Your Questions
Your Questions
Q: I have two scars, one on each side of my head from previous surgery (about 1.25 inches by 0.25). I was wondering if it was possible to make them less noticeable?
A: While all lacerations and surgical incisions leave scars, scalp scars are unique in what makes them visible. That is the fact that they occur in skin that contains hair. Any loss of hair along an incision or scar in the scalp will result in a wide and visible scar. The same scar somewhere else on the body may not be as noticeable as there is only the color change in the skin that draws attention to it. Scalp hair follicles are frequently injured during incision and lacerations and sometimes even from the suturing and stapling that is done to close them. It is actually fairly uncommon to not have scalp hairs injured dueding handling.
Scalp scar revision is done by cutting out the non-hair bearing scar and bringing the edges of the scalp that contain hair together. The scar will end up better and less noticeable if the distance between the skin that contains hair ends up less wide. My Indianapolis plastic surgery experience is that most scalp scars can be made better but there are certain surgical manuevers that must be done to increase the chances of improvement.
Handling of the unscarred scalp is critical to not injure new hair follicles that will make up the edges of the scar closure. Scalp scars do not tolerate tension very well at all and the tissues must be elevated sufficently to allow for as tension-free closure as possible. In some cases,a straight line closure must be changed to an irregular one, such as a w-plasty pattern, to distribute the tension better and get ‘fingers of hair’ to interdigitate with each other.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I have a medpor chin implant as part of some cosmetic surgery 4 years ago. The implant is eroding the bone and my oral surgeon says it must come out. He doesn’t want to replace it. I am in no pain and I like the way I look. Do I have to have this surgery to remove it?
A: Medpor chin implants have a uniquely porous material of which they are composed. One of the purported benefits to its material is that it will cause less bone erosion underneath when it is placed in the chin area. The phenomenon of the implant settling into the chin bone is known as pressure resorption. This unique chin implant phenomenon has been recognized for decades. It is a natural phenomenon and is very similar to what is seen in breast implants. When breast implants are replaced many years later, the underlying rib cage will often have a concave surface or bowl where the implant sat. Such bone resorption is what happens when the soft tissue is stretched by an implant, it pushes back just a little bit over a long time. Since the synthetic implant is a solid non-resorbable material, the underlying bone relieves itself of the pressure by some resorption. ..and the implant settles or erodes to some degree into the bone.
While you may have some chin implant settling into the bone as evidenced on an x-ray, it is not a problem in my opinion. You have no symptoms and you are satisfied with your existing chin projection. Surgery to replace your chin implant seems to be an overreaction to a non-problem.
Indianapolis, Indiana
Q: Can a chin implant be an alternative route to mandibular advancement? I went to the orthodontist today for my overbite and excessively gummy smile and was told that my options are to get the Lefort maxillary surgery (or place 2 screws on my upper jaw and have wires pull my teeth-in sections via braces- upwards to reduce the gummy areas) and mandibular advancement. Read about LeFort and mandibular advancement and don’t think I want to go through all the pain and side affects so I looked into chin implant and I am entertaining the idea of a chin implant and the 2 screw method to pull my teeth upwards….. any suggestions?
A: Both chin augmentation and mandiibular advancement will have similar effects on the chin…bringing it further forward. How much each approach will bring it forward is more adjustable with a chin implant as different sizes can be chosen. In mandbular advancement, the chin will only be brought forward as far as the jaw comes forward and the teeth still fit together properly.
Chin augmentation is certainly a far easier and more efficient choice if the primary motivation for the surgery is the aesthetics of the chin. But it will not obviously change one’s bite so there may be some functional chewing and temporomandibular joint tradeoffs if the lower jaw is significantly short.
Mandibular advancement is a commitment both in orthodontic preparatory time and in surgical recovery. Therefore the amount of jaw shortness and how well one is able to chew and bite comes into play as to whether this effort is worth the risks.
Indianapolis, Indiana
Q: I was wondering if a scar on my forehead can be improved by plastic surgery. Two years ago, I fell and had a deep cut into between my eyebrows. Even though it was stitched up in an emergency room, it has still left a very noticeable scar. Because of where it is located next to my eyebrow, it always looks like I am frowning even though I am not. I am only 29 and don’t want to look like I am scowling or have wrinkles at this age. Would scar revision be helpful?
A: Scars are particularly noticeable when they are in unnatural locations. Whle most people will eventually develop some vertical lines between their eyebrows due to excessive muscle activity (expression), that is not a ‘natural line’ for a younger person. Having seen such scars in this are before, they are noticeable because they are indented along the scar line. This creates a vertical groove which can certainly look like a deep glabellar furrow or wrinkle.
Unlike expression-induced glabellar furrows, Botox is not an answer because it is caused by injury and scar. The problem is in the skin and not the muscle. Most scars in this area can be significantly improved by surgical scar revision. By cutting out the old scar and closing the line in an irregular (running w-plasty) pattern, the scar will usually become much less noticeable. Not only in the scar line no longer completely straight but it will not indent and be smoother. This simple procedure can be done in the office under local anesthesia.
