Your Questions
Your Questions
Q: I recently had cheek implants but now one side of my face has hollowed out and both sides of my mouth have developed drooping pouches of tissue . It looks very uneven and has distressed me greatly. I would like your opinion about this.
A: This is certainly a very unusual type of mouth result from cheek augmentation. The reason it is unusual is that cheek implants add volume to an otherwise prominent facial bone area. If anything it may cause a very mild cheek tissue lifting effect but not dropping of tissues as you state around your mouth. Early after surgery, in the first few weeks or month, one could have swelling and some bruising which drifts downward along the mouth and even into the neck. But if this is would not be the case more than a month after surgery. If other facial procedures were done at the same time, which would be common, then this could still be residual swelling which may yet go away.
Uneveness of cheek implants, however, is not rare and is probably the number one complication of cheek augmentation. It is more difficult than it looks to place cheek implants in the identical position on both sides of the face. The thickness of the cheek tissues do not make it easy to see minor differences in position during the actual surgery. I would wait at least three months after surgery to let everything settle before making a final judgment about cheek symmetry.
Indianapolis, Indiana
Q: My breasts are in terrible shape after having had 4 children and nursing them all. They are saggy and disgusting. I think they need a total breast overall. They look so bad I don’t even know if they can be helped. I have read about breast implants, breast lifts, and breast reductions and I think I need all three. Is it possible to have all three of the procedures I am asking for done at the same time?
A: The combination of a breast lift (skin reduction and tightening) with an implant is a very common procedure for the breast that is small in volume but has an excess amount of skin that sags over the lower breast crease. With the breast in this kind of shape, all three procedures are needed simultaneously to give a more pleasing and uplifted breast shape. This is the most difficult of all cosmetic breast procedures and is best thought of a breast reconstruction rather than a simple breast reshaping.
Unlike breast implants alone, this more extensive form of breast reshaping will result in scars on the breast. The scars will be similar to that of a breast reduction. Because of the difficulty of the procedure, secondary revisional surgery is not rare to get the best shape and symmetry between breasts that often start off not only badly shaped but different.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a Thyroid cartilage reduction. I am a male but this is not for any kind of transgender procedure, I just have an oversized adam’ s apple and I do not like it. i am in my 30’s and I’m not looking to have it removed just made smaller. Is it possible to have this procedure at my age?
A: Most of the thyroid cartilage reductions that I do are in heterosexual males, not transgender patients. Like yours, the issue is the same…an adam’s apple that is just too big and sticks out too far. Your age is fine as age is actually irrelevant. As long as one is skeletally mature (fully grown, age 18), it is acceptable to have the procedure. This is a fairly simple operation that is both effective and requires minimal recovery. At the price of a very fine 1 1/2″ horizontal line in a skin crease over the cartilage, it can be substantially reduced.
The thyroid cartilage plays a very valuable role in supporting the vocal cords and certain neck muscles and ligaments. Its removal is not possible. Thyroid cartilage reduction merely shaves down or reduces a portion of the V-shaped prominence of the upper or superior part of the cartilage. Their paired upper borders come together in the front and form a notch whichi is easily felt. Removing this portion of the cartilage does not interfere with vocal cord function or other neck functions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a bullhorn lip lift three weeks ago and feel that the scar under my nose is quite hard (harder when I start talking) and still visible. Can you please tell me if the scar will soften and dissappear eventually? I much appreciate a second opinion.
A: The healing of scars from a surgical incision, as well as from any injury, is much different than most people perceive. When people see the dressings or tapes from a surgical incision, or the sutures placed to close it, removed a week or so later, they are often surprised how well it looks. When viewing the same scar weeks to a month later, it will look worse and some patients feel that something is going wrong.
In reality, this is part of the normal healing process. Actual healing of a wound or incision does even start to take place for weeks. That is why it looks so good just a week later, nothing is really going on and the body is not reacting fully to the insult. The scar will naturally turn redder and get firm weeks later as the body recruits the necessary elements to actually heal the incision. Blood vessels grow in and collagen is laid down to help knit the tissues back together. Collectively, this natural healing process creates a red and firm scar for months. Once the incision is getting more healed the redness fades and it will get softer, eventually getting that faded scar and softness of the tissues.
This healing process takes months and often is only complete at close to a year after the surgery. At this point, it will return to what it looked like at just a week or so after the initial surgery. When the incision is just under your nose, from a lip lift, one is forced to look at it daily. One’s awareness and uncertainly as to what will happen with it is understandably high.
Indianapolis, Indiana
Q: Hi, I’m an Asian female in my late 20s. Over recent years, my jaws have become really prominent, making me look somewhat masculine and heavy. In ooking for a way to reduce the angle of my jaw, I found the masseter reduction technique with botox injections on the internet. Since I don’t want to change my bone structure, I am considering Botox as a solution. My only concern is how much the cost would be. Could you please let me know the range of cost? Thank you so much!
A: There are two options for prominent jaw angle reduction, surgical jaw angle bone reduction and pharmacologic masseter muscle shrinking. There are advantages and disadvantages to each approach. Which is better for any patient depends on their bone and muscle anatomy and what type of result and effort that one wants to go through.
