. Once the keloid is formed, radiation will not be useful.
Radiation therapy is not usually an out-of-pocket expense and, when done as an adjunctive treatment in keloid surgery, should be covered by your health insurance. That will require a pre-determination letter to verify that it is a covered benefit.
Indianapolis, Indiana
Q: I have some questions about the lip lift. I know that this procedure is quite controversial in cosmetic medicine. The plastic surgeons in my area will not perform it. However, after doing some research I have found that there are ways for it to be done successfully without cutting the orbicularis muscle. What is your opinion and experience with this procedure?
A: When you say lip lift, I will assume you are referring to the subnasal lip lift. (aka bullhorn lip lift) This is where skin is removed from under the nose to lift up the central third of the upper lip and shorten the long upper lip. Despite a lot of hesitancy from plastic surgeons to perform this lip enhancement procedure, I have found it to be very straightforward and uncomplicated. There is no reason whatsoever to remove any orbicularis muscle when shortening the upper lip. This is fraught with problems if done including a tight upper lip and an abnormal smile. While muscle resection probably does prevent any vertical relapse, it causes irreversible lip problems. Relapse is a much more easily treatable ‘problem’ so only skin should be removed. As a general rule, no more than one-third the vertical distance along the length of the philtral columns should be removed. One can expect 1 to 2mms of relapse in the first few months after the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have scleroderma and there are quite a few things that bother me about my face. Because of the scleroderma, it has caused a lot of damage to my appearance and the whole left side of my body is smaller than the right. If I could change how I look, I would want to look as close to normal as possible. I know I won’t look perfect but just looking like I’m not sick is good enough for me. My main issues are my cheeks which are sunken in, my chin which is uneven, my lips in which the top and bottom left sides are smaller and my nose which I think is too pointy. There is also an indentation on my forehead and the area under my eyes seems very hollow, all these affected more on the left side. I would really like to hear your opinions are on what I mentioned and your recommendations. I have attached a series of pictures for you to review.
A: I have taken a look at your pictures and your overall problem which is two fold; a short lower face and a lot of soft tissue thinning and atrophy. (more on the left than the right) In making an effort to get you looking better, you need a two-level approach. First, it is necessary to change the bony foundation by making the chin longer, more even and further forward by a chin osteotomy as well as a rhinoplasty to bring the nose/middle part of the face back into better balance. (this is what is imaged in the side views) Cheek implants are also needed to add some fullness to the cheek area. (this is what is imaged in the front views) The soft tissue deficiencies, which are difficult to image, are addressed by the placement of multiple dermal grafts and/or fat injections (if you have any fat elsewhere on your body to harvest) in the forehead, lower eyes, side of the face below the cheeks and in the left upper and lower lips. All of these could be done in one single surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a question about jumping genioplasty. I am curious, if you have had previous chin surgery with indwelling plates and screws as well as possible internal scarring of the muscle that causes creases in your chin when you smile, can you still undertake a jumping genioplasty? Or would the scar tissue and plates and screws from the previous ostetomy prevent this? I understand this makes surgery more difficult to carry out. I was just wondering if it is still possible.
A: While you are correct in that it is more difficult, it is not impossible and sometimes is fairly uncomplicated. The only limiting factor is the plates and screws used from the first osteotomy and how easy they are to remove. The typical osteoplastic genioplasty, if the chin has been advanced, is a step titanium plate with 4 or 6 screws. As long as bone had not completely grown over these metal devices, they are often fairly easy to unscrew and pry out the step plate. But if bone has completely covered these devices, their removal can be very difficult and destructive. Fortunately, complete bony healing over the plate and screws is not common. Once the devices are removed, the osteotomy is straight forward and the prior chin surgery actually makes it easier to complete a secondary bone cut.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi there, I was interested in your lip lift procedure and wondering if you did fat transfer to the face for reshaping/volumizing, and a butt lift using fat transfer. I’ve been researching for several months and I’m ready to have it done, but I’m wanting to find the right surgeon for me.
