Your Questions
Your Questions
Q:I have been taking melatonin for sleep. Is this harmful before surgery? I also take a host of vitamins and antioxidents, such as Acai and COQ10.
Should these be eliminated before surgery? My plastic surgery is in 9 days.The Vitamin C seems to be a dilemma. I have heard not to take Vitamin C before surgery due to the effects on anesthesia.
Doctors do not seem to know the answers to this. Can you help?
A; The issue of any medications a patient may be taking before their plastic surgery is always an important consideration. Your medication issues revolve around the use of supplements rather than prescription medication based on your question. While there has been some debate about the use of certain herbal supplements (such as ecchincea and valerian root) and their potential impact on surgery, it is always best to discontinue these beforehand, preferably two weeks if possible. Some studies have shown no negative effects but their use is optional so there is no reason to not eliminate even the most remote risk for elective plastic surgery. I know of no risk from taking melatonin on its effects on anesthesia or the surgery. Vitamin C, a water-soluble vitamin, would be the safest of all supplements to take for surgery. I have never heard of any problems with it. Some suggest, because of its positive effect on collagen building, that it should be taken in high doses before surgery to help with healing afterwards.
You should ask the plastic surgeon performing your procedure these supplement questions and get his/her opinion most importantly.
Indianapolis, Indiana
Q: i am interested in changing the bottom front part of my nose. i believe it is called the columella. I think this is where the skin between the nostrils meets the upper lip. In my case, that angle is too small. It should be more open. I have read that an implant can create that effect. If an implant is placed there will it also lift up the tip of my nose? I have attached pictures which show what changes I want.
A: In doing assessment of the ‘columellar implant’ in your desired image look, there are three changes I see that you have made: 1) opening up/fullness of the nasolabial angle, 2) change in the angulation of the columella to the lip, and 3) nasal tip narrowing and lifting. It is important to note that to really achieve these changes an open tip rhinoplasty with an implant needs to be done. I would use cartilage for an implant in the columella rather than a synthetic implant. The columellar skin is not very thick and less potential problems will occur from a graft from your own body. That is so for the following reasons:
1) a premaxillary implant will push out the columellar base (open up the nasolabial angle) but will not push up the tip of the nose.
2) A true columellar implant will push out the columellar skin but will not, in and out itself, narrow and lift the lip of the nose.
The concept here is that a columellar implant or strut is an adjunct to a tip rhinoplasty but not a substitute for it.
Indianapolis, Indiana
Q: Dr. Eppley, one of my earlobes is split. This is a result of earrings. Discoloration has taken place at the opening of the split earlobe. Is there any hope for my situation?
A: A torn or split earlobe is a very common ear problem. In fact, it may be the single most common reason for plastic surgery performed on the ear. The earlobe frequently separates from the long-term use of heavy ear rings or the inadvertent pulling on a dangling ear ring from a child. The earlobe is easily torn because there is no cartilage in it, unlike the rest of the ear. The two layers of skin and the intervening fat poses little resistance to the rounded edge of a metal object.
The split or enlarged ear ring hole can be easily repaired. It is a simple office procedure done under local anesthesia. The edges of the healed split earlobe are made fresh and put back together as a vertical line. Any discolored skin is removed at the same time. This does heal with a very fine line scar but it is often very hard to see. It will usually be obscured by future ear ring wear or the insertion of a new ear post. Re-piercing of the repaired split earlobe can be done six weeks after the procedure. Usually the new hole is made at the top of the healed scar line which is usually at the center of the earlobe.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am considering getting jaw angle implants and have some basic questions. I want the Medpor RZ angle implants but don’t know if 3mms or 7mms width is the best for me. How can I decide? Will looking at patients with each size implant in help? Also, what is the recovery from this surgery like? I am having a hard time finding helpful information on the internet. Thanks!
A: It is tough to say which size is really best for any patient when you are looking at a 4mm difference in lateral projection. (0.15 inches) In different people with varying anatomies, the look can be quite variable. The best way to approach this question in your mind is…would you rather error on being a little too small or a little too big. While I obviously want a perfectly sized result, sizing is still an art form and not completely scientific.
I would order a 7mm implant and cut it done if need be during surgery. An 11 mm wide implant, which is the third and final size, is quite big and is only reserved for those men who want the most extreme jaw angle accentuation.
The best way to think about recovery from jaw angle implants is that it will be tougher and longer than you think. In general, most patients underestimate recovery from any type of plastic surgery and jaw angle implants are no exception. The issues are prolonged swelling and stiffness/soreness of mouth opening and chewing. One really doesn’t start to feel and look more normal for about 3 weeks after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I am 49 years old and at least 30 lbs over weight. I am in the process of losing this weight. I want a facelift and liposuction under my chin to help my neck. My second question is about burn scars on the bottom of both of my large toes. These scars cover my toe pad and are up under my toe nails making it very difficult to trim my nails. I have never had a pedicure because I’m too embarassed and scared the clinician will cut into the tissue causing pain and bleeding. What procedure would be used to reduce these scars?
A: One should ideally be within 20% of your weight target before undergoing any facelift/necklift procedure. Most people will lose some weight in the neck with their weight loss, creating more loose skin. You don’t want to do the procedure on the front end of the weight loss as you will end up with more rebound skin relaxation once the weight loss occurs negating some of the hard-earned benefit of the operation. Plus, having the procedure as a ‘reward’ after the weight loss may be more motivating. When it comes to weight loss it is always best to have a definitive but realistic weight target.
