Your Questions

Q: I had rhinoplasty over one year ago for a small bump on my nose and a tip that I thought was too wide. While it looked absolutely perfect for a few months, an indented area on the right side of the bridge of the nose  appeared. When I brought this to the attention of the plastic surgeon, he told me to let it continue to heal and wait and see what it looks like at one year after surgery. I just saw him earlier this week and, although that indent is still there, he said it is not worth trying to improve it and I should just live with it since the rest of the nose looks fine. Do I have any other options at this point?

A:  Like all forms of plastic surgery, the risk of a less than perfect result afterwards always exists. Rhinoplasty surgery is no exception and secondary aesthetic deformities are not uncommon. The risk of the need for revisional surgery in rhinoplasty is estimated by some to be 10% to 15%, although that risk varies based on the difficulty of the initial nose problem.

In my Indianapolis plastic surgery experience, I find that the dorsum or bridge of the nose is one of the most common areas where irregularities can eventually appear. It is the least precise area in rhinoplasty because it is the least visible and involves bone edges. Because of small amounts of persistent  swelling  and the months that it takes for the skin of the nose to shrink back down and adapt to the modified underlying bone and cartilage framework, any asymmetries of the bridge area will usually take three to six months after surgery until they become visible.

The recommendation to wait until one year after rhinoplasty before considering revision is generally a sound one. The reason is two-fold. First, you want to be sure that the area that needs to be improved is a  ‘stable target’ so to speak. Because of the length of time it takes for all of the swelling of the nose to go away, operating too early may underestimate what needs to be done. Secondly, the nose needs to soften up so that dissection is easier once the scar tissue has settled down. While this is usually one year or so after surgery, a better estimate is how the nose feels. If it is still stiff, it is too early. It should feel soft and flexible again for the best revisional results.

Dorsal irregularities may only need to filed or rasped to smooth out a rough edge, but often indentations require some form of graft augmentation. Many graft options exist but I prefer diced cartilage because it is both a natural and easily moldeable augmentation material.   

Dr. Barry Eppley

Q: I am a 23 year-old graduate student and former college athlete. My breasts are so large I am miserable all the time and can’t even run anymore. I wear a 36DDD bra and this puts too much strain on my body. My shoulders hurt all the time.  I have been in physical therapy for my neck and back, have migraine headaches and asthma. I am 5’ 10 and weigh 190 lbs. Will insurance pay for my breast reduction?

A:  Breast reduction surgery is commonly covered by insurance but not always. There are certain very specific qualifications that all health insurances require that a patient must meet to be eligible. These include being within 20% to 25% of their ideal body weight (not being too overweight), having a documented history of physical therapy or chiropractic treatments for three months that did not result in sustained pain relief (emphasis on being documented), failing other non-surgical therapies such as anti-inflammatory drugs and support bras (all patients meet these criteria), and having your plastic surgeon document the specific amount of grams that will be removed that meets the minimum amount based on your body surface area calculations. (estimated by your plastic surgeon) All of this information will be put in a letter by your consulting plastic surgeon and sent in with photographs of your breasts to your insurance carrier for their determination.

Generally, if all of these criteria are met a patient will be approved for breast reduction surgery. The most common reasons patients are rejected coverage is because they weight too much for their height, have not tried some form of physical therapy, or not enough grams of breast tissue are estimated to be removed. (in this patient based on height and weight, the BSA is 2.05 with a requirement of at least 1,000 grams removed per breast)

While any amount of breast reduction provides relief in all patients, and a patient’s weight or amount of breast tissue to be removed has not been proven to matter for pain symptom relief), these are the insurance criteria. Debating their merits with the insurance company is not a productive endeavor.  

In patients where insurance coverage has been denied, breast reduction surgery can always be done on a fee-for-service basis. Your consulting plastic surgeon will be happy to provide you with a cost estimate.    

Dr. Barry Eppley

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

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

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

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

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

Dr. Barry Eppley

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

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

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

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

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

Dr. Barry Eppley

Identity theft is a growing problem that now threatens just about everyone, even if you don’t spend a lot of time online. It is a huge problem with risks that are estimated to place most Americans as having a 1 in 4 chance of being victimized in the next five years. With credit card and social security numbers flying around in cyberspace by the billions, it is a wonder that those risks are not even higher.

Plastic surgery faces its own identity theft problem but of a different nature. In the most noteworthy case of plastic surgery identity theft to date, an American in the Middle East was recently arrested posing as a renowned U.S. plastic surgeon. Shockingly, he had operated on scores of patients in his Dubai villa. There he allegedly performed numerous cosmetic surgery procedures with primitive surgical equipment and lack of any sterile conditions. To no surprise, several of his patients (victims) have suffered serious complications requiring additional surgery and medical care.

This former Oregon physician was impersonating and using the good reputation of a plastic surgeon in Washington, D.C. who performs several surgeries per year at the American Academy of Cosmetic Surgery Hospital in Dubai. Aside from facing legal charges in Dubai, this fake plastic surgeon is wanted in the U.S. by the FBI and Interpol on charges of drug trafficking and numerous other crimes from when he held a medical license in Oregon.

While this identity theft story seems remote and far from the American medical scene, plastic surgery identity theft occurs more regularly here…but it is of a more subtle and insidious nature. With the ongoing erosion of medical fee reimbursements and increasing practice revenues and regulation demands (which is only going to continue to worsen, particularly with the passage of the new Health Care Reform Act), some physicians search for methods of cash only services. No seemingly ‘riper fruit’ currently exists than that of cosmetic services. (although weight loss is a close second) Between public interest and the all-to-willing drug and device manufacturers to sell to anyone with a medical license and a credit card, there is a dearth of cosmetic surgery providers with quite dissimilar education and training backgrounds.

While many of these cosmetic surgery ‘adopters’ are largely involved in office-based injection and laser treatments, some perform invasive surgery which is within their legal right as a licensed physician. As long as you hold a valid medical license, you can do almost anything in your office which is largely unregulated unlike a hospital or surgery center. A great illustration of this phenomenon can be read in the April 7^th issue of The New York Times where a California physician (non-plastic surgeon) was interviewed touting his breast augmentation surgery technique under local anesthesia. Claiming that patients can now have a say in the breast implant selection process, he teaches weekend courses to physicians of any background (the articles states mainly family practice and Ob-Gyn docs) who are willing to pay.