Botox injections, in my Indianapolis plastci surgery experience, can be an effective masseter muscle reduction method. My protocol is 50 unit injections (25 units per side) into the muscle at the angle done every four months for one year. After three injection sessions, some permanent muscle reduction will be seen. Whether maintenance injections are needed is determined on an individual basis. Cost can be determined by knowing what the provider charges per unit and simply do the math. In general, the costs are around $750 per injection session.
Indianapolis, Indiana
While my parents, and their parents, have lived much of their lives with fairly similar methods of doing business, the present world has seen a near total transformation in just the past decade. The merging of two initially unrelated technologies, electronic communication (now wireless) and social networking, have created a paradigm shift in societal thinking and strategies. While most who will read this have felt the impact on their business and personal lives, health care is one area where an equal transformation is rapidly occurring.
Plastic surgery has been one of the early adopters of both social networking and digital communication in the medical world. Part of this is because so much of plastic surgery is visual. Almost all of what we do can be seen and easily imaged. This is a double edged-sword as assessment is easy but with that can come an equal opportunity for criticism. Plastic surgeons rely on imaging only less than that of radiologists, whose entire practice is essentially the analysis of complex three-dimensional arrays of pixels. While a plastic surgery patient can provide great verbal detail and descriptions of their concerns, a good picture or two can leapfrog hundreds (or is it thousands?) of words.
Because of the need to market fee-for-service elective surgery, social networking sites have become a popular medium for plastic surgeons and numerous other practitioners of cosmetic services. In the old days (2000?), one would rent a hotel conference room and put on an evening program for the public. Advertising by word of mouth or newpaper ads might get an audience of 50 to 75 people. Post a blog or a promo on Facebook or Twitter and the potential exposure is to thousands.
I could pontificate on the medical impacts of these technologies, and there are too many to mention here, but one recent story makes the point. Driving home one evening after a day of surgery, I received a call from an emergency room halfway across the city. They had a five year-old boy that had a laceration on his forehead after his older brother yelled, fore!, and swung. These type of calls are common in plastic surgery and despite that I would have liked to fix this child’s problem, being up since 4AM and driving 35 miles was not beyond what I could muster. I asked the emergency room doctor to pass along my regrets and asked them to call another plastic surgeon. As I was settling down for the evening and just put my feet up, I received an unrecognized e-mail on my iphone with a one sentence message and a picture attachment. The message said, ‘My son is in need of your skills.’ signed by a mother’s name I had never heard of. The picture showed a close-up of a child’s face with a laceration down the center of the forehead between the eyebrows and the scalp…right down to the bone.
I don’t need to tell you what happened later that evening. With estimates that at least two-thirds of American physicians have smart-phones, doctors are prime targets for access from multiple wireless methods. With nimble technologies, from smart phones to health-monitoring devices, patients as well as doctors are becoming more empowered. Will this make health care better and reduce costs? Who knows but interactive health and wellness programs already surround us. Apple alone has thousands of health-related applications. Cell phone services using the Droid are not far behind.
Medical care is becoming more wireless at a brisk pace. While receiving the actual care still requires an in-person visit, the day may not be too far away when all you need to do is hold your cell phone next to what hurts.
Indianapolis, Indiana
Q: I had a chin surgery in the past with a silicone implant placed from inside my mouth. I didn’t like it so the doctor removed it two weeks later. Within a few days after its removal, I could feel fluid inside. The doctor removed it by a needle and it looked fine. But five days later I had a hard ball in my chin and the doctor told me that it was scar tissue. He assured me that I would return to the profile I had before my surgery. But it did not go back and I went to see another doctor who also told me it was scar tissue and injected me with steroids. The steroid helped a little but the labiomental sulcus is still much fuller than it was before the chin implant was placed. It now feels soft but is still fat. I think that the majority of the problem is in the upper part of the chin in the mentolabial sulcus. I don’t have the normal S curve that divides the chin and the lips. When you touch it you can feel something soft inside and the doctors here have told me it is scar tissue but they only want to fix the problem with more steroid injections. But I am afraid now because I have a dent from the steroids. Do you think it is possible to take out the scar tissue in the labiomental sulcus ?
A: You have experienced one of the problems from intraoral chin implant placement. When the implant is removed, the muscles remain expanded and an ‘open’ pocket exists where the implant once was. While the implant removal was undoubtably done quickly and easily in the office, no effort was made to put the mentalis muscle back in place and re-tighten it. A technique well known in plastic surgery as eliminating the dead space. Since the body abhors dead space, it will fill it with serous fluid…a perfect nidus for the development of scar tissue.
My recommended approach for this type of chin scar revision is excise scar tissue and reposition the muscle back down to the bone. This would be done from inside the mouth through your old incision. This is the most assured way to get back your chin profile and re-establish the depth of the labiomental sulcus.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I got the mole on my nasal bridge removed by elliptical excesion. The wound got infected (pus). The stitches were removed after five days of operation. Because the pus was still there the wound opened up. Now 15 days after the removal of stitches, I am left with 1mm deep large hole in place of mole, which is still pink. Please suggest a remedy, My doctor says I should wait for three months, If the scar remaining is too big then I can go for another sugery. I dont want to wait for so long, as it is effecting my life . Please suggest something.