Your toe scars are unusual in that they seem by your description to come right up under the nail. (eponychium) I am assuming that your toenails have no problem growing. It is just the thickness of the scar right under the nail edge. I would suggest that dermabrasion (not microdermabrasion) be done to reduce the thickness of the scar. This could remove a few millimeters and reduce the scar hypertrophy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have always been bothered by these fat collections on the lower part of my stomach and around into my back. Despite working out regularly and really focusing on these araes, I have been unable to lose them. Several years ago I tried fat-dissolving injections (I can’t remember their name) but they were very painful so I never did it more than one time. I have been hearing about the Zerona laser and it seems that these fat treatments do not cause any pain or swelling afterwards. This sounds almost too good to be true. Do you think as a plastic surgeon that it really works?
A: Zerona is the newest and most popular method of non-invasive fat removal. Using cold laser technology, it has the ability to pass through the skin and disrupt the membranes of the fats cells. This causes release of fat when the cell membranes breaks open. This released fat is absorbed and eliminated through the lympatic system. This is proven science and is significant enough that its clinical data passed through and was approved by the FDA. Through the concomitant use of exercise, increased water intake, and oral supplements, the effects of the laser are enhanced.
Is Zer0na a replacement for liposuction….no. It is effective but not that dramatically effective and effiicient as actual surgery. I think it is a proven method that for the right patient can be very effective at making visible fat reduction. Its success is patient-specific and better results are undoubtably obtained when the patient follows all of the adjunctive recommendations.
Indianapolis, Indiana
Q: Hello, I am 27 years old and thin but have always had these little fat pouches that are positioned below the corners of my mouth. It’s hard to explain but it makes my cheeks look like they’re sagging (but they aren’t). If I put one finger in the inside of my mouth, and one on the outside and pinch that area, I can feel the distinct fat pocket. I have two questions. What is this fat called? I can’t find any similar cases online, and I’ve done lots of searches. And secondly, what can I do to remove this?? Thank you in advance.
A: It sounds like you may have a unique facial condition known as pseudoherniation of the buccal fat pad. This is where the normal buccal fat pockets, which lie right under the cheek bone, fall or prolapse through their containing fascia and create a low fullness opposite the corners of the mouth or even lower. While rare, this problem has been described in the plastic surgery literature before. Undoubtably the ‘ball of fat’ that you feel is a part of the buccal fat pad.
Q: I had breast implants originally done about 8 or 9 years ago and am looking to have them redone. My existing breast implants are saline 600cc and I think I am between D and DD depending on the bra. I want them increased but not sure if that is something you do? I know i would like to be DDD cup. I am a body builder and I think it would balance my shape better. Any information back would be great!!
A: Ideally, the size of a breast implant should stay within the base diameter of one’s breast. This produces the most natural looking result and also avoids the potential of the implants bottoming out over time due to loss of tissue support. That being said, some women prefer to go larger than these parameters. While some plastic surgeons have objections to that desire, my feeling is that as long as one realizes there may be a price to be paid long-term with bigger sizes (eventual removal and downsizing with breast skin reduction), then I have no objection.
Since you already have 600cc implants in place, the largest available implants are 800cc, either saline or silicone. At this size increase, that represents a 33% size increase. Saline implants can be further filled up to 960cc, representing an approximate 50% increase over your current size. At these size increases, one should definitely go with a high profile implant to get the base diameter as narrow as possible. Whether these sizes are appropriate are based on your height and chest width and breast augmentation size desires.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi doctor, I have a big forehead and I need a scalp advancement to make it smaller. To do this surgery do you needs to shave my hair? What is the maximum of centimeters that you can reduce? How much does this surgery cost? Thank you.
A: A long forehead can be reduced by moving the scalp forward (hairline advancement) and removing upper forehead non-hairbearing skin. While this does leave a fine line scar along the frontal hairline, that is usually nto a problem for most women. As long as the hairline is distinct with reasonable density, the scar is usually a good trade-off. One of the keys to a scalp advancement is to secure it to the underlying frontal bone in its new position. This will not only prevent relapse but will also take the tension off of the scarline so it heals as narrow as possible.
In answer to your specific questions:
1) No hair is ever shaved for the procedure.
2) Usually at least 2 to 2.5 cms of scalp can be advanced with the same vertical reduction in forehead skin. That tapers off into the temple areas. The greatest amount of advancement is in the center.
3) The overall costs are about $ 7500 – $ 8500
For those women afflicted with a very high hairline, a forehead reduction procedure through a scalpadvancement can be life-changing. One can think of it as a ‘reverse browlift’ so it is an outpatient procedure that takes about 2 hours to perform. The very next day one can wash and style their hair.
Indianapolis, Indiana
Q: What is Dr. Eppley’s experience in fixing breast implants that have bottomed out? What is the success rate in it staying fixed?
A: Bottoming out in breast augmentation is when the implant falls below the level of the lower breast crease. There are numerous factors which contribute to this problem, but the main one is when the size of the implant exceeds the ability of the tissues to hold it up. This is a problem that is usually seen long-term, not immediately after surgery. The implants may have initially been in good position but have dropped over time. Sometimes this may not occur for years.