The argument that women want to be awake and watch their surgery being performed is fundamentally flawed. I know of no female patients who want to sign up for that experience. But the underlying premise for such surgery under local anesthesia was not revealed in the article. Without proper training and credentials, an uunregulated office environment is the only place he could ever perform such procedures. And without an anesthesiologist, the only option is local anesthesia. Hardly good reasons for choosing a surgical method or even offering the procedure.

Dr. Barry Eppley

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

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

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

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

Dr. Barry Eppley

Everyone knows the phrase…’beauty is skin deep but ugly goes to the bone’.  While commonly said, this phrase is only partially correct. Beauty is also bone deep as the outward appearance of the face begins down at this foundational level. How the face looks at the outside has a lot to do with how it is shaped on the inside. Any forensic scientist can attest to it. Many have seen on TV shows how an unidentified corpse’s face is ‘rebuilt’ with clay layers on top of the skull and facial bones based on established soft tissue measurements. Like a roof on a house, the outer appearance of the face is highly influenced by the shape of the bone underneath it.

Treating facial bone problems has a long history in plastic surgery. Since World War I, when trench warfare created a large number of severe facial injuries (sticking your head up out of a trench was usually not a good idea), plastic surgeons have been rebuilding, rearranging, and enhancing facial bones. Today’s plastic surgeons pay particular attention in cosmetic surgery to how the skin, fat and muscle of the face redrapes over the bones, knowing full well its influence on the final shape. Whether it is a facelift, nose job,or making one’s face more masculine, being aware of and changing the shape of the bone can lead to a better balanced and more attractive face.

Facial bone changes can be done by building the bone up with synthetic implants, or in some cases, actually moving select facial bones themselves. A remarkable array of changes in the forehead, nose, cheeks, midface, lower jaw and chin are now possible.

Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you down deep inside the face on a tour of its palpable architecture. Learn how many of the commonly known, and some less commonly known, cosmetic facial bone procedures work and help make for more beautiful faces.

INSIGHTS FROM ‘BEHIND THE NEEDLE’

In the past, plastic surgery was all about having operations to reverse the effects of aging on the face.  Time was, once you could no longer stand to see yourself in the mirror or in pictures…facelifts, eye tucks and the like became appealing with all of the associated swelling and bruising, recovery, and expense.

Over the past ten years, non-surgical injectable treatments have become popular for men and women of all ages…and have become part of mainstream society in ways that rival Starbucks, energy drinks, and iPhones. The concepts of muscle paralysis, plumping fillers, and fat dissolving agents have made it possible to have smooth foreheads, fuller lips and softer laugh lines, and maybe some subtle tightening of the jowls and neck in a few simple visits to the doctor’s office.  Unlike surgery, injectable facial treatments are as much about the prevention of the effects of aging as they are about reversing what has already taken place.

Along  with this explosion of available injectable treatments have come the inevitable, unbelievable marketing claims, and so-called ‘expert’ injectors. But, like much of what you may read on the internet, in popular magazines, and hear in commercials , what can you really believe? How do you separate reality from marketing hype? How can you decide where-or if-injectable treatments are for you? And if so, which ones??

Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a broad tour of every injectable treatment option. Providing insight into Botox®, the many injectable fillers, and lipodissolve, Dr. Eppley provides the current science behind the treatments, and talks plainly about his experience and observations. These insights from ‘behind the needle’ about these incredibly popular injectable treatments are available nowhere else.

Whether you are just researching Botox® or fillers, or are  a seasoned expert with an upcoming consultation about the next new option, Dr. Eppley gets you ready for Injecting Youth!

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

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

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

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

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

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

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

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

Dr. Barry Eppley

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

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

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

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

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

Dr. Barry Eppley

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

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

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

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

Dr. Barry Eppley

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

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

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

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

Dr. Barry Eppley

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

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

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

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

Dr. Barry Eppley

The eyes may be the window to the soul, but they also create a strong impression of how we look. So many people comment to and about others based on how their eyes look. We all have had the experience of someone asking us if we are tired or have been up late. You can be certain their question is not probably based on how we were dressed or what we were eating.

But it is not the eyes per se that give these impressions, it is what is around them. The drapes of the eyes, the lids or window shades, are largely responsible for their appearance. Too much skin, deepening wrinkles, and bulging fat creates a tired and aging appearance. When combined with falling eyebrows, the amount of eye we see gets smaller and one really does look older. All this excess lid tissue is also prone to collect and retain fluid, hence those swollen eyes in the morning.

Because of the impact of how our eye area looks, eyelid surgery (blepharoplasty) is the best value in all of facial rejuvenation surgery. This is certainly true based on the size of the treated surface area. But more importantly, changing the look of the eyes does exactly what one is after…to look more refreshed. Few want to look different, but all want to look like themselves, only better.

While there are some non-surgical treatments that can make some areas around the eyes look better, none of them can improve the way the eyelids look. Botox can decrease wrinkling between the eyebrows and around the sides of the eyes, and that can be a great benefit for sure, but that affects expression only. If you look in the mirror without your face smiling or moving and your eyes still look tired, eyelid surgery is the only option.

By the way, forget about some magical cream making your eyelids look better. Amongst the many hundreds that exist, a few can make some minor reduction in fine wrinkles and puffiness. But really visible differences require removal of what makes them look that way, too much skin and fat.

While blepharoplasty surgery works on the lid skin, there are differences between what is done on the upper versus the lowers. The upper eyelids are largely about skin removal and re-creating an upper eyelid crease. Having a well defined eyelid crease is more important than trying to remove all excess skin. In the lower eyelid, more focus is on fat removal and skin tightening and making it as smooth as possible. There is no lower eyelid crease that needs to be made.

Many potential patients fear that blepharoplasty surgery will make them look unnatural. While this is possible if too much skin is removed from the eyelids, most overdone results come from browlifting not blepharoplasty. While browlifting can be a valuable addition to eyelid tucks, it is a procedure that is easily overdone. High eyebrows can easily change the appearance of the eye area and not favorably. Consider browlifting very carefully. It is not a cavalier addition to eyelid surgery.

If you are tired of looking tired, blepharoplasty may be a good choice to get a more youthful look back.     