A:I do a lot of fat injection surgery, most commonly to the face for volumetric enhancement and to the buttock for augmentation, otherwise known as the Brazilian Butt Lift. Fat transplantation by injection is a really exciting approach for numerous face and body contour problems even if its ultimate survival is not always assured. The exact technique for fat preparation varies by surgeon and there is no absolute agreement as to how it should be done. I use a fat concentration technique and then mix it with PRP and Acell Particles to enhance survival and volume retention. These are by far the most common recipient locations. The key is whether one has enough fat to harvest which is an issue for the buttocks and not the face.
Lip ‘lifts’ can be done as either a subnasal lip lift or a vermilion advancement depending upon the shape of the upper lip and the patient’s scar tolerance. Please send me some photos of your lip for my assessment. Both approaches can be very successful when properly done. Vermilion advancements produce the most dramatic change in lip size and shape. True subnasal lip lifts are more limited in how they change the shape of the upper lip.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 35 year old mother of two. I’m 5’4″ and 144 lbs. I have been planning my mommy makeover for a while now and have put a alot of thought and research into it. I need a breast makeover with a lift and implants and a tummy tuck. The other area that bothers me a lot is my inner thighs. I have very little fat just loose skin with a lot of stretch marks. I know an inner thigh lifts creates scars and I am not wild about that idea. I know that thse groin scars can move downward as they heal which could be a problem in a swimsuit. Would a body lift be a better option? I know the scar goes the whole way around but how well would it lift the inner thigh area? What are your thoughts?
A: Your thought process is a good one but you have an understandable misconception about what the the lower body lift or circumferential lipectomy procedure can do. By removing skin and fat all the way around (360 degrees), it will make significant changes to your abdomen, lower back, buttocks and outer thighs. But it will have little if any effect on the inner thigh area. You wouldn’t do a lower body lift if you thought one of its main advantages was improvement in the inner thighs. The only way to improve the inner thighs is to treat them directly with an inner thigh lift. This would be far easier and more effective than a lower body lift. With well-placed incisions, the scars should remain fairly hidden in the groin creases.
Dr. Barry Eppley
Indianapolis Indiana
Q: My forehead sticks out from the side is there anyway you could make it flat and look at least normal? I have attached s side view of my forehead so you can see how far it really sticks out.
A: Thank you for sending your picture. It does show a fair amount of convexity to your forehead. The amount of convexity could be reduced but it can not be made to be flat. The bone thickness will not support that much reduction.
Here is a computer image of what I think is the best that could be achieved with a burring reduction of the forehead bone. There is one way to know absolutely for sure how much reduction can be done and that is to get a simple lateral skull film x-ray. On that x-ray the thickness and, most importantly the thickness of the outer cranial table can be seen. The skull (forehead) is composed of three layers; an inner and outer hard cortical bone layer in between which exists a softer marrow diploic space. The amount of horizontal reduction of the forehead is limited by the thickness of the outer cranial table. It can only be reduced until one gets close to the diploic space. Measuring that on the x-ray could show how much the forehead could be reduced in thickness. A tracing of the before and after cranial contour could then show you the exact profile change that could be achieved.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is a cheek implant that is placed high (near the orbital rim) and lateral, that extends to the orbital rim and that provides a significant augmentation (5 mm or more), able to lift the portion between the iris and the lateral canthus (not the lateral canthus itself) of the lower eyelid a little bit? I noticed this feature of the lower eyelids in people who have naturally very high and prominent cheek bones.
A: The simple answer is that it is unlikely. While it seems logical that the lower eyelid can be pushed upwards, and it is easy to do with one’s finger, try it by pushing up on the cheek tissue. You will notice the lower eyelid does not really move upward but just creates bunching of tissue right beneath the lid line. This is because the lateral lid line is fixed by the lateral canthal tendon. The only way to change the lateral lid line is by repositioning or tightening the lateral canthus. I suspect that putting in a cheek implant as you have described may seem to work during surgery, only to be disappointed later when no change is seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very high jaw angle. My goal is to have a jaw implant that will lower my jaw angle as much as possible. The problem is that the biggest implant I have seen only has 35mms of vertical length and the inferior ridge is just under 10mms. Does a bigger jaw angle implant exist and I have just not seen it? If not, how can a bigger one be made if possible?