When this problem is seen right after surgery it is the result of the pocket dissection going below the attachments of the lower breast fold. This is acute fold attachment disruption not its weakening over time.
Either way, the treatment of breast implant ptosis (bottoming out) can be done by two different methods. The most common approach is to suture the attachment of the breast fold back onto the chest wall, which pushes the implant back up. This is the simplest approach but loosening of the sutures can happen and dropping of the implants can happen again. If this were to happen it would usually occur within the first six weeks after surgery.
The other approach, which is newer, is to insert a lower sling of allograft dermis between the pectoralis muscle and the chest wall. Like an internal bra, this tissue supports the bottom part of the breast better. It is more reliable in terms of success but is much more expensive due to the cost of the dermal graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: What can I have done to make my breasts look fuller but still feel as natural as possible?
A: Breast implants are the only reliable method for increasing the size of one’s breasts currently. Many women have breast implants that look quite natural while others have a breast look after augmentation that some perceive as unnatural or fake. What is the difference between the two?
There are many element that contribute to the appearance of a breast augmentation. How loose or tight is the overlying breast skin and the size of the implant are the major contributing anatomic factors. A large implant with an initial tight breast skin will create a more rounded look with a full upper pole. A smaller implant with loose pre-existing breast skin will end up as more of a tear-drop shape.
The feel of a breast implant, however, is slightly different. Regardless of implant size, either saline or silicone gel implants can feel quite natural. Outside of the body, most people would agree that silicone implants feel more like natural breast tissue. But inside the body that difference is not as obvious. Saline breast implants can feel unnatural if rippling is present on the bottom or sides of the breast or if the implant is significantly overfilled so that it feels too hard.
In general, most breast augmentation patients are quite pleased with the feel of their implants. Unhappiness with implants that are too hard or too soft is a rare reason for revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hopefully someone there can fill me in even though I have no insurance! I want to know the approximate cost for an abdominal panniculectomy. I am very obese, weigh 360 lbs and am 5′ 2″. The majority of my weight is in my abdomen. This apron is like a catch 22, It is getting harder to walk and then I don’t so I eat and don’t walk and gain weight. I fell and hurt my knees 4 years ago, gained 100 lbs since then. Thanks for providing an outlet for me to vent. I liked the idea that you have had experience with this surgery for obese people. I still want to know what the surgery would cost. I maintained a weight of 250 to 260 lbs for over 25 years before the knee injury that never got fixed. Fat never stopped me before and it won’t now. My health history is otherwise remarkably good. My blood pressure is 115/60, fasting blood sugar 70 to 80 and the rest of my blood work is normal.
A: The abdominal panniculectomy procedure provides great physical benefits to those patients such as yourself. By the removal of overhanging weights that often approximate 30 to 40 bs, if not more, the strain on one’s back and knees is significantly reduced. This is in addition to the improvement in groin and genital hygiene.Most medical insurances will cover this procedure as ythey should given the medical benefits that it provides. The abdominal panniculectomy can not really be compared to the more common tummy tuck which is performed in more weight appropriate patients and is smaller in surgical magnitude and recovery.
Unlike a tummy tuck, the cost of an abdominal panniculectomy is out of reach for most patients. Costs could easily approach $10,000 to $15,000. It takes longer to do and will almost always require an overnight stay and often several days in the hospital. Complications rates are high and secondary problems such as fluid collections and wound breakdowns are common. Secondary surgical revision for wound closure is not rare ane exposes one to even greater expense. For these reasons, one should attempt this procedure under insurance for the really large type pannuses that you appear to have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a few questions that I have been wondering about for a long time. First, what causes frontal brow bone growth? The reason I am asking is because since I turned 21 it seems that my frontal brow bones have grown outward. When I look at the side of my face, there is not that smooth appearance that there once was when I was a teenager and this is because of my frontal brow bones poking out. I have always been considered a good looking guy but since this has started happening, I have gotten to be very self conscious of my looks.
One more question…. and this may seem like a very odd question. Does sleep deprivation or a very weird sleeping pattern have any thing to do with frontal brow bone growth? The reason I am asking this is because just before I turned 21, I developed a sleeping disorder. Not long after this sleeping disorder started, it seems like I started noticing my frontal brow bones getting a little bigger. I am 24 today and I still have a sleeping disorder. I have helped it quit a bit by taking medications to help with sleep. Anyway, my brow bones are bigger than I think they should be and I am just wondering if sleep deprivation has anything to do with frontal brow bone growth.
I have really want to know the answers to these questions for a long time and it would be greatly appreciated if you could please answer them for me. Thank you.
A: The development of the frontal sinuses does not begin until after age 6 and often will nolt be evident on an x-ray until age 9 or 10. The frontal sinuses are air-filled cavities that drain into the nose. Their growth should be consistent with that of the skull which is usually complete no later than age 18. Prominent brow bone often do not become apparent until after puberty for many young males and they seemingly ‘grow’ up until the late teenage years.
Sleep deprivation or any form of sleeping disorder is not a known case for the development of prominent brow bones.
Prominent brow bones can be reduced through skull reshaping surgery. I perform this by taking off the frontal later of bone over the sinuses, reshaping the forehead, and putting it back on. While very effective, a male must consider the trade-off of a fine scar in the hairline which is needed to gain access to the bone to do the procedure.