Dr. Barry Eppley

This book has been written to provide a basic education and awareness of the surgical specialty of Maxillofacial Surgery.  It is not designed to be an all- inclusive text, but an outline of the terminology, anatomy, diagnosis, and treatment of the broad and complex array of maxillofacial and craniofacial problems. It is intended to serve as a pocket guide that is visually- oriented, can be quickly used as a reference, and read from cover to cover in a short period of time.

Maxillofacial surgery, a long-standing subspecialty of Plastic Surgery, had its beginnings in the early part of the 20^th century during World War I when trench warfare created a large number of severe facial injuries. Their treatment required  the development of an integrated approach of reconstructive surgery and dentistry which remains the guiding principles of Maxillofacial Surgery today. It has grown from its beginnings in facial trauma to include congenital cleft and craniofacial deformities, jaw surgery, reconstruction of extirpated tumor defects, to aesthetic facial surgery.

Maxillofacial surgery requires an understanding and assimilation of medical and dental principles involving anatomy, biomaterials, and manual dexterity. Surgical manipulation of facial anatomy is unforegiving in its visible outcome to the patient and society.

The specialty of Maxillofacial Surgery combines a knowledge base and techniques drawn from all of the head and neck disciplines with particular emphasis coming from plastic surgery. The field has expanded greatly over the latter half of the 20^th century, led primarily by the interest and innovations established by the tenets of contemporary craniofacial surgery where maxillofacial surgery was expanded to the orbits, forehead, and the cranial cavity to make a better life possible for many congenitally deformed but intelligent human beings.

The specialty of Maxillofacial Surgery is designed to provide the highest standards of care for all surgery performed in the face and skull, whether it’s origin be of bone, soft tissue, or  both. It can be difficult work in an anatomic area where many essential functional and aesthetic structures intermingle and proper training of the surgeon is paramount to achieve the desired end result, a patient with a more normal face and smile. It endeavors to achieve these aims through education, research, and awareness amongst the general public and medical field about the specialty.  This handbook, in its own small way, is another brick for that building. May its reading provide insight into the astonishing work possible from Maxillofacial Surgery.

Dr. Barry Eppley

Breast implants are a very common plastic surgery procedure that has not waned in popularity despite the recession. While they are unparalleled in making an instant body change, they have also make news for other interesting and unfortunate reasons. In the past year, these are the noteworthy breast implant stories you may not have read.

This week a California woman was sentenced to six months in jail and required to pay monetary reimbursement for ‘stealing’ breast implants as well as other cosmetic surgery back in 2008. Under an assumed name, the 30 year-old woman used a credit line in someone else’s name to obtain $12,000 in plastic surgery which included breast implants and liposuction at a plastic surgery center in Huntingdon Beach California. She pleaded guilty to burglary, grand theft and identity theft for using another woman’s personal information to obtain the surgery. How did she get caught you may ask? Police tracked her down using the serial numbers from her old implants, which she had removed when the new ones were put in.

In a similar scenario, but much more tragic, you may remember the murder of model Jasmine Fiore last August in California. The Playboy model mysteriously disappeared and was later found mutilated. With missing teeth and fingertips, she was initially unable to be identified as was the intent of the murderer. She was later identified by something her assailant had overlooked…literally…the serial numbers on her breast implants.

Proving that many criminals are dumb, most implantable medical devices today have serial numbers for tracking purposes as an FDA requirement. Usually the benefit of them on breast implants is for replacement and warranty reasons, but they also serve nicely as a human identification method that is more precise than fingerprints or dental records.

On a happier note, it was reported that a silicone breast implant saved the life of a California woman who was shot in the chest.  A woman working in a Beverly Hills dental office last July was struck by a bullet after one of the employee’s estranged husband entered the office and killed her with a handgun. On exiting, the gunman ran into another employee and shot her in the chest. Unlike her co-worker, she miraculously survived. According to the Los Angeles Times, one of her breast implants stopped the bullet and prevented any fragments from getting as far as her heart. A physician who took care of her at the hospital stated that the bullet fragments were just millimeters from her heart.

A forearms expert was later quoted as saying that the breast implant probably slowed down the bullet enough that it caused it to stop short of the heart. While its an appealing story, that is not likely. A silicone gel or saline breast implant would not slow any bullet fired at close range. Breast implants have the stopping power similar to that of Jell-O. More likely her sternum or ribs was the reason that the bullet was deterred from going any deeper. The intervening breast implant, however,  is happy no doubt to take the credit.

Breast augmentation and the implants needed to do them have weaved their way into the mainstream of American society, sometimes in ways not exactly as intended.

Dr. Barry Eppley

Published in 2003 with co-authors Dr. Peter Ward-Booth (United Kingdom) and Dr. Rainer Schmelzeisen (Germany), Dr. Eppley co-authored this now classic textbook entitled Maxillofacial Trauma and Esthetic Reconstruction. In a single volume, the comprehensive topic of the management of bone and soft tissue injuries to the face was done in just over 650 pages with 33 chapters and more than 500 color illustrations.

Bone and soft tissue facial trauma is one of the three major areas in the field of maxillofacial surgery. Having its origins in World War I and II from the last century where many facial injuries occurred, the need for specialized surgery methods for facial reconstruction began. It has now evolved into very sophisticated technologies for bone fixation and movement (plates and screws) as well as replacement of missing soft tissues. (pedicled and free flap transfers) The ‘high-rent’ district of the face allows the need for numerous medical specialities to participate including ophthalmology, neurosurgery, radiology, and dentistry in addition to the classic three surgical specialities of maxillofacial, plastic and otolaryngologic surgery. This book does an excellent job of bringing the knowledge base of all such disciplines together in a single concise volume.

One of the real strong points and emphasis in the book is what most facial trauma books historically lack, reconstruction of secondary facial defects. Despite the best surgical techniques and equipment, not all facial trauma patients end up with perfect results. Beyond simple lacerations and isolated bone fractures, the injury pattern of many facial trauma patients is complex and the best outcome will usually defy a single surgical effort. From scar revisions to occlusal discrepancies to soft tissue deficiences, secondary reconstruction of facial trauma is not rare and the book spends about as much time on those topics as that of primary repair.

This book is now undergoing a 2nd edition which should be forthcoming in the fall of 2011.

