Your Questions
Your Questions
Q: I am interested in making my nipples less prominent. I think they stick out too far and it can be embarrassing sometimes with different types of clothes and in colder weather. How big of a deal is it to go through and what is the recovery?
A: Nipple reduction surgery is really a very simple procedure. While nipples are undoubtably very sensitive, they can easily be made numb with a little injection of local anesthetic. The actual size of the nipple is quite small so the procedure is appropriately a minor operation. When done by itself, it is an office procedure that takes less than one hour for both nipples.
There are two basic nipple reduction techniques. Which one is best for any patient is determined by how much nipple reduction is needed and how much nipple sensation one wants to preserve. Either way, small dissolveable sutures are used so there is no need for a follow-up suture removal appointment. A small band-aid is used for the dressing. One can shower the next day and not be concerned about getting the area wet. A little dab of antibiotic ointment and a daily band-aid change is all that is needed for one week after surgery. There are no physical restrictions and one can return to running and working out the very next day. I would not, however, immerse the breast in a hot tub or swimming pool for at least one week after the procedure is done.
Nipple reduction surgery creates an immediate change. Even with the little bit of swelling that occurs, the change is readily apparent. Complete settling of the nipple takes about three weeks until its final shape and amount of residual projection is seen.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting my cheekbones slimmer or smaller. Is there any way to apply pressure to them everyday or put something on them to make them gradually get smaller without the need to undergo plastic surgery?
A: The concept of making facial bones smaller is a surgical one. No amount of pressure or any form of outward manuevers will change the shape of a facial bone. Outward pressure, even if it were possible to do, would only make the overlying soft tissues thinner (pressure resorption) but would not change the shape of the underlying bone.
Cheek bone reduction requires cutting the ‘legs’ of the bone and allowing it to sit down or inward. In some cases, only the front legs of the bone need to be cut (body of the zygoma).In other cases, the back legs (zygomatic arch attachment to the temporal bone) need to be cut as well. By inward positioning of the cheek bone and its backward bony arch, the width of the face is narrowed. When done on both sides of the face, the narrowing effect can be quite noticeable.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I am in the military and am unable to make tape or weigh ins. I had two c-sections and my stomach looks like I am still pregnant. I am also having trouble passing my sit ups. I will not be able to be promoted until I am able to make at least tape and pass my fitness test. I have tried everything to lose the weight from my tummy but I haven’t had any luck. Not even basic training has helped slim my tummy. I am desperate to do something and I think a tummy tuck may be the only answer. How long does it take to recover from this procedure?
A: This is a tummy story that I have heard quite often in my Indianapolis plastic surgery practice. Women often come in for a tummy tuck (abdominoplasty) when they have exhausted all of the conventional options for trying to make it look better. Most women do view a tummy tuck as a last ditch effort.
When you have suffered the ravages of pregnancy, no amount of dieting or exercise will improve stretch out loose skin and muscles. The protruding floppy stomach is not just a ‘fat’ problem. It is tissues that have been irreversibly damaged. While I think it is prudent to get in the best shape as possible before undergoing a tummy tuck, those efforts will not repair the tissue damage which exists.
While a tummy tuck is a wonderful body shaping operation, it should be considered major surgery. With major surgery comes a significant recovery. While recovery can be defined different ways, complete recovery that would allow one to perform strenuous activities will take six weeks for most people.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a tear trough and orbital deformity. One year ago I had surgery in which malar implants were placed. But it is too big and was the wrong choice for me. I only wanted to make my midface look healthy. I want make another surgery in 3 months and I now think an orbital rim implant is the right choice for me. Do you have experience with this type of facial implant and what are your feelings about it? Are the risks for an orbital rim implant surgery higher than a malar implant which I have now? Thank you very much.
A: The use of malar vs. orbital rim implants are for completely different facial problems or concerns. Even though they are anatomically close and contiguous, what effects they have on facial structure is completely different. If a malar implant was used in the treatment of a tear trough (orbital) deformity, it would have likely made it look even worse.
The midface has six structural components to it including the orbital rim, malar, lateral malar, submalar, paranasal and maxillary regions. The tear trough deformity represents a central and medial soft tissue recession even though the underlying bone deficiency may extend out into the malar area. Tear trough, also known as orbital rim, implants come in several different shapes and sizes which differ in the extent of the orbital rim that they cover and in how much projection they provide. It requires a careful assessment of the lower orbit and cheek to see which implant is best. Even with good implant selection, tailoring and shaping for fit is almost always required.
Unlike malar (cheek) implants, orbital rim implants must be placed through a lower eyelid (blepharoplasty) incision. This induces one potential risk that does not exist with an intraoral approach for malar implants, that of ectropion or lower eyelid retraction. Careful handling of the eyelid tissues and orbicularis muscle and canthal suspension are needed to avoid this potential problem.
Of all available facial implants, orbital rim implants are the most sensitive to size, placement and incisional access. To those with a lot of experience in maxillofacial trauma and craniofacial surgery, orbital manipulations is a comfortable place to work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My 12 year old daughter has had both ears repierced due to holes closing, but now the newer holes have closed due to infections and she now has unattractive scar tissue. Is there a surgery that she can have done to remove the scar tissue so she can wear earrings again? She has been very upset about this for a couple of years now. Thank you!
A: Despite the large number of earlobes (and ears) that get pierced, the number of infection and scar complications is remarkably low. This is a testament to the good blood supply to the ear and its relative resistance to typical skin bacteria. But minor complications to piercings do occasionally occur and, while they all resolve, they often end up with excessive scar tissue formation over and around the original ear hole.