A: Your are correct in your assessment that no off-the-shelf jaw angle implant can drop one’s angle down anymore than 10mms at most. Anymore more than that requires a custom implant to be made which can bring it down closer to 20mms. Such exceptional jaw angle extensions are uncommonly requested or needed which is why no stock implant exists with that degree of accentuation. I have made custom jaw angle implants that do achieve what you are after. They require a jaw model to first be made which is done from a 3-D CT scan of the patient. The jaw model made is then the exact anatomy of the patient from which the design and model are created.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested, I think, in some fillers, Botox and perhaps a partial facelift. What I would like to achieve is a firmer jawline, reduce my crow;t feet and just have a refreshed look. I am attaching some pictures for you to review and give me your recommendations. Thanks!
A: Thank you for sending your pictures. I have done some imaging looking at firming up your jawline. You hve the typical jowling the comnes with aging and this also creates a prejowl indentation as the jowl sags. That is best corrected by a lower facelift (neck-jowl lift) and adding in a small chin-prejowl implant to bring the chin out slightly (yours is a little short) and filling in the prejowl deficiency. The combination of these two makes for a smooth jawline. At the same time, I would place some fat injections in the nasolabial folds (lip-cheek grooves, parentheses) as this is the best ‘filler’ to use when you have are doing a facelift as it is the only filler that potentially can be more permanent. Botox for the crow’s feet can be done either during a facelift or anytime in the office. Just for the sake of one additional suggestion, I have also imaged a rhinoplasty by doing some nose narrowing and lifting the tip a little as this can also have a rejuvenating effect as one gets older.
These computer images will help you think more about what can be done for a refreshed look.
Dr. Barry Eppley
Indianapolis Indiana
Q: Six years ago I had a mandibular implant placed as well as malar implants. I am unhappy with the end result and do not feel the result was what I requested. I think, as I did then, that a geniomandibular groove implant with extended malar implants would provide my desired results.
A: I am assuming when you say mandibular implant you are referring to a chin implant. Since you feel that a geniomandibular groove implant is better, it appears that you feel that the transition between the chin and jowl area is not a smooth or confluent one or that the jowl area needs to be more enhanced as well. Do you know what type of chin implant you have in now?
From a cheek standpoint, the desire for further malar extension suggests that either you desire more fullness out across the zygoma to the zygomatioc arch or that your desire more fullness in the submalar area suggesting more of a malar shell design. Do you know what type of malar implants you have in now?
Please send me some photographs of your face and let me know, if you can, what type of implants you have in place. A copy of your original operative note can also be very helpful as often the type of implants used are described there. Once I have this information, I can offer a more qualified response as to the best replacement facial implants for you.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m planning on having a tummy tuck and have read that they can be done without using any drains. I don’t want a drain because it creeps me out thinking about a tube coming out of my body. I have also read that some plastic surgeons still use drains because they think it is better. What are your thoughts as to which way is best?
A: I have done tummy tucks both with and without drains. There are pluses and minuses each way which is why drain use is controversial and variable amongst different plastic surgeons. The purpose of a drain is to remove fluid that the body produces in the healing space of the tummy tuck area. When doing a tummy tuck without a drain, this open space is closed down with extra sutures which takes time and does add to the cost of the operation. Even though a drain might not be used, there is a small chance that fluid can still accumulate and have to be tapped later. When doing a tummy tuck with a drain, it will stay in for 7 to 10 days. There is about a 1/3 chance later that some fluid will still accumulate and have to be tapped.
Having done tummy tucks both ways, I have seen numerous cases where fluid still had to be tapped later whether a drain was placed or not. Unless a patient is possessed about not having a drain, I will use a drain most of the time. When a patien is opposed to a drain, I will use extensive plication sutures and extra OR time to perform it. That will add about a one-half hour to the cost of the operation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a 3 years old with mild plagiocephaly. I’m very interested in kyptonite injection to correct that problem in the future. Here’s my question about that technique: what is the method you are using to determine where (on the head) and how many (what quantity) kyptonite you will inject? Can we see a proposed “corrected headshape” before the procedure?