While scar revision is not a magic eraser, it can reduce its appearance to be much less noticeable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 58 year old female who is looking for a highly qualified plastic surgeon to perform a breast reduction surgery. I need to be able to work with someone who can help me get my insurance plan to cover the cost as I feel this is medically necessary. I honestly don’t have a clue how the insurance works in a case such as mine . My health issues include fibromyalgia, arthritis, diabetes type 2, GERD, chronic depression, and anxiety disorder. I had a back surgery in 2008 for a lower back condition that required a L5S1 partial laminectomy, spinal fusion, surgical hardware, and a bone graft. I have arthritis in the rest of my spine as well. I have many issues with headaches, neck pain, shoulder and back pain. I also have problems with rashes under my breasts and bruising caused by wearing underwire bras for support. My bust size is a 44DD and, although I am not a small person, the size has become a hinderance to me as far as activities, heat intolerance, and the pain I live with daily. Please let me know if you think there is a chance we might be able to have a reduction covered under my insurance. I simply cannot afford to pay for any kind of health care or surgery on my own. Thank you for your time.
A: Breast reduction is often covered by one’s insurance if you qualify by their standard and well-known criteria. These include the following three items that your insurance will evaluate. First, you can not be obese or significantly overweight. One should not be more than 20% over their ideal body weight. If you are, you will be told by your insurance company that you have to lose weight to qualify. Secondly, you must have symptoms of back, shoulder and neck pain that has NOT responded to three months of conservative management such as physical therapy and/or chiropractic therapy. Such treatments must have documentation, not just saying that you have had them. Lastly, the amount of breast tissue that is going to be removed must be of a certain amount based on a calculated number known as your BSA. (body surface area) If the amount of breast tissue that can be removed does not meet the amount based on your BSA, you will be denied.
All of this information is put together in a letter, written by your plastic surgeon, and then sent in to the insurance company. This is known as a pre-determination. One then waits to get back written approval or denial before ever proceeding to breast reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
The first of the month of July marks the first visible sign of the recently passed Health Care Reform Act. You might not notice it unless you are paying to get a tan. The 10% tax on tanning salons has gone into effect and it will cost you that much more to get one now. Tanning salons were easy targets for Washington legislators. With analogies to tobacco and alcohol, its association with increased skin cancer risks made it easy pickings with no significant protest. The initial cosmetic target was a Botox tax but that ran aground due to being a gender-biased tax. The elephant sitting in the room with the tanning salon tax is that it is a racially-biased tax…but I digress.
The debate over the Health Care Reform Act is all but a faint rumble now but it was really a largely economic and taxing exercise over an issue that has long been decided. With Medicare and Medicaid now making up well over half of whom most doctors and hospitals service, and with the percent growing, we have insidiously grown into a nationalized health service that existed before this recent discussion. Throw in the large Veteran’s Administration and military service health facilities and the government is by far the biggest payor for our nation’s health. The recent legislation was merely the tipping point that made the path to greater government control over heath care just go faster and even more evident.
While many clamored that the health system in the U.S. was broken, the reality is that it functions pretty well but is overwhelmed with demand that exceeds the economics to pay for it. The idea of insurance coverage and a societal safety net established in the 1960s never could have envisioned the population demand and the magnitude of health care advancements that have occurred in the past forty years. The very feature that makes our health care system the best in the world…a system driven by entrepeneurship…is exactly what is making it suffocatingly affordable to many individuals and businesses now.
The one certainty that will result from this legislation is that you will be paying more…and eventually getting less. No matter how it was painted and sold in Washington, this is an absolute certainty. As a result, we have been seeing for the past few years the development of the field of concierge medicine. As a fee for service concept, you pay a flat fee per year for an individual or family and get access to medical care 24-7. Various tests that may be needed are still billed to your insurance company. This allows you to use your health insurance as a catastrophic plan (and even a one day stay in the hospital can be an economic catastrophe) and pay lower premiums. This may only lower your out-of-pocket a little but it changes the level of service and cuts down on the amount of paperwork needed for doctor visits, etc.
While concierge medicine may not be the right choice for everyone, it is taken out of the playbook that plastic surgeons have used for decades. Elective cosmetic surgery, such as breast augmentation, facelifts and tummy tucks, is the original form of the concierge medicine fee-for-service concept. The idea of paying a fixed price for a certain medical service is re-emerging and will become increasingly popular. As more doctors withdraw from Medicare and Medicaid, due to the abysmal reimbursements and the labryinth of befuddlling paperwork and coding schemes, cash providers and practices will again become more commonplace.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I’m an Asian female in my late 20s. Over recent years, my jaws have become really prominent, making me look somewhat masculine and heavy. Looking for a way to reduce the angle of my jaw, I found the masseter reduction with botox injection on the web. Since I don’t want to change my bone structure, I came to consider botox as a solution. My only concern is how much the cost would be. I know it is hard to get an estimate before I visit you, I’d have even a ball-park idea about the money I should pay, including consultation fee. Could you please let me know the range of cost? Thank you so much!