Removal of earlobe scar tissue can easily be done with minimal to no visible deformity of the earlobe later. It is a simple ear plastic surgery procedure. Under local anesthesia, the scar tissue can be cut out and the earlobe defect closed. Because the earlobe has no cartilage framework, it is very elastic and flexible. This makes for closing most earlobe defects relatively easy without causing a visible deformity such as a notched earlobe or making it significantly smaller than the opposite earlobe.
There is one difficult type of earlobe scar, that of a keloid. While many earlobe scar patients think they have a keloid, they really have a hypertrophic or typical scar. A keloid is an abnormal form of scar tissue formation that will not stop growing, often causing a cauliflower-like appearance to the scar and distorting the entire earlobe. These have high rates of recurrence after being removed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in cheek bone reduction surgery. I want to know if there are any permanent side effects or can they develop years later.
A: Reduction of prominent cheek bones is not nearly as common as augmentation or enhancement of deficient ones. Cheek bone reductions are almost always an ethnic request, usually commonly from patients with Asian or Pacific Rim heritages. Usually the concern is that the cheeks are too wide and the goal is to try and have a more narrow or ‘slimmer’ facial appearance.
Narrowing the cheek area is done by first understanding the shape of the bone. The zygoma (cheek bone per se) and the zygomatic arch (which extends back to attach to the temporal bone like a spanning bridge) together form the width of the middle part of the face back from the eye area. Reducing its width comes from cutting the bone (zygomatic osteotomies) at the two attachments of the bridge and allowing it to settle inward. Sometimes only the front part needs to be cut through the cheek bone itself. (done from inside the mouth) Other times the back part where the zygomatic arch attaches to the temple needs to be cut as well. (done from a small incision in the temple hair)
The biggest potential side effect or risk of the procedure is asymmetry, one side not being as far inward as the other. In theory, if the zygomatic arch goes in too far (unlikely), it may impinge on the masseter muscle causing some pain on oral opening and eating. (that I have never seen)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to have a consultation but live far away. Can I get some answers to my questions on the phone or by e-mail? I have read that some plastic surgeons consult with patients online. Is that possible?
A: The large amount of internet material on cosmetic surgery has helped to fuel the demand for these procedures. But access to the internet is not, unfortunately, always the best way to get accurate information. Prospective patients still need a professional to help them decipher what all they read means and how it applies to their individual needs. While an actual visit to a plastic surgeon and a face-face consultation is a necessary step before ever scheduling surgery, the accessibility and low expense of the internet provides a very convenient method to answer some basic questions from afar.
In my Indianapolis plastic surgery practice, I use the internet service, Skype, for webcam video conversations. For the first time in medical history, it is now possible to have an online video discussion with a plastic surgeon from anywhere in the world provided you have a webcam on your computer or laptop. (you can even do it from your smartphone)
To take advantage of this option, first find a plastic surgeon who offers Skype and performs the type of cosmetic procedures in which you are interested. Then go to the Skype website, download the application and register under your name. This process is free and takes less than five minutes to do. You will need to add the plastic surgeon to your contact list. That requires knowing how their name is registered and that should be available on their website. In my case, it is dr.barry.eppley. Add the name to your contact list and then send a message requesting a video conversation.Tell briefly in the message what your subject area or concerns are.
While this video conversation method is not a replacement for having an actual consultation in the plastic surgeon’s office, it provides a unique opportunity to ask questions directly to a plastic surgeon without leaving the comfort of your own home or city. It can be a great first step in your informational gathering process.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was wondering if you had any procedures that would reduce severe stretch marks. I just had a baby and my baby tummy is very loose and I have really bad stretch marks.
A: Stretch marks are a very common skin deformity that results from Ebook Creation Simplified tissue expansion(e.g., pregnancy, weight gain) followed by deflation thereafter. (e.g., delivery, weight loss) What stretch marks really represent is IRREVERSIBLE skin damage from partial tearing of the dermal component of the skin. The thicker collagen layers have been partially split due to the stretching of the skin. That is why when you run your fingers over them they feel rippled or indented over the stretch mark. There has been a loss of some of the skin’s thickness.
Why some women get them from pregnancy and others don’t is a result of numerous skin factors. These include their native thickness and elasticity of the skin and how much and how fast the skin was stretched. There probably is some merit to apply a topical emollient or moisturizer to the skin during the pregnancy process. Anything that can hydrate the collagen layers to allow it to stretch without deformation (irreversible breaking of the molecular bonds, like a broken spring) would be helpful.
Once the stretch marks exist, however, solving or eliminating them is virtually impossible. While many urban legends exist about ‘magical potions’ and patients who have completely gotten rid of them, there has never been any scientific or documented evidence that these often touted methods really work. It is simply not possible to thicken back up or repair the split dermis anymore than you can restore the tighten of a stretched out rubber band.
That being said, however, there are some treatments that may help reduce their final appearance if they are done early. Early means within less than 90 days after delivery or when they have appeared. The redness of the stretch mark can be reduced by pulsed light treatments (BBL) in my Indianapolis plastic surgery experience. Early treatment may help make the stretch mark do some collagen repair so it is less deep. The key, however, is EARLY treatment.
