Your Questions
Your Questions
Q: I have a severe asymmetry in my face. I was born with a condition called plagiocephaly which has twisted by face and skull around in a weird fashion. My eyes are at two different levels and this really makes my face go to one side. I had a browlift performed locally but it did not make ay difference in how I look. I have attached some pictures. What do you think can be done?
A: Thank you for the facial pictures. On evaluating them it is important to realize that the apparent orbital asymmetry is not the basis of the problem. It is that the entire facial skeleton below the orbits is severely rotated to the left. This makes the orbits seem much further asymmetric than they really are. There are some differences in the forehead and orbital shapes but the real problem is what lies below.
Such facial asymmetry is best improved by doing total facial skeletal repositioning that can open up right facial vertical length and shorten the longer right side. In essence, to derotate the face back to the right. This would be done by preparatory orthodontics followed by orthognathic surgery to change the entire position of the maxilla and mandible. (LeFort I osteotomy and mandibular sagittal split osteotomies) I don’t know if that has ever been discussed with you or whether is a viable option for your consideration.
If orthognathic surgery is not in the future, then there are a variety of what I call camouflage procedures to attempt to achieve one similar goal…lengthen the left side of the face. Camouflage procedures can not be done that will really shorten the right facial skeleton. These would include a chin osteotomy with a shift of the chin midline to the right with lengthening of the left side of the chin and shortening of the right side of the chin. This would be combined with a left cheek and jaw angle implants to provide further left facial fullness. A rhinoplasty coule be done to narrow the tip and move the nasal midline back to the right. The left nasal alar base would be rotated down and around to be level with the other side. Lastly, a right brow release would be done with the intent of lowering the brow on the right side. This combination of fairly standard facial procedures combined into a single operation would help the facial asymmetry considerably. This still leaves the smile line tilted up to the left but this is virtually unchangeable.
I have attached a frontal view of the proposed changes that would occur. These are done conservatively and may likely be more significant in real life. The photo has been leveled at the eye level to demonstrate that the real problem is the rotated facial skeleton below the eyes. You undoubtably have a head tilt to the left side as well but that can not be changed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am currently pregnant and I can tell that my stomach is going to be a problem after I deliver. I have gained 60 lbs with my pregnancy and stretch marks have appeared that weren’t there before. Do you think liposuction or a tummy tuck would work best to get my stomach back to being flat again after I deliver?
A: There is no doubt that pregnancy, for most women, has an adverse effect on the look and shape of the abdomen afterwards. Large weight gains and the appearance of stretchmarks are synonymous and signify that the elasticity of the abdominal skin has been altered. The ability for the skin to snap back into place afterwards is not likely.
The two choices of liposuction and some form of a tummy tuck are the only truly effective abdominal contouring options. In many cases, they are done together as a combined lipoabdominoplasty procedure. What they are effective for, however, is different, Liposuction removes fat only and relies on the overlying elasticity of the skin to get a smoother abdominal contour. A tummy tuck removes skin and fat (the fat that lies directly underneath the skin cutout) and uses excision and abdominal flap advancement as the skin tightening method. It is easy to see that how much loose skin one has is the determining factor in the choice between the two options. With a large weight gain and the stretch marks, it is most likely that you should be thinking tummy tuck rather than liposuction alone.
The timing of any abdominal contouring procedure after pregnancy does vary but, as a general rule, it should be about six months. This will allow adequate time for any remaining ‘baby weight’ to be gone and have a full appreciation of what the final ‘damage’ really is. In addition, this allows you time to focus on the baby and enjoy the experience of the very early months of their life.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 55. I love wearing pierced earrings. I notice that they are sagging a little bit. I wonder if putting filler in the ear lobes is the best action to take, or would it just allow me to wear heavy earrings and destroy the cartilage that much faster?
A: The earlobe, unlike the rest of the ear, is only composed of skin and fat. It does not contain any cartilage which would give some stiffer support. This is why earlobes get stretched out, sag with aging, and even develop splits or tears in them from earring wear. If they had cartilage in them, none of these problems would develop.
Your question is based on the concept of adding a ‘stiffener’ to the earlobe to make it more resistant to sag or to be able to wear heavier earrings.While injectable fillers are quick and easy to do, and they can immediately make the ear lobe bigger, they will not make it more resistant to the pull effect of earrings. Injectable fillers are soft and much more like ‘jello’. The one exception to that would be the injectable filler, Radiesse, which has tiny ceramic particles in it and is more like toothpaste than jello. If you were to consider an injectable filler into the earlobe, Radiesse would be the one of choice.
The best long-term approach to prevent earlobe sag or stretching is to place small curved cartilage grafts beneath the underside of the piercing hole. This is done through a small incision on the back of the ear. The graft is harvested from above from the backside of the concha. One conchal harvest is enough for both sides. This then makes the earlobe more like the rest of the ear as the ear cartilage graft directly resists earring wear better.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 40 year old male with medium acne scars over my cheeks While I have acne scars other places, these are the most bothersome to me. Will cheek implants help lessen the acne scars and be a good anti-aging step?