A: The protocol for Botox injections for masseter muscle reduction along the jaw angles is a one year program. It has been shown by multiple studies that it takes at least three injection sessions to get the most muscle reduction. Since the effect of Botox is approximately four months, injection sessions are done every four months for one year. Results are usually seen as early as a few mmonths after the first injection session. The amount of Botox should be a minimum of 25 units per side or 50 units per injection session. More may be needed in men depending upon the size of the masseter muscle. While the cost per unit of Botox varies greatly across the country, in my Indianapolis plastic surgery practice the cost of such a treatment session would be around $ 700.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I was very impressed by your comments on lip lift. I feel confident that you understand more about this procedure and the possible things that can go wrong than other plastic surgery websites I have seen. Since I have had two prior rhinoplasty surgeries, will this procedure affect my nose? Some surgeons have said that I would need another operation on my nose if I were to have a lip lift. I really don’t want to touch my nose again. I’m happy with it and just want to leave it alone. If a lip lift will alter the shape of my nose, then it’s probably not the best option for me. In terms of why I need the lip lift. I’m only 30 but have always had a VERY long lip lift. My lips themselves are very full and attractive, but even when smiling, you can’t see ANYTHING of my upper teeth and I feel that it’s quite a big thing and stops me looking as attractive as I otherwise could be.
A: I do not know of, nor have I ever seen, any problems with a lip lift affecting the shape of the tip of the nose. A lip lift is a simple removal of skin at the base of the nose. It does not, and should not, remove any muscle from the subnasal area. In theory, I can see how it is possible with too much skin removal to pull down on the columella causing distortion of the nasal base. But the skin resection should never be greater than 1/4 to 1/3 of the vertical skin height along the philtral columns. Since there is no recovery (replacement) of too much skin removal, it is always best to not be too aggressive in the lip lift procedure.
Indianapolis, Indiana
Q: Hi Dr Eppley, I was wondering if fillers can be used on a sagging elbow area instead of the surgical procedure?
A: Sagging of skin around the elbow area can be the result of age, body type, and weight loss. Most commonly I have seen it to be an issue in the extreme weight loss patient (greater than 75 to 100 lb weight loss) and it is one of the areas dealt with using bariatric plastic surgery techniques. While the usual approach to loose skin is to cut it out, the creation of a scar around a joint area can be problematic. The skin around joints, such as the elbows and knees, is not meant to be fixed. Rather it needs to have some flexibility and movement so the joint can go through its range of motion. Scarring around the joint may cause joint motion restriction in the long run and wound healing problems in the short run. (motion across a suture line) Known as elbow or knee lifts, the excision of loose skin must be carefully done to avoid these problems.
I suspect in this question that it is not a weight loss issue. Rather it likely is aging and the development of some loose skin around the elbow in an otherwise non-overweight person. (can particularly happen in an aging thin person) Therefore, excision and the scar that it creates is not an acceptable solution. This changes the approach to maybe an opposite solution…filling or reinflating the tissues. While injectable fillers can be placed anywhere, their temporary effects and the large volumes needed for a body area make them impractical. The only soft tissue filling option to be considered would be fat grafts. Harvested by liposuction, fat can be purified and then reinjected into soft tissue spaces. This is the only option I would consider when it comes to injecting any body area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a deep vertical line in between my eyebrows that is still noticeable despite having Botox injections. I was wondering if endoscopic browlift could correct this. Im only 27 years old. Please help.
A: The development of vertical wrinkles between your eyebrows, known as the glabellar area, is common and is the result of excessive muscle activity. There are a set of six paired muscles that affect the glabella area and create what has been described as a number system of galbellar wrinkles or furrows. As the popular ad goes, are you a 1, 11 or 111? These numbers describe whether one has one, two or three vertical glabellar wrinkles.
The first approach for glabellar wrinkles is Botox which will be highly effective for most people. For many the wrinkling is completely or nearly completely gone by this temporary muscle paralyzing treatment. For those with more deeply etched glabellar furrows, Botox will soften it to some degree but may not reduce it enough for the person’s satisfaction. This is the result of the skin being ‘etched’ or having a permanent v-shaped change in the skin. Muscle paralysis will not change permanent deformation of the skin.
An endoscopic browlift will not create a better effect than that of Botox because it works on the muscle only. It may help decrease the long-term need for Botox and, rarely, the need for Botox at all.
A companion treatment for the deep glabellar furrow is some type of soft tissue fill. Usually this is an injectable filler but its effect will only be temporary. More permanent options include the threading of an allograft collagen dermis material or actual synthetic implant. (e.g., Advanta)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have multiple lipomas over my arms and legs. Is there anything new to having them removed?
A: The standard treatment for lipomas remains excisional, making a small incision over the lipoma and pushing it out. While effective, this does result in a very small skin scar. While this approach is fine for several or even up to ten or so lipomas, it is tedious and results in many fine scars.
An alternative non-surgical approach is Lipodissolve injections. A needle is used to inject each lipoma with about a .5ml solution of phosphatidylcholine and deoxycholic acid. This is a fat dissolving solution that will shrink the size of the lipoma and in some cases get rid of it completely. Usually, however, it takes more than one injection to be assured of its complete eradication. If you are seeking a truly non-surgical approach, these injections are a treatment to be considered as long as one understands that more than one injection may be needed for maximal results.
Another ‘minimally-invasive’ approach is spot laser treatment. Using a Smartlipo (laser liposuction) fiberoptic probe, a nick is made in the skin and the probe is inserted next to or into the lipoma, it is turned on and used to heat up the lipoma until it is melted or destroyed. Like excision, this does require a local anesthetic.
Dr. Barry Eppley
Indianapolis, Indiana
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Q: I am interested in getting an inner thigh and knee lift procedure but am concerned about the scarring. I have looked on the internet but pictures of these type of scars seem hard to find. Do you have any suggestions about how I should make the decision for this kind of surgery?