Indianapolis, Indiana
Q: I was wondering if liposuction can be done on the calfs? Ever since I was little my calfs have always been disproportionate compared to the rest of my body. I have been teased my whole life because of them, even now at 24 I still am teased, and I have tried everything short of surgery to reduce their size. I am 5’7″ and 145 lbs and my calves are 16.5″ around, but if I workout or am on my feet all day, which I usually am, they can be 17″ to 17.5″.
I am tired of not being comfortable in a skirt, or swimsuit, and not being able to find boots that will fit around my calves. I have attached pictures of them so you can see what I mean. They are muscular, but they do have fat, when I flex I can grab a handful of fat from my ankle all the way up to just under my knee. I don’t know if it is possible to remove this. I have contacted a few other clinics, and they said they do not perform the procedure. I have attached some pictures so you can see what I mean.
A: Thank you for sending those excellent pictures. I can clearly see your calf size concerns as they do not seem to fit the rest of youor body frame. Liposuction of the calfs can be done and definitely make a contour improvement. Think of calf liposuction not as completely circumferential but done is select areas that will provide more shape to the calf. Fat removal on the inside of the lower calf, at the outside of the ankle, and in the inside of the upper calf be low the knee are all good shaping areas. Circumferential liposuction of the calf causes a lot of swelling that takes a long time to go away. It is better to think of calf reshaping rather than calf size reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Four years ago I had a rhinoplasty for a tip deformity. After the surgery my nose looked extremely nice and I was receiving excellent comments. However, about one year later a dimple appeared on the tip of my nose. I asked my plastic surgeon about it and he referred me to a dermatologist. I have spent a year going from one dermatologist to another and no one was able to help me. One of the dermatologists took a biopsy but the biopsy revealed nothing. After being exhausted I went back to my plastic surgeon and he diagnosed that the cause of this dimple may be some stitches that did not go away after the surgery. He operated on my nose again and told me after the surgery that his diagnosis was correct and he removed all the stitches from my nose. However, the dimple was not removed. He asked me to be patient. I went to him several weeks later as my situation didn’t change so he did a minor surgery in his clinic and again with no success. I then went to another plastic surgeon who was able to remove the dimple and he said there was some white cheesy stuff behind it that he completely removed. However the surgery resulted a scar in my nose. What do I do now?
A: Your rhinoplasty problem is rare but not unheard of. Your explanation of the events is perfectly understandable and it paints a very clear picture to me. Undoubtably what has happened are sutures reactions to internal sutures used to reshape the nose cartilages. This is common practice. I use dissolveable sutures for this purpose but other surgeons do not always do so. While rare, they can cause a delayed inflammatory reaction which is the initial culprit in your case. Now because of the biopsy and subsequent excision, there is an indented scar.
Cosmetic plastic surgery has long been unintentionally gender-biased. Since the field began, the vast majority of patients who seek cosmetic enhancements, albeit it surgery or office-based treatments, have been women. Men have always made up less than 10% of most plastic surgery practices. Hollywood would lead you to believe otherwise but it just isn’t so. The only rare exception to that has been the more recent popular treatment of laser hair reduction. When it comes to hair removal, men make up about half of the patients seen with the hairy back and shoulders being the prime targets.
But more men are finding their way into the plastic surgeon’s office in the past few years. Besides a steady increase in male numbers, what is noteworthy is the change in what what men are requesting. While there remains some traditional procedures that have always been of interest, technology, societal trends, and younger men have opened up new areas of the face and body for change and improvement. Here are four of the most popular younger male (teenage to early 40s) procedures today.
Liposuction still remains the most requested male procedure. The culprits are always the same, the stomach and love handle areas. But most men that want liposuction are not fat and many are not even overweight. To the contrary, they are lean but have fat collections at the side of the waist and flanks. Even in men that work out regularly, those love handles can be impossible to work off. Today’s liposuction techniques can even give that ‘six-pack’ look for those leaner men that are not opposed to a little surgical cheating.
Chest recontouring is the one male plastic surgery procedure that is really on the rise. Male breast enlargement, known as gynecomastia, has always been an issue. But with increasing teenage weights and the present young male aesthetic for a completely flat and smooth chest, improvement in the male chest is sought out like never before. Even small nipple protrusions can be bothersome for the teenage male. Obvious man boobs are not desireable at any age.
Nose reshaping (rhinoplasty) has always been a popular male operation and that has not changed. It is the one procedure of the face that young men are not afraid to change. Noses that are big with prominent humps and wide nasal tips are bothersome and distracting to an otherwise balanced face. Sports and recreational activities make the young male nose a good target for injury causing twisted and deviated noses that often pose problems for breathing as well.
One set of procedures that is really new and undoubtably influenced by movies and models is structural facial reshaping. Creating that chiseled and angular face is what some young men aspire to achieve. A good jawline in particular is associated with enhanced masculinity. While one perceived just as making a strong chin with an implant, modern plastic surgery implants can be extended all the way to the back of the jaw. With the development of jaw angle implants, the jaw line can become more defined than just with a chin implant alone.