It is possible to lessen the appearance of new stretch marks if done early enough. In established stretch marks, there are no effective treatments. Stretch marks are not responsive to laser or skin resurfacing and any attempts to do so may result in a worse scar appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have breast implants originally placed in 2002. I got pregnant shortly afterwards and once I delivered my breasts changed afterwards and I developed some drooping. So I went back and had new implants placed in 2007 that were bigger and helped to fill out some loose and droopy skin. After having these implants for a while, I have decided that I want to go back to my original augmentation size. But I fear in doing so that I will get saggy breasts again. What do you recommend?
A: Going up in breast implant size is always easy because loose skin is expanded and filled out. While breast implants alone are often not the sole solution to a really saggy breast, they do help tremendously and are very forgiving of less than ideal breast skin.
Going down in breast implant size, however, is not so forgiving. Even the smallest amount of loose or droopy breast skin will get much worse as the ‘balloon deflates’ so to speak. As a result, some form of breast lift is often needed in many breast implant downsizings. What makes this aesthetically difficult is that this will involve creating breast scars which is another form of a cosmetic breast deformity.
If the nipple is fairly centered on the breast mound, a smaller implant replacement may not involve any type of lift or only a very small one such as a nipple or circumareolar type lift. If the nipple is off-center or points any amount downward, then a more significant lift with breast skin scars may be necessary when the breast implants are down-sized.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m interested in learing more about dermabrasion or micropeeling. Can this be done on the eyelids? (above and below) Will this help reduce the beginnings of a fold in the top eye crease? I live two hours away. If you can answer these two questions about this procedure would help me determine if I should come in for a consultation.
A: By the way your question is phrased, it appears that you seek a non-surgical solution to the appearance of wrinkles on the eyelids. There are a variety of skin resurfacing methods that are commonly used on all other areas of the face so it is reasonable to ask about their use on the eyelids.
The eyelids represent skin that is very unique from that of the rest of the face. It is different primarily because it is so thin. Being thin makes it very sensitive with higher risks of scarring if the skin resurfacing method is not carefully selected and performed.
Microdermabrasion (superficial) and dermabrasion (deep) are not effective (microdermabrasion) or safe (dermabrasion) skin resiurfacing methods for use on the eyelids. Traditional laser resurfacing is not either for the same reason that dermabrasion should not be used, it penetrates too deep.
The use of laser micropeeling and chemical peels, however, are both effective and safe methods for the eyelids. Laser micropeeling at the depth of 20 microns or less, TCA (trichloroacetic acid) chemical peels of 15%, 25% and 35% as well as the newer Vi chemical peel are all potential choices. Which one of these is best for your eyelids will require an actual consultation to determine.
Another very effective option is the combination of ‘mini-blepharoplasties’ with chemical peeling. The actual removal of a small amount of excess skin and then tightening the rest can be a very effective eyelid wrinkle-reducer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m a 62 year old female interested in widening a narrow face with a chin/jaw widening implant that would also help with jaw lifting and mild jowls. Is this possible for someone my age?
A: It is unusual for a female at any age to desire a wider lower face. This is almost always a male procedure for the obvious reason of making the jaw line more prominent to create a masculinizing effect. It would be particularly rare, and the first time in my Indianapolis plastic surgery experience, to have an older woman make that request.
I suspect that the real reason for this request is to help improve the classic signs of facial aging which is that of jowling, loss of the jaw line, and neck sagging. While it is true that jaw line enhancement at the chin and even more posteriorly at the jaw angles can help fill out a lower face, I question whether the effect would be significant enough to achieve your goals.
While I will have to see your pictures, it is possible that chin and jaw widening in combination with a limited or tuck-up facelift may create a more ideal result. Widening and lifting along the jaw line is a diametric movement of soft tissues that will usually result in a better outcome than either procedure done alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I need help with my nose and lips. Four years ago I had a rhinoplasty. While no work was done on my lip it changed after surgery. My upper lip seems longer than before. My upper lip was long to begin with but now it covers my upper teeth and rests heavily on my lower lip when at rest. My nasolabial angle changed so that it is more of a 90 degree than tethered as it was before. I am a female 32 years old and was wondering if these problems can be fixed.
A: It is unusual for one’s upper lip to change after rhinoplasty but it is theoretically possible. If the base of the caudal septum, where there are muscular attachments at the anterior nasal spine, is resected to change the nasolabial angle, it is possible that there may be some release of the upper lip as well. If one had a longer upper lip to start with, then the risk of lip lengthening is greater.
Regardless of how it may have happened, a longer upper lip can be shortened by a procedure known as a subnasal lip lift. That can be very effective at reversing your lip lengthening that has occurred and can even make it shorter than were you were prior to your rhinoplasty. As a general rule, an upper lip lift can remove up to one-third of the skin length between the nasal base and the height of the cupid’s bow along the philtrum.
Changing of the nasolabial angle can also be done. While it is far more common to open up the nasolabial angle during rhinoplasty with caudal septal resection, the reverse can also be done. This would require a septal cartilage graft attached to the caudal septum which is so placed that it pushes back down on the nasal tip cartilages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have several old scars on my legs that really bother me. I had laser done on my scars over a year ago in a plastic surgeon’s office but I don’t see any improvement. How can I get rid of my scars?
A: When discussing possible scar treatments, one concept that needs to be eliminated from any patient’s vocabulary is the phrase, ‘getting rid of scars.’ A scar represents permanent damage to the skin layer that once had normal tissue (with good color and suppleness) replaced by abnormal tissue. (depigmented, less pliable) Therefore, the realistic goal is scar reduction not scar elimination. This is why the term ‘scar revision’ is fairly accurate, the scar may be improved but it is not completely eliminated.