A: Acne scars come in a variety of shapes which determines what procedures may be helpful for them. Surgery by excision is the preferred approach, for example, of the classic ‘ice-pick’ acne scar because of its depth. No superficial treatment of a deep acne scar, such as laser resurfacing, will work.
Many of the most troubling acne scars over the cheek area tend to be the ‘saucer-shaped’ variety. These are larger, less deep, acne scars that do resemble a saucer or a moon crater. They still are too deep to respond well to laser resurfacing (taking down the edges will not usually work) and their larger surface area causes a noticeable contour deformity. These are the type of acne scars that can respond well to injectable fillers as the problem is loss of skin dermis (thickness) and some subcutaneous fat. They represent a true volume deficient problem.
While injectable fillers can work for cheek acne scars, it is not unreasonable to consider the push of an underlying cheek implant. By pushing out from the bone, the expanded underlying tissues can help ‘fill out’ some of the saucer-shaped skin depression. I have done this a few times and do find it helpful. The existing size of the cheek area should be considered as the trade-off of a flatter acne scar for an overbuilt cheek may not be worth that trade-off.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was interested in the buttock augmentation with fat injections. I was wondering what parts of the body the fat is taken from, whether I would be a good candidate for the procedure, and the time it will take to heal.
A: The use of injectable fat grafting for buttock augmentation, also known as the Brazilian Butt Lift, has become popular as an alternative to the use of buttock implants. The success of the procedure is based on three factors; having enough fat on the body from which to harvest from, having enough buttock subcutaneous tissue to inject into and how well does the inject fat survive.
Patient selection is the key element in the first two factors and can be determined before surgery is ever performed. The best donor site to get then most fat is usually the abdomen, flanks, and thighs. In general, a harvest volume of at least 1,500 ccs is needed to end up with a processed and concentrated volume of around 800ccs. This allows 350cc to 400cc to be injected into each buttock. Less volumes than this will usually not make the procedure worthwhile. The patient also gets the benefit of contouring from the harvest site as well. Whether one has enough fat to harvest is very easy to determine. Whether one has enough buttock subcutaneous tissue into which to inject is a bit more subjective. Buttock far augmentations work better in those that already have ‘some butt’ present. Completely flat and non-existant buttocks will have a much better result with an implant.
Recovery from buttock augmentation with fat injection is related to the donor site and not the buttocks. Overall recovery is just a few short weeks whicih is far less than when buttock implants are used.
Dr. Barry Eppley
Indianapolis Indiana
Q: Do paranasal implants any effect on the length of the upper lip? Do they lengthen the upper lip, what is common with premaxillary implants, or do the paranasal implants rather lift the upper lip a little bit? In one of your You Tube videos about Advanta PTFE facial implants you soaked these implants in an antibiotic solution before they are implanted. Would you similarly dip the Medpor implants in a antibiotic solution also? I noticed that you use both implant materials – silicone and Medpor – and you obviously know the advantages and disadvantages of both very well. I personally would prefer the Medpor implants because they permit tissue ingrowth. But I often hear that Medpor implants are virtually unremovable once they are incorporated. Have you ever removed an incorporated Medpor implant? Is it true that it is extremely difficult to separate the periosteum from the surface of an incorporated Medpor implant?
A: Paranasal implants will not lengthen or push the lip down like a premaxillary implant. Neither will they lift the upper lip either. They merely provide fullness to the nasal base.
I soak all implanted materials in an antibiotic solution. This is particularly valuable in porous implants where bacteria can become trapped into the pores of the implant and not easily washed or rubbed off. The porous nature of the Medpor material also allows an antibiotic solution to be impregnated into the implant with vacuum infiltration or prolonged soaking.
Tissue incorporation into a facial implant is a two-edged sword. It has a benefit of providing anchoring of the implant to the bone site through tissue fixationalthough that advantage can be gained by screw fixation at the time of placement. Removal is definitely more difficult but by no means impossible, particularly for a small anteriorly located implant under the nose. It is more tedious and more tissue disruption must be done to get them out but it is not that difficult.
Dr. Barry Eppley
Indianapolis Indiana
Q : I have a bad scalp scar from a prior brain surgery that I would like revised. I have read about a product from a company called Acell that says it can make scars heal and look better if put into it at the time of the surgery. I have talked to someone at the company and it sounds very promising. Have you ever heard of it and would you use for my scar revision?
A: The search for ‘pixie dust’ in plastic surgery is both alluring and ongoing. We would love to be able to add something to our surgical wounds and incisions that would make them heal better and scar less. While this is of great interest in plastic surgery, I suspect every other surgical specialty would feel the same.
The company to which you refer is known as ACell, Inc. which has developed an implantable material that exergts its effect through the concept of regenerative technology. The product name is MatriStem which is a bioscaffold derived from porcine tissue. (from their bladders) When implanted into a surgical site or wound, it is resorbed and replaced with normal tissue where scar tissue would normally be expected. It purportedly does this by bypassing the typical inflammatory process of wound healing and inducing the body to heal the wound with tissue that is native to the site rather than just dense scar, It comes in sheets and a powder form (micronized particles). It is this powder form that some may call pixie dust. The product is relatively new and has been used for a diverse range of wounds including partial and full-thickness skin wounds, pressure ulcers, venous stasis ulcers, diabetic ulcers, skin donor sites and grafts, after laser skin resurfacing, burns and traumatic abrasions and lacerations.
