Your Questions
Your Questions
Q : We have a potential new hire for our company that has about a ¾ inch insert gauged in both ears. This person regrets having this done and wants to abide by company requirements and have them removed. How is this done and what does the earlobe look like afterwards. Also, what would the potential cost be to have both earlobes repaired?
A: Gauging of the earlobes creates a central hole surrounded by a thinned out or thin ring of earlobe skin. The size of the gauge determines how thin the ring of earlobe skin is. As long as the gauge is not too big (greater than one inch), the expanded earlobe can be put back together and have about the same size as it was before having the insert. When the insert becomes much bigger, it not only stretches out the earlobe but the tissue becomes much thinner as well. (pressure atrophy) When put back together, the final size of the earlobe will likely be smaller than before.
Earlobe reconstruction is done by cutting out the skin along the central hole, including some of the rim, and putting it back together in the shape of a more normal earlobe.
Like the split earlobe deformity, reconstruction of the gauged earlobe can be done under local anesthesia. This can usually be done in the office which saves a lot of expense when the cost of an operating room and anesthesia is not used. The typical cost of such earlobe surgery is in the range of $750 to $1,000 per ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q : Hi, I read online that other girls have the same problem as me. I had a jaw reduction and the doctor shaved too much bone and side of the jaw, is uneven to the other side. You gave advice to them to have jaw implant. My question is that since the jaw is now uneven, how can you make it even by putting jaw implant? Will the implant be different since it is not the same? How much does it cost for chin augmentation? Not the implant but the moving if the chin. Thank you.
A: It sounds like you had a jaw angle reduction. Often times, too much bone is removed and the sides are uneven as more bone is taken from one side than the other. The only way to improve that problem is to replace the lost bone with an implant. The size and shape of the jaw angle implant is taken from tracings off of a panorex x-ray as both implants can not obviously be the same when asymmetry is involved.
Jaw angle reduction must be carefully done as it is easy to remove a large bone segment from this intersection of the posterior and inferior border of the jaw. This not only makes the jaw angle blunt but can make one look more aged as well.
A chin osteotomy is done much less frequently than an implant for chin augmentation. But in the right patient, it can offer some different dimensional changes that may be more ideal for facial balance. (e.g., chin lengthening) The average cost for a chin osteotomy is around $6500 when done as a one hour outpatient procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q : Last year I had a facelift which made my sagging neck and jowls look so much better. I love the result but have developed some raised and mildly painful scars behind my ear. My plastic surgeon said they would eventually go away but I am not so sure. They have not changed in size and they feel like small ropes along the backside of my ears. What do you suggest?
A: Nearly one-half of the incisions that are used in a facelift are behind the ears. Going along the grooves where the ear connects to the side of the head, these scars run along this groove where they go back into the scalp near the top of the ear. The skin behind these scars is used to pull up loose skin from the neck where it is trimmed off.
These skin flaps behind the ears are very thin and often are the slowest to heal after a facelift…even though they are not easily seen. Because these incisions behind the ears are stitched back together under some tension, a few patients can develop hypertrophic or raised scars because of it. Once the scar thickens it will become and stay sensitive.
Sometimes these raised behind the ear scars will settle down on their own with just time and scar maturation. If these raised scars persist beyond a few months, I recommend steroid injections. I repeat these injections every month for up to three injection sessions. They will usually cause the raised scars to settle. If they have not gone away by then, cutting out the scars is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am getting saline breast implants in the next several months. I am getting them because they are less expensive and the size of the cut to put them in is much smaller. What I want to know is where is the best place to put them through…my armpit, nipple, or under my breast in the crease?
A: One of the two advantages to saline breast augmentation, besides a lower cost, is that they can be inserted through very small incisions. Because they are put in deflated, they are rolled up to about the size of a small burrito. This enables them to pass through incisions as small as one inch or 2.5 cms. Once in place, they are the inflated to their desired size.
While all three incision locations will work (armpit, nipple, lower crease), choosing one of them is based on the patient’s preference for scar location and how soon they must return to work and what type of work they do. If one has darker skin color (e.g., Asian or Hispanic), they I would definite choose the armpit or axillary approach. This is because this puts the scar away from the breast and women of these ethnic backgrounds are very sensitive about any visible scarring. Conversely, if one needed to return to work quickly and their job involved lifting, then I would choose the lower breast crease. Becasue the entire pectoralis muscle does not need to be elevated (only the lower half is), one will have less pain and a quicker recovery due to the more limited muscle trauma.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting breast implants but only want to go up maybe one cup size. I don’t want anything drastic just a little change. I want the result to be completely natural looking and not fake. How can I be sure that will happen?
A: The concept of natural breasts can mean different things to different women. In general, however, what most women are referring to is a breast that is not disproportionate to their body and chest size and one that does not have a completely round shape. (too much upper pole fullness)
The most assured way to avoid an unnatural breast augmentation result is to have properly sized breast implants. In short, don’t get too big of an implant for your chest or the amount of breast skin that you have. The single best way to avoid that problem is to keep the diameter of the implant at or less than your own breast base diameter. Implants that are wider than your breast base will always look unnatural or too big. This may also mean to avoid a high profile implant which can have a tendency to look rounder after surgery, particularly if you have small breasts with tight skin to start.