A: The strategy that your surgeon has suggested in this right one. It is better to let the wound heal and contract down in size. It is possible that it may heal to the point where you will find the scar acceptable. Most likely, however, this will not occur as the nose is one of the most unforgiving places to scar on the entire face. By letting it heal, the scar (like the original mole) can be excised again later. By this approach the size of the defect will be smaller and the tissue quality will be much better for handling and holding sutures. While this is certainly distressing to allow this process to evolve on a prominent area of your face, it is the wisest and will result in the best scar result long-term.
Q: I had saline breast implants placed three years ago. I went from a A to a C cup. While I like the results, there are ripples along the bottom and the sides of the implant. I know some people have them and can feel them, but in me you can actually see them. They are really evident when I bend over. Is there any way to fix these? Would a smaller implant be a fix? Would smooth implants be a fix? Would alloderm be a fix for rippling ?
A: By the way you have framed your question, I am assuming that you have textured saline implants. Whether they are above or below the muscle is another very relevant question. Either way, however, saline breast implants are well known to have this problem. Sometimes the rippling is relatively minor, other times it can be quite significant. It is a ‘natural’ feature of saline implants which reflects the differences in how water vs. a silicone gel coats the inside of the silicone shell or containment bag. While it is common and expected in saline breast augmentation, several things can make it more pronounced, such as using a textured implant, placing the implant above the muscle and underfilling the implant from its recommended minimum volume.
While there are still some unanswered questions about your breast implants, there are several known effective strategies. Changing to a silicone implant is one of the successful as these implants have much less rippling. If cost is an issue, a more economic approach is to simply fill your existing implants with more volume. (it would be important to know beforehand what base size implant you have and how much saline is in them) While alloderm can thicken the capsule and theoretically lessen the amount of rippling, it is the most expensive strategy and the least assured of making a significant difference.
Indianapolis, Indiana
Q: I have had quite noticeable under eye hemosiderin staining since a rhinoplasty nearly 20 years ago. I’ve had several laser treatments over the years and am currently applying a hydroquinone cream. Nothing has ever truly worked, but I still hold out hope. Any suggestions would be greatly appreciated.
A: Hemosiderin staining represents the deposition of residual iron oxide pigments from the breakdown of the hemoglobin molecule. While most hemosiderin staining problems resolve on their own, they do so within months due to macrophage activity. Once this problem exists beyond 6 to 12 months after surgery, the body is telling one that it will not remove it on its own. It is faur to say after 20 years that your hemosiderin staining is fixed into the tissues.
This is a difficult problem and I think the chances of any treatment’s success is very unlikely. Certainly, no topical cream is going to work. Iron pigment in the subcutaneous tissue is not going to respond to any form of topical cream. Bleaching creams work on the skin for pigment, the iron oxide molecules lie much deeper. I don’t know what type of laser treatments you have been receiving. The only type of laser treatment that makes any theoretical sense is the Q-switched laser, the type of laser used in the treatment of tattoos. The residual iron oxide pigment must be viewed like a tattoo pigment being metallic in composition. Like a tattoo, the age of the pigment in the tissues shouldn’t matter. No other type of laser or pulsed light therapy (i.e., IPL) will work. A vascular laser will also not work since its focused light is for the oxygenated red hemoglobin, not the rusty brown color of hemosiderin.
Indianapolis, Indiana
Q: Dr. Eppley, do you perform the procedure, laser blepharoplasty? I have read about it and it seems the way to go if you want your eyes done.
A: The term or procedure, laser blepharoplasty, can mean several seemingly similar but different things. The use of the laser in blepharoplasty or eyelid surgery can mean that it is used to make the incisions, is used to remove the protruding fat pockets, or is used for resurfacing of the lower eyelid skin. Any or all of these can be defined as laser blepharoplasty. Knowing to which of these you may be referring to can answer your question better.
The use of the laser in blepharoplasty understandably captures a patient’s attention. Using the ‘Stars Wars’ effect of the laser and its seemingly magical properties, it is believed that its use would make any medical procedure better. But the laser is just a tool that can be used to cut or burn tissue and it is not a magical wand. It can not really do anything more than what a traditional scalpel or electrocautery can do. The real question is…can the laser make a blepharoplasty result or at least make the recovery quicker and better? (less bruising, swelling and pain)
Despite what many believe, there is no evidence that the use of the laser is a better way that traditional techniques for performing a blepharoplasty. While the laser can be used for a blepharoplasty for the making of incisions, vaporizing fat, and for skin resurfacing, it’s best benefit is it’s impact on marketing and the recruitment of patients for those that advertise and perform it.
Indianapolis, Indiana
Q: I have been self conscious about these bumps on my forehead ever since high school and that has been 8 years ago. It all started when I shaved my head and a friend asked me how I got the horns (bumps) on my forehead. Then my girlfriend (ex-girlfriend now) said the same thing and then my cousin. So every morning I wake up since then I have been wearing a hat, every day all day. I constantly look at my head and notice these bumps. It’s really noticable when the light hits my forehead from certain angles. I have never heard of anyone having this problem before. What causes this and how do I get rid of it? I am so self-conscious about it.