The material is certainly easy to place into a wound and could be easily applied at the time of closure of your scalp scar revision. It is also not overly expensive as medical products go. Whether your scar will turn out better as a result of using MatriStem particles is unknown but there is no downside to doing so and it does sound promising.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I am a male. I would like to know if Dr. Eppley can do orbital brow bone shaving and whether this can be done without coronal incision. My goal is to achieve a more feminine smooth forehead.
A: Brow bone reshaping can involve different areas of the brow depending upon what one’s aesthetic goal is. If one is interested in a total brow bone reduction, as one would want for a very prominent supraorbital ridge (brow bone), then a coronal incision is needed. This is because at the inner half of the eyebrow are the supraorbital and supratrochlear nerves which supply feeling to the forehead. They can only be pushed out of the way from above without injuring them. In addition, the inner half of the brows are not solid bone but just a thin bone covering over the air-filled frontal sinus. Total brow bone reduction can not be done by shaving but by taking the outer bone off, reshaping it, and putting it back in place.
The outer half of the brow, however, can be surgically altered by both shaving and without needing a large coronal incision from above. This is because the outer half of the brow is solid bone and away from the frontal sinus. It can be done through an upper eyelid incision. The tail of the brow can be reduced and tapered to create more of a lateral sweep which is associated with more of a feminine look.
Indianapolis, Indiana
Q : I am interested in cheek implants but am not looking for a drastic change, just enhancement. I want to look better but have people not be able to tell what is different. I have a few questions. What is the recovery time from work and physical activity (running and cross training/weight lifting)? Are the implants inserted from the mouth and fixed to the jaw? Do cheek implants inhibit ability to smile? Approximately what % of patients are happy with the cheek implant procedure?
A: Cheek implants are done as a simple 1 hour outpatient procedure. They are inserted through the mouth and secured to the bone with a screw. There are no restrictions of any kind after surgery. While you will have some cheek swelling (but no bruising), there is nothing you can do from an activity standpoint that will hurt the implant or their position on the bone. One can eat and drink right after surgery. Pain is very minimal although usually there will be some temporary numbness of the cheek skin and a little bit of the upper lip. Cheek implants will not change your ability to smile or how your smile will look. Initially, your smile will feel a little stiff but that is due to the swelling. The vast majority of patients who receive cheek implants are happy but I also feel that it is the one facial implant that undergoes higher revision rates than all others due to inexperience in placing them, size and position selection, and style of implant used. It is a simple procedure to do but there is definitely an artistic flair to doing them well.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I’m interested in having paranasal implants and I noticed that you have experience in using these implants. Could you please tell me how exactly these implants effect the nose and the upper lip? Does this implant usually widen the alar base of the nose? Does it lift the tip of the nose, which is common in LeFort I osteotomies? Is the upper lip lifted by these implants or is the upper lip seemingly becoming smaller, because of the new relation between the new volume around the nose and the volume of the upper lip? How does it usually effect the nasolabial angle and how does the upper lip change in the profile view? Are there slightly different ways to place the paranasal implants, for example to place the implants closer together towards the spina nasalis anterior or a little bit more apart from each other? I talked to another plastic surgeon and he said they had the same effects on the nose as the LeFort 1 advancement, but I´m not sure if this is correct, because the position of the spina nasalis anterior is usually changed by performing a LeFort I osteotomy. However, by placing the paranasal implants the position of the spina nasalis anterior stays the same. Also the upper teeth stay in the same position and I wonder what effect this might have on the upper lip.
A: Paranasal implants are placed at the base of the ala along the perimeter of the pyriform aperture. They help fill out the paranasal area but will not create the same effect as LeFort I osteotomy. To do so they have to be combined with a premaxillary implant which sits in front of the anterior nasal spine. They have no significant effect on the size, shape, or position of the upper lip or the nasolabial angle.
For central midface deficiency they can help ‘pull the face forward’ when used in conjunction with cheek implants. They add fullness to the nasal base but will not change nasal tip projection. Over the years, the greatest use of them in my Indianapolis plastic surgery practice is in unilateral cleft lip and palate to help build out the upper alveolar and nasal base deficiency.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Are you familiar with the wire release for nasolabial folds and does it work? Will it leave a scar?
A: The nasolabial fold, also known as the facial parentheses, is an interesting facial fold that is not really a wrinkle. It develops as the cheek tissues fall with aging over the more fixed and immobile upper lip. This creates a deepening fold as the cheek tissue piles up on top of the lip. While injectable fillers are the most common method of softening the nasolabial fold, they are temporary and don’t address the actual problem. There are surgeries that treat the real problem, cheek sagging, through a midface or cheek lift but that is usually too extreme for most patients and is best done if the lower eyelid has significant signs of aging as well.
Other methods of nasolabial fold treatment have focused on releasing the attachment of the fold. One of these methods has become known as the wire release. Through several small stab incision and a triangulation technique, an actual wire under the skin is used to widely release the dermal attachments of the fold. While the same technique could be done with scissors, it would require a larger, more visible, incision. This is the advantage of the wire technique. The wire does effectively release the nasolabial fold and produce some initial impressive early results. (after the bruising clears) But the long-term results with this method show a fair amount of relapse as the tissues adhere back down. For this reason, I like to place a dermal graft underneath the released tissues to provide a better long-term result.