While scars on the face represent the best opportunity for maximal scar reduction, scars below the neck are not so forgiving. This is because trunk and extremity skin is thicker (thicker dermis creates more scar) and the healing wounds are exposed to more shear and frictional stresses which work to stretch out the scar. Therefore, non-face scars never (and I emphasize never) can look as good as facial scar work no matter how it is done or by whom.
Leg scars represent the least successful area for scar revision on the body in my Indianapolis plastic surgery experience. They are particularly refractory to any significant improvement for the reasons stated above, particularly below the knee. The thickness and tightness of the skin in this area makes scar revision work difficult.
Lasers are often touted and perceived as having some magical properties for scar improvement. While lasers do have a role in scar treatments, it is not a dominant one. They are best used as a finishing treatment for some minor skin resurfacing or retexturing. They are not like an eraser tool on Photoshop.
Dr. Barry Eppley
Indianapolis Indiana
Q : My jaw is asymmetrical. It is tilted and is also bigger on one side. I have read some of the articles you have written on facial asymmetry and wanted to ask you about how best to correct my problem?
A: Jaw or mandibular asymmetry is often a major cause of facial asymmetry. Often the entire side of one’s face is different if one looks for it carefully. Sometimes it is the lower face (jaw) that is the most significant part, other times the cheek, orbital, and forehead bones are equally involved and part of the problem. It is critically important to assess both sides of the face from top to bottom with photographs and measurements from different angles to get an accurate assessment.
In most cases of minor to moderate facial asymmetry, camouflage techniques are used. This means the use of facial implants to lengthen and broaden the smaller and flatter facial prominences. These are good options for jaw angles and cheeks. Chin asymmetry is often better done with osteotomies where the bone can be differentially lengthened between the vertically shorter and normal sides. Soft tissue deficiencies can be simultaneously improved by fat injections.
If significant facial asymmetry exists and one’s occlusion (bite) is very tilted, another consideration is orthognathic surgery. In younger patients this may be a better option if one is prepared to go through several years of preparatory orthodontics and then jaw surgery to directly treat the primary bone, differential bone growth.
Dr. Barry Eppley
Q : I would like information on the horizontal chin reduction procedure. My chin juts forward to a point (witches chin) and I think it being reduced would really help my appearance. Most interested in knowing how the procedure is done, down time needed for recovery, surgery location (outpatient in center or hospital, or in physician’s office), and rates of success.
A: A big chin (macrogenia) can be either too far forward (horizontal excess), too long (vertical excess) or a combination of both. Determining the 3-D dimensions of what makes the chin too big is important as it can change the method by which the chin is reduced.
Horizontal chin excess is best reduced through a submental (under the chin) incision rather than from inside the mouth. This is because it is important to properly manage the soft tissue excess which will result once some of the bone support is removed. If the soft tissues are not removed and tightened, one will end up with what is known as a witch’s chin deformity. (exactly the appearance of what you wanted to improve in the first place!)
The chin is horizontally reduced by burring down its prominence and tapering the bone into the sides of the chin. The mentalis muscle is brought down over the underside of the reshaped chin and any excess removed as it is re-attached to the its fellow muscle. Likewise, redundant skin and fat are removed so that the chin soft tissues are nice and tight.
Chin reduction surgery is done as an outpatient surgery under general anesthesia. It takes about an hour to perform. The chin is taped and will be sore but there are no restrictions after surgery. It takes about 3 weeks for the chin swelling to largely go away and it begins to feel normal again. The success rate is 100% in terms of having less horizontal projection. The usual amount of actual horizontal chin reduction that is achieved is from 5 to 8mms.
Dr. Barry Eppley
Q : I have broken my cheekbone 2 times and never had surgery. Now my face is assymetrical and I have frequent headaches and can’t breath thru one side of my nose. People close to me say that my face looks caved in. It also affects my vision and I sometimes have localized pain in my cheek. Do you think my insurance will pay for reconstructive surgery? How would this be fixed?
A: Cheekbone, or zyomatic or malar, fractures are common facial bone injuries. They are second in frequency to the most common facial fracture, that of the nose. When a cheek bone fractures, a classic set of problems results from the bone rotating downward into the maxillary sinus. The cheek prominence will become flatter (caved in), one may develop sinus congestion, and numbness or pain may occur from the infraorbital nerve being bruised or pinched. (the fracture line usually goes through the nerve foramen) It does not usually cause any vision problems.
If not repaired early, the secondary cosmetic deformity is that of an asymmetrical face with a flatter cheekbone prominence. There are two ways for its correction after the bone has healed. Building out the depressed cheekbone with a cheek implant is often very successful and is certainly the easiest. The other approach is to re-cut the cheekbone and move it back into its proper place. This is obviously more complicated with a longer recovery but can also be successfully done. Which approach is best is largely determined by the magnitude of the cheekbone depression and whether it extends into the surrounding orbital (eye) area.
Typically, reconstructive surgery from a facial bone fracture should be covered by one’s medical insurance. However, this must be determined by a written pre-determination process before proceeding to surgery.
Dr. Barry Eppley
Reality TV is often far from ‘reality’ but sometimes there is a kernel of significance in a portion of a show. In a recent episode of the ‘Real Housewives of New York City’, one of the women accompanies her friend to a plastic surgery consultation. During the show, she recommends and helps her friend to ask the plastic surgeon some important qualifying questions about liposuction in which she has interest. During the consultation, the women asked the plastic surgeon if he was board-certified and when, did he have operating privileges at a hospital for the procedure in question, and if he was a member of American Society of Plastic Surgery.