Too much fat is a near ubiquitous problem. The sheer number of weight loss diets, medications, and exercise programs that we are inundated with each day is a testament to their ‘popularity’. Accompanying these fat concerns, to no surprise, is the desire for liposuction as a surgical fat removal method. Liposuction is by both number and surface area the most common cosmetic plastic surgery procedure in the United States.

Contrary to the perception of some is that most liposuction patients are not trying to use it as a weight loss method. Almost every liposuction patient that I have ever seen in my Indianapolis plastic surgery practice has come in with a history of diet and exercise efforts. Whether it is the 35 year-old mother who can’t get that stomach pouch off after her second child or the very trim 42 year-old male who just can’t get rid of those stubborn love handles, liposuction is usually sought out for the right reason…as a spot method of body contouring.

As potential patients seek out liposuction today, they are surrounded by an array of technology that did not exist just ten years ago. And such information is freely available for their assessment on the internet. Between marketing ads and alleged patient testimonials, every manufacturer and many doctor’s practices tout one liposuction method over another. Whether it is tumescent, ultrasonic, laser, water jet or cold liposuction, they all seem to be the ‘best’. At the least, many are relatively new and after all newer is better…isn’t it?

To understand this maze of liposuction technology, it is important to appreciate how the liposuction process actually works. Essentially, it is a two-part process. Simplistically, the first part of liposuction requires that the fat be loosened by some method. The second part is that the loosened fat is then suctioned out. All the different liposuction techniologies need to use the second phase, suctioning. The difference between all of them is in the first part, the method they use to loosen up the fat.

In traditional ‘old-style’ liposuction, good old elbow grease is how the fat is gotten free. Most everyone has a good vision of how that is done by the in and out motion of a cannula that looks like a good beating up, to quote quite a few patients. In ultrasonic liposuction, it is the high intensity sound waves that do it. With laser, it is the heat and melting of the fat. With water jet, it is the high pressure of water. With cold, it is the reverse thermal effect of heat that does it.

I have left out the tumescent method as it is not really a liposuction method per se. Every liposuction technique first infuses a fluid to make the suctioning part easier, to make the treated site numb, and to lessen bleeding. It is called tumescence because it inflates or tumesces the planned treated area. It is necessary to do this first for all liposuction methods. While this may have been a liposuction advance by the late 1980s and early 90s, it is standard today and not a novel liposuction approach.

While great and appealing arguments can be made for each of these liposuction technologies, the reality is that none of these methods have been proven or shown to be better than another. They are accepted techniques that can make for an acceptable liposuction outcome. The most important technology or technique, however, remains that of the hands and the experience of the plastic surgeon wielding the device. The greatest tool ever made is only as good as the person using it. Conversely, skill and experience can make  an average tool do a great job.  More focus should be placed on that assessment by potential patients, if possible, than the allure of the next great liposuction wand.

 Dr. Barry Eppley

Almost everyone has now heard of the facial wrinkle treatment, Botox. While some may not know exactly what it is really good for, its recognition and popularity is because it simply works. When it comes to softening facial expressions, it does something that even surgery can’t do.

Many misconceptions exist, however, about Botox (and now Dysport) and it is time to reveal some of its secrets. Here are some facts about its use that are not commonly known.

Botox is a poison and can be quite lethal if the dose is high enough. It is administered in units which originally stood for mouse units. A unit was the dose of Botox that could kill a mouse. Fortunately, there is a big difference in size between a mouse and a human. To poison a human, it is estimated that it would take about 25,000 or more units to do so. The average dose for wrinkles is around 20 to 30 units, so it is well within the margin of safety. (mathematically, cosmetic dose units are a mere 0.001% of the doses that could be fatal). Cosmetic injections are precisely placed 2 to 4 unit doses in select facial area.

While Botox is touted for a lot of facial uses, it is largely a ‘northern’ face procedure. The areas of the forehead and around the eyes accounts for much of its use. Weakening of the muscles between the eyebrows, in the forehead, and at the sides of the eyes produces the desired effect of less frowning, a more relaxed forehead, and less lines around the eyes. While some do use it down south around the mouth, it is not effective as a primary wrinkle reducer in that area. A little too much Botox there can affect the way you smile.

Botox injections do not produce immediate results. It usually takes one week or more to see its effects. This is because it blocks the release of chemicals from the nerve endings that cross over to stimulate the muscle fibers to which it is attached. Because there is a supply of chemicals in the nerve endings to start, they must first be depleted. As a result, the muscle will work normally for a few days before it begins to weaken as its ‘gas supply’ diminishes.

The effectiveness of Botox can vary from one doctor to another or from one treatment center to another. This seems initially unusual because one of the benefits of a prescription drug is that it has been tested and approved for the uniformity of its effects. But Botox differs from a pill and many other prescription medications. It comes as a dry powder and must be formulated or reconstituted prior to treatment. How well it works, therefore, is affected by how it is mixed and how long ago it was prepared. It is designed to be mixed according to the manufacturers recommendation in a very specific way. (2.5ml of saline per vial) and it should be used either immediately or within a few days after preparation. But treatment centers vary on how they mix it and how quickly they can use it. You have no way of knowing if you are getting diluted or old Botox. If it doesn’t seem to be working well or lasting very long, this could be the reason.

Like all drugs, there is an effective dose to Botox or a ‘sweet spot’ at which it works well. What you want as a patient is to find the Minimum Effective Dose as well as the right injection spots. You may regularly be getting 40 units in the forehead are, for example, when 32 may work just as well. More Botox than necessary does not make it work better or any longer. Don’t be afraid to ask your injector to adjust the does or injection locations to see if the results improve…or become less.

Botox and Dysport have a very consistent duration of effect of around 4 months. Repeat treatments, unfortunately, do not make it last longer. But some patients feel that it does. This is likely an effect of muscle re-education, a chemical training if you will. It may take your body awhile to begin using those muscles again if they have been weakened repeatedly. Conversely, most people will not build up tolerance or immunity to Botox. But a few patients say that they have and resistance to any drug is always possible. One can than switch to Dysport which has a slightly different molecular structure.

Dr. Barry Eppley

Of the very large number of cosmetic surgery procedures that are performed each year in the United States, a certain number will undergo subsequent revision. While this is a concept explained to patients by their plastic surgeon beforehand, it is understandable that it falls on deaf ears for the most part. The euphoria of the upcoming outcome blocks any realistic consideration that anything but the best will happen. The decision to undergo cosmetic surgery is both emotional and optimistic.