Indianapolis, Indiana
Q: Hello, I read about the Patriot Plastic Surgery Program on your website and have a few questions. I was wondering if that included the National Guard as well. I am in the Army National Guard and I am being deployed next summer. I was looking to have a tummy tuck done before my deployment so I would have time to get back in shape. I have lost around 50 lbs from the birth of my daughter and have the excess skin that needs to be removed. I would appreciate any information you may have about the Patriot Plastic Surgery Program. Thank you so much for your time.
A: The Patriot Plastic Surgery program is for all members of the Armed Services and their immediate families. It provides some financial relief for those desiring many popular cosmetic surgery procedures. The costs of surgery are both fixed and variable. The fixed costs of any surgery are the fees associated with the use of the operating room, anesthesia charges, and the costs of any implants used. The only variable fee in cosmetic surgery is what the plastic surgeon chooses to charge for his/her professional time. Dr. Eppley makes an adjustment in his surgical fees to provide some well deserved financial relief for those who qualify for the program.
Many members of the Armed Services have taken advantage of the program since its inception in 2009. Given the young age of most program participants, the most popular procedures include tummy tuck and liposuction, breast reshaping, and rhinoplasty and otoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have two differently sized nostrils. My left nostril is smaller than my right. It looks like just removing some skin will fix the problem. How easy is this to do? I have attached a picture of my nose from below for you so you can see the problem.
A: There are numerous causes of one nostril being different than the other one. Since the nostril is geometrically a triangle, changes in the any of three legs (columella, alar rim, nostril sill) can cause a change in nostril size and shape. The most common cause of nostril asymmetry is an alteration of the vertical leg. That is the piece of skin between the nostrils known as the columella. It is supported from behind by the end of the septal cartilage, known as the caudal septum. This is frequently deviated or deflected to the side into the nostril space. When this occurs, the oval-shape of the nostril will become deformed making it look smaller. This is exactly what your picture shows…a classic deviated caudal end of the septum.
Whether more of the septum is off of the midline as it goes deep into your nose is unknown. You would probably know that because such a deviation is likely to cause breathing problems of which you would be aware. Regardless, correction of this problem is through a septoplasty procedure. The septum is moved back to the midline behind the columella. This anatomic correction returns the nostril size and shape back to better symmetry with the opposite nostril.
Septoplasty is commonly performed as part of many cosmetic rhinoplasty surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
The desire for fat reduction is a near universal one that crosses all age, gender and ethnic lines. From the countless number of diet and exercise approaches to the opposite choice of liposuction surgery, loss of body fat can be successfully done with varying degrees of individual effort. But between these two ends of the fat loss spectrum lies the developing field of non-invasive body contouring. The concept of losing fat without surgery through an external device is both appealing and promising.
External ‘machine-driven’ methods for fat reduction are not new. Whether it was the belt-driven shaking machines from the first half of the last century to sitting in a sauna box and sweating it off, letting something else do the work and hopefully losing weight will always catch the public’s attention. Taking a pill, of course, is the simplest and requires the least amount of effort. But you probably didn’t get overweight or develop those few fat areas by taking pills, so it seems unrealistic that you can lose this fat by pills alone. While science and technology has come a long way, does today’s non-invasive body contouring devices really work…or are they just a modern-day version of the old ‘shaking machine’?
The newest technology for non-surgical body contouring is Zerona. This is an external cold laser that helps make fat cells leaky and loss some of their lipid contents. While people think of a laser as being a focused beam of light that hits a target and causes it to vaporize or melt, cold laser technology is different. It can pass through the skin without injuring it and penetrate up to 5 cms (2 inches) in depth. This can reach localized fat and exert its photochemical effect. The concept of photochemical-induced leakiness of fat cells is a bit hard to grasp but its physics are a little similar to the way cell phones actually work. I have a hard time wrapping my mind around cell phone technology to understand how all these messages and images are flying around and get to their intended recipients….even when I am on an elevator or a plane. But despite my ignorance I have plenty of evidence every day that it does work. So I won’t hold it against photochemical-induced fat loss simply because I don’t completely understand the science behind it.
The effects of Zerona on fat is very short-lived so multiple treatments are needed, spaced but a few days apart. Over a course of several weeks and multiple treatments, many patients have been shown to lose several inches around the waist, hips and thighs. But along with the treatments it is advised to drink water and take a niacin supplement to support the lymphatic clearance of the released fat. Herein lies the important difference from today’s technology and yesterday’s devices of hope…the use of some modest lifestyle changes and good patient selection.
Non-invasive body contouring is not a substitute for what liposuction can achieve or for the large amounts of weight loss that occur from bariatric surgery. Rather it is intended to benefit those who have some stubborn areas of fat that are just not responsive to what you can do at home with your best efforts. And for those who do not feel they have enough of a fat problem to justify surgery or want to do anything to try and avoid that solution. By using these criteria, most patients that use Zerona have more modest fat collections. This size of the problem and the modest lifestyle changes that are part of the program account for the generalized success and satisfaction that occurs from this non-invasive body contouring device.