A: The determination of where to place the injectable cranioplasty material is determined before surgery by what everyone feels is the flattest area on the back of the head. That area is marked out prior to surgery. The location and size of the area to be filled in is a joint decision between the parents and myself. The amount of Kryptonite material needed is the greatest variable and the real guesswork in doing the procedure. What I know from experience is that 5 grams is inadequate and 20 grams would likely be too much. Usually 10 to 15 grams of material is needed. But the diameter of the defect is measured and then a benchtop test is done to determine whether 10 or 15 grams is best prior to surgery. Computer imaging is also done based on a superior view of the back of the head to get a prediction as to what may be obtained. It is important to realize that computer imaging is a prediction and not a guarantee of the exact outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I emailed you about a month ago about getting 5-FU injections for lumpy scar tissue underneath my nipple for a revision gynecomastia surgery I had about 4 1/2 months ago. I have been really busy at work and unable to get time off to make an appt. Last time you emailed me about a month ago you said I could schedule an appt. and possibly get a 5-FU or kenalog injection. I would really like to do this but an injection of kenalog makes me nervous due to the possibility of skin atrophy and other side effects I have heard about. I have heard that 5-FU mixed with a small amount of kenalog does not really carry these side effects and can work quite effectively. I have to travel about two hours or so to get there so I just want to make sure that 5-FU injections are a possibility before I make the trip. Also I have an issue about the scar I have from the surgery I had and I saw on your website that you deal with scar management. I know that the scar I have is only 4 1/2 months old but it does not seem to be getting any better and I was wondering if there are any non-surgical procedures or techniques, such as laser therapy, that you specialize in that could help to minimize this scar? Thank you for any help you may be able to give me.
A: We can certainly do 5-FU injections for scar therapy as that is an item I keep stocked her for injection treatments. While it is uncertain whether 5-FU is really better than Kenalog, it does have a higher safety profile. Kenalog done judiciously (low dose), however, can be done without significant side effects as well. As for scar management, there are numerous options regarding non-surgical approaches depending upon the scar issue such as hypertrophy or redness. Most commonly we do pulsed light therapy (Broad Band Light, BBL) or laser treatments. That decision would have to be made at the time of examination.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a rhinoplasty six months ago. My main goal was to make my nose larger in the middle. I have breathing problems and when I use nasal strips it makes me breathe better. I didn’t want to change my nose very much but just add support and width to the middle part. My rhinoplasty surgeon said he would put in spreader grafts and a columellar strut. After surgery when the splint was removed, he said he had also put in an onlay dorsal graft to make my nose look more balanced and masculine. My problem is that I didn’t want the dorsal graft. Now that I have more support in the middle vault, the dorsal graft makes my nose higher which I do not like. Can this dorsal graft be removed?
A: Dorsal grafts are onlay materials, usually cartilage, that is simply put on top of the bridge of the nose. How long it is and its size is largely irrelevant when it comes to removing it. The graft should be fairly easy to remove through a closed endonasal rhinoplasty approach. Unlike a bone graft, a cartilage graft never really becomes part of or truly incorporated into the underlying cartilage and bone but simply sits there with a surrounding capsule. This makes its secondary removal fairly easy. Since you are six months out, it is fair to say that you have a good idea of what your nose looks like and are certain that the dorsal graft does not fit into the desired aesthetic shape of your nose.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am interested in both malar and paranasal implants and I have learned a lot about facial implants on your homepage! In one article you stated that some areas in the face are more sensitive to implant size than others. For example, the orbital rim is one of these areas where the size of implants have to be chosen very carefully because 1 mm can make a huge difference. I guess it is the opposite with paranasal implants because (although they can be tailored) they are only available in such big sizes like 4.5 mm and 7 mm. I am not sure if I should choose the 4.5 mm or the 7 mm implant, but I am sure that I want rather a more dramatic look than a very subtle outcome. Do you think 2 mm difference in the paranasal area can make such a huge difference? Is the paranasal area more tolerant towards a slight overcorrection? Is my assumption, that paranasal implants are less sensitive to size, right? The worst thing that could happen to me after the implantation of the paranasal implants would be an increase of my nose tip projection, an increase of my nasolabial angle and a lengthening of my upper lip. Of course I know that paranasal implants usually don´t do this, but I am a little bit afraid that this could be different with the large 7 mm implants. Have you ever implanted the 7 mm paranasal implants and what are your experience with patient´s satisfaction? Did they rather wish to have more or less projection after they saw their final paranasal implant result?