Natural breasts are also those that don’t have palpable (able to feel) implant rippling. This is more of a concern with saline implants who have a greater tendency to develop implant rippling, which may also be able to be seen as well.
In summary, natural breast augmentation is best done by choosing a silicone gel implant that is slightly narrower than your breast base width. For many women this means that implants sizes will run between 250cc to 350cc.
Dr. Barry Eppley
Indianapolis, Indiana
Q: How do you do mouth widening? I have a relative that is scheduled for that procedure and we are hesitant to do it. We have never heard of such a thing. How safe is the procedure? Thank you for any information that you can share with me.
A: The concept of making one’s mouth wider is possible but very rarely done. I can only assume that your relative has a small horizontal width to their mouth (small mouth) and wants it to be extended further horizontally.
Such an operation is possible by using the principles of commissure creation or modification. Known in plastic surgery as a commussuroplasty, the corners of the mouth can be either shortened (closed down) or opened up. (made wider). To make the mouth wider, a modified isoceles triangle of skin is removed out to the distance you want and the inner lining of the lip (mucosa/vermilion) is advanced out and sewn to it. (a Y-V advancement) This relatively simple procedure will make the mouth wider but does so by leaving small scars at the corners of the mouth at the junction of the skin and the lip tissue. If not overdone too much, it can definitely make a difference and look fairlu natural. Such a technique is used in the more commonly done corner of the mouth lift, where downturned corners are turned up and made more horizontal to get rid of frowning or a downturned smile.
Conversely, the reverse can be done to make a wide mouth small. (a V-Y advancement) This leaves a more noticeable scar in its wake as the lip lining is moved further inward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to know more about a procedure that will lower my upper lip. I show a lot of gum when I smile and this bothers me. I have read about a ‘mucosal roll-out’ operation that brings down the upper lip. Please tell me more about it.
A: An upper lip mucosal roll-out will have only a very minimal effect on actual upper lip lowering. That is used more to make the upper lip fuller but, in and of itself, will only lower it maybe a millimeter or two at best. To lower an upper lip for the purposes of a gummy smile treatment, the upper lip must be treated by levator myotomies (release of one of the main lip elevators) , an upper lip spacer insert (to keep the muscles from healing back together and to help push it down) and a V-Y mucosal release (frenulectomy, although technically it is a frenulotomy) and advancement. Moving the inner lining of the upper lip (mucosa) only will not be effective.
Lowering an upper lip is even more difficult to achieve than raising a depressed lower lip. While bone shortening (maxillary impaction) is the most effective way to bring the horizontal lip level down closer to the teeth during smiling, most patients do not want that much surgery to achieve that goal. Soft tissue surgery to lower the upper lip can be expected to achieve about 3 to 5mms of actual lip lowering. This can be combined with other dental procedures (crown lengthening) to get an even greater amount of gummy smile reduction.
Indianapolis, Indiana
Q: Dear Dr Eppley, I am contacting you with interest in stem cell-enriched breast augmentation. I think it is an interesting new technique and it has raised many questions in my mind. Here is my list of questions.
1) First of all, how is the surgery done and how much fat do you need to do it?
2) Specifically, I would like to know whether it is possible to transform my small A-cup to a preferred C/D cup. Is this possible with the procedure. What is the average gain in ml when you have an A-cup?
3) What are the risks? From other plastic surgeons I hear that the long-term effects are very uncertain.
4) I am kinda slim, so I am wondering if I have enough fat on my body to do the procedure?
I am looking froward to our answers.
A: In answer to your questions about breast augmentation with fat injections and stem cells, here is some current realities with it:
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in having a jawline tuck procedure. The only part of my face that bothers me as I have aged is along the jowls. That is the only place where I have some excess skin that affects my appearance. Please tell me where the incisions area and what part of the face this operation does, and does not, affect. Thank you!
A: Basically, a jawline tuck is a simple modification of a limited or mini-facelift. It is similar to the advertised and marketed ‘Lifestyle Lift’ which is a franchise approach that offers a very similar procedure. As the name would imply, it is a facial rejuvenation procedure that has very little downtime hence the branded name. The fine line incision starts at the top of the front of the ear, goes inside the ear behind the tragus, and then around the back of the earlobe. Through this hidden incision, any loose skin along the jawline (jowls) is lifted smoothing this area out. There is some benefit in the neck area but not as significant as that of the jowls. This procedure is as described….a tuck for the jawline or jowls. It does not affect any other part of your face.
Many times other facial procedures are done with this ‘little’ facelift such as neck liposuction, laser resurfacing or chemical peels, and eyelid tuck procedures. But when done alone, there is less than a week of any visible swelling and bruising so recovery is quite rapid.
The key concept to grasp is that a facelift is an isolated jowl and neck procedure. A limited facelift or jawline tuck is just a smaller version of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had breast reduction surgery last year and , while those results were great, my stomach area is now the problem. What is the best way to get rid of some (or a lot of!) stomach fat? I have read about Zerona. Is it better than liposuction or does it just depend on the person?
A: It is not uncommon after breast reduction that one notices that they now have ( or have had) a larger stomach than they knew. Since the breasts hung down on the stomach, the size of the stomach is usually obscured. After breast reduction, where the breasts are lifted and reduced, these ‘new’ stomach problem appears.