A: Body contouring of almost any kind always results in scars. Short of scars on the face or breasts, most scars that result from body contouring procedures will not look as good as they do on these two areas. Regardless of even seeing good scar outcomes from these procedures, that does not mean that yours will turn out as well.
Therefore, the decision to go forth with any type of ‘leg lift’ should be based on the acceptance that the scarring will not be as good as you would like it. Scars are the lower extremities are never great. They are faced with too much tension and movement after surgery that always stretches them out to some degree. You have to decide which is more acceptable, the loose skin or the scars. If you can not accept the concept of scars or have any hesitancy about them, then you should not do the procedure.
My approach to scarring in body contouring surgery is…it is always about trading off one problem for another. The operation is good one for you if the trade-off into scars is better in your mind that the excess skin problem that you had before.
Quite frankly, mentally going through this thought process is better than looking at pictures of scars from the procedure. The people that are truly happy with the results from this type of body contouring procedure don’t care what the scars look like because they hate what they have now. That is the attitude to have the scarring, no matter how it looks it is better than this loose hanging skin that I have now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had jaw angle reduction surgery three months ago and I am unhappy with it. I wanted to make the thickness of my jaw angles more narrow and thought that Botox injections to the muscle would work. Instead the doctor told me that I needed bone removed instead. During surgery, the doctor cut off my entire jaw angle and I just don’t understand why? It’s make my face look too short now and I am less attractive than before. I am very sad about having this surgery.
I am only 32 years old and don’t want to live the rest of my life looking like this. I have attached some pictures and x-rays (before and after surgery) for your review.
A: I have reviewed your case and the x-rays. What you had was a classic jaw angle reduction surgery. This is well shown on the x-rays and in your before and after photographs. Overall, I think the surgery was done adequately. One of the jaw angles has been cut off more than the other, accounting for the asymmetry in how the jaw angles look now.
For those seeking to get a narrower and less square face, this can be a good operation. One of the negative aspects to the procedure is that it makes the jaw angles blunted in addition to making it more narrow. In fact, it makes the jaw angles more narrow by virture of changing a square corner into a rounded one. That may not always be a good aesthetic trade-off. (and is what bothers you now)
In the desire to make a square face more narrow in a female, you have to distinguish between keeping the jaw angle square but making the bigonial width more narrow…or narrowing the width of the jaw angles but keeping the squareness to it. That is a very important distinction to make because achieving those looks requires two completely different approaches. The former needs to be done with Botox injections or doing a sagittal bone reduction in a flaring jaw angle (if present). The latter is done by the classic jaw angle reduction osteotomy. They both will make the lower face more narrow but the shape of the jaw angle will look different. Jaw angle reduction surgery makes the face look shorter in the back, muscle reduction or sagittal bone reduction does not create that effect.
The question now is. where do you go from here? Do you want some of the squareness to the angle back? If you do, then one may consider a thin jaw angle implant. (3 -4 mms) This will get the definition of the jaw angle and not add much width to it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: How come with breast augmentation the work seems flawless with no scarring at all. But with a breast lift, there appear to be scarring and are not always even. Your augmentation is beautiful, the best i’ve seen so far. I dont think I need an implant because I am already a DD.
A: Breast augmentation is virtually scarless because the small incisions that are used to pass the implants through are placed in very unnoticeable areas. Whether it be in the lower breast crease, around the nipple, or in the armpit, they are undetectable except on the very closest of inspections. Breast implants do all the work of making the breast, including its new shape, and this makes it almost scarless.
Conversely, breast lifts must create their reshaping effect by removing skin. Because all aspects of the breast skin are in view in a well shaped breast mound, the scars are much more visible. In a typical breast lift, the scars will run around the nipple and vertically down to the lower breast crease. In more extensive breast lifts, the scar may also run along in the lower breast crease.
Unlike breast implants, which are symmetric in shape to start with and can be equal in volume, breast lifts are much more artistic in execution. They require a lot of judgment in how and where to cut the skin and, as a result, can not be expected to be as perfect in shape and symmetry as many breast augmentation results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I recently had cheek implants but now one side of my face has hollowed out and both sides of my mouth have developed drooping pouches of tissue . It looks very uneven and has distressed me greatly. I would like your opinion about this.
A: This is certainly a very unusual type of mouth result from cheek augmentation. The reason it is unusual is that cheek implants add volume to an otherwise prominent facial bone area. If anything it may cause a very mild cheek tissue lifting effect but not dropping of tissues as you state around your mouth. Early after surgery, in the first few weeks or month, one could have swelling and some bruising which drifts downward along the mouth and even into the neck. But if this is would not be the case more than a month after surgery. If other facial procedures were done at the same time, which would be common, then this could still be residual swelling which may yet go away.
Uneveness of cheek implants, however, is not rare and is probably the number one complication of cheek augmentation. It is more difficult than it looks to place cheek implants in the identical position on both sides of the face. The thickness of the cheek tissues do not make it easy to see minor differences in position during the actual surgery. I would wait at least three months after surgery to let everything settle before making a final judgment about cheek symmetry.