A: Most likely what you have are known as osteomas. These are the development of a benign bony mass, much like a stalagmite. Why they develop is not well known although a history of trauma to the area can cause bleeding. When blood gets under the cover of the bone, known as periosteum, they will usually calcify creating a hard mass. Your forehead issue may well be osteomas and I have seen them on both sides of the foreheasd before, looking like horns.
Skull or foreheads osteomas are fairly easy to remove. They ‘chip’ off of the underlying skull bone with a chisel or sharp instrument. They can also be burred down. While they are easy to remove, you have to have an access point, i.e., an incision somewhere. Direct access by an incision over them is the easiest and if a forehead wrinkle is close by that is an opportune place to put a small incision. They can also be removed with an endoscopic approach with the small incision back in the hair-covered scalp.
Indianapolis, Indiana
Q: I have a very asymmetrical jawline and am thinking about having a custom implant formed to the side of my jaw with the deficiency. For the rest of my face, I am hoping to achieve a balanced look, trying to get the best of both sides of my face, without exactly mirroring either side. One side is overly large, the other side is overly small. Both sides are appealing but different, except for the major sallowness to my face in my cheek area due to the smaller jawbone. I only want to have that filled in.
I was hoping to being treated with Radiesse or a facial filler to help even out the side with the deficiency without going through a drastic implant that might take away some of what I like about my face or compromising the way my muscle system has developed. Would it be a possibility to achieve some balance as a short term option?
A: One of the best benefits to injectable fillers is their immediate volume adding effects without having to undergo surgery to get it. For the soft tissue zone below the cheek bones but above the jaw line, only a filler material can add volume. This is not a facial area where a synthetic implant can be effective, there is no underlying bone to push off of.
The downside to facial fillers is that they do not last. And most will not last as long as the manufacturers claim in my experience. For this submalar facial area, good choices can be Juvaderm or Radiesse. One can expect about six to eight months of added volume before it dissipates.
Indianapolis, Indiana
Q: I would like some information about facelifts. Do you do lower face/neck lifts.? How much is the average facelift? Do you have financing for facelift procedures?
A: Very detailed information on facelift surgery can be found on my blog, www.exploreplasticsurgery.com. Just search under facelift and more than 50 articles on various aspects of facelift surgery will come up on the topic. From what a facelift is and its different types, to how it affects the facial aging process and how long they last, and to recovery and postoperative instructions after a facelift are covered in detail in these articles.
The cost of a facelift can range from $5500 to $9500 depending on the type of facelift done. More limited facelifts, like Lifestyle Lifts cost less while more complex full facelifts cost more.
All facelifts are really neck-jowl lifts and affect only the lower third of the face. It is a common misconception that it is a procedure that treats the entire face, from the forehead down to the neck. Many facelifts are done at the samed time as other facial procedures such as blepharoplasty (eyelid surgery), browlift, rhinoplasty and chin augmentation.
The financing of cosmetic surgery is common and many companies offer this service. Plastic surgeons essentually act as referral sources to these companies as both a service and convenience to their patients. One of the most popular is Care Credit although there are many others. Plastic surgeons do not offer the financing directly but provide needed financial information so that you can apply.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Have you ever used a patient’s own fat to fill in the nasolabial folds? I had it done in the past and it seems to last longer than other injectable fillers. Besides, I find it more appealling as it is completely natural.
A: The nasolabial folds have been injected with every conceivable form of injectable filler, including fat. To date, there does not appear to be an ideal filler for this, or any other, facial area. Off-the-shelf injectable fillers offer convenience but last less than one year at best. The use of fat injections is less convenient, as it must be done in the oeprating room in most cases, but does offer a natural material. Unfortunately, it has not proven to be permanent in most cases and has not been shown to last longer than commercial injectable fillers.
I do use fat as an injection material when one happens to be in the operating room anyway doing other procedures. This is a good time to take advantage of the natural or autogenous injection opportunity. This is particularly convenient when one is having some liposuction performed. In this case, some of the discard can be used for injection into the nasolabial folds.
Another fat option, not thought of very often, is that of the dermal-fat graft. Using a strip of skin with fat attached (and the top layer of epithelium removed), these grafts can be threaded into the nasolabial folds through small incisions above and below the folds. This type of fat graft provides very consistent survival. It does require a donor site, however, and that is a disadvantage if an excisional procedure (such as tummy tuck or breast reduction) is not being simultaneously performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can “love handle” surgery be combined with the hip and inner thigh area? I have lost several pounds through the years. I was told laser treatment to melt the fat would be the way to go, but not sure what would happen with the excess skin?
A: It is very common to combine at least two, and often, up to five areas at a time during liposuction surgery. It is actually very uncommon to do just one area. Since liposuction is about reshaping body areas, it usually takes several areas at a time to get the best result. The only limit that I put on liposuction in my Indianapolis plastic surgery practice is the amount of volume removal and time, which are closely aligned. I have learned by experience that it is usually best to get a single session of fat volume removal under five liters or 5,000 ccs. If more is required, then the liposuction procedure should be done in stages. This decreases the potential risk of complications and makes the recovery more tolerable for the patient.
How much skin exists around a liposuction area is critical in determining what type of result can be obtained. The skin can shrink only so much even with laser liposuction or Smartlipo. If too much skin exists, then one may need to consider some type of excisional procedure. This is particularly relevant in the neck, arms, abdomen, and inner thigh areas.