Dr. Barry Eppley
http://eppleyplasticsurgery.com/
Indianapolis, Indiana
Q: I have two forehead bumps that are very distressing to me. They have been there since I was very young. They stick out like horns and I am very self-conscious of them. Can they be taken down and made smooth with the rest of my forehead? What is involved in this type of surgery and what are the risks?
A: Thank you for sending your pictures. I can clearly see the two upper forehead bumps. While they are not true osteomas, they are protrusions of the frontal bone. They can easily and simply be reduced through burring reduction. You can take down the outer table of the frontal bone in these areas up to 5mms to 7mms which should make them smooth and even with the rest of your forehead contour. This can be done through an incision either back in your hairline or just along your hairline. This would result in a very fine line scar. The hairline incision, commonly used in pretrichial or hairline browlifts, offers an advantage in that one could advance the frontal hairline forward if one desired. In your pictures, it appears that your forehead is fairly long between the hairline and the eyebrows. That distance could be easily reduced at the same time by bringing the hairline forward. I have found that to be very helpful with burring down upper forehead prominences as the combination of bone reduction and a shorter forehead length makes for a very smooth and more pleasing forehead shape.
Indianapolis, Indiana
Q: I have had some body changes which have left me looking like a man. My head is also bigger. I have lost the contours of my face and my hips are strapped like boy’s. My hair is shorter too. Is there a way you can help?
A: Questions like this, while well intentioned, are a waste of time for both the patient and the plastic surgeon. The description of concerns are very vague and non-specific. Plastic surgery is about doing very specific procedures for identifiable specific and focused concerns. When a collection of procedures are done, it may very well be possible to change the look of one’s face or body. But plastic surgery is not magic and having plastic surgery does not ensure anyone that they will look different or feel better about themselves.
The most satisfied patients in plastic surgery are those that come in with observable anatomic problems and a reasonable amount of concern about them. As a plastic surgeon, I have no hope of making someone satisfied with a result when the exact problem is not clear beforehand. As the old motto goes, ‘you can not hit a target you do not have’.
When I sit done with patients in a consultation, I want at the end to have a list of specific concerns and have them listed in their order of priority. If we start at the top of the list and only do just one or two procedures gthat are directed to improve them, the patient is likely to end up feeling that their results were worth the effort.
Indianapolis, Indiana
Q: My son has torticollis which has contributed to his skull and facial plagiocephaly. We did not know about the cranial helmet when he was young and his condition was left untreated. He is now a teenager and very self conscious about his head being flat on one side and his face being skewed. He asked if there were any surgeries or anything we can do to correct it. I found your website and was amazed that you have experience with his exact condition. What can be done for him at this point?
A: Deformational plagiocephaly causes a very predictable pattern of skull and facial changes when untreated as an infant. As the craniofacial bones rotate around an axis, the pattern of asymmetries become flatness on one side of the back of the head and a protruding forehead, brow bone, cheek and jawline on the same side on the front. This can create very visible facial and front (forehead) and back (occipital) skull changes. I have seen a wide range of facial plagiocephaly problems in the degree of expression of the amount of asymmetrical differences.
Since the fundamental problem can not be reversed, changes must be done in an effort to camouflage or improve the different asymmetries. These can include an occipital cranioplasty to build up the flat area on the back of the head and numerous facial structural changes. The face can be altered by forehead and brow bone reshaping, cheek augmentation and jaw angle , and a chin osteotomy, all done with the objective of improving facial symmetry. The combination of skull and facial procedures that are helpful will be different for each patient. It requires an individualized assessment and computer imaging to determine the best plastic surgery plan for each patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi. i am an 18 year old male who is looking at getting something done to flatten my forehead and reduce my brow ridge, as I am unhappy with how it looks. i just wanted to know if I am a bit young to be getting something like this done? Also I play a fair bit of soccer so would like to know if it would affect how I header the ball permanently if I was to get surgery like this? Also would the scarring be noticable if it were not on the hairline?
A: From your description, it appears that one side of your forehead is more protrusive than the other, giving you forehead and brow asymmetry. The surgical technique for brow reduction is more effective than forehead reduction. The middle and tail of the brow bone (which is usually the most noticeable) can be burred down fairly significantly. The forehead bone that extends above it, however, can not be so significantly reduced. The outer table of the forehead bone (cranium) is only about 5mms or so thick before the diploic space is entered. From a practical standpoint, you don’t want to be reducing the bone into the diploic space so only about 4mms or so of bone can be reduced. While this would make some difference, the brow reduction and shaping would be more significant. The other important issue is that to do the forehead reduction, a large coronal scalp incision would be needed. This creates it own aesthetic issues and the trade-off of the scar for the amount of forehead reduction may not be a good one.
Doing the brow bone reduction, however, can be done through an upper eyelid incision. Given this hidden scar and for the amount of brow improvement, this would be a much better trade-off.
Indianapolis, Indiana
Q: I have been researching getting breast implants for some time. I know the differences between saline and silicone types of implants but am confused about these ‘gummy bear’ implants. I know it is some form of silicone but it is the best type of implant to get? Why is it different and are there any known problems with it? Is it the best type of breast implant to have?