While these questions would no doubt bring acclaim for our national organization, these queries today can be answered long before you ever enter a plastic surgeon’s office. If you have to get these basic qualifying answers from a personal visit, you mustn’t have a computer in your house or have never ‘Googled’ or ‘Binged.’
Historically, patient’s were advised to ask a basic list of questions to their plastic surgeon to be certain they were qualified to perform the surgery. These included board certification and in what specialty, society membership and hospital privileges. While these are still good questions, they are so simple to find and don’t have the significance that they once did. If the plastic surgeon doesn’t have a contemporary website that easily provides this information, I would quickly move on to one that does. An informative website for a plastic surgeon, or any business for that matter, is an essential as any individual having a cell phone. If one isn’t investing in an internet forum for patient education, I doubt if they are investing much in advanced medical education either.
With today’s ease of information gathering, photo acquisition, and methods of presentation, contemporary plastic surgery qualifiers are much different and more defining. I believe these are the more relevant questions to search for in finding a qualified plastic surgeon. They include photographic demonstration, recent patient experiences, and educational information.
Photographic publication surrounds us at every corner today. Whether it is on Facebook or other social media, even the most basic cell phone can take a pretty good picture. Plastic surgeons are the most advanced and proficient of all medical specialities in photography on average. Therefore, one should come to expect a good demonstration of a plastic surgeon’s most valued asset, before and after patient photographs. While it is true that any business is going to put out its best results, at the least you need to see a handful of actual patient before and after photographs. The more, the better.
A past customer’s experience is a good barometer of service and results for any business. But a patient who had surgery a long time ago is not as useful as one who has had a surgical experience in the past weeks to months. Fresh experiences are what you need and preferably from more than just one patient. Having a recent patient also suggests that the procedure is performed more than just a few times a year.
Brochures and flyers are standard educational pieces in any plastic surgery practice. But there are so many boiler-plate pieces that are available to purchase for any plastic surgery procedure that they are not only unimaginative but provide generic (and often useless) information as well. What you want to see is customized practice information that provides detailed and meaningful procedure information that reflect’s what that plastic surgeon specifically does. You want to know what this plastic surgeon does, not what the ‘average’ plastic surgery approach is.
Dr. Barry Eppley
Q: I am inquiring about the correction of a pixie ear deformity from a previous face lift done two years ago. I have read about so I know what it is. How did this happen and how can it be corrected. My ears really look funny and that is not a good look for someone 55 years old!
A: The pixie ear is a well known earlobe deformity that can occur after a facelift. It has been described for decades and, while once more common, modern facelifting techniques have largely eliminated this problem.
While folklore pixies are usually cute and even beautiful, they often have distorted facial features. One of those is the elongated earlobe, hence the name pixie ear deformity. If a facelift is pulled up too much (undue tension), there will be some secondary pullback of the tissues later due to gravity and wound relaxation. Since a facelift incision goes around the ear, the earlobe at the lower end of the facelift incision can show how much the tissues have pulled back down. Because the earlobe is the only portion of the ear that is not supported by cartilage, it can easily be pulled downward months later as tissues settle. Since this is a well recognized potential problem, plastic surgeons strive to keep the tensions point on the scalp areas above and behind the ear and not on the earlobe. It is also helpful to not try and pull a facelift so tight.
Correction of the pixie ear is relatively simple. The earlobe can be detached and restored to its normal shape. This will leave a small residual scar below the earlobe but it can be done in the office under local anesthesia. If it has been years and some jowl or neck relaxation has occurred, one can undergo a simple tuck-up facelift and restore the earlobe shape. By relifting some small amount of loose facial skin, there would be no visible scar below the earlobe as it is tucked back up underneath.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I am in the beginning stages of finding a surgeon for breast implant replacement to suit my needs the best. My previous surgeon has since retired and my breast implants are almost 10yrs old. They are saline and I am now a D cup but was a C cup when they were new. I don’t think the increase is due to weight gain. I think its because they have dropped a bit. What do you recommend in regards to implant replacement.
A: The ‘need’ to replace breast implants occurs either to a desire for some type of further enhancement (size change) or an existing problem with one of both of the implants. When it comes to saline implants, the absolute need to replace them is when one fails or deflates. There is no need to change just because they are getting older. My Indianapolis plastic surgery practice motto has been on this very subject…’if they look and feel fine, then there is never a need to replace a saline breast implant.’
That being said, most saline breast implants will eventually undergo a deflation usually in the 10 to 20 year range after their initial placement.
One of the unrecognized (by patients) phenomenon of breast implants is that they can change position over time. Whether it be weight loss, pregnancy, or a larger size implant, the soft tissue containing them can and often does change. When the soft tissue around the implant changes (stretches or relaxes), the position and shape of the breast may soften and settle. In larger implants, their size and weight may cause the lower breast fold (inframmary crease) to drop. This sounds like what has happened in your case.
While silicone gel breast implants were not available 10 years ago, you should seriously consider converting to them at this point if you are looking for further breast improvements. They will not have rippling and may feel softer and more natural. You would also eliminate the lifelong risk of a spontaneous implant deflation. When replacing the implants, you may also consider repositioning of the lower breast fold back up higher to correct any implant bottoming out that has occurred.