Dr. Barry Eppley
Indianapolis, Indiana
Although eyelid surgery (blepharoplasty) treats only a small area of the face, it has a dramatic impact on facial appearance. Dollar for dollar, blepharoplasty surgery has the best value of any plastic surgery procedure of the face because it is seen by all in everyday conversations. The eyes show age more than any other body part due to smiling, squinting, frowning, sun damage , and heredity. A lot of what you perceive in other people has to do with how their eyes appear. Most of us know this because when we go into work, more often than not, what does someone seem to frequently say…you look tired!
Upper eyelid surgery gets rids of hooding and excess skin that may be hanging down on your eyelashes. Upper blepharoplasty helps restore a natural, youthful appearance by removing skin through an incision in the eyelid crease. In some cases, fat may also be removed or redistributed. Since the incision is carefully placed, it is undetectable once healed. The only way that fine little scar can be seen in the upper eyelid is if they look while you are sleeping!
The lower eyelids are one of the first areas of the face to show age-related changes. Most of us know this because the appearance of bags and wrinkled skin. Loose skin and muscle create a droopy appearance and a protrusion of fat, which normally is under the eyeball, creates that classic but dreaded appearance of lower eye bags. These bags are really prone to absorbing fluids which is why they are more swollen in the morning or if you have eaten really salty foods the day before. The lower eyelids can be improved by an incision which is hidden either inside the eyelid (if fat only needs to be removed) or just below the lashline. (when all tissues need to be treated) The muscle, support tendon, and skin are reshaped and tightened back up against the eye. That protrusion of fat is either removed, tucked back in, or repositioned over the edge of the eye socket bone, dependent upon what will look best. In some patients, chemical peels or laser resurfacing can be done at the same time (only when the incision is on the inside of the eyelid) to improve wrinkles and loose skin on the lower eyelid and crow’s feet area.
One of the most interesting things about these procedures is that most patients say… the most surprising thing about eyelid surgery is the lack of pain during recovery. While eyelid surgery may look bad, it actually produces very little pain. Your recovery is largely social and about how you look.
The other comment that patients often say is…why did I wait so long? I spent a lot of money on creams and other potions and none of them worked…and they promised they would! (hope still remain the #1 selling point) Eye creams are beneficial but they are largely about prevention and not about reversing the age changes that are already there. They simply can not tighten or lift skin to any visible degree.
Dr. Barry Eppley
Indianapolis, Indiana
Q: How soon should I quit smoking before my facelift? I have smoked for nearly 30 years and I know it has not helped me age well. I think a facelift will really help me look better but I don’t want to have any problems after surgery. On the flip side of that coin, when after my facelift can I start smoking again?
A: There are some things in plastic surgery that don’t go well with it…and smoking is at the top of the list. Besides the obvious deleterious effects on aging that smoking causes, it has its worse effects on skin flap-driven operations. These include facelifts, breast reductions and tummy tucks to name the top three of cosmetic procedures. Because these operations raise long skin flaps that rely on small vessel perfusion from the dermis, anything that impedes or constricts blood flow decreases oxygen delivery to the injured tissues. Without oxygen, survival of healing of the edges of the skin flaps is impaired. It is the carbon monoxide (steals a space on the hemoglobin of red blood cells where oxygen can occupy) and nicotine (causes blood vessel constriction_ which together really hurts tissues from getting what they need to heal.
One should ideally quit three weeks before facelift surgery. If you can’t, and it is important to be honest with your plastuc surgeon, then he or she can modify their facelift technique to lessen the risk of healing problems.
If you are going to invest in a facelift, it makes little sense to keep on smoking. One should use a major event and expense like a facelift to be the motivation to finally quit smoling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Doctor, I just had juverderm ultra injected into my lips several weeks ago. But I am not happy with the amount of lip size that I got from it. I am interested in having more filler put in and want to change to Aquamid. Is it safe to use Aquamid a few weeks after having a Juvederm treatment ? What are the potential problems that could happen?
A: There are no studies that provide comfort that the mixing of different injectable fillers is safe. In fact, a recent report that looked at multiple different injectable fillers used in the same patient indicates that complications do arise from doing so. It may be one thing to mix and match different hyaluronic-acid based fillers (such as Juvaderm and Restylane, for example), but putting two completely different chemical compounds into the same facial site is unknown in terms of their compatibility and asks for problems. No facial area is more sensitive to inflammation and granulomatous reactions from injectable materials than the lips.
I would highly recommend that you want at least 6 months before considering injecting another filler into your lips because of these concerns.
I would also not recommend the use of any semi-permanent or particulated injectable filler be placed into the lips. Fillers, such as Radiesse, Artefill and Aquamid, are comprised of a mixture of polymer beads suspended in some form of a more liquid carrier vehicle. In the lips, these particles have been shown to have a higher incidence of foreign-body reactions, lumps, and even infection. The injectable fillers with the best track record of safety in the lips are of hyaluronic-acid derivation. Do not risk long-lasting results at the price of soft tissue problems. This is a particularly poor trade-off in the lips.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I am a 28-year old male with very prominent brow bones and I would like to have them reduced to a normal size and shape. What is involved in doing this kind of plastic surgery? Are there any significant risks and do you think the results will be worth it? Thank you very much and I look forward to your reply.