A: The first thing to appreciate is that there are numerous type of breast implants from which to choose. They all will work and are FDA-approved with the exception of the gummy bear implant to which you refer. It has yet to be shown that there is one type of breast implant that is superior to any of the others. They all have some advantages and disadvantages and each woman has to weigh out those implant differences to determine what is the best breast implant for them. If there was one specific type of breast implant that was definitely superior that would be the only one that I would be using in my Indianapolis plastic surgery practice.
The gummy bear implant is a different type of silicone that is more firm than regular cohesive silicone gel. Hence the name gummy bear as it resembles this consistency. It is a textured anatomic implant that remains under clinical trials through the sponsoring company Allergan. It has not received FDA-approval as of yet. Because of its textured surface and its more form consistency, it must be placed through a larger lower breast fold incision than would be used for either saline or cohesive gel breast implants. Whether its added firmness is an advantage in cosmetic breast augmentation is a matter of debate. Its physical properties seem to offer advantages in breast reconstruction where the breast tissue may be thinner and more prone to contracture deformity. Gummy bear implants can and do ‘fracture’, requiring removal and replacement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I could not find info on your website regarding earlobes. Mine are large and I think it would look much more aesthetic if they were trimmed. Was wondering how it would be done. Thanks!
A: Large earlobes can be the result of one’s natural genetics or from aging and the use of heavy ear rings. In women, it is often the latter. In men, since they don’t wear heavy hanging ear rings, it is the result of one’s genetics. There is some component of aging and gravity that can make the marginally large earlobe larger and longer in later life. Either way, the surgery to reduce them is the same.
Earlobe reduction is a fairly simple surgery that often can be done under just local anesthesia. Like all earlobe surgery, it is not extensive because the earlobe is relatively small compared to the rest of the ear. There are several different methods of cutting out extra earlobe tissue and the differences are all about where the scar ends up on the earlobe. The wedge excision technique removes a triangular piece of earlobe from the central part. It is very effective at making the earlobe smaller and better shaped but does place the scar right down the middle of the earlobe. This scar usually ends up looking fairly indistinct but one must know beforehand that is where the scar will be. The other technique of earlobe reduction is to remove the lower hanging portion of the earlobe. This places the scar along the more hidden location of the rim of the earlobe. Both methods are effective and the choice between the two is partially influenced by the shape and size of one’s earlobe and preference for scar location.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a divot in both of my shoulders from Vitamin B12 injections in which one became infected. I am a fitness competitor. Vitamin B12 is used for energy when dieting and also temporarily enhances the roundness of the shoulders (it is not discussed but used by competitors – injectable Vitamin B12 can be ordered from Canadian pharmacies). I no longer do this of course, but I am not happy with the divots left in my shoulders because of these injections. I was interested in fat grafting to replace the lost fat.
A: Loss of fat beneath the skin, known as subcutaneous atrophy, is not an uncommon sequelae of numerous types of injections. In plastic surgery, it is frequently seen in repeated steroid injections in the treatment of scars. I was not aware that Vitamin B12 has a similar effect and it is unclear if the fat destruction occurs as a result of the vitamin or the solution in which it is suspended to make it injectable.
The treatment (recontouring) of these divots is best done and is ideal for fat injections. While dermal-fat grafts can also be used, they require an incision to be placed and that requires an additional cosmetic burden that may be just as distracting as the original depression. Any of the off-the-shelf injectable fillers can also be used but there effect is only temporary and not a good long-term economic approach. Small divots like these are perfect for fat injections as their small volume makes it more likely that the fat will take and survive long-term.
Indianapolis Indiana
Q: Is there some place on the web to view close up frontal photos of scars from direct excision neck lifts? Do surgeons use traditional sutures that can leave trackmarks or are there other methods to close the site that won’t leave tracks?
A: Like a traditional facelift, the closure and the subsequent scar of the direct necklift is critically important. Since the direct necklift is fully exposed, it can be argued that the final scar is even more important than a more hidden facelift scar.
To see good close-up pictures of direct necklift scars, go to my blog…www.exploreplasticsurgery.com…and search under direct necklift. There are several blogs that address direct necklift scars and show photos of them. If you can’t find them let me know and I will send some to you to review.
The closure (suturing) of the neck wound is done with very small sutures that are removed a week later. Because the size of the suture is so small, they can not leave track marks. In my out of town patients who can not come back for suture removal as they have returned home, I use small dissolveable sutures that do not leave track marks either. Track marks are primarily the result of using large sutures that are left in a long time.
Another way to judge the outcome of a specific type of incisional scar is to look at the number of scar revisions that have been needed from the procedure. In my Indianapolis plastic surgery practice, I have yet been requested to do a scar revision from a direct necklift in a man. This can be explained by the great healing capability of bearded skin and the incidental scar therapy of daily microdermabrasion. (shaving)
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like to know few things about butt implants Dr. Eppley did my breast implants few years ago and now i would love for him to do my butt. I want to go big. What sizes and shapes can I pick from?