While fat reduction can be done both surgically (liposuction) and non-surgically (Zerona), the results and the process are not the same. Do not equate Zerona and liposuction as providing the same results. Liposuction is a much more effective and rapid way of eliminating unwanted fat, albeit with surgery. Zerona is best considered as a non-surgical step before one considers liposuction. In the right patient (5 to 20 lbs overweight), Zerona may provide enough of a result that liposuction may never be needed. In larger fat collections, liposuction may ultimately be needed.
Therefore, patient selection is critical when deciding what approach to take for abdominal fat reduction. For small to modest abdominal fat fullness, Zerona is probably worthwhile as enough of a result can usually be obtained without surgery. But if you have a large abdominal girth or any excess overhanging abdominal skin, some form of surgery will be more effective whether it is liposuction, a tummy tuck or some combination thereof.
Dr. Barry Eppley
Indianapolis, Indiana
Q : When I was 20 and in the service I had a breast reduction. I went from a 44DD down to a C cup. I am now 50 and my breasts have slowly over the years grown back. I have been so uncomfortable physically and mentally from their size. I didn’t know breasts could grow back after they were reduced. Can I have another breast reduction at my age?
A: Breast reduction is a very successful operation at reducing one’s breast size as well as lifting it back up onto a better position on the chest wall. (where it once was) In most cases, once the breast is reduced it does not return to its original size. But breast regrowth has been reported and it does occasionally occur. This is almost always in the young female population when the operation is done during the teenage years. When done under the age of 18, exposure to continued bodily growth, weight gain and pregnancy can all be hormonal signals for breast tissue growth. But even in these circumstances it is still rare. Having it happen after one is developed is rare but not unheard of as you illustrate.
There is no age limit when breast reduction can not be performed. It is not an operation that is stressful to one’s bodily systems. It can be done using your existing breast scars as the operative pattern. It would be fair to say that there is no chance your breasts would regrow after being reduced at age 50.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I wanted to get some information as far as migraines and Botox. I have suffered with migraines for many, many years and have read that Botox can help. My headaches usually start around the eyebrow area. Thank you.
A: The fact that your migraines have a focal area of initiation at the eyebrows strongly suggests that their origin is compression of the supraobital/supratrochlear nerves. Contraction of these muscles squeezes the nerves that they surround and causes a painfuol migraine to start. Botox has a good chance of having a positive effect since it weakens the muscles around those nerves as they exit from the brow bone. This is a simple treatment that looks like it may work well for you. For a few hundred dollars, you can easily prove this migraine theory. While the effect of Botox is not permanent, many responsive patients find it to be a temporary miracle that provides a level of relief that no other medication does. In select migraine patients, plastic surgeons have learned many years ago that Botox around the brow area reliefs headaches. The key to whether Botox will be a successful migraine treatment is to have a very specific point of headache origin at one of the major cranial sensory exit sites from the skull. Botox is not effective for many types of migraines, just ones that have a very specific focus or loci.
If Botox is effective, that would mean that endoscopic supraorbital/supratrochlear nerve decompression may provide some long-term reduction in your migraine symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: i am going to have my chin shortened by cutting the bone, a procedure known as a vertical chin reduction. But I wanted to know something that is very important to me. After the surgery, the people that know me which i see everyday, will they see the difference in my face without me telling them? Will they know I have had some type of surgery? I am worried that they might say something like ‘Hey, what happened to your face?’ or something like that.
A: It is perfectly normal to assume that everyone that sees you after surgery will know exactly what you have had done. In reality, we give other people too much credit when it comes to perception. Most people, other than those who know us closely, see our faces in a more overall impression but not a lot of detail. Known as a facial gestalt, it is the image of our face people know, not the specific details. Therefore, after surgery people make see some difference (hopefully positive) but can not usually put their fingers on what was done. They will perceive that you look better, more refreshed, etc but they rarely can tell what part of the face was changed.
This is particularly true in anti-aging facial surgery (facelifts, eyelid tucks etc) but is also true in structural facial surgery. (rhinoplasty, otoplasty, facial implants, etc) Just because you know it doesn’t mean everyone else will. This is also because of another basic human characteristic….we are all more focused on ourselves than anyone else. Almost every human is more interested in how they look as opposed to how other people look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a prominent ‘apron’ and it’s getting difficult to navigate. I had twin girls last year and would just like to have a lap to hold them in. I am not expecting to be a size six overnite but I just need to get rid of this extra baggage. I have read about the operation ‘abdominal panniculectomy’ and it sounds exactly like what I need. I would like to have that operation but just want to be sure it it safe since I have a young set of twins. What complications have you seen with this operation and how quickly does one recover?
A: The abdominal panniculectomy is essentially an amputation operation of the overhanging apron. It should not be confused with its cousin, an abdominoplasty or tummy tuck. While they are seemingly similar procedures as they do recontour the abdominal wall, how it is done and what the final result looks like is different. The goal of a panniculectomy is to get rid of the overhang, not to create a slim waist or flat stomach. That simply is not possible given the large anatomy of the abdominal pannus. Getting rid of the pannus will improve back and knee pain as well as skin hygiene underneath the skin flap. In most panniculectomies, it is best to eliminate the belly button (umbilicus) so there is less potential for wound healing problems after surgery.