A: Brow bone reduction is more than just burring down thick brow bone ridges. It actually involves removes the outer plate of the frontal sinus, reshaping it, and putting it back on. A prominent brow bone is really not bone, it is an overgrowth of the frontal sinus. Brow bone reduction is really about reducing the size of the air space of the frontal sinus, in essence making a room smaller by lower ing the height of the roof.
Brow bone reduction must be done through a scalp incision. While the operation is not complex or dangerous for those trained in craniofacial plastic surgery, it requires that expertise and training to be very comfortable doing it. The key aspect in the decision to have the operation, in my opinion, is the acceptance of a scalp scar. One should have a good density of scalp hair and some confidence that all hair on the top of the scalp may not be eventually lost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m interested in customized mandibular angle implants for enhancement and to camoflage asymmetry and a contour defect from previous corrective jaw surgeries. I’ve had several jaw surgeries in the past. I had corrective jaw surgery which involved moving the lower jaw and chin forward. This surgery did not go very well. Due to an impacted wisdom tooth on the left side, I suffered a substantial amount of bone loss and was wired shut for several weeks. I also suffered nerve damage on the left side from the nerve be badly stretched. I had a revision surgery with another surgeon who repositioned the chin to correct asymmetry and placed a lateral onlay medpor jaw implant on the left side. I would like to have the implant removed and different style implants placed on both sides of my jaw. I would like to camoflage my defect and at the same time enhance the lower angle.
A: It appears you had orthognathic surgery and suffered what we call a ‘bad split’ on one of the mandibular osteotomy sides. (this is why it is a good idea to take out the wisdom teeth six months in advance of the procedure so the bone can heal and have better bone to work with. (I have been there before) I am assuming that the left side eventually healed but it resulted in the jaw being more posteriorly positioned on that side, resulting in chin asymmetry. Then you went on to have a chin osteotomy for anterior asymmetry correction and an onlay implant over the healed but deficient side of the lateral mandible where the sagittal split went bad.
I don’t necessarily think you need a custom implant on the left side. While it certainly can be done, the cost difference to do so may not be the effort. A careful analysis of your facial photos and x-rays is first needed to determine of that is necessary. Most of the time the problems can be improved with implants that are available off-the-shelf. You will likely need a different style and size of implant for the left side than the right. One option is the Medpor Ramus jaw angle implant with an inferior ridge on the left side. That type of implant would cover both the angle and the ramus and inferior border where the old bone defect site is. That would provide 7mms of angle width with the choice of either 5mm or 10mm lowering of the inferior ridge. The best way for me to make that determination is to look at a panorex film, which I suspect you have had at least one since your last surgery.
The other issue on the left side is the removal of the old onlay implant. That is usually not very easy with these Medpor implants but possible. You just don’t want to undergo a lot of ‘destruction’ trying to remove it unless it is really necessary. Sometimes it is better to leave it and implant over top of it. But that would depend on the size and location of the current implant in place. Again, a panorex film would be critical as the implant outline will usually show on that type of x-ray.
As for the opposite right side, I think either the smaller Medpor Ramus angle implant with the inferior ridge may suffice or a Medpor RZ angle with 7mms width. I would have a better feel for that based on an x-ray analysis.
What I would recommend is to get, or find if there are old ones, a panorex and a lateral cephalometric x-ray. With these I can trace out the mandibular shape and get a better 3-D for your unique anatomy. Then we can decide whether off-the-shelf or custom jaw angle implants are needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My daughter had a breast reduction at the age of 14. She is now 19 and would like to have implants to bring some shape and fullness back to her breasts. Can you explain what happened? It seems like we are going in reverse. Once her breasts were too big, now they are too small.
A: While breast reduction reduces breast size by removing tissue volume and skin, the long-term results of the operation are not always stable. In fact, if you look at a woman’s breasts over a lifetime, they do change throughout her life for a variety of reasons. The younger a breast reduction is done, the more likely the breasts will eventually undergo shape and size changes.
The first explanation is that the initial breast reduction may have been overly done. While it may have initially looked good, once the breast swelling went away the amount of reduction may have been too much. Years later, the breasts will bottom out and look deflated and flat.
Breast reduction results are affected by a variety of bodily changes long after the surgery has healed. The two biggest are weight loss and pregnancy. Both cause breast involution or tissue shrinking, resulting in a decreased breast size and more loose breast skin.
Since her breast reduction was done early at age 14, she was barely through puberty. Often breasts can ‘regrow’ when done this early but I have never seen in my Indianapolis plastic surgery practice significant breast shrinkage after just five years by age 19. If she has become pregnant and delivered, this would explain what has happened. More likely, however, is that the initial breast reduction may have been too aggressive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a facelift last year but am unhappy with some ‘dogears’ in my scar under my chin. Can this be improved by extending the scar?
A: Most full or more complete facelifts involve an incision under the chin. (submental incision) This is done to access the central neck area for fat removal and neck muscle tightening. Usually this is a very small incision and does not involve the removal of skin. It is simply a point of access. It is closed and there is very rarely any scar issues with it. Dog ears, a redundancy or bunching of skin at the ends of a scar, do not usually occur with this submental incision as no skin is removed. In short, this inicision is not there to do some sort of ‘neck tuck-up’.