Indianapolis, Indiana
Q: I am interested in a Thyroid cartilage reduction. I am a male but this is not for any kind of transgender procedure, I just have an oversized adam’ s apple and I do not like it. i am in my 30’s and I’m not looking to have it removed just made smaller. Is it possible to have this procedure at my age?
A: Most of the thyroid cartilage reductions that I do are in heterosexual males, not transgender patients. Like yours, the issue is the same…an adam’s apple that is just too big and sticks out too far. Your age is fine as age is actually irrelevant. As long as one is skeletally mature (fully grown, age 18), it is acceptable to have the procedure. This is a fairly simple operation that is both effective and requires minimal recovery. At the price of a very fine 1 1/2″ horizontal line in a skin crease over the cartilage, it can be substantially reduced.
The thyroid cartilage plays a very valuable role in supporting the vocal cords and certain neck muscles and ligaments. Its removal is not possible. Thyroid cartilage reduction merely shaves down or reduces a portion of the V-shaped prominence of the upper or superior part of the cartilage. Their paired upper borders come together in the front and form a notch whichi is easily felt. Removing this portion of the cartilage does not interfere with vocal cord function or other neck functions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a bullhorn lip lift three weeks ago and feel that the scar under my nose is quite hard (harder when I start talking) and still visible. Can you please tell me if the scar will soften and dissappear eventually? I much appreciate a second opinion.
A: The healing of scars from a surgical incision, as well as from any injury, is much different than most people perceive. When people see the dressings or tapes from a surgical incision, or the sutures placed to close it, removed a week or so later, they are often surprised how well it looks. When viewing the same scar weeks to a month later, it will look worse and some patients feel that something is going wrong.
In reality, this is part of the normal healing process. Actual healing of a wound or incision does even start to take place for weeks. That is why it looks so good just a week later, nothing is really going on and the body is not reacting fully to the insult. The scar will naturally turn redder and get firm weeks later as the body recruits the necessary elements to actually heal the incision. Blood vessels grow in and collagen is laid down to help knit the tissues back together. Collectively, this natural healing process creates a red and firm scar for months. Once the incision is getting more healed the redness fades and it will get softer, eventually getting that faded scar and softness of the tissues.
This healing process takes months and often is only complete at close to a year after the surgery. At this point, it will return to what it looked like at just a week or so after the initial surgery. When the incision is just under your nose, from a lip lift, one is forced to look at it daily. One’s awareness and uncertainly as to what will happen with it is understandably high.
Indianapolis, Indiana
Q: Hi, I’m an Asian female in my late 20s. Over recent years, my jaws have become really prominent, making me look somewhat masculine and heavy. In ooking for a way to reduce the angle of my jaw, I found the masseter reduction technique with botox injections on the internet. Since I don’t want to change my bone structure, I am considering Botox as a solution. My only concern is how much the cost would be. Could you please let me know the range of cost? Thank you so much!
A: There are two options for prominent jaw angle reduction, surgical jaw angle bone reduction and pharmacologic masseter muscle shrinking. There are advantages and disadvantages to each approach. Which is better for any patient depends on their bone and muscle anatomy and what type of result and effort that one wants to go through.
Botox injections, in my Indianapolis plastci surgery experience, can be an effective masseter muscle reduction method. My protocol is 50 unit injections (25 units per side) into the muscle at the angle done every four months for one year. After three injection sessions, some permanent muscle reduction will be seen. Whether maintenance injections are needed is determined on an individual basis. Cost can be determined by knowing what the provider charges per unit and simply do the math. In general, the costs are around $750 per injection session.
Indianapolis, Indiana
While my parents, and their parents, have lived much of their lives with fairly similar methods of doing business, the present world has seen a near total transformation in just the past decade. The merging of two initially unrelated technologies, electronic communication (now wireless) and social networking, have created a paradigm shift in societal thinking and strategies. While most who will read this have felt the impact on their business and personal lives, health care is one area where an equal transformation is rapidly occurring.
Plastic surgery has been one of the early adopters of both social networking and digital communication in the medical world. Part of this is because so much of plastic surgery is visual. Almost all of what we do can be seen and easily imaged. This is a double edged-sword as assessment is easy but with that can come an equal opportunity for criticism. Plastic surgeons rely on imaging only less than that of radiologists, whose entire practice is essentially the analysis of complex three-dimensional arrays of pixels. While a plastic surgery patient can provide great verbal detail and descriptions of their concerns, a good picture or two can leapfrog hundreds (or is it thousands?) of words.
Because of the need to market fee-for-service elective surgery, social networking sites have become a popular medium for plastic surgeons and numerous other practitioners of cosmetic services. In the old days (2000?), one would rent a hotel conference room and put on an evening program for the public. Advertising by word of mouth or newpaper ads might get an audience of 50 to 75 people. Post a blog or a promo on Facebook or Twitter and the potential exposure is to thousands.
I could pontificate on the medical impacts of these technologies, and there are too many to mention here, but one recent story makes the point. Driving home one evening after a day of surgery, I received a call from an emergency room halfway across the city. They had a five year-old boy that had a laceration on his forehead after his older brother yelled, fore!, and swung. These type of calls are common in plastic surgery and despite that I would have liked to fix this child’s problem, being up since 4AM and driving 35 miles was not beyond what I could muster. I asked the emergency room doctor to pass along my regrets and asked them to call another plastic surgeon. As I was settling down for the evening and just put my feet up, I received an unrecognized e-mail on my iphone with a one sentence message and a picture attachment. The message said, ‘My son is in need of your skills.’ signed by a mother’s name I had never heard of. The picture showed a close-up of a child’s face with a laceration down the center of the forehead between the eyebrows and the scalp…right down to the bone.