A new generation is redefining male plastic surgery. Have a lean body, flat chest, and a nose and jaw line that creates a well defined face has probably never been out of style. But modern surgical developments make them more attainable than ever before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had 2 c-sections and they were emergency so they cut me the “old” way- and my abs have never recovered. So my main question would be, what areas will show the differences of before and after? It seems like I currently have 2 “tubes” around my belly. The top where my abs used to be (and even when I have lost a lot of weight still seemed to appear puffy) and then my belly button kind of creates a line that goes into the bottom innertube. The idea of a tummy tuck in my head will smooth everything down so I would not have these 2 rolls of fat around my waist as well as the fat that is on my back. Does that sound right?
A: I think you have hit the general concept right on the head. You are right for two specific reasons. First, to get rid of what is not desired between your belly button and the pubic region, it has to be cut out. That is the definition of a full tummy tuck, a horizontal excision of skin and fat that goes just above the belly button. Secondly, the only way to unravel the excess tissue around the belly button is to allow the skin and fat above it to be stretched down over it, again the definition of a full tummy tuck. The only concept you have in error is the rolls of fat along your waistline and into your back. A tummy tuck will not remove those, only liposuction will. That is why most tummy tucks incorporate liposuction into the flanks area as well to avoid the dreaded ‘muffin tops’ afterwards if it is not done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My initial breast augmentation was over ten years ago. Two years later, my left breast implant suddenly ruptured. I have had my current saline Mentor Round textured implants in since then and have recently noticed some slight soreness and what seems to be a section that is possibly hardening in the center, all of this is in the left breast again. I do not want to have revision surgery if it is not necessary at this point. I realize that I will again as I am only 35. I am not against it if it is recomended now,I just want to prolong the life of my implants as long as possible. I have read that there are some asthma medications that have been used to treat early stages of capsular contracture with some success. I would like advice on treatment, either trying out the asthma medication or revision surgery or waiting it out to see. I really need advice on what is needed in my situation, an educated opinion would be greatly appreciated. I look to you because your video says you do not believe in selling the surgery, you listen and help clients make informed decisions. That is exactly what I need right now. Thank you very much.
A: Capsular contracture is far less frequent today due to improved implants and the general trend of placing the breast implant under the pectoralis muscle. Even when it was far more prevalent, what causes this excessive scarring and potential breast distortion is not well understood. When medical conditions are not well understood that usually means the treatment(s) for it does not work that well either. Capsular contraction treatment consist only of release and excision (surgery) or a drug medication. The use of Singular, an asthma medication, has been reported to have some success with preventing recurrent capsular contracture. These reports are largely anectodal and are not the result of information of a controlled clinical trial nor is it FDA-approved for this use. From those that report some success with it, it is in the use after a capsulotomy or capsule excision and is given with the intent of prevention. I am not aware that it has any effect on an ongoing or pre-exiting capsular contracture.
Because Singular is expensive and unproven in established or progressive capsular contracture, I would not recommend its use in your case. If the capsular contracture is significant, then surgery should be performed. If it is only minor, which it sounds like, then I would wait it out and see if it becomes more severe.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to have my skin tone more even. Due to the sun, my skin color on my face and neck is much darker than rest of my body. I was born with darker private areas as well as my butt. I am an African American with a yellow skin to light brown complexion similar to Beyonce complexion in the L-oreal ad.
A: Skin lightening is a well known pharmacologic treatment that is well proven for the treatment of dark spots, primarily from aging and sun exposure on the face and hands, as well as reactive hyperpigmentation from injury or ablative skin treatments. Using established agents, such as hydroquinone and kojic acid, they work to inhibit the cells (melanocytes) that are responsible for creating the pigment in our skin. They are many combination products today that combine these pigment treatment agents with our adjunctive topicals such as exfoliants.
What you are referring to, however, is a more global color treatment of an area. Rather than treating a specific pigment problem, your quest is to lighten the base pigment in the skin. This has become recognized as a possibility by the plastic surgery exploits of Michael Jackson who definitely used skin lightening agents. While often conjectured, it is now proven after his untimely death last year after police investigations found many tubes of skin lightening creams. Whether he was treating a medical condition such as vitiligo or just overall lightening his skin is unclear.
The concept of skin lightening one’s base pigment is possible but is fraught with several concerns. First, it would take a lot of cream used continuously to create a lightening effect. Given the volume needed, one may be able to lighten small areas such as the face and neck but ot larger body regions. Second, how effective topical creams are for base pigment lightening is not a certainty. Lastly, these drugs do have side effects and the high doses done over a long time may have undesired effects that are not known. These topical creams were never designed and studied for a more overall skin bleaching effect.
Indianapolis, Indiana
Q: I am a 35 year-old heterosexual male who is interested in getting my adam’s apple reduced. I do not want to look feminine but the way it sticks out is bothersome to me. How is the operation done, how bad is the scar, and what is the recovery like?
A: Most of the Adam’s Apple reductions (technically known as reduction chondrothyroplasty) that I do are in heterosexual males and they make up most of the patients. Contrary to popular perception, transexual patients requesting this procedure are in the minority. That is not surprising given that the ratio of heterosexual males far exceeds the number of patients requesting a transgender change. While once done mainly for feminization, that has changed today. It is becoming an increasingly requested procedure amongst men in general who find a large thyroid bulge detracts from a pleasing neck contour.