A: Buttock augmentation is similar to breast augmentation in some ways but different in others. Buttocks implants, unlike breast implants, are made from a very soft and flexible solid silicone rubber material. They are not fluid-filled. Like breast implants, they can be placed above (subfascial) or under (actually into) the gluteal muscle. Those two different locations carry greater significance in buttock implants than in breast implants,, particularly in terms of recovery. Intramuscular implant placement is preferred but that also limits the size of the implant that can be used and makes the recovery much more prolonged and uncomfortable. One’s anatomy also can also drive this choice because if there is little subcutaneous fat present over the buttocks, the intramuscular location will produce a smaller but more aesthetic looking result. (concealing the implant edges better)
Buttock implants come in either round or oval shapes and have volumes ranging from about 150cc to 400ccs. Unlike breast implants, in which the size range that can be used is much more variable, the size and shape of buttock implants must be more closely matched to the surface anatomy and measurements of one’s buttocks. In the buttocks you don’t have the luxury of just putting in whatever size implant you want. The risks of postoperative problems and complications is higher when you do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey doc, I’m a girl who is of Chinese and Siamese descent. My question is, is it possible to reduce the size of my face in general through plastic surgery? The thing is I don’t have a specifically prominent area of my face as it is generally very wide and big. There is little to no fat and just very wide bones and I would like them to be smaller. My cheekbones are the most prominent while my jaw is simply wide but not very defined This gives me a very flat looking profile from the side but a very ‘big’ face from the front. So what is your take on this?
A: The best way for me to answer your question is to let me see some photos of you. The description is helpful but is not the same as actually seeing you. That being said, changing a facial ‘look’ is about picking a few facial areas that can help create a different facial gestalt or general appearance. Changing a ‘flat face’ requires providing more anterior projection and maybe doing some spot areas of reduction. In the Asian face, cheek and jaw angle reduction possibly combined with augmentative rhinoplasty helps change facial projection. While you can not really make a face smaller by actual measurements, you can make it appear more proportioned and this not look ‘so big’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My ears stick out and I am looking into getting them fixed. Can you tell details of the procedure to do it?
A: The correction of protruding ears, known as otoplasty, is a relatively simple procedure that makes for a dramatic change in the shape of one’s ears. Using an incision on the back of the ears, the shape of the ear cartilage is changed primarily by using suture techniques. The primary reshaped areas of the ear are the antihelical fold, which often is missing or poorly developed, and the concha which is often too big or too strong. Both the size of the concha and the absence of an antihelical fold make the ear stick out too far from the side of the head. Once the cartilages are reshaped, the incision is closed with small dissolveable sutures. A wrap-around ear dressing is used in adults for just one day. It can be removed the next day and one can shower and wash their hair normally.
While the change is immediate and clearly visible once the dressing is removed, the ears after otoplasty will definitely be swollen and sore. The swelling will go away in about a week. The tenderness will remain for several weeks longer however. Complications from otoplasty are not common. The most significant ones would be over- or undercorrection, asymmetry between the ears, and delayed extrusion of one of the permanent sutures. (which can occur years to decades later) Of all of the otoplasties that I have done, revisional surgery has been limited to less than a handful.
Dr. Barry Eppley
indianapolis, Indiana
Q: I have a high forehead along with a long face and I think it would look better if my hairline was brought forward and my forehead shortened. Is this something you could do in a male? I am 27 years old.
A: Shortening the vertical length of one’s forehead can be done by bringing the hairline forward. Much like a ‘reverse browlift’, the hairline is lifted up and brought forward rather than the eyebrows lifted. As a simple variation of the hairline or pretrichial browlift, forehead skin is removed to allow the hairline to come forward into a new and lower position, usually 1 to 2 cms of forehead reduction can be obtained. For women with long foreheads (greater than 7 cms. of length between the frontal hairline and the eyebrows), this is a very effective procedure that may allow them to change their frontal hairstyle afterwards.
In men, however, a long forehead is usually due to a receding hairline. The frontal hairline position in most men is not stable and naturally lengthens with age as hair loss ensues. While a young male does not yet have this problem, and it may not occur in every male, it is impossible to predict which male hairline may or may not recede. If a hairline lowering is done in a man, the scar line will eventually be seen as the hairline recedes later in life. I do not think this is a wise risk to take in just about any male patient.
Dr. Barry Eppley
Indianapolis, Indiana
For those who don’t know, the “wattle” is that fleshy fold of skin hanging down from the neck or throat. While not seen as an endearing piece of anatomy as one gets older, it is quite common in birds be it the pelican, common rooster or a Thanksgiving turkey. While it may be cute in a bird and makes it identifiable as a species, I have found no human yet that finds it flattering. Common amongst men and women alike as they get older, this sagging piece of skin and fat is often what bothers them the most about their aging face.
The wonderful world of digital cameras and cell phones have helped some people discover their neck wattles by seeing themselves in side view in a picture. Men make the discovery when wearing certain shirts and often feel it ‘flopping’ around when they move their heads. (swinging a golf club seems to bring on this sensation)
The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.