The most common complications after abdominal panniculectomies are fluid collections (seromas) and wound healing problems of the incision. They are so common it is fair to say that 100% of panniculectomy patients will experience them. Most of them they don’t require further surgery to solve but sometimes they do. Major medical problems, such as blood clots, pneumonia or heart problems, are not common. But most panniculectomy patients are often overweight and may have other accompanying medical problems. This is why a good medical work-up before surgery with approved clearance by your doctor is very important.
It is best to think of complete recovery after a panniculectomy as taking up to four to six weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had cheek implants 3 yrs ago which I am looking at having revised. I am tall and athletic and they are just giving me a bony gaunt look to my face which also makes my eyes appear too far apart. What I really wanted in the beginning were midface implants, but wasn’t able to make this clear with the doctor. They are screwed in and I am wondering if they can simply be reduced or shaven down? Also I have jaw implants and am not happy with the square shape that has resulted from their outcome .
A: Facial implants today come in a wide variety of styles and sizes. They are far more versatile than just augmenting the chin, cheeks or jaw angle in a single way. Frequently, I have patients come to my Indianapolis plastic surgery practice that have existing facial implants but did not end up with the result that they wanted. Communication and computer imaging is key in facial bone augmentation with implants.
Both cheek and jaw angle implants can certainly be modified, exchanged, or simply removed. The question for both areas is what is the best strategy to achieve your goals. From a cheek standpoint, you may have been more interested in submalar implants (on the underside of the cheek bone) rather than malar implants which sit on top. They create different looks. With the objective of improving a gaunt looking face, submalar augmentation is preferred. Malar implants will actually make that appearance worse. In jaw angle implants, the size may be too big or their position on the bone may be too high or too low. The style and shape of the implant can also affect how square or sharp the mandibular angle is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I’m 20 yrs old and currently in my junior year at college. I just found out earlier this year I have a breast deformity called ‘Constricted Breasts”. I knew something was wrong growing up when I wasn’t developing as I should. So I asked my doctors, at 18, about that, and he told me that when I get 20, my breasts should be fully developed. Well I’m 20 now, and they still look the same as they did in 7th grade. I have already tried to see if my insurance would cover a breast augmentation procedure, but they won’t, and my heart just sunk. It hurts so bad. It causes me mental, physical, and emotional pain. Just talking about it I burst into tears. My self-esteem is low, and I am not happy with the way they look and I also find myself cringing when I look down at them. I’m contacting you because I’ve seen your work here and I’m very impressed. I don’t want to seem as if I’m begging, but please, would you grant me with a free procedure? Being in a low-middle class family and in college, at times it’s really hard to make ends meet. I really don’t have anybody around me that understands the way I feel, or where I’m coming from, but you would make me smile from the inside out if you did this. I will be so blessed, and you can possibly change my life forever. From my heart, please consider this procedure for me. I can’t explain how happy I will be if you did this for me.
Thanks for your time, and I hope that for your kindness of your heart, you will make me happy.
A: I have great empathy for the concerns you have about your breasts, and wish that providing you with a free procedure were an easy choice. Given the number of women who come into our office with similar concerns about their bodies, I can understand how connected self-esteem and a positive self-image are. Providing surgery for free may seem like a simple and straightforward thing to do, but there are many factors involved that make the concept of ‘donated’ surgery not exactly free. While any plastic surgeon can give away his time at no cost, a surgeon’s fee represents just a fraction of the total costs of surgery. The cost of the breast implants, use of the operating room, and the fee for the anesthesiologist expertise are other cost factors that must be accounted for and paid. The surgery center, implant company and anesthesiologist are under no obligation to provide services and materials at their expense for a cosmetic procedure. Often times, these costs make up more than that of the surgeon’s normal fee.
One obscure but significant cost of any surgery is the potential medical-legal responsibility that exists in every state. Unfortunately, donating surgery does not equal any waiver of responsibility on the surgeon’s part. Should any untoward events happen, such as a rare but possible complication, the surgeon is still liable and responsible. The possibility exists too, for the need for revisional surgery after the initial procedure and the question then becomes is the surgeon again expected to waive his or her fees? There are no forms or waivers that a patient can sign that can legally hold harmless the physician for the services that he or she has provided.
While a plastic surgeon may choose to donate his or her skill and experience for free, the rest of the costs of surgery remain, and are usually out of the surgeon’s control.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I am 3 weeks post SMAS facelift and necklift. I had a friend who had her facelift months before me. She was very thin and her face looked too tight to me (really pulled along the jaw line). I have a round face despite losing 50 pounds with very sagging neck and jowls. I read where you wrote that a facelift will not get rid of a round face. I know know you were right. My dilemma is that it almost appears that I had nothing done. My round face is still….round.
My plastic surgeon says my neck looks like an 18 year olds neck. I am extremely pleased with that and it is tight as a drum. I feel like my face is tight and a little lifted only on the sides near the ears. I still have loose skin around my mouth. Is this normal? Does the SMAS facelift not address the nasolabial folds? I am very disappointed after spending 11k. What should I do now? Should I address this with my plastic surgeon? He proclaims a “natural” facelift is one that is not too tight or pulled. It may be too natural for me.