I don’t need to tell you what happened later that evening. With estimates that at least two-thirds of American physicians have smart-phones, doctors are prime targets for access from multiple wireless methods. With nimble technologies, from smart phones to health-monitoring devices, patients as well as doctors are becoming more empowered. Will this make health care better and reduce costs? Who knows but interactive health and wellness programs already surround us. Apple alone has thousands of health-related applications. Cell phone services using the Droid are not far behind.
Medical care is becoming more wireless at a brisk pace. While receiving the actual care still requires an in-person visit, the day may not be too far away when all you need to do is hold your cell phone next to what hurts.
Indianapolis, Indiana
Q: I had a chin surgery in the past with a silicone implant placed from inside my mouth. I didn’t like it so the doctor removed it two weeks later. Within a few days after its removal, I could feel fluid inside. The doctor removed it by a needle and it looked fine. But five days later I had a hard ball in my chin and the doctor told me that it was scar tissue. He assured me that I would return to the profile I had before my surgery. But it did not go back and I went to see another doctor who also told me it was scar tissue and injected me with steroids. The steroid helped a little but the labiomental sulcus is still much fuller than it was before the chin implant was placed. It now feels soft but is still fat. I think that the majority of the problem is in the upper part of the chin in the mentolabial sulcus. I don’t have the normal S curve that divides the chin and the lips. When you touch it you can feel something soft inside and the doctors here have told me it is scar tissue but they only want to fix the problem with more steroid injections. But I am afraid now because I have a dent from the steroids. Do you think it is possible to take out the scar tissue in the labiomental sulcus ?
A: You have experienced one of the problems from intraoral chin implant placement. When the implant is removed, the muscles remain expanded and an ‘open’ pocket exists where the implant once was. While the implant removal was undoubtably done quickly and easily in the office, no effort was made to put the mentalis muscle back in place and re-tighten it. A technique well known in plastic surgery as eliminating the dead space. Since the body abhors dead space, it will fill it with serous fluid…a perfect nidus for the development of scar tissue.
My recommended approach for this type of chin scar revision is excise scar tissue and reposition the muscle back down to the bone. This would be done from inside the mouth through your old incision. This is the most assured way to get back your chin profile and re-establish the depth of the labiomental sulcus.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I got the mole on my nasal bridge removed by elliptical excesion. The wound got infected (pus). The stitches were removed after five days of operation. Because the pus was still there the wound opened up. Now 15 days after the removal of stitches, I am left with 1mm deep large hole in place of mole, which is still pink. Please suggest a remedy, My doctor says I should wait for three months, If the scar remaining is too big then I can go for another sugery. I dont want to wait for so long, as it is effecting my life . Please suggest something.
A: The strategy that your surgeon has suggested in this right one. It is better to let the wound heal and contract down in size. It is possible that it may heal to the point where you will find the scar acceptable. Most likely, however, this will not occur as the nose is one of the most unforgiving places to scar on the entire face. By letting it heal, the scar (like the original mole) can be excised again later. By this approach the size of the defect will be smaller and the tissue quality will be much better for handling and holding sutures. While this is certainly distressing to allow this process to evolve on a prominent area of your face, it is the wisest and will result in the best scar result long-term.
Q: I had saline breast implants placed three years ago. I went from a A to a C cup. While I like the results, there are ripples along the bottom and the sides of the implant. I know some people have them and can feel them, but in me you can actually see them. They are really evident when I bend over. Is there any way to fix these? Would a smaller implant be a fix? Would smooth implants be a fix? Would alloderm be a fix for rippling ?
A: By the way you have framed your question, I am assuming that you have textured saline implants. Whether they are above or below the muscle is another very relevant question. Either way, however, saline breast implants are well known to have this problem. Sometimes the rippling is relatively minor, other times it can be quite significant. It is a ‘natural’ feature of saline implants which reflects the differences in how water vs. a silicone gel coats the inside of the silicone shell or containment bag. While it is common and expected in saline breast augmentation, several things can make it more pronounced, such as using a textured implant, placing the implant above the muscle and underfilling the implant from its recommended minimum volume.
While there are still some unanswered questions about your breast implants, there are several known effective strategies. Changing to a silicone implant is one of the successful as these implants have much less rippling. If cost is an issue, a more economic approach is to simply fill your existing implants with more volume. (it would be important to know beforehand what base size implant you have and how much saline is in them) While alloderm can thicken the capsule and theoretically lessen the amount of rippling, it is the most expensive strategy and the least assured of making a significant difference.
Indianapolis, Indiana
Q: I have had quite noticeable under eye hemosiderin staining since a rhinoplasty nearly 20 years ago. I’ve had several laser treatments over the years and am currently applying a hydroquinone cream. Nothing has ever truly worked, but I still hold out hope. Any suggestions would be greatly appreciated.
A: Hemosiderin staining represents the deposition of residual iron oxide pigments from the breakdown of the hemoglobin molecule. While most hemosiderin staining problems resolve on their own, they do so within months due to macrophage activity. Once this problem exists beyond 6 to 12 months after surgery, the body is telling one that it will not remove it on its own. It is faur to say after 20 years that your hemosiderin staining is fixed into the tissues.