The operation is a one hour outpatient procedure done under general anesthesia. There is minimal pain and swelling afterwards. The small incision is just an inch and a half long and heals with an imperceptible scar. I have never had to perform a scar revision for it. There are not sutures to remove. The typical result reduces the prominence of the thyroid cartilage but 50% to 75%. You usually can not get the neck profile completely flat but the improvement is substantial and patients are uniformly pleased. The location of the vocal cords, and the necessity to protect them and the patient’s known voice quality, prevents the cartilage to be reduced to the point that the neck has a smooth profile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Greetings. I have a problem that I hope Dr. Eppley can address. I had a light therapy treatment (IPL) to my face that ended up too deep or too hot. It not only burned my skin but I also developed underlying fat loss as well. My skin is a series of pockmarks, holes, scars, lines. The problem that bothers me the most, however, is around my mouth. It appears to be scarred and my mouth has gotten smaller. It concerns me that may still be getting smaller. I have found that Dr. Eppley does many mouth revisions and am hoping he will take interest in my case. I am in need of help. Thank you in advance.
A: Such a reaction from a pulsed light facial treatment is certainly unusual. While I have seen some superficial skin burns from IPL or BBL treatments, deeper or more partial thickness burns have not been previously reported that I am aware.
Like all burn injuries around the mouth, the most restrictive area is usually around the corners or commissures. This is the side union between the upper and lower lip and needs to be the most flexible of any area on the lips. Tightness in this area makes mouth opening more difficult and may actually make it look smaller if there is scar contraction.
Early mobilization or physical therapy is important in the initial phases of healing after any burn injury around the mouth. It can help scar contraction from significantly tightening the commissures. In established commissure scar or restriction, surgical help may be needed. This could consist of scar release or a commissurotomy. This procedure can help open up the corners, making the mouth a little wider and lessen the tightness on opening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My friend who just had a facelift had a slim face before and it’s even slimmer after the facelift. I am considering a facelift but I don’t want to lose any volume in my face or lose my round face. I think a round face keeps you looking younger. I have that St. Bernard look and is why I want a facelift. Could you explain better the SMAS part of a facelift? I want to have the volume that is now around my mouth back up in my cheeks without having that “alien” look (inverted triangle). That to me is the tell tale sign of a facelift. I want a smoother transition between my cheeks and my lower face and not all the fat in my cheeks. In other words, I don’t want to lose my round face. Would you mind explaining this some more to me please. The best facelifts I have ever seen is when the volume is added to the outside of the cheeks (side closest to ears) making the face wider hence more volume. Is it possible to ask the doctor where to reposition the fat as he marks up my face next week for my nip tuck?
A: A facelift fundamentally works by pulling the skin and the underlying tissues back up along the jaw line and neck towards the ear. In thin faces, tightening these tissues can often make it look even slimmer or more gaunt. That is a simple function of having very little subcutaneous fat between the skin and the muscle. It definitely can give the impression of being pulled too tight even though it really isn’t.
The SMAS part of a facelift is the separation and lifting of the tissue layer between the skin and the muscle. It s usually lifted up in a more vertical direction than the way the skin is moved back. (which is up and back at about 45 degrees) It can help add volume to the side of the face if the SMAS layer has enough bulk. In thin-faced patients, it is quite thin.
In really round faces, a significant slimming effect will not happen after a facelift…even if you wanted it too. It will make the neck and jawline better shaped (which is the lower face) but it will not change what most people interpret as the ‘meaty’ part of the face, the cheeks and side of the face. The change in the neck is what creates the impression that you have lost weight, which is what many people comment on afterwards. (provided they didn’t know you had a facelift)
Indianapolis, Indiana
Q: I am interested in getting a deltoid implant but am having a hard time finding out much about it. I know it is not commonly done but have read that it is done. I would like to get my one shoulder to look more like the other rather than deformed and asymmetric. What can you tell me about this type of implant?
A: The deltoid muscle is a bulky triangular muscle that covers the shoulder joint and contributes to movement and stability of the upper arm, particularly when it is lifted away from the body. The rounded curve of the shoulder is due primarily to the bulk of the deltoid muscle. Deltoid muscle atropy is most commonly caused by injury to the axillary nerve or muscle wasting after shoulder surgery or injury.
Placing silicone implants into the arm or shoulder has been historically avoided by plastic surgeons. Besides being rarely done, there is an understandable fear that the complication rate is higher than many other implant locations. To avoid complications, implants are placed beneath the muscle and just on top of the humerus bone. The deep location of the implant then acts as a spacer providing a deep push on the outer contour for volume enhancement. Placement of the implant right under the skin is easier but has a much higher rate of infection and capsular contracture and often results in visible outlining of the implant on the shoulder.
The type of implant used is the same as any other body implant, a soft and flexible form of silicone rubber.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I have a bump at the front of my head. I would like for it to go down a bit. Please help me. Thanks.
A: Bumps on the forehead are not rare and are commonly seen by plastic surgeons. While the exact diagnosis can be varied, the usual suspects are either bone-based (osteoma) or of soft tissue origin. (lipoma) Feeling the bump can usually help one distinguish between the two. If in doubt, a CT scan can easily tell which one it is.
If the bump is hard and doesn’t move it most likely is a classic osteoma. These are benign bony growths that develop slowly. For many patients the exact origin is unknown. They can develop after being hit on the forehead, particularly if a bruise or hematoma resulted. It is thought that bleeding under the periosteum serves as a nidus to stimulate the laying down of bone.