A: The paranasal area is less sensitive to implant size for a variety of reasons. The first is that the skin around the base of the nose is thick so implant thicknesses are easily masked. A paranasal implant also has to push the base of the nose (nostrils) outward so it takes a bigger implant to do that. Lastly the surface into which the implant is placed is curved inward and not outward, further decreasing its influence. In general, small paranasal implants placed at the bone level has little effect so thinking bigger (7mms or more) will have a more visible effect. I don’t recall using a paranasal implant that was ever smaller than 7mms at its thickest portion.
A paranasal implant has no influence on the projection of the nasal tip, regardless of size. Only when a premaxillary implant is placed across the anterior nasal spine will it change the nasolabial angle with a small influence on the nasal tip.
Dr. Barry Eppley
Indianapolis, Indiana
The large number of stem cells in fat has led to a new wave of treatments in plastic surgery that hopes to harness the potential of this ‘wonder’ cell. Since a stem cell can turn into any type of cell if properly stimulated, it is not hard to see why any treatment attached to it is being hyped as a rejuvenative or regenerative therapy. These R words translate to anti-aging or make me look younger.
Given the ease from which fat can be extracted through liposuction, fat is being reprocessed and injected all over the body by plastic surgeons mainly because it is easy to do and perfectly safe. You might say it is the ultimate form of recycling, a green procedure if you will that is most certainly organic. Injected fat can be used from body contouring to facial rejuvenation. For the body, buttock augmentation and breast reconstruction (lumpectomy defects) are being widely done. Breast augmentation using fat instead of implants is being approached more cautiously. The other good body use is in the aging hands, using injected fat to make the hand look more plump and have a less bony appearance.The face, however, is the most common area for fat injections. Research has now shown that we loss fat in our face as we age. This facial deflation is one of the reasons that we look old and contributes to skin sagging. This has led to younger people getting fat injections at an early age and fat injections being used as part of a facelift procedure for more advanced degrees of facial aging. For the aging gaunt-looking face (or even a younger gaunt face), fat injections can be a good complement to traditional skin removal and tightening procedures.
In the most contemporary spin of fat grafting to the face comes the Stem Cell Face Lift. The concept is that stem cell-rich fat grafts combined with skin tightening makes for a better facelift result. Proponents claim that the stem cells provide a regenerative effect that makes the fat take better and helps the quality of the overlying skin as well. By mixing the fat with a little of your own blood, a theoretical youthful elixir is created.
Is the Stem Cell Facelift actual science or more science fiction? Is it hype or hope? At this point I would say a little of science and a lot of hype. The real scientists of stem cells would most certainly tell us that it just isn’t that simple. While stem cells have been extensively studied, how to make them work is far less clear. Conversely, the hopeful part of stem cells in facial rejuvenation is that it exemplifies the concept of ‘heal thyself’. Our tissues have a remarkable ability to heal themselves from injuries throughout our entire lives. It just seems that we should be able to use that to our advantage at some point.
One of the benefits of fat grafting to the face, whether the stem cells really make a contribution or not, is that it adds volume. And with our current appreciation of what happens as most faces age, becoming a little more cheeky might not be a bad thing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a corner of the mouth lift. I have checked in my area but have been unable to find anyone as of yet. How would it work if I was to choose to see you? How many trips would I need to make? Have you done many of the corner mouth lift procedures? I am 48 and do not feel I need, nor do I want at this point, a face lift as it is really only the beginning of slight mouth droop/marionette lines that really bothers me.
A: In answer to your questions, We have many patients how come from afar so we are very familiar with working with out-of-town patients. Ultimately, a corner of the mouth lift is done as an isolated procedure in the office done under local anesthesia. One only needs to come once, for the procedure only. An initial consult can be done by phone or Skype with photos of the mouth area sent in advance. Everything that needs to be discussed and determined can be done from afar. Once the procedure is done, there are no sutures to remove as they are just tiny dissolveable ones on the skin. There are no restrictions after surgery. Any follow-ups can be done like the initial consultation by phone or Skype with photos. A corner of the mouth lift is really a simpl;e proedure with the minor trade-off of a small scar. I have performed many of them either as a sstand alone procedure or often in conjunction with facelift surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 24 year old male who was born with a right cleft lip and palate and have been through five surgeries so far in my life. Besides my inital cleft lip and palate repairs, I underwent iliac crest bone grafting at age 11 and a Lefort 1 osteotomy combined with alveolar cleft bone grafting again at age 21. I have a fixed bridge across the alveolar cleft site. My current complaint is that I feels my upper jaw is collapsing again causing poor fitting of the bridge and thus pain. A CT shows a very small, but present, bridge of bone across the alveolar cleft. Also, the Lefort 1 plates appear in good position. I have no visible fistula but I can force air into my nose from the upper buccal sulcus. What, if anything would you recommend to try and solve my current orofacial problems? Thank you sincerely for your help.