A: My first comment is that it is only three weeks from your facelift. When you are living it that seems like an eternity. However, when it comes to facial swelling you still have a ways to go. I would not pass final judgment until three months after your surgery.
That being said, you appear to have a mismatch between expectations and the anatomy of a facelift. You actually have exactly what a facelift can achieve…a nice tight neck and jawline. That is all that an isolated facelift can achieve, no more and no less. It does very little to nothing around the mouth area (nasolabial folds and mouth corners) as they are too far away from the point of pull. (which is around the ears) This is a frequent point of expectation and subsequent disappointment if patients are not properly educated from the beginning. In reality, a facelift is a neck procedure and does little for what most patients believe in their ‘face’.
This also explains why a round face can never be changed from a facelift. The source of the round face is not what is treated by a facelift. The round face is largely a function of the size and thickness of the facial bones, muscles and fat layers.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have been suffering from angular cheilitis subsequently leading to cutaneous candidiasis and sometimes even a secondary bacterial infection for the past 18 months. If my face starts to sweat I immediately dry off my face but am mortified when I awake to realize saliva has pooled in the little cracks in the corner of my mouth. Despite my best efforts, I cannot always keep this area dry.
My dentist told me that it was due to a parafunctional habit and anatomical variation. So I changed the one thing I could control and stopped licking my lips. However, since then my best efforts barely keep this at bay and last week I had a tiny pimple in that area, the skin broke open, and you know the rest, the lovely normal flora became and opportunistic pathogen eating my face away, looking unsightly, and cracking my skin open if I accidentally open my mouth too far.
People think I am crazy for wanting surgery and I fear the opinion of female family members due to the new age stigma of getting plastic surgery too young. This is not for vanity unless you count wanting to be kissed vain, and when I have this crap on my face even I do not want to kiss me! Or look at me for that matter, not to mention how painful and itchy this can be and how long it takes to heal!
I have read that there is a possible surgical treatment for angular cheilitis. What is it and do you think it will be helpful for me. I am just looking for a permanent solution to this nasty mouth problem.
A: Angular cheilitis, also called perleche, is an inflammatory mucositis at the corner of the mouth and usually affects both sides. It presents as deep cracks or splits which may bleed when the mouth is opened widely. Why it occurs is not known precisely. Chronic wetness at the corners is the incipient event and that is most understandable in the elderly edentulous population who experience a loss of vertical dimension due to loss of teeth, thus allowing for over-closure of the mouth. This creates a spillway for saliva and chromic wetness in the mouth corners. Yet I have seen it just as often in younger patient who have a normal angulation of the corner of the mouth.
For those patients that have exhausted all medical treatments for angular cheilitis, surgical treatment is possible. When the corners of the mouth are sufficiently downturned, I have found a corner of the mouth lift to be helpful to change angulation and eliminate that spillway effect. In younger patients with a normal horizontal angulation, a resection of the mouth corner mucosa with mucosal advancement can be done. Sometimes this can include skin as well. The theory here is that the tissues are chronically infected and it is removed. I have seen improvements of the condition with both approaches.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I just have a few questions about a cosmetic issue that I have been dealing with for really all of my life, but just became totally aware of within the last few years. I have a condition called Plagiocephaly. I’m sure you know what that is, so I won’t go into that. I will say, however, that I have a flat spot on the left side of my head. It has caused my left ear to protrude, and my left brow ridge(the part that the eye brow covers), also protrudes. It is very noticeable, especially to me, but others do notice it too. My question is whether or not I can have a procedure done to either A.) Reconstruct the left side of my head and brow ridge so it looks more symmetrical with the other side of my head, or B.) Just correct one of the two areas. I really would like both done and I would like to know about scarring and what would they look like, and whether they would be covered by my hair or not.
A: The physical changes that you have described are classic for occipital plagiocephaly in children and adults in which the condition was not treated early or was felt not to be severe enough for traditional skull molding therapy. On the same side, one can have a flat spot on the back of the head, a brow protrusion and an ear that sticks out more than the other side.
All three cosmetic problems can be effectively treated through known plastic surgery procedures. These include an injectable occipital cranioplasty using Kryptonite material (limited scar technique), a simple ear setback (otoplasty) , and a burring down of the tail of the eyebrow (brow bone reduction) using an endoscopic technique. All three can be treated during a single operation or only the most bothersome can be treated alone.
Indianapolis, Indiana
Q: Dr. Eppley. Five years ago, I had surgery on the right upper eyelid to reduce the size of my eye opening. My right eye used to be larger than the left one. Some times for a few seconds my right eyelid seems relatively normal but as I blink, it seems like the skin detaches from the muscle and the eyelid goes back to a droopy appearance. Unfortunately, it seems like the scar didn’t heal well or the stitches weren’t placed correctly. If the inner crease or fold would stay inside it would have a normal look. I wouldn’t want my right eye to end up larger or deformed compared to the left side again.
A: In looking at your pictures, one can see that with the eye open there is a fold of skin that hangs down onto the lashes of the upper eyelid. However, when the upper eyelid closes completely that fold of skin disappears. That dynamic piece of information is critical in selecting the right blepharoplasty procedure.