This is a difficult problem and I think the chances of any treatment’s success is very unlikely. Certainly, no topical cream is going to work. Iron pigment in the subcutaneous tissue is not going to respond to any form of topical cream. Bleaching creams work on the skin for pigment, the iron oxide molecules lie much deeper. I don’t know what type of laser treatments you have been receiving. The only type of laser treatment that makes any theoretical sense is the Q-switched laser, the type of laser used in the treatment of tattoos. The residual iron oxide pigment must be viewed like a tattoo pigment being metallic in composition. Like a tattoo, the age of the pigment in the tissues shouldn’t matter. No other type of laser or pulsed light therapy (i.e., IPL) will work. A vascular laser will also not work since its focused light is for the oxygenated red hemoglobin, not the rusty brown color of hemosiderin.
Indianapolis, Indiana
Q: Dr. Eppley, do you perform the procedure, laser blepharoplasty? I have read about it and it seems the way to go if you want your eyes done.
A: The term or procedure, laser blepharoplasty, can mean several seemingly similar but different things. The use of the laser in blepharoplasty or eyelid surgery can mean that it is used to make the incisions, is used to remove the protruding fat pockets, or is used for resurfacing of the lower eyelid skin. Any or all of these can be defined as laser blepharoplasty. Knowing to which of these you may be referring to can answer your question better.
The use of the laser in blepharoplasty understandably captures a patient’s attention. Using the ‘Stars Wars’ effect of the laser and its seemingly magical properties, it is believed that its use would make any medical procedure better. But the laser is just a tool that can be used to cut or burn tissue and it is not a magical wand. It can not really do anything more than what a traditional scalpel or electrocautery can do. The real question is…can the laser make a blepharoplasty result or at least make the recovery quicker and better? (less bruising, swelling and pain)
Despite what many believe, there is no evidence that the use of the laser is a better way that traditional techniques for performing a blepharoplasty. While the laser can be used for a blepharoplasty for the making of incisions, vaporizing fat, and for skin resurfacing, it’s best benefit is it’s impact on marketing and the recruitment of patients for those that advertise and perform it.
Indianapolis, Indiana
Q: I have been self conscious about these bumps on my forehead ever since high school and that has been 8 years ago. It all started when I shaved my head and a friend asked me how I got the horns (bumps) on my forehead. Then my girlfriend (ex-girlfriend now) said the same thing and then my cousin. So every morning I wake up since then I have been wearing a hat, every day all day. I constantly look at my head and notice these bumps. It’s really noticable when the light hits my forehead from certain angles. I have never heard of anyone having this problem before. What causes this and how do I get rid of it? I am so self-conscious about it.
A: Most likely what you have are known as osteomas. These are the development of a benign bony mass, much like a stalagmite. Why they develop is not well known although a history of trauma to the area can cause bleeding. When blood gets under the cover of the bone, known as periosteum, they will usually calcify creating a hard mass. Your forehead issue may well be osteomas and I have seen them on both sides of the foreheasd before, looking like horns.
Skull or foreheads osteomas are fairly easy to remove. They ‘chip’ off of the underlying skull bone with a chisel or sharp instrument. They can also be burred down. While they are easy to remove, you have to have an access point, i.e., an incision somewhere. Direct access by an incision over them is the easiest and if a forehead wrinkle is close by that is an opportune place to put a small incision. They can also be removed with an endoscopic approach with the small incision back in the hair-covered scalp.
Indianapolis, Indiana
Q: I have a very asymmetrical jawline and am thinking about having a custom implant formed to the side of my jaw with the deficiency. For the rest of my face, I am hoping to achieve a balanced look, trying to get the best of both sides of my face, without exactly mirroring either side. One side is overly large, the other side is overly small. Both sides are appealing but different, except for the major sallowness to my face in my cheek area due to the smaller jawbone. I only want to have that filled in.
I was hoping to being treated with Radiesse or a facial filler to help even out the side with the deficiency without going through a drastic implant that might take away some of what I like about my face or compromising the way my muscle system has developed. Would it be a possibility to achieve some balance as a short term option?
A: One of the best benefits to injectable fillers is their immediate volume adding effects without having to undergo surgery to get it. For the soft tissue zone below the cheek bones but above the jaw line, only a filler material can add volume. This is not a facial area where a synthetic implant can be effective, there is no underlying bone to push off of.
The downside to facial fillers is that they do not last. And most will not last as long as the manufacturers claim in my experience. For this submalar facial area, good choices can be Juvaderm or Radiesse. One can expect about six to eight months of added volume before it dissipates.
Indianapolis, Indiana
Q: I would like some information about facelifts. Do you do lower face/neck lifts.? How much is the average facelift? Do you have financing for facelift procedures?
A: Very detailed information on facelift surgery can be found on my blog, www.exploreplasticsurgery.com. Just search under facelift and more than 50 articles on various aspects of facelift surgery will come up on the topic. From what a facelift is and its different types, to how it affects the facial aging process and how long they last, and to recovery and postoperative instructions after a facelift are covered in detail in these articles.
The cost of a facelift can range from $5500 to $9500 depending on the type of facelift done. More limited facelifts, like Lifestyle Lifts cost less while more complex full facelifts cost more.