There is a neck procedure done known as a submental tuck-up which is done for chin ptosis or sagging. But this is not done to create a neck lift. That is a fundamentally flawed approach as the neck can not really be lifted by this limited incision. To do so would require a much longer incision which would usually be cosmetically unacceptable. I have seen a few patients over the years who have had this type of procedure done elsewhere and the results have not been good for this very reason. You can not lift and remove enough neck skin with a cosmetically acceptable submental incision.
If you have dogears in your submental scar, I am wondering if this might be the operation that you had. The dogears can be removed but it will require extending the scar length as you have surmised.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a brow lift or botox treatment…maybe a facelift. I am 43 years old and I believe I look ten years older. Do you know if I could try one procedure now and then gradually work up to a progressive series of surgeries?
A: The wonderful thing about the many procedures for facial rejuvenation is that both small and big changes can be done. And the procedures can be customized to how much one wants to do, how much one wants to spend, and how much recovery one can allow. Since facial aging is a progressive phenomenon, younger patients will need smaller procedures while bigger changes are reserved for those with more loose skin and wrinkles.
Since you have never had any of these cosmetic procedures before, it is understandable that one often does not know where to start. To ‘put your toe in the water’ so to speak, doing something non-surgical like Botox or injectable fillers is a good way to start. One can venture ‘further into the pool’ with laser treatments and even facelift surgery at a later date. A progressive approach to facial aging treatments is both reasonable and prudent.
Always start with the facial concerns that bothers you the most. To get started, it is helpful to meet with a plastic surgeon and have an educational session about what is appropriate now and what may be beneficial in the future.
Dr. Barry Eppley
Indianapolis, Indiana
The mixing of religion and plastic surgery are an unlikely pair that on the surface go together like oil and water. The current Gulf oil leak brings vivid images of how such things don’t go well even though they are closely aligned by proximity. Those considering plastic surgery with deep personal convictions undoubtedly feel like those contrasting mixtures. While no Christian religions of which I am aware specifically forbid having cosmetic surgery, it is with a certain amount of guilt that one of such beliefs ponders such a seemingly self-aggrandizing act.
I recently saw a mother on whose son I had operated many years ago to repair a birth defect. To leave a child’s face deformed is, of course, unimaginable in our society. But there are many third-world countries where, due to lack of medical care, such facial birth defects are not routinely repaired. Even those persons with the deepest and strongest of personal convictions against ‘plastic’ surgery would not quibble about a parent’s decision to seek reconstruction of a birth defect. The same could be said for a church secretary that I saw who had breast cancer and wanted immediate breast reconstruction. But what about my former pediatric patient’s mother who now wanted a tummy tuck? Or what about the individual who has body issues so serious after a 100 lb. weight loss that their mobility is affected?
For some, plastic surgery seems like a selfish and indulgent pursuit. While this response is often a knee jerk reaction on the part of some who see it that way, those with religious convictions are forced to look even deeper and confront their beliefs and sometimes even question their spiritual integrity. But in a modern consumer-driven society, the awareness of such personal improvements is all around and are as readily available as the office across the street or in the next biggest town.
Over the years, I have performed cosmetic surgery on many more than a handful of patients with deeply held personal convictions who have undergo everything from breast augmentations to facelifts. I know of their personal convictions because they told me so. While most patients offer an explanation (although not needed) as to why they want cosmetic surgery, those of religious persuasions are upfront about their struggle with this decision. There are few others that they can turn to for this discussion for fear of judgment in their community as well as to avoid the criticisms they would feel even if such words were unspoken. Most of us are quite quick to judge the motives of others without any real knowledge of their story.
A baby with the cleft lip and a mother who wants a tummy tuck seem worlds apart. But are they really? My observation is that both situations are wholly about the need to look and feel ‘normal’. No parent corrects a birth defect with aspirations their child will one day become a supermodel, and a mother of four kids whose body has borne the brunt of repeated pregnancies are very similar. These surgeries are about normalcy; and about feeling confident. Few cosmetic patients that I have ever met really want to be special, most only want to feel better about themselves- they want confidence. Whether that desire conflicts with the integrity of one’s religious beliefs, or are mutually exclusive, is not for me to say.
What I tell any patient, of strong religious convictions or not, is that plastic surgery is a tool. It is a method for personal improvement. The decision to have surgery or not is only part of the personal enrichment process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had cheek implants placed over10years ago and an oral and maxillofacial surgeon told me one of them is infected. It started with a visit to the dentist.I had 2 fillings done in my upper molars.The freezing was in the same area the implants are and this somehow caused one of them to get infected. It is swollen and I am upset it happened and worried about the infection. I have been on antibiotics for about a month.I know infection is rare but I got unlucky and I was wondering how many times you’ve had to take one or both implants out?
A: You are correct in that infections with cheek implants are rare, but they are not unheard of. It has been reported that cheek implants can get infected with local anesthetic injections during dental treatment. An upper vestibular or intraoral nerve block puts the needle very close to a cheek implant and could very easily, unknowing to the dentist, touch or penetrate into the implant. This would be a source of bacteria brought into the implant capsule from the needle track.