Trying to correct this problem by only removing all the extra skin may cause exactly the problem you are trying to avoid. Rather, a very conservative amount of upper eyelid skin should be removed and the dermis then sutured down to the tarsus or levator muscle. This is very similar to the classic ‘double eyelid’ operation done in Asians where they lack an upper eyelid fold. Your problem is conceptually similar.
Because it is only one one eyelid, the procedure can comfortably done under local anesthesia. This would also be helpful in that you would be awake and the dynamic action of the eyelid can be observed as the blepharoplasty repair is being performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can you tell me how the Zerona laser is supposed to remove fat. When I think of a laser it seems to be that it is hot and would burn the skin before it ever got to the fat underneath. I am interested in it to help me reduce my lower tummy, back and thighs. I just can’t bring myself to have liposuction as that seems too invasive and painful. I like the idea of not having surgery and not having to recover and less money is good too! but I want to know it is safe and won’t hurt me in anyway.
A: The type of laser that is used in Zerona treatments is not a ‘hot’ laser. It is a low frequency laser which makes it ‘cold’. It passes through the skin without injuring it. It can not cause a burn injury. It has a photochemical effect on the fat cells which makes them temporarily leaky. By being leaky, they ooze out some of their fatty acid content. This leakiness is only very temporary which is why treatments are needed every few days to keep them open for a period of time. Once the free fatty acids are out of the fat cells, they enter what is known as the interstitial space. In this space they are transported to the liver where they are broken down and eliminated. This is the process of fat reduction and elimination.
It is important to remember that Zerona is not a substitute for liposuction and it is a program, not just a machine. Other components of the program include water intake, niacin supplements and exercise. These help the effects of the laser treatments to be more pronounced.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I recently had a rhinoplasty approximately 3 months ago. The purpose was to make my nose more symmetrical (nose was crooked due to getting hit in the nose 10+ years ago) and smaller/narrower. I consider the results (as I see the nose today) as somewhat of an improvement, but I believe that better results (potentially much better) are possible. Furthermore, I am not 100% certain, but I believe that the results were better the day I got the cast off than they are today (could be my imagination though).
A: Thank you for sending your photographs. My first general comment is that the details of a rhinoplasty often don’t become revealed for several months after surgery. While all areas can look great right after the splint is removed, asymmetries may appear in the tip or bridge as the swelling subsides over the next few months. As I tell my patients, we will not have a victory parade until 3 to 6 months later when the final results will be seen.
In looking at the pictures and reading your comments, the issue is that of the asymmetry of the upper part of your nose from the position of the nasal bones. There is an asymmetry of the nasal bones after osteotomies, the right is more infractured (and perhaps more thoroughly osteotomized) than that of the left. The asymmetry is probably a combination of positional issues on both sides, the right nasal bone is in too much and the left nasal bone is out a little far.
Correction could consist of further infracture of the left nasal bone and onlay augmentation of the right nasal bone. Outfracture of a nasal bone is unpredictable in stability.Ideally, cartilage is the best onlay material but an adequate piece in size may not be obtainable from the septum. (based on your previous surgery) An alternative onlay option is a thick piece of allogeneic dermal graft.( available in 2 and 3mms thickness)
Since it has been three months, I suspect that what you see now is the way it will be. A revisional rhinoplasty could be done in the next few months, about six months after your initial surgery.
Dr. Barry Eppley
Indianapolis, Indiana
The desire to eliminate excess fat is both universal and historic. The sheer number of diet books, meal programs, and fat burning medications and supplements are a testament to what the majority of the American population would like to do. If one of these approaches was universally effective, there would not need to be so many treatment choices.
Liposuction is a proven surgical method to reduce spot areas of fat and trim down specific body areas, but it is surgery and involves expense and recovery. Lipodissolve injections are a non-surgical method of spot fat reduction but it is a slow and somewhat uncomfortable process that really works for the smallest areas of fat.
Along now comes ZERONA. Imagine a painless body slimming method that is medically proven to remove fat and inches without surgery with zero pain and downtime. Seem too good to be true? As a weight loss method…yes. As an effective body slimming method that can shrink your tummy, hips and thighs without surgery…no.
ZERONA is uniquely different from liposuction and other body slimming methods. How does it work? Using a low frequency ‘cold’ laser that uses the 635nm wavelength, the energy passes through the skin without injury and penetrates up to 5 centimeters. The laser energy causes the fat to emulsify through a photochemical process. Not to be confused with a photothermal (heat) or photoacoustic (vibration) method, this non-heat generating process makes the fat cells ‘leaky’. The fat cells shed their liquid fat content, now known as free-fatty acids, which is subsequently absorbed through your lymphatic system. The lymphatic system transports it to the liver where it is processed and broken down, and most importantly, not re-circulated and stored again as fat.