All facelifts are really neck-jowl lifts and affect only the lower third of the face. It is a common misconception that it is a procedure that treats the entire face, from the forehead down to the neck. Many facelifts are done at the samed time as other facial procedures such as blepharoplasty (eyelid surgery), browlift, rhinoplasty and chin augmentation.
The financing of cosmetic surgery is common and many companies offer this service. Plastic surgeons essentually act as referral sources to these companies as both a service and convenience to their patients. One of the most popular is Care Credit although there are many others. Plastic surgeons do not offer the financing directly but provide needed financial information so that you can apply.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Have you ever used a patient’s own fat to fill in the nasolabial folds? I had it done in the past and it seems to last longer than other injectable fillers. Besides, I find it more appealling as it is completely natural.
A: The nasolabial folds have been injected with every conceivable form of injectable filler, including fat. To date, there does not appear to be an ideal filler for this, or any other, facial area. Off-the-shelf injectable fillers offer convenience but last less than one year at best. The use of fat injections is less convenient, as it must be done in the oeprating room in most cases, but does offer a natural material. Unfortunately, it has not proven to be permanent in most cases and has not been shown to last longer than commercial injectable fillers.
I do use fat as an injection material when one happens to be in the operating room anyway doing other procedures. This is a good time to take advantage of the natural or autogenous injection opportunity. This is particularly convenient when one is having some liposuction performed. In this case, some of the discard can be used for injection into the nasolabial folds.
Another fat option, not thought of very often, is that of the dermal-fat graft. Using a strip of skin with fat attached (and the top layer of epithelium removed), these grafts can be threaded into the nasolabial folds through small incisions above and below the folds. This type of fat graft provides very consistent survival. It does require a donor site, however, and that is a disadvantage if an excisional procedure (such as tummy tuck or breast reduction) is not being simultaneously performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can “love handle” surgery be combined with the hip and inner thigh area? I have lost several pounds through the years. I was told laser treatment to melt the fat would be the way to go, but not sure what would happen with the excess skin?
A: It is very common to combine at least two, and often, up to five areas at a time during liposuction surgery. It is actually very uncommon to do just one area. Since liposuction is about reshaping body areas, it usually takes several areas at a time to get the best result. The only limit that I put on liposuction in my Indianapolis plastic surgery practice is the amount of volume removal and time, which are closely aligned. I have learned by experience that it is usually best to get a single session of fat volume removal under five liters or 5,000 ccs. If more is required, then the liposuction procedure should be done in stages. This decreases the potential risk of complications and makes the recovery more tolerable for the patient.
How much skin exists around a liposuction area is critical in determining what type of result can be obtained. The skin can shrink only so much even with laser liposuction or Smartlipo. If too much skin exists, then one may need to consider some type of excisional procedure. This is particularly relevant in the neck, arms, abdomen, and inner thigh areas.
Dr. Barry Eppley
Indianapolis, Indiana
Although eyelid surgery (blepharoplasty) treats only a small area of the face, it has a dramatic impact on facial appearance. Dollar for dollar, blepharoplasty surgery has the best value of any plastic surgery procedure of the face because it is seen by all in everyday conversations. The eyes show age more than any other body part due to smiling, squinting, frowning, sun damage , and heredity. A lot of what you perceive in other people has to do with how their eyes appear. Most of us know this because when we go into work, more often than not, what does someone seem to frequently say…you look tired!
Upper eyelid surgery gets rids of hooding and excess skin that may be hanging down on your eyelashes. Upper blepharoplasty helps restore a natural, youthful appearance by removing skin through an incision in the eyelid crease. In some cases, fat may also be removed or redistributed. Since the incision is carefully placed, it is undetectable once healed. The only way that fine little scar can be seen in the upper eyelid is if they look while you are sleeping!
The lower eyelids are one of the first areas of the face to show age-related changes. Most of us know this because the appearance of bags and wrinkled skin. Loose skin and muscle create a droopy appearance and a protrusion of fat, which normally is under the eyeball, creates that classic but dreaded appearance of lower eye bags. These bags are really prone to absorbing fluids which is why they are more swollen in the morning or if you have eaten really salty foods the day before. The lower eyelids can be improved by an incision which is hidden either inside the eyelid (if fat only needs to be removed) or just below the lashline. (when all tissues need to be treated) The muscle, support tendon, and skin are reshaped and tightened back up against the eye. That protrusion of fat is either removed, tucked back in, or repositioned over the edge of the eye socket bone, dependent upon what will look best. In some patients, chemical peels or laser resurfacing can be done at the same time (only when the incision is on the inside of the eyelid) to improve wrinkles and loose skin on the lower eyelid and crow’s feet area.
One of the most interesting things about these procedures is that most patients say… the most surprising thing about eyelid surgery is the lack of pain during recovery. While eyelid surgery may look bad, it actually produces very little pain. Your recovery is largely social and about how you look.
The other comment that patients often say is…why did I wait so long? I spent a lot of money on creams and other potions and none of them worked…and they promised they would! (hope still remain the #1 selling point) Eye creams are beneficial but they are largely about prevention and not about reversing the age changes that are already there. They simply can not tighten or lift skin to any visible degree.
Dr. Barry Eppley
Indianapolis, Indiana