Removal of forehead osteomas is traditionally done through an overlying horizontal skin incision. In an older patient, this can be skillfully placed in an adjacent wrinkle and the scarring can be quite minimal. In patients without a close wrinkle or few wrinkles, the scar is not as appealing. In most casesw of forehead osteoma removal, I prefer the use of an endoscope to recontour the bone of the forehead. By placing the incision in the hair, no visible scar is left on the face. Osteomas can usually be made to pop right off the bone by using a small chisel. Through two endoscopic incisions, the scope and the osteotome can be simultaneously used.
.
Indianapolis, Indiana
Q : I am scheduled for a facelift next week. My friend had hers last week. We both go to the same plastic surgeon who is well known. I was shocked today when I saw my friend. It appeared she had been beaten up and looked horrible. Granted it has only been six days but is this normal? When I asked the plastic surgeon about the swelling, he said my friend was still swollen. He does the SMAS lift and pulls the skin as tight as he can knowing that in 3 months it will look normal. Is this routine? I really want a natural look and now am not sure what to do. Please advise. Thanks.
A: Your concern is understandable and let me provide you with this analogy. Facelift results are a lot like getting a haircut. Sometimes in the beginning it looks bad right after, you think it looks good during the middle part of its growth cycle, and then dislike it again once it is too long or outgrown. That is analogous to a facelift because it is not a static result over time.
Meaning…if you have don’t do too much (conservative facelift) then your swelling will be more mild, recovery will be quicker, and your result will look more natural from the getgo…but the result may not last as long. If an aggressive facelift is done, one will have a lot of bruising and swelling (i.e., look awful) and look overdone in the beginning…but will relax into a more natural reesult much later and the results may last a little longer.
As you can see, the facelift operation is balance of how much recovery one can sustain for perhaps a longer lasting result. While everyone wants the best result possible that lasts the longest, the reality is that the initial and short-term recovery period from doing the most aggressive/extensive facelift is not for everyone. Unfortunately, plastic surgeons generally use whatever facelift technique that they prefer on everyone.
Indianapolis, Indiana
Q : Three years ago I had a nose job. The result was initially perfect. Then at six months after surgery, a mysterious bump appeared on the tip of my nose. The surgeon tried to remove it but that effort met with no success. Subsequently, I have had three minor surgeries to try and get improvement, and to make things worst, these surgeries left a scar on the tip of my nose. I wonder if you can help me.
A: The success of any rhinoplasty should not be fully judged for at least 6 months after surgery. Because the overlying skin must shrink back down to the structural framework of the nose (bone and cartilage), a process which can take up to a full year after surgery, the final shape and contours can take awhile to be fully revealed. Any irregularities of the bone and cartilage may not show themselves for a long time. In addition, reactions to sutures or any synthetic grafts used to reshape and contour the cartilages may not develop for many months after surgery. I have even seen a few cases where reactions to indwelling sutures did not appear for years.
The finding of a bump or irregularity on the tip of the nose indicates exactly that point. What initially looked good developed a bump later. The question that remains unknown is what was the cause of the bump? Was it a cartilage edge or irregularity or a reaction to a suture? If it persists, only re-entering the tip of the nose (revision rhinoplasty) and exploring it can answer that question. Some surgeons may attempt to treat the bump with injectable steroids but that approach is only helpful if the problem is excessive scar tissue or swelling.
Indianapolis, Indiana
Q: Hello Doctor, my question is about how to correct the sagging chin after chin implant removal. I had a chin implant removed several years ago and developed initially fluid and then a ball of scar tissue. My chin hangs down now off of the bone. I know that the scar tissue can be cut out from the labiomental sulcus and chin, but how do you reposition the muscle back onto the bone? No one seems to explain that part of the procedure. How that is done is very important for me to know before I consider having the procedure.
A: In the treatment of soft tissue sag after chin implant removal, the muscle must be reattached back to the bone and in a higher position…if one is doing the surgery from an intraoral or inside the mouth approach. When the chin sagging is not that severe or one wants to avoid a submental scar, then the intraoral approach is used. Putting the muscle and soft tissues back is done using small suture anchors. These are small resorbable bone anchors into which are attached sutures. They are first placed into the bone in the desired position (below the teeth roots) and then the sutures are passed into the muscle and tied down. This is a classic orthopedic surgery approach that is commonly used when they reattach tendon and muscles to the bone around joints.
When the chin sag is more severe, it may be best to consider a submental approach and remove and tighten tissues from underneath the chin.
Dr. Barry Eppley
Indianapolis, Indiana
Cosmetic plastic surgery has long been gender-biased with the vast majority of patients being women. While one could argue that this speaks significantly towards our societal standards and to women in general, men are increasingly having plastic surgery as well. While men still make up less than 20% of surgery and office-based cosmetic procedures, those numbers continue to increase each year.
What separates men from women in plastic surgery is two-fold. First and perhaps surprising to many, most men require extreme discretion and privacy. Men are much more sensitive to how they might be perceived by others for having plastic surgery. Secondly and not surprisingly, the type of procedures that men undergo in plastic surgery are different from women. The top male cosmetic procedures in my Indianapolis plastic surgery practice are nose reshaping (rhinoplasty), eyelid tucks (blepharoplasty), facelifts, gynecomastia reduction and liposuction.