A: It sounds to me like you still have a small oro-nasal fistula through the original alveolar cleft site with inadequate bone stock. I would look at repeating your alveolar cleft site grafting using a combination of some marrow and a cortical onlay graft screwed into place across the cleft site. It is very common to have resudal alveolar fistulae even though the site has been grafted more than once. If you can force air through it then there is a fistula. Plus if you have been grafted twice and it was done well, you should have more than just a small bridge of bone across the alveolus. I would wager you have a fistula going behind that bridge of alveolar bone. While alveolar cleft grafting seems simple, it actually is technically difficult and results can be less than ideal in many cases.
Indianapolis Indiana
Q: I am an 18 year old looking to correct “witch’s chin” deformity or chin ptosis. I do not know of any doctors in my area who have experience with this procedure, so I am seeking your advice and hopefully you can educate me a bit more about my case. The problem is that I have a lot of extra soft tissue in my chin that folds under and looks very awkward when I smile. I had a consultation with a plastic surgeon who said he would scrape out some of the fat and pull the skin back. He also said that he would cut the muscle. I know he has not seen this case before and that is why I have not confirmed the surgery with him. How exactly is this surgery performed and what are the different ways to go about it? How complicated is the procedure? What are the risks of going to somebody who has not done it before and how high is the risk of causing a deformity? I have attached some photo of me smiling and not smiling from both a front and side views. Your insight is very much appreciated! Thank you.
A: Based on your photos, you are correct in that you do indeed have a witch’s chin deformity. The smiling view magnifies the redundancy of muscle and skin and pulls it down abnormally over a pointy bony chin. In the truest definition of a witch’s chin, it is a deformity that occurs after some form of bone chin manipulation. Your case is different in that this is a developmental/congenital problem and not an iatrogenic or surgically-caused one. In these non-surgical cases, the bony chin is also protrusive and that can be seen at rest in your profile view. So the actual anatomic proboem is one of ‘too much chin’ from all tissues involved.
Surgical correction is done from an incision underneath the chin, what is known as a submental approach and the overall procedure can be called a submental chin reduction. From below the chin bone is shaved down and excess muscle, fat and skin is removed. The chin is then reshaped by adapting the shortened soft tissues over the reduced bone. This is not a complex procedure but must be done carefully and all chin tissues musts be reduced and tightened. The trade-off is a scar under the chin. I have attached a patient example of the procedure for you to see the results and the scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: My 14 year-old son has developed breast enlargement that is quite troubling to him. Do you know if insurance will cover gynecomastia surgery?
A: There is no way to predict whether any insurance company will or will not cover an adolecent’s gynecomastia surgery. I have seen numerous cases over the years that has been covered (most before 2000) and many (since 2000) that has not. Regardless of what an insurance company may say in its declaration of coverages or what may be spoken on the phone by their representatives, nothing is certain unless it appears in writing. Therefore, pursuit of insurance coverage must be qualified with a predetermination process. This is essentially a letter from a plastic surgeon stating the diagnosis and intended surgery, complete with photographs of the patient’s chest. In addition for gynecomastia determination, it is important to have an endocrinologic work-up which demonstrates that there is not an hormonal basis for the gynecomastia which could be treated and reversed by medical treatments and thus not needing surgery. Even with this approach, there is at best a 50:50 chance. If the photographs do not show a significant breast mound (like a woman’s breast) those chances drop significantly. Only the most severe gynecomastias would be likely to be covered, anything less will be judged to be just a cosmetic gynecomastia surgery problem.
Dr. Barry Eppley
Indianapolis, Indiana