Dr. Barry Eppley
Q: I was just wondering if I am a good candidate for a tracheostomy scar revision. I had a tracheostomy back in 2005 and never knew that a revision surgery was possible until recently. I am really self-conscious of this hole in my neck. Plus it constantly reminds of why it is there in the first place. (a car accident)
A: Tracheostomies that remain in for any extended period of time (weeks to months) will often leave a depressed scar once they are removed and heal. This is the result of a phenomenon known as pressure atrophy of the subcutaneous fat. The pressure of the tube and the subsequent scar that it creates results in fat loss and tethered or scarring down of the skin edges. Tracheostomies wounds are now closed after tube removal and are allowed to heal in on their own.
Some initial tracheostomy scars may look depressed or indented but may ‘fill out’ as healing progresses to an acceptable level. This is why I don’t do tracheosotomy scar revision in the first six months after tube removal unless the wound has real trouble healing. Conversely, it is never too late to revise the depressed neck scar.
Many tracheostomy scars can be improved by simple scar revision. Others may require some fat volume restoration with scar revision. I prefer a small dermal-fat graft to replace the lost tissues between the scar overlying the trachea and the underside of the skin. Even a small graft, 2.5 cm x 1 cm, can be really helpful. There is no substitute for your own natural fat for small areas of tissue filling. The graft can be easily harvested from old scars almost anywhere on the body.
Dr. Barry Eppley
Q: I have some acne scarring on my face that I`d really like to get rid of. I have a rolling icepick scar and I want to know if a deep chemical peel would help. It isn`t very deep. One maybe two layers deep. Help! What should I do?
A: To understand whether any form of skin treatment or resurfacing will reduce a specific scar, it is important to appreciate the depth of the scar compared to the thickness of skin. Then one can look at the treatment method and see if it can go to the level of the depth of the scar.
Let us, for the sake of this discussion, assume that facial skin thickness is 1mm or 1000 microns. (some areas of the face are thicker and some areas are thinner, but let’s use this simplistic number as it is easier to understand) The top epithelium usually occupies about 5% or so, around 50 to 75 microns. This is the part of the skin that peels and sloughs off and is easily regenerated. The rest of the skin, 95%, is a thicker collagen called dermis. It is into the dermis that all visible scars really go. Most visible scars are at least several 100 microns (100 to 500 microns) Pitted or icepick acne scars will usually go much deeper than even that level.
Microdermabrasion, for example, removes only 2 to 4 microns of skin. This is why it is not an effective scar treatment, it simple can’t go deep enough. Microlaser peels, or superficial laser peels, remove skin from 10 to 50 microns. They have a minor effect but it will take a lot of treatments to have any visible scar reduction. Deeper CO2 laser peels do go down 200 to 400 microns which is why they can be more effective for scar reduction. But a laser peel can not go too deep (greater than 400 microns or so) or it will be a source of its own scarring.
Chemical peels, even deep ones, do not reach these laser depths. This is why a chemical peel, of any sort, is not an effective scar treatment.
Dr. Barry Eppley
Q: Hello there… I was curious on whether you dabble in computer imaging for let’s say a jaw enhancement procedure. Thanks.
A: When considering structural facial alterations, as opposed to age-related changes, it is extremely important for the patient to have a reasonable idea as to what their face may look like. For this reason in my Indianapolis plastic surgery practice, I never do such facial surgery without computer imaging before surgery.
Several points about computer imaging, however, are important for patients to understand. First, facial computer imaging is a prediction but not a guarantee of results. It is the plastic surgeon’s best estimate of what he or she thinks may happen. But plastic surgery is not like Photoshop. How the body heals and responds to surgical manipulation of its tissues is not precisely predictable. Think of computer imaging as a communication tool primarily. It helps ensure that what the patient finds acceptable is surgically possible.
Secondly, the most predictable facial features to image are those that can be done in profile. With a contrast between flesh-colored skin and a solid color background, it is much easier to change the feature in a more precise manner. Therefore, procedures that change the brow (brow bone reduction), nose (rhinoplasty), chin (chin augmentation/reduction), and neck (liposuction, facelift, tracheal reduction) can be imaged with reasonable realistic accuracy. Certain frontal (face forward) structures can also be done, such as the ears and lips, but most of the face is this view do not have good color contrast between adjacent parts.
Last, if you can not get computer imaging for these types of facial plastic surgery procedures…go find another plastic surgeon.
Dr. Barry Eppley
Q: I have read about using my own fat as an injectable filler. This seems like a perfectly natural, and if I must say, an obvious thing to do to build up certain body areas. Is it not widely done however and several plastic surgeons that I have talked to either don’t do it or seem uncomfortable or unfamiliar with it. Is this because it doesn’t work well or is there something unsafe about it?
A: The concept of injectable fat grafting is in a state of development or evolution. Liposuction makes for an easy way to harvest an injectable natural material but its survival or retention after injection has been the issue. Using the fat suctioned from the body, technologies exist and are being developed to process the fat and extract and concentrate either the fat and/or the stem cells which naturally occur there. The concentrated fat with or without stem cell concentrate is then injected into the desired areas of the body or face.
Currently, more marketing than science exists about injectable fat grafting. Unfortunately, some surgeons actually tout that they have developed such a procedure and have ‘proprietary or special’ methods of their own to prepare an injectable fat concentrate. Multiple uses are being done from to facial or hand fillers. I have even read from some surgeon’s websites that their procedure ‘not only removes fat you don’t want, but it replaces it and changes multiple areas of your body, making for a more full-body change.’