Liposuction still remains the most requested procedure for men. Unlike women, however, male liposuction is done in the abdomen, love handle, and neck areas. Even in relatively lean individuals, fat collections at the side of the waist and flanks are common as one ages. Even in men that work out regularly, those love handles can be impossible to work off. Today’s liposuction techniques have been refined to produce better results with less risk of skin irregularities and etching procedures are now available for the leaner male who want an easy way to the ’six-pack’ abdominal look.
In younger males and teenagers, nose reshaping (rhinoplasty) remains a popular operation. Putting the nose into better balance with the rest of the face can make a significant aesthetic change. It is not commonly done in men over forty who have come to accept the shape of their nose. Changing the nose in mid-life may make one feel ‘not like themselves’. Rhinoplasty may frequently be performed with chin augmentation for an overall better facial profile. Computer imaging is used before surgery to determine what changes to make on the nose and whether chin augmentation would be beneficial.
Gynecomastia reduction is the one male plastic surgery procedure that is really on the rise. Whether it be a small protrusion of the nipple in a teenager, to a more traditional larger gynecomastia in adolescents, to the sagging and deflated appearance in the middle-aged and older male, improvement in the male chest is sought out like never before. Liposuction, nipple lifting and reduction, and pectoral implants are potential methods for male chest enhancement. Refined liposuction techniques, known as etching, provides better definition to the pectoral muscle outlines which can be combined with any of the other chest contouring procedures.
Eyelid surgery (blepharoplasty) in the male is the best way to get rid of that tired and saggy eye look. Unlike women, most men wait until they have a lot more loose eyelid skin and wrinkles before considering surgery. Browlifting is rarely done in men lest they end up having the ‘Kenny Rogers’ result. Removal of eyelid skin and fat should be conservative in men to appear less tired and more rested, not create a new look. In the more senior male, the upper eyelids can become heavy with skin hanging down onto the eyelashes resulting in obstruction of one’s vision. Upper eyelid surgery in this situation can help one see better than they have for years.
Facelifts are the most misunderstood cosmetic procedure for men. As a tuck-up for the neck and jowls, a facelift only improves the jaw line and neck angle. Like eyelid tucks, men often wait until they have a very noticeable neck wattle that may interfere with shirt closure and may move unflatteringly when the head turns. Facelifting in men is best done in moderation, producing a neck change that is improved but not too dramatic. In very large neck wattles, a direct neck lift is a simpler and easier solution with the trade-off of a thin neck scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 50 years old and my average weight hovers around 108 lbs. I have had four pregnancies. I have already had a mini tummy tuck but now have belly fat above my belly button and at the rib cage. There is also fat around the hip area as well. I have a surgery scheduled for liposuction but was told I would have to later have a “full body lift” to get the loose skin off. There is maybe two inches at the sides. I am in good shape. I use to go to the gym. Is it possible to do the liposuction with the other procedure or will it “kill the skin” as I am told and would not a tummy tuck be preferred to a “full body lift”?
A: At your age, regardless of how good your skin quality may be, liposuction will not tighten up the skin to any significant degree. While I can’t see what you look like, your statement that you have extra skin now is a certainty that you will have more extra skin after liposuction.
It makes sense, therefore, to consider some type of skin removal when you are doing the liposuction procedure. It would be unusual for someone like you to need a full body lift. Body lifts are exclusively done on patients who have lost a lot of weight, whether by bariatric surgery or on their own. You more likely need an extension of your previous tummy tuck out to the hip areas or maybe a little beyond to get the excess skin. The 360 degree or circumferential scar that results from a body lift is not likely needed in your case.
Liposuction can be safely done at the same time as the skin excision. While devascularizing the undermined skin is possible (‘killing the skin’ as you have indicated), an experienced plastic surgeon will know how to blend those two together to minimize that risk.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I just would like to know if BOTOX and DYSPORT would lift a droopy upper eyelid? Thank you.
A: Both Botox and Dysport are equivalent injectable drugs that induce muscle paralysis where injected and weakness in the surrounding region. They are superb at stopping that undesireable frowning between your eyebrows or those crow’s feet wrinkles at the side of your eyes. By weakening the overactive forehead muscles, many people may experience a bit of a browlift. This occurs because the paralyzed forehead muscles no longer pull down on the eyebrow, allowing it to raise a little higher.
It is logical to assume that a similar effect would occur in a droopy eyelid. But that assumption would be wrong. A droopy eyelid, known as eyelid ptosis, is the result of a weak levator muscle. The levator muscle is the primary muscle that moves the upper eyelid. When it is weak for whatever reason or is partially detached from the tarsus of the upper eyelid, the lid margin will hang down lower. It becomes noticeable when the lid margin comes down lower on the iris and it only takes a few millimeters lower to be evident.
Since Botox and Dysport paralyze muscle, it would actually make a droopy lid worse. In fact, one of the most dreaded esthetic complications of Botox and Dysport is a droopy eyelid when it inadvertently diffuses into the upper eyelid from above if it is injected too close.
Eyelid ptosis can only be improved by surgery. The amount of lid droop and its cause determines what type of ptosis repair technique is needed.
Dr. Barry Eppley
Indianapolis, Indiana