ZERONA is more than just a machine, it is a process. Through a typical series of 9 treatments, up to 5 inches off of the hips, waist and thigh in two to three weeks can be achieved. But, to aid the lymphatic process, the patient must significantly increase their water intake, and take a twice-daily niacin supplement during the treatment process. The treatment sessions require a commitment and must be done every two to three days to really be effective. Once the fat cells get leaky, you can’t let them heal themselves by missing treatments or having them too far apart. Each treatment session takes just under an hour, and is painless. Some have described them as almost ‘zen-like’ which I interpret as relaxing and non-stressful. Equally important, the patient can get up, go and return to all regular activities without any restrictions. There is no pain, bruising, or need for restrictions, but daily exercise (such as brisk walking, light running, or other cardio training) can increase the final results by aiding in lymph mobility.
If you are looking for a quick, safe, and affordable way to lose some fat areas, ZERONA may be a good option. For some people, it will be an effective alternative to liposuction and may eliminate the need for liposuction procedures altogether. For others it may not be a magic pill, but does offer a jump start to a healthier lifestyle…and along the way you may be able get back into that favorite pair of jeans.
Dr. Barry Eppley
Indianapolis, Indiana
Divorce is an unsettling experience for everyone involved, and represents a time of unwanted and maybe even unexpected change. Divorce is often cited as the second major stressor in life, second only to the death of a loved one. Divorce can be a crushing experience, and can easily produce feelings of failure.
As a way to feel better about themselves again, or searching for a fresh start in a newly single world, opting for plastic surgery after divorce occurs more and more frequently. The benefits of plastic surgery after divorce are far greater than what occurs on the outside. It can have a profound emotional and psychological uplifting effect. From my perspective as a plastic surgeon, I believe this is its most significant benefit. Patients can feel almost reborn after surgery, generating a fresh start to another chapter in their personal life.
Many patients, particularly women, have spent a significant part of their adult lives looking after others. Whether it’s for their children, husband or their own parents, their needs are often subrogated to everyone else around them. As a result, their own self-value and worth may have become diminished. Combined that with the effects of time on the face, and the stress of childbirth on the body, it’s not hard to understand why the self-esteem suffers. It can reach rock bottom when presented with the prospect of divorce.
The impact of childbirth on the female body is well recognized. When those changes occur in the company of the man who helped create these kiddos, sagging breasts and loose belly skin are just part of the child-rearing experience. But when it comes to having a new set of eyes view those changes, it is perfectly normal to be apprehensive that forgiveness and understanding may not be part of the equation. This makes some of the most popular and effective procedures women undergo is from the collection of Mommy Makeover options. These include breast implants and lifts, tummy tucks and thigh liposuction or some combinations thereof to get back to that once smaller and more firm body that existed before childbirth. For some women, their bodies actually end up looking better and more shapely than they ever were.
While the body can be disguised by clothing, the face can not be so obscure. Lines, wrinkles, and sagging jowl and neck lines are the hard-earned result of life’s experiences, but a refreshed countenance can go far toward turning back the proverbial clock. Some women test the plastic surgery waters with in-office Botox, injectable fillers and skin resurfacing procedures. Others go for more significant rejuvenation through eyelid tucks and lifestyle versions of face and necklifts which produce change without a lot of recovery.
While plastic surgery can drastically boost self-image and confidence, it is not a fix for most of life’s problems. When done for the wrong reasons of expectation for some secondary gain, short-term euphoria can soon be met with disappointment. It can’t make someone else like you better or get you a better job or promotion. It is really about making you feel better…about you.
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One of the benefits of a more firm face and body is that it can be combined with the wisdom of life’s experiences and lessons. That combination can only bode well for moving on to new opportunities and challenges.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m interested in a facial fat graft. You’ve mentioned in one your Explore Plastic Surgery blogs about the use of growth factors with fat grafting. My understanding is that these can be derived from the patient’s blood . How is that done and how does it work?
A: Fat grafting to the face through injection techniques become popular because it is both natural (organic you might say) can be placed fairly precisely. Its one drawback is that the survival of the fat is not predictable. There are numerous steps with fat grafting that will influence survival from the way it is harvested to how and where it is injected. One historic variable in this pathway has been the addition of agents to the fat graft that may help it survive. Insulin is the best example of this approach. A contemporary agent to add to fat grafts is growth factors. This is done by adding the patient’s own concentrated platelets. Known as platelit-rixh plasma (PRP), this is an extract from the patient’s own blood that is drawn during surgery. The blood is processed in such a way so that several ccs. of platelet concentrate is obtained. This is then mixed in with the fat graft.
While the use of platelets with fat graft injection is a natural agent, it has yet to be proven to be conclusively beneficial to an improved survival volume. Its concomitant use is currently based on more of an alchemy approach with the hope that the potent growth factors which the platelets contain will help the stem cells in the fat graft survive, differentiate into fat cells, and help main graft volume.
Indianapolis, indiana
Q: I’m 29, very healthy and I weigh 128 lbs. I have always wanted a more rounder shapely butt for years but never could get enough money for the procedure and was afraid of the risks associated with the procedure. My self-esteem is very low because of my small buttocks. I just want to feel good and feel secure about myself and my looks.
A: While buttock augmentation can be done with either an implant or fat injections, your small frame and low weight leave you with only the implant option. The good thing about buttock implants is that they produce a very nice result in a single operation and the augmentation is stable over one’s lifetime. Because it is an implant, however, there is a longer recovery and there are potential implant risks of infection or seroma formation.