Why does surgery not always turn out to be exactly as desired? While there can be numerous reasons, including the wrong operation for the problem or that the operation was not done well, but the most common reasons for these undesired outcomes are less obvious. How the body responds to the trauma of surgery and the not always predictable events of wound healing account for much of the need for revisional surgery. The occurrence of complications in cosmetic plastic surgery is uniquely different from that of most other types of surgeries. Unlike common surgical problems, such as infection or bleeding, the healing of a cosmetic surgery site may be perfect but the aesthetics of the healed site may still not be what was desired. Cosmetic surgery results are judged by a higher standard, they must both heal and look good as well. Even the avoidance of common wound healing problems is not enough in cosmetic surgery.

While the real number of the incidence or need for revision in cosmetic surgery will never be known, estimates are thrown around of around 15% on a national average. This estimated number will be quite different depending upon the type of procedure being performed. For example, any form of breast surgery carries a higher revisional risk than that of a facelift. Any operation that relies on an implantable device to achieve the outcome will always have more potential problems than those operations that don’t. While revisional surgery in most cases is minor and nothing in comparison to the original operation, potential patients need to appreciate that the need for secondary surgery in cosmetic procedures is not rare.

When postoperative complications occur and revisional surgery is needed, there is unhappiness on the part of both patient and plastic surgeon. The cosmetic patient is understandablely unhappy as they never really believe it would happen to them no matter how it was disclosed or what forms they signed. Such surgical problems happen to other people, no one thinks or hopes that it will happen to them. Other people make up statistics but not themselves. Patient naivety in this regard has been promoted, inadvertently, by cosmetic surgeon’s themselves through countless promotional efforts. Advertising ‘lunchtime facelifts’, ‘weekend recovery’, and other seemingly too good to be true procedures has only added to dumbing down that fact that it is real surgery with associated risks.

Like the patient, plastic surgeons are equally not pleased about the need for revisional surgery. There are many reasons for such a response by the surgeon from facing a patient’s disappointment, a perceived failure of their own skills and expertise, and how this result reflects on their own reputation and image. Sometimes, a difference in opinion may develop between the patient and surgeon as to the need and advisability of revisional surgery. In these circumstances, patients often seek out other surgeons to undergo their revisional surgery, getting a fresh perspective on their adverse outcome. When needed, however, surgical revisions should be done in the proper setting and under the appropriate circumstances. Certain minor revisions can be reasonably performed under local anesthesia in the office. This approach is simple and avoids the use of the operating room. Many times, however, this office approach to revisional surgery is overused in an effort to save the patient further expense. As a result, the desired outcome may still be suboptimal. In many cases of revisional surgery, the patient and surgeon needs to be willing to accept the additional arrangement and expense of an operating room to put themselves in a position where the procedure can be carried out properly.

The potential need for revisional surgery after a cosmetic procedure is a statistical reality. Revisional cosmetic surgery has associated physical, emotional, and economic consequences. It will often test the depth of the relationship and preoperative dialogue between plastic surgeon and patient.

Dr. Barry Eppley

The greatest trend in plastic surgery in the past decade has been, ironically,  the explosion of procedures that don’t involve actual surgery. Comprised largely of injectable therapies, such as Botox and fillers, and laser and light treatments, making the face look rested, supple and youthful  has become as easy as a quick visit to the doctor’s office. By sheers numbers, non-surgical facial enhancement far exceeds the actual number of cosmetic surgeries performed per year.

Such ‘beauty treatments’ have been very successful for concerns of facial aging but the same approach has not seen the same successes for body concerns. The search for an effective non-surgical method for the reduction and removal of fat remains as elusive as finding the magic pill or diet for weight loss. Much has been promised, but little has been delivered so far.

The allure of ‘non-surgical’ is always a compelling one and any device or product that offers it always attracts a large amount of public interest. But within that appeal lies the often ignored fact that non-surgical treatments are not equivalent to surgery. They produce results that are far less and should be of thought as a delaying tactic or a complement to what surgery can do, not a substitute.

Non-surgical facial methods should never be equated to what actual surgery can do. You can reduce a few wrinkles, plump up some thin tissues, and get your skin to look fresher. And, to be sure, those are great changes for many people, but many patients often expect or believe much more will occur. This is unfortunately not helped by the sometimes very ‘broad’ promotional claims of product manufacturers and doctors alike. Unless properly advised, it is easy for one to undergo some form of office treatment, often not inexpensive, and be disappointed with the results. This is especially seen when it comes to a wide variety of ‘facelift-like’ methods. I have seen many such patients, all of whom in the search for something less, did indeed end up with less.

While seriously ‘injurious’ complications are rare with underperforming and overpromised cosmetic treatments, there is always the economic loss. Wasted money may prevent someone from contributing to and having a more significant procedure that would provide much better long-term benefit. The point being is that one must keep an eye on the concept of value when comparing non-surgical versus surgical cosmetic procedures.

One good illustration of this concept  is in the highly promoted ‘Liquid Facelift’ procedure. Plumping your face up with injectable fillers does create some more fullness in the face and it could  be called  a lift of some sort (it does nothing for the neck which is why most people seek a facelift).  But its effects last perhaps six months and costs several thousand dollars. Some form of a real facelift (and there are many variations) may cost two or three times more but the results are much more significant and could easily last a decade or more. Is either one wrong? No. Each person has their own objective and needs and either approach could be right for different people.  But from the concept of value, removing, lifting and tightening is actually more economical in the long-run than plumping and a little smoothing.

Most non-surgical office treatments have no recovery, a near instant result, and cost less …and do so at the ‘price’ of being less effective as well. Expectations are the key to any plastic surgery procedure and simple office treatments should be judged more for their contribution to value than their ease of doing them.  

Dr. Barry Eppley

As an appreciation of what our military does around the world, our Patriot Program exists to help make plastic surgery more affordable to them. Having seen and talked to many of these military patients, I have become aware that elective plastic surgery is often done at Armed Services facilities. In addition, one of my plastic surgery techs spent nearly a decade in the military and he often speaks of the cosmetic surgeries that he knows where done or participated in.