The good news is that injecting your fat poses no harmful effects other than it may not work well. The less than good news is that some are claiming benefits that have yet to scientifically substantiated or proven. Injectable fat grafts holds great promise and, for small volume areas like the face and hands, does seem to be significantly retained. Good success has also been seen in the buttocks although multiple grafting sessions may be needed to get the best size result. Other areas, such as the breast, are purely investigational for now and are far from a replacement for implant augmentation.
Dr. Barry Eppley
Celebrities who undergo plastic surgery without question have a compelling influence on the general population, particularly those under the age of 40. One has to look no further than the checkout aisle in the grocery store to see how celebrity visibility is thrust upon us. From these consumer magazines to numerous television shows, anyone with a Hollywood connection is tracked and speculated upon about their cosmetic surgery, even if they have never had it. The media’s desire to push these cosmetic surgery tales of the stars fuels the public’s obsession with discovering the secrets to what keeps the beautiful and famous looking so.
While the star’s experiences may fascinate, they do little to actually educate. It is easy to confuse entertainment with reality because it is simply more interesting. Take the recent case of 23 year-old Heidi Mondag who had numerous cosmetic procedures done to satisfy her narcissistic and career agendas. While she may have had a lot of procedures, they were all quite small in scope. Most of her procedures were really ‘nip and tucks’ and not major overalls. After all, how many physical problems could a young person really have particularly given her appearance beforehand? But this is not how the media interpreted her surgery. Rather it was made to sound like it was a great undertaking and required supernormal surgical skills to complete.
These ‘tweakments’ are largely what is fueling the increasing visibility of plastic surgery. Botox, injectable fillers, lasers and minor skin lifts of the face have created a whole new set of treatment options that did not exist just a decade ago. While a 23 year-old partaking of this cosmetic menu does border on the overly self-indulgent, those in their late 30s and 40s have a more significant purpose. Fending back the early signs of aging is proving to be a more effective strategy than awaiting the day when major plastic surgery is needed. While my mother may have waited until retirement to wage the battle against the effects of time, today’s middle agers understandably what to look better and more rested now.
What is unique about these minimal procedures is that most of them are fueled and promoted by the cosmetic device and pharmaceutical industry. Plastic surgeons have taken a back seat to the promotions and marketing that billion-dollar-in-sales companies can do. The once retail approach to cosmetic and beauty products has expanded to include drugs and surgery. Targeting consumers through popular magazine and internet strategies, rebate coupons for Botox and eyelash stimulants are widely available as well as even franchise surgery for facelifts. Breast implant sizer kits are mailed to prospective patient’s homes with incentives for other procedures packed inside. Plastic surgeons collectively spend an insignificant fraction on marketing compared to that of the corporate world. This wave of industry’s promotion for profit and media attention for sales is why most people today know something about cosmetic enhancement and why it is now mainstream.
But like all entrepreneurial endeavors, making a profit and driving sales does produce some good byproducts that have wide benefit. Like the old commercial slogan from decades ago, there is ‘better living through modern chemistry’.
Dr. Barry Eppley
Q: Just wondering how common abdominal etching is amongst females. Most research online seems to be pointing to men only.
A: Abdominal etching is a plastic surgery procedure for the artificial creation of a ‘six-pack’ appearance. This is done through liposuction techniques by removing linear strips of subcutaneous fat to highlight where the muscular inscriptions would be. This creates indentations in the overlying skin which looks like muscular definition. It should only be considered in a fit individual whose has a limited fat thickness over the abdominal area. It not only works better in this type of patient but will also look more natural. I currently use a Smartlipo technique which has a 3mm wide probe and metal cover which creates nice thin tunnels with very small entrance incisions. The heat from the laser helps the skin contract down as well.
You are correct in that it is much more commonly requested and done in men. That undoubtably reflects our current cultural fashion standards where men are defined by their muscle mass and definition while women are better appreciated for their curves. (history also shows that this is true through the ages) In my Indianapolis plastic surgery practice for every 10 abdominal etchings I have done, nine are done in men. But I have done a few in women.
The surgical technique is the same in women and is actually a little easier to do with more consistent definition in my observation. This is likely due to the thinner subcutanous fat layer that exists in most athletic women.
Dr. Barry Eppley
Q: Hello, I wonder if you can help my son (19 year of age) who suffers from low self esteem due to the appearance of his head size since he started school. He has seen four psychologists and therapists to help him deal with his concerns. The problem is his head size which is too big. I know that nothing can be done to reduce the overall size of his skull but he also has very prominent brow bones which draws attention to his face making him more self conscious. Can anything be done about this?
A: Skull shape and size is one of the features of our appearance that we take for granted…unless it is too big or small and out proportion to the rest of the face. When the skull is bigger, a form of cosmetic macrocephaly, the sheer thickness and surface area of the bone make any reduction not practical to surgically consider.
It is not surprising that another part of the skull (brow bones) is big given the overall size of the skull. Changing something on the face that is likewise bigger and out of proportion as an alternative is a form of ‘camouflage’ and can be psychologically empowering. When faced with a physical problem that is unchangeable, being able to positively modify something else can be a good diversion that can provide some self-image enhancement.
Prominent brow bones are the result of overgrowth or pneumatization of the frontal sinus. Reducing them involves takes off the front table of bone, which is quite thin, and putting it back in a reshaped and flatter form. That can soften the forehead and orbital appearance which is where most eye contact in conversation is directed.
Dr. Barry Eppley
Q: I have multiple lipomas along nerves in my arm and am interested in finding out how to get injections to decrease their size. These lipomas give me pain because they are up against my ulnar nerve. I have about 80 lipomas all over my body. I am female, fit, 35, and frustrated with surgeries to remove them.