The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the manufacturer and seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost hundred to thousands of dollars per jar. (wrinkles are one thing, wattles are quite different) The other hopeful but unsuccessful effort is that of neck exercises. If the loose neck was primarily due to muscle looseness, this approach might have some benefit. But for the skin and fat that has become loose and is sliding off the face into your neck, the ‘neck gym’ remains more theoretical than useful. Neck exercising will have about the same benefit as it would for lifting the sagging breast or those eyebrows that just keep getting lower.
While many people would consider having a necklift, they wouldn’t dare undergo a facelift.This comes from a misunderstanding of the two procedures, not realizing that they are largely one and the same. I have found only a handful of patients who have ever actually known what a facelift really was. A facelift is really a necklift. But facelifting comes in two varieties which differ based on how much improvement in the neck is needed. A limited facelift (popularly known as a Lifestyle Lift or jowl lift) is great for jowling but not so much for the neck wattle. For small neck wattles, a Liftstyle Lift combined with liposuction in the neck may just do the trick. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears. To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck.
The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that hasn’t been seen for decades. The price for this most effective and simplest of wattle solutions is a fine line scar down the center of the neck. For the beard skin of men, this scar heals beautifully and may be the procedure of choice in the older male. For women, the location of this scar must be thought about carefully to determine if this is a good trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: After two rhinoplasties (a good minor tip refinement in 2001 and a rather aggressive septo-rhinoplasty in 2009 which contrary to my request shortened and upturned my nose a little), my aim is very mild tip lengthening, about 1.5 to 2mms and downward rotation. There are no problems of symmetry or breathing now, but my doctor used columellar strut, dorsal onlay, tip onlay and peck grafts and believes that my septal cartilage is probably inadequate so an ear graft must be used. Is this a safe solution for a very small improvement, or could the removal/repositioning of some used graft contribute to slight de-rotation? Can a combined solution, or even the use of hyaluronic acid, provide the best and least risky solution? I would really appreciate even a very mild lengthening/de-rotation, and much is being reported about the impressive progress in stem cells engineered cartilage. I really hope that you might be able to help me without extreme procedures and considerable risk.
A: To lengthen and de-rotate your nasal tip slightly, an onlay graft is a good solution. For the small amount of change that you want in your nasal tip, building out the area with a graft would be the most predictable. The use of ear cartilage grafts from the concha in rhinoplasty is very common, safe, and produces predictable results. It is a simple cartilage to harvest as it is taken from the back of the ear, leaving no visible scar. The natural curve of the cartilage is quite good for use in the nasal tip, which has numerous curves to it. The use of injectable fillers will produce your desired result quite simply but will go away in six months or less so it would need to repeated with some frequency and expense. Cartilage grown from stem cells currently remains a laboratory technique that may one day be useful in humans.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I always had a very thin upper lip with down turned corners. I have had dental implants (7) and a permanent bridge for my upper teeth recently. I noticed that my top teeth no longer show when my mouth is at rest and that my bottom teeth which hardly showed before are now quite visible when my mouth is relaxed and when I am talking. My dentist said this was due to aging (I am going on 51) I read an article by you on Lip Augmentation and was curious if I should be looking into a face lift or a lip procedure? I had my lips enchanced once (not sure what product was used, I am allergic to collagen) and the results were overly swollen and then within two weeks all was gone. What do you recommend?
A: The thin upper lip can be due to aging, a naturally smaller amount of vermilion tissue (pink part of the lip) or a combination of both. When you combine a naturally thin upper lip with aging and the need for dental implants (maxillary bone atrophy), you have the perfect setup for a very thin upper lip problem. When the vermilion is this thin, no injectable filler will provide a good outcome. While I think it is good that you tried the simple approach of a filler, one could have predicted that the results would not be good. But you have now at least proven that a surgical treatment is needed.
The way to get a fuller upper lip is to create more vermilion. This can be done very successfully through a lip advancement procedure. By removing a strip of skin above the lip and moving the existing vermilion upward, the upper lip will instantly and permanently become fuller. When this is combined with a corner of the mouth lift (through the removal of small triangles of skin above the downturned corners), you will have an instant change in the entire look of your upper lip and mouth area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I underwent a heart surgery in 1987 and I have a scar that gives me a problem. I always wear something to hide the scar because I think all the time that people see it. My question is how much of a scar is possible to reduce in percent?
A: While I have not seen your chest scar, you most likely had an open heart procedure through a classic midline sternotomy approach. This leaves a scar right down the center of the sternum from just below the sternal notch to just above the xiphoid process. For some patients this long vertical scar can get wide and raised, now as a hypertrophic scar. While often confused with a keloid, a hypertrophic scar is fortunately different. It is the result of the typical tension forces on a scar that runs perpendicular to the relaxed skin lines of the chest rather than a true pathologic abnormality of healing like a keloid. In women with large breasts, this scar may be pulled on even more than in a man due to the weight of the breasts. This can be a particualr problem in the cleavage area.
Scar revision of hypertrophic sternotomy scars is not rare in my plastic surgery experience. Scar revision of them consists of complete excision (cutting them out completely) and re-closure. Usually a significant improvement in their appearance can be obtained, trading off a wide raised scar for one that is flat and much more narrow. By percent, that improvement would be between 50% to 75%.
Dr. Barry Eppley
Indianapolis, Indiana