According to a recent article in Stars and Stripes (passed along to me by one of my military patients…he thought I might be interested), the military says it does not pay for unnecessary plastic surgery. But an audit of patient records released in February by the Pentagon says this is not so. The audit found that military doctors were regularly performing breast augmentations, tummy tucks, liposuction and other cosmetic surgery without charging the patients as they are supposed to do.

Plastic surgeons exist in the military to perform reconstruction of many injuries that are sustained from war, accidents and disease. The very existence of plastic surgery as we know it today is the result of the experience gained in the first two World Wars in the first half of the last century. Because military plastic surgeons need to keep their skills up for when they get out (and to encourage them to enter the military in the first place), they are allowed to perform cosmetic plastic surgery for patients as long as they pay for it…just what people have to do in the civilian world. Such requirements have been in place for the military for some time. Troops have had to do so since 2005 and dependents and retirees have been required to pay since 1992.

However, it appears that some service members and their dependents are having cosmetic surgery on the military’s (your) dime according to the audit. Arguments can be made that they deserve it or it doesn’t really matter since most of the costs are already built-in anyway. The basic costs of the facilities and doctor’s and operating room staff salaries is an ongoing expense, it is really just a supply issue to perform the surgery.

One of the real interesting sides to this story, and one that we face every day in the civilian world with medical insurance, is what is the difference between medically necessary (reconstructive) and cosmetic plastic surgery. From the military’s standpoint, what should they be paying for and what should patients be paying for?  By definition, plastic surgery is reconstructive if it restores or repairs appearance or function from trauma, disease, or birth defects. Cosmetic plastic surgery is changing what is not deformed, injured, or diseased. That seems like a simple differentiation…but it often is not.   

In the Stars and Stripes article, for example, they discussed male breast reduction or gynecomastia surgery. This is a source of embarrassment for many young men but is often viewed as a cosmetic problem in the civilian world and is not often covered by medical insurance. But in the military, male breast enlargement can make wearing body armor difficult and that can make it medically necessary. Similar situations may exist for rhinoplasty (breathing problems), otoplasty (helmet wearing), and even tummy tucks. (hernia repair)

One of the side, but important, issues is being able to recruit or retain plastic surgeons in the military. Outside of being close to a war zone, plastic surgeons in the military may encounter few combat casualties and may not do enough reconstructive surgery to keep their skills and board-certification current. (in some ways, this is thankful) Cosmetic surgery techniques are an extension of those used in reconstruction. A midface lift, for example, is a cosmetic procedure developed from repairing cheek bone fractures and lower eyelid deformities. There are many connections between cosmetic and reconstructive plastic surgery and their differences in technique are often more gray than trying to determine the medically necessary basis of the procedure.

Of significance, the military report suggests that plastic surgeons are increasingly leaving the military because of their inability to keep up their cosmetic surgery skills due to the 2005 patient payment policy. That is unfortunate as plastic surgeons have  a lot to offer our military service members. Perhaps continuing to provide cosmetic surgery is a retention factor for both plastic surgeons and our military alike.

Dr. Barry Eppley

While plastic surgery is comprised of hundreds of different procedures that are used to correct problems all over the body, they are all true medical operations and treatments. Yet some of the most popular cosmetic treatments have almost as much in common with a retail or commercial product as they do with being a medical procedure.

Botox as a non-surgical procedure and breast augmentation as a surgical operation have begun to acquire many retail product characteristics over the past decade. Both are highly marketed and promoted, so much so that few people in the world would not recognize what they are. From billboards to magazines, and endless exposure on the internet, the offering of services and the recruitment for paying customers is extensive. Some of these are from the commercial product suppliers on a national front and many others are from physicians on a local basis. Such enticements are right in line with what has also occurred in the pharmaceutical industry by the manufacturers for certain prescription medications.

Unlike most drugs, however, Botox and breast augmentation largely targets the fee-for-service customer.  These are cosmetic services which are either paid for at the time the treatment is done (Botox) or some time in advance. (Breast Augmentation) With the allure of immediate cash payment comes the inevitable price war and the potential slide into a commodity service. Ads are a plenty for Botox at specific per unit prices and flat low-end fees for breast implant surgery. Dysport, the recent competitor to Botox, has offered incentives if you are unhappy with your Botox results. Breast implant manufacturers have lifelong replacement warranties and even $3500 cash for surgical costs should an implant need to be replaced in the first ten years after surgery.

But unlike most commodity services or pure retail products, these medical procedures do have other intrinsic values. It is obviously important to be able to receive these services with the lowest risk possible and be able to get the desired outcome. The intrinsic value is in the expertise and experience of whom is performing it. Lowest price for medical services is not always the best value. Price alone is not the best barometer to judge whom and where these services should be received.

Competition amongst cosmetic providers has fueled the reduction of services like Botox and breast augmentation into partial commodities. Prices amongst them in any community usually stays within a fairly narrow range as a result. Such competition is not necessarily bad. It keeps all providers sharp and makes sure that their prices, no matter how much intrinsic value they may have, stay within a reasonable range. Be wary, however, of really low prices that are different from the community average. There may be a good reason why they are priced that way and it is not usually for your benefit. You do not want inferior quality medical services when it comes to having something injected or implanted into your body.      

Dr. Barry Eppley

While the way and the changes that a face undergoes as it ages may not have changed since time began, the treatment of it has. Facelift surgery used to be an extensive operation largely because it was done on older people. (who needed a lot of work!) In a generation past, most people (primarily women) underwent a facelift when they retired, rewarding themselves for a lifetime of work and when they can most afford it.

But today’s approach to facial aging is different and reflects changes in both society’s attitudes and plastic surgical techniques. People now want to age less obviously and remain youthful appearing in middle-age as they participate in the ever competitive workplace. As a result, facelift surgery has adapted to these needs becoming less invasive and suited for less severe signs of aging that exist in the 40 and 50 year-old ages.

Besides the common misconception of what a facelift really, most people perceive that it is a highly invasive procedure that requires a long recovery.  These two perceptions are tied together under the belief that a facelift is a ‘scalp to neck’ lift. In reality, a facelift only changes the lower third of the face…a neck and jowl improvement. It does not change the mouth, cheek, eye or forehead area. These require separate and often combined procedures with a facelift to create a complete facial makeover. When one understands the more limited scope of what a facelift is, it becomes less scary and intimidating.