The key, in my opinion, to your buttock augmentation is to place the implant into the gluteal muscle and not to place too big of an implant. Going above the muscle in the subfascial plane is not advised with low buttock soft tissue coverage. Getting good closure of the muscle over the implant during the surgery is important as it helps reduce the risk of any problems.
Recovery is the biggest short-term concern for buttock implants and one should really allow about three weeks before returning to work and most more normal activities. More physical activities like working out, running, and cycling will take up to 6 weeks until one is more confortable to do them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have an old indented fracture of my left cheekbone. I fell several years ago on my face and was diagnosed with an ‘infracture of my zygoma’. It didn’t seem to bad at the time but maybe the swelling made it look better than it was. Now that side of my cheek is flatter and asymmetric to the opposite cheek. Can it be repaired?
A: Zygomatic, or cheekbone fractures, are common facial injuries. When fractured, the cheekbone rotates downward and inward, causing loss of prominence of the cheek. While the swelling may camouflage the ultimate degree of cheek flattening, eventually an asymmetric cheek will result if not repaired as the swelling goes away and the overlying soft tissue contracts.
Secondary correction of the cheek flattening can be done by one of two approaches. A cheek implant can be placed through the mouth to build the depressed part of the cheek back out. With some many different styles and sizes of cheek implants available today, a lot of cheek reshaping can be done with an implant alone. The other more extensive alternative is to re-fracture the cheekbone and move it back into its original position. (cheek osteotomy) Generally, a cheek osteotomy is reserved for those cheek deformities where the amount of cheek flattening is severe, the position of the corner of the eye is pulled down, and/or there is numbness of the lip and nose from the infraorbital nerve being impinged from the bone displacement.
I suspect your cheek deformity is more modest, since it was not initially repaired, and an implant would be the simplest and less complicated treatment approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q:I’m 20 years old and I had a direct brow lift a year ago and now i have very obvious and wide depressed scars over each brow. I started out getting Botox and liked the effects that it had on lifting my brows. My doctor then told me that if I had a direct browlift I would not have to get Botox again. I’d love to know if scar revision will help. I have attached some pictures for you to see the scars.
A: Your case is most unusual for two reasons. First, the need or indication for doing a direct browlift on someone who is 20 years old is hard to fathom. Short of some form of severe congenital brow ptosis, I could see no reason what that procedure was ever done on you. It was ill-conceived and inappropriate at your young age. If some form of a browlift had to be done, it certainly should have been an endoscopic technique to both limit the scars and keep them back in the hairline.
Your scars are exceptionally wide and I have never seen such direct browlift scar results. The good news is that they can be made much better through scar revision. They can be cut out and closed into a narrow fine line. While there will always be a scar along the upper eyebrow line, it will be much narrower.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Doctor: I’m a 47 yr. old white male in good health. A few years ago I went to India to have a jaw augmentation that was done by lipo injection which was absorbed in a short period of time. I’m looking for a better and lasting result. I would like to know if you think implants would produce a better and more permanent result?
A: The use of fat injections in the past decade has gained in popularity and effectiveness for many plastic surgery problems. The appeal of using your own tissue to create a ‘redistribution effect’ is undeniable. Since most people have some (or a lot) of fat to give, it is not surprising that the technique is being widely used. As part of that widening use effect, it is inevitable that some will use it for uses that are not biologically sound. Fat as a tissue graft has real value for soft tissue augmentation but it is ill-conceived to use it as a bone-based graft. It will fare very poorly as a replacement for chin, cheek or jaw angle implants. The reason is in understanding how implants actually work. They function as a spacer on top of the bone to provide a push to the overlying soft tissues. It takes a fair amount of sustained pressure to hold the overlying soft tissues outward. A non-resorbable synthetic implant can maintain that effect. A soft tissue graft, like fat, will resorb under that kind of pressure.
Advocates may argue that the fat graft is put into the soft tissue and not the bone and therefore has a basis for being effective. Results like you have obtained provide all the evidence you need to counter those claims. Bone-based synthetic implants are simple and effective for facial bone augmentation even if they are not your own tissue.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a birthmark removed, and I went back to the plastic surgeon for him to cut out the remaining area he missed. He ended up cutting out more than he should have and left me a huge scar on my face, with dog ears at the ends. The scar is already twice the size it was, and I don’t want to cut the scar any bigger. Isn’t there any other way to get rid of dos ears on your face?
A: Dog ears, or redundant skin edges, are a common problem with elliptical or fusiform excisions. They appear as mounds of tissue at the end of the scar or may actually have visible overlapping skin edges. Their removal is fairly simple by performing a smaller elliptical excision around the dog ear or opening the incision and raising and trimming one of the skin edges.
Such dog ear treatments will always make the scar line longer to some degree. In a tummy tuck, for example, extending the scar line is not a big issue given the location and already long scar line which exists. On the face, however, every extra millimeter of scar is burdensome and keeping the scar line as small as possible is paramount.
Facial dog ear scar revisions can be kept limited by defatting of the bunched scar ends and a minimal extension of the scar line of just a few millimeters for excision of redundant skin. Careful technique can make this minimal scar extension of little consequence for the elimination of the dog ears.
Dr. Barry Eppley
Indianapolis, Indiana