A: While the benign fatty tumor, known as a lipoma, are common soft tissues masses seen, multiple or many lipomas that recur in a patient is uncommon. When large numbers occur, they are as familial lipomatosis. Throughout one’s life new ones continue to grow and develop. Modern medicine does not have an explanation for why they develop or what causes them.
While I have had positive experiences with Lipodissolve in the treatment of more superficial lipomas, I would have concerns about injecting near a motor nerve. There is the distinct possibility that permanent damage may occur to the nerve, causing forearm and hand dysfunction. That is a risk that would not be a good trade-off.
Lipodissolve remains a non-FDA approved treatment method for any type of fat removal or shrinkage. It is not even a pharmaceutical-grade chemical as it is made through compounding pharmacies. While widely used as a cosmetic treatment for ‘dissolving’ fat, its use as a lipoma injection treatment has never been scientifically evaluated in any clinical trial method although anectodal reports exist that attest to its effectiveness.
If these ‘lipomas’ in fact do involve or are connected to the nerves, they may well be neuromas or neurofibromas which would not be responsive to fat-dissolving injections anyway.
Dr. Barry Eppley
Q: I am interested in getting a portion of my skull reshaped. The top part is narrow and slopes off to the sides. As a man with shorter hair, it would look better if the top was rounder and didn’t slope so much. Can some material be added to build up these areas? There are also two smaller areas on the sides which need reduced. I have attached some photographs which show the areas that I am concerned about.
A: Thank for sending your detailed photographs. That is extremely helpful and you have clearly defined what your skull contouring needs are. There is no question that all of those contours issues can be done. Whether it is some side reduction by burring in the two spots you have indicated or adding a material (PMMA acrylic vs HA hydroxyapatite) to give it a more rounded shape and decrease the slope, that is very straightforward from my standpoint. This is fairly simple craniofacial plastic surgery as it is outer table cranial contouring.
The most relevant question is one of surgical access. While all of those can be done, it is most ideal to do that through an open scalp incision. While you have a wonderful head of hair, this would leave a fine line scar. Given that you wear your hair very closely cropped, I would be concerned that the trade-off of this scar versus the skull contour concerns may not be a good one. I would need your further input on that issue.
Otherwise, there are some more limited injection methods to place materials under the scalp onto the skull bone. This is best done with PMMA which hardens after being injected and can be molded while it hardens. Such limited approaches do not provide enough access for the side bone reductions though. The other injection option would be to place fat grafts instead of a synthetic material. This can be done with a few simple punctures using your own abdomen as the harvest site. The disadvantage of fat grafts is their unpredictability of survival however and how smooth and even the contours would be.
Dr. Barry Eppley
Q: I am interested in some form of gynecomastia surgery. At one time I was much heavier and have lost a lot of weight through the help of bariatric surgery several years ago. Since the weight loss, much of my chest has not only gone flat but it sags with nipples that are very stretched out. My chest needs to be reshaped. Help!
A: Chest changes after weight loss are common in men. Men suffer a deflation of the chest soft tissues after bariatric surgery which is magnified by the usual presence of weight-related gynecomastia. This results in a skin sag with enlarged nipples that is particularly unflattering in a man.
Correction of this type of male chest wall change is not really gynecomastia surgery per se. There is usually not much fat or breast tissue to contend with. Rather it is more like a breast lift in a female. Skin needs to be removed and tightened and the nipple needs to be lifted and usually made smaller. If the skin sag is very minor, a circumareolar skin lift with nipple reduction can be made. This has the advantage of keeping the scar relegated to around the nipple area. More significant chest skin sag, however, needs a skin excision pattern that goes beyond the nipple. This is always problematic in men where scars are not well hidden in the more flat topography of the male chest.
Chest wall reshaping is usually the second most requested change (abdominoplasty is number one) in men who have had gastric bypass.
Dr. Barry Eppley
Q: I am inquiring about breast surgery for my son who is 14. He has developed small breasts and is quite conscious of it. He will not go swimming or even take his shirt off during gym class. (so I am told by his brother) My family doctor said it is gynecomastia and that it goes away in most teenage boys. He said we should wait until he is 18 years old before considering surgery. Given that it bothers him so much, and has made him very shy and reclusive, I was wondering what your thoughts were. Can surgery be done sooner rather than waiting? I am just desperate to help him and make him feel better.
A: While gynecomastia, male breast enlargement, does go away in some teenage boys, many times it does not. The historic teaching is to wait until the teenage male is near full development. In analyzing that approach further, its intent is to not subject a teenager to unnecessary surgery. In the spirit of such waiting, however, the teenage boy may (likely) develop self-image issues and psychosocial issues.
Given the exposure to potential social pressures and ridicule, I not think that such waiting is worth the trade-off. Gynecomastia surgery can be repeated (although I have never seen that necessary) but the emotional damage can be very difficult to get past. Therefore, in my Indianapolis plastic surgery practice I am an advocate of surgically treating gynecomastia early (age 14 is an acceptable age) provided that it is significant enough and one is certain that there is not a hormonal reason for it. While a hormonal cause (endocrine tumor) is a very rare cause of gynecomastia, they do occur. If the gynecomastia involves both sides of the chest and is not subtle, I would recommend getting him seen by an endocrinologist first.
Many cases of teenage gynecomastia that I seen today are less significant than they used to be. This is undoubtably a reflection of the changing cultural standards from decades ago.
Dr. Barry Eppley