Facelifts have evolved into two different types, complete and limited. The difference is in the amount of neck improvement that is obtained. Since many younger patients have more jowling than sagging neck issues, the limited facelift has become widely used. The surge in the number of facelifts has been because of this scaled down version and accounts for at least half of all facelifts now performed.

The  popularity of the limited facelift can be seen by the numerous marketing approaches taken by both plastic surgeons and franchises alike. Catchy names that imply the ease of recovery, such as Swiftlift and SimpleLift to name a few, are used to differentiate this technique from that of the historic facelift perception. Promoting surgery under local anesthetics, one hour procedure times, and a few days of recovery, it can make it seem that it is hardly surgery at all. I have seen numerous patients initially seen at these franchise establishments and they were surprised to find out it was an actual surgical operation.

But limited facelifts are real surgery, even if it isn’t the same as an extended full facelift. It can become a more extensive procedure if combined with other facial aging treatments such as eyelid tucks (blepharoplasty)or browlifts, which is quite common. The concept of several smaller operations at a younger age is a sound maintenance approach that may make the need later for a full facelift unnecessary.

Limited facelifts, however, are not just for the young. For the older patient, who may really need a full facelift for the best result but does not want it, the limited facelift offers moderate improvement with less recovery and costs.

Contemporary plastic surgery is about adapting the operation to the magnitude of the problem. The limited facelift is a great illustration of that principle.

Dr. Barry Eppley

Just when you think you have heard it all, a new and bizarre tale of cosmetic surgery rears its head. If I didn’t know any better, this story may well have happened in China or the back streets of a remote Siberian city.

From the Garden state of New Jersey in Essex County, a group of female patients (six to be exact) ended up in hospitals after undergoing buttock enhancement. Apparently, they received buttocks enhancement injections containing caulking material. The same material that is used to caulk windows and bathtubs was injected to make their glutes larger. Different from medical-grade silicone, the substance used in these Mengele-like botched procedures was believed to be a diluted version of a nonmedical-grade silicone. Traditional buttock enlargement procedures are done with either a medical-grade solid silicone implant or with fat injections.

Apparently administered by unlicensed providers, the women were admitted to hospitals following  the injections after developing raging infections. They were treated with surgery and antibiotics and appear to be recovering (although, you can be certain their buttocks will never be the same).

While many may wonder why anyone would want their buttocks enlarged (since many women would actually want them reduced), this is a popular request amongst certain ethic groups where a fuller and rounder buttocks is more appealing. Some have called this the Jennifer Lopez effect.

While these cases are certainly a tragedy, the looming question is how could this happen? In a country with the finest and most advanced medical technology in the world, how does someone come to the fate of having their butt caulked?

While injectable aesthetic treatments, such as Botox, collagen and fat, have been a real advance in plastic surgery, there is a rare, dark side to the concept. Because injection therapy is not surgery, it is not regulated like traditional plastic surgery procedures. There is no oversight and many of these treatments take place in a wide variety of settings by ‘providers’ of all backgrounds.

Because of their apparent simplicity to administer, injectable treatments are often viewed as a commodity. As in, ‘what treatment can I get for the lowest price’? While searching for bargains is commendable in many retail situations, a faux watch or look-alike handbag does not carry the same risk as do faux injection materials.

While not common in this part of the U.S., black-market injectors do exist and their practitioners prey on the weakest and least educated consumer- those that often can least afford it. As crazy as the butt caulking incident sounds, there has been a recent history of dubious practitioners  providing cosmetic implants of nonmedical-grade materials. They function in a makeshift office for a short time, then get put out of business…only long enough for other shady providers to take their place.

Most of these incidents happen in large metropolitan cities with a high percentage of immigrant populations. In such an environment it is easy to hide, to be invisible to the authorities, and find plenty of victims before moving on. Smaller cities like Indianapolis are more difficult for unlicensed providers to remain anonymous as they are more quickly exposed, and appeal to a much smaller population.  

The conclusion is …Caveat emptor: Buyer beware.  If the costs of the procedure look too good to be true, there is probably a reason.

Dr. Barry Eppley

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

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

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

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

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

Dr. Barry Eppley

When spring just around the corner, this is the time of year when many people start thinking about their body again. Warm weather and less clothing cause some women to think about their ‘curves’.  Perhaps to the surprise of some, spring is the peak season when the greatest number of breast augmentation surgeries are done. This is a seasonal trend that is very unique to this type of cosmetic surgery.

When considering breast augmentation, most women today opt for silicone gel breast implants. Since they have become available again for human use in late 2006, they rapidly have become the preferred implant for many breast augmentations. Yet, despite FDA-approval, many patients understandably ask about their safety. Even if one was not old enough to even be aware of what transpired in the early 1990s with the previous generation of silicone breast implants, there remains some lingering concerns that are easy to find on the internet.

Since silicone gel breast implants are FDA-approved, and they would not be available if they were not, that speaks to their safety. But most do not know the extent of information that goes into that type of approval process. And because of their history, silicone gel breast implants have become the single most studied implantable device in the world. As a result, the most common questions that women may have about this type of breast implant has well known answers.

Can breast implants make me sick? In 1997, the Federal government (Department of Health and Human Services) appointed the National Academy of Science to study the likelihood of medical complications after breast implant surgery. After reviewing years of evidence and research concerning silicone gel-filled breast implants, they found that health problems such as connective tissue illnesses, cancer, and other diseases were no more common in women with breast implants than in women who had never had the surgery.

 In the 1990s, thousands of women claimed that they had become ill from their implants. Some studies around that time suggested that these health symptoms of women with implants may improve when their implants are removed. We now know conclusively that this is not true. The relationship between autoimmune diseases and breast implants is coincidental…both largely occur in women between the ages of 20 to 50…but one does not lead to the other. The FDA has even gone so far as to conclude that there is link between fibromyalgia and breast implants either.

Will breast implants cause cancer? Reviews of research and medical studies on silicone breast implants show that breast cancer is no more common in women with silicone breast implants than in those without. In fact, for reasons different than one may think, women with breast implants actually have earlier breast cancer detection. This has nothing to do with the implant per se, it is a function of breast awareness. Women with breast implants are more likely to be ‘attuned’ to their breasts and how they feel.

 Can I breast feed with breast implants? For the younger women, this is a frequent question. The issue is not whether one can physically do it, but will any harm come to the baby by doing so. The American Academy of Pediatrics concluded in 2001 that having silicone breast implants is not a contraindication to breastfeeding nor does it pose any health risks to the infant. Similarly, epidemiological investigations have not found any increased risk of health problems in children born to women with silicone breast implants.

Dr. Barry Eppley

The mere mention of the word ‘facelift’ is to many people a frightening concept that is best avoided.  Beyond implying surgery, images of ‘perpetual surprise’, ‘wind-tunnel’ and ‘unnatural’ come to mind. It is these very misconceptions and fears that have led to a surge of procedures that have become broadly known as non-surgical facelifts.

Cleverly marketed as appealing improvements known as ‘lunchtime facelifts’ and ‘liquid facelifts’ , these facial procedures are hopefully performed in a doctor’s office with a combination of Botox, injectable fillers (such as Juvaderm and Radiesse), and light and laser treatments. They are tremendously appealing precisely because they are not surgery, and involve no scarring or downtime. And they are based on a recently appreciated anatomic understanding of facial aging which is that of volume deflation (loss of fat) and not just sagging tissues alone. ‘Re-inflation’ of the face is the result of these treatments, even if it is only temporary (there are no permanent injectable fillers).

Under the guise and enthusiasm of anything that is pain and recovery-free being better than a real facelift, a patient inquired about the ‘new’ Y-facelift published this past weekend in New York Times Sunday Magazine.  Buried in the center pages of this magazine was a story entitled ‘Houston, We Have Facelift’. Reading this story got me thinking about everything that is both good and bad about the non-surgical facelift ‘revolution’.

The concept:  Developed by a dentist who claims to have taken four years to develop this approach, the Y-facelift involves filling the face with large volumes of injectable fillers, molding it around with one’s fingers, and then treating the skin with radiofrequency treatments to tighten it. I am not sure what the Y means but some filling out of the face is most certainly achieved, without surgery, for a subtle improvement.

The bad:. It may be shocking for some that everything in New York isn’t always better (although always twice as expensive) and the New York Times Style magazine does not carry the same scientific clout, for example, as the New England Journal of Medicine. Cosmetic procedures are fraught with a common problem- marketing that frequently gets way ahead of proven science. This practice is so prevalent that doctors and companies alike have learned that appearing in Allure, Cosmopolitan and other beauty magazines with exaggerated and unfounded claims drives business better than a scientific discourse in any medical peer-reviewed magazine. (and much easier to get published) Even the pharmaceutical industry has this figured out which is why almost one-third of television ads today are for some prescription drug.   The bottom line is the ‘Y-Lift’, while based on a few known plastic surgery procedures, is an unproven amalgamation which most likely benefits the treatment provider more than the recipient.

What matters:  The debate between non-surgical or surgical facelifts can be debated ad nausem. Both may be appropriate for any patient under the right circumstances. The practitioners of both will hotly contest each one’s merits. But the non-surgical boom of cosmetic procedures speaks to an important issue that is rarely discussed…value. What does one get for what one pays? The non-surgical Y-facelift retails between $4,000 and $8,000 for results that will last one year, maybe slightly more. The price of non-surgery, when looked at long-term, is frequently more than that of actual surgery…with results that are not nearly as long-lasting.

There are many factors that go into deciding what is the best facial rejuvenation procedure. Never forget that the concept of value in plastic surgery, like any other retail purchase, is extremely important. But the medical merits of such procedures should not be determined by what is written in a trendy magazine whose sole intent is newsstand and ad sales, not satisfied and happy patients.  

Dr. Barry Eppley

With the winter Olympic games ongoing in Vancouver, it gives one pause to ponder about more than the traditional meaning of this event. Every two years, the Olympics and the media exposure that surrounds it provides athletes, known and unknown, with the rare opportunity to showcase their skills and personality on an international stage. As an audience we are glued at night (and sometimes during the day thanks to Tivo) to watch athletes perform in ways that we only fantasized about in our youth. For some of these athletes, their accomplishments will be a springbroad to fame and riches thereafter.

The ancient Olympics were held in Olympic Greece over a span of nearly 1300 years beginning in the 8^th century BC. Revived 1400 years later in 1894, Baron Pierre de Coubertin resumed the games in Athens. To adapt the games to the ‘new’ world, a variety of modern inventions since their rebirth have included the Winter Games for ice and snow sports, the Paralympic Games for physically disabled athletes, and the Youth Olympic Games for teenage athletes. To support all these activities, the games have long shifted away from pure amateurism to complete corporate commercialization. Over half of the Olympic coverage seen in Vancouver on NBC were commercials.

The vast majority of Olympic competitors are under the age of 35. As a result, most athletes  have much, if not all, of their youthful appearance. Some have had some form of plastic surgery, however, to look better under all this media exposure. Few have owned up to it however. In this young age group, Botox, injectable fillers, rhinoplasty and ear surgery would be the likely plastic surgery procedures. For obvious reasons, liposuction and other body contouring procedures would be unlikely given their state of physical conditioning.

Olympic gold medalist and four-time Word tennis champion  Lindsay Davenport has freely spoken about her experience with Juvederm injectable filler. The years of sun damage from playing tennis led her to seek non-surgical facial rejuvenation. Concerned about her ‘parentheses’ (laugh lines), she had those injected to restore volume and had Botox in her forehead and around her eyes to decrease wrinkles as well. Her experience was so positive that she has been a spokesperson for Juvederm’s educational campaign.

Olympic hurdler Jana Rawlinson from Australia has opted to have her breast implants removed in preparation for the 2012 Olympics in London. Such a cosmetic move may be the first in the world of competitive athletics. She felt they were slowing her hurdling down. Having breast implants, adding just 1% to one’s total weight and causing some minor adjustment in balance, may make the fraction of a second difference between winning and losing. Interestingly, she cited  a patriotic duty to do the best that she could  for her country over her own vanity for the removal decision.

While most recognize the Olympic symbol of the five interlocking  rings, fewer know that there is an accompanying motto as well. The Olympic motto is “Citius, Altius, and Fortius” which in Latin means “Faster, Higher and Stronger”.  Given the evolution of the Olympics today, perhaps the motto should include Richer and Better Looking as well.
Dr. Barry Eppley