Once a cheek implant, or any facial implant for that matter, gets infected, it is likely that it will eventually require surgical treatment. An implant is an avascular surface, that once contaminated, can not easily get rid of an infection. Antibiotics are a logical first choice but they will tend to only suppress it for the duration that you are them. Once off, the swelling and infection usually returns. If this does not work after a month or so, I would re-operate, remove and clean off the existing implant and either replant it or replace it with a new one. This approach will work. The opposite cheek implant is at no risk from the infection of the other one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 53 yrs. old and have very deep nasolabial folds (more so on one side than the other). I don’t know why they are so deep at my age but they are. I was interested in the “Cutting out” of the fold, however, my question is what happens to the cheek? Would the skin not sag? This is a problem I have and am very self conscious about it.
A: The development of nasolabial folds occurs in everyone as they age, some are more pronounced than others. How deep and early nasolabial folds appear is a function of numerous factors including thickness of one’s facial skin, thinness or fullness of one’s face, cheek bone support and how much cheek soft tissue sagging or ptosis develops. The nasolabial fold develops as the cheek tissues sag down over the more fixed and stable upper lip region. They are really tissue that is ‘falling over the fence’ so to speak.
By far, the most common treatment for softening the nasolabial folds are injectable fillers. But in advanced stages of nasolabial folds, an inverted-V deformity exists in the skin and injectable fillers do not produce a significant or worthwhile reduction. Usually inverted nasolabial folds are seen in older patients. (> 60 years of age)
In the inverted V or deep nasolabial fold, excision is a treatment option. Because this technique cuts out the fold, it is very effective at restoring a smooth transition between the lip and the cheek again. However, there is a trade-off of a scar which make proper patient selection critical. While this fine line scar does quite well, it is a scar nonetheless and that deformity trade-off is not right for everyone.
Another treatment option for the deep nasolabial fold is a ‘release and fill’ technique. A fine surgical wire is used to release the dermal attachments of the fold and an interface of injectable fat placed under the release. While this sounds like it would be theoretically successful, long-term follow-up has not borne out this theory.
Before considering nasolabial fold excision, one may want to try injectable fillers to be certain that their effect is not sufficient since they are reversible. Nasolabial fold excision is a one-way commitment.
Dr Barry Eppley
Indianapolis, Indiana
Q: I was just wondering if Dr. Eppley could do scar revision on old keloid acne scars. I went to a Dermatologist over 7 years ago and he told me that plastic surgeons could remove the scars with great success. I am very self conscious and I love to swim, but I haven’t really done it because I know people are staring and want to know why I have these ugly scars. I wish I could tell them to mind their own business but obviously I can’t. I have them on my shoulders, top of my biceps, and a couple on my chest area. I was just wondering if you had done this kind of surgery before and what was the outcome from the surgery?
A: The success of scar revision is measured by how much the scar appearance is improved. Improvement in problematic pathologioc scars as you decribe is ultimately measured by whether hypertrophy or keloiding reappears. There is no question that scar revision is successful early because the previous scar is cut out and temporarily eliminated, trading off a thick raised scar for a more narrow scar line. But what does the scar look like three or six months later?
How successful scar revision is depends on many factors, including skin type, anatomic location of the scar, and what caused the scar. Hypertrophic or keloid scars in thicker skin with darker pigmentation over stretch out areas such as the sternum and shoulders can be very difficult scar problems with a high rate of recurrence. They remain a plastic surgery problem where a better understanding of the science of scar formation is needed before more effective treatments are developed.
Until that day arrives, we must consider traditional scar excision and see what happens. I would recommend to do just one of the scars and see what happens, using it as a ‘test’. Based on that outcome one can determine if the other scars are worth the surgical effort.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley. I’m a 25 yr old male who is dissatisfied with my cheeks. They are very round and full, and give me a infantile or boyish look, rather than a more angular, defined, masculine one. I’m pretty thin so weight loss is not an option. I’m wondering what my surgical options are. Apparently plastic surgeons don’t think buccal fat reductions are a good idea. Would creating a cheek dimple help? What do you think?
A: Full cheeks do contribute to a more round facial shape although they are just one factor in creating that appearance. Depending upon how one defines the cheek area, a full cheek can be due to a prominent cheek bone, a large buccal fat pad, a thicker subcutaneous fat layer across the cheeks and face, or some combination of all three. It is obviously important to know what in the cheek area is creating that look when one tries to figure out how to change it.
From a practical standpoint, the only reliable method of ‘cheek’ fullness reduction is partial or complete buccal fat pad removal. While this is a very simple procedure, one has to appreciate what type of facial slimming effect that it will create. Buccal fat removal will create a soft tissue indentation below the cheek bone prominence. If you put your finger under the prominence of the cheek bone, this submalar or under the cheek location will be the area effect. The slimming effect will not go down or past the corner of the mouth.
For most patients, buccal lipectomies will create a mild reduction in cheek fullness in the submalar area, but never dramatic. It is a good procedure, in my opinion, in the properly selected patient. It has gotten a bad reputation because of poor patient selection and over aggressive fat removal. In patients with thin or lean body types, the short-term facial sculpting effect may not be worth the potential for a long-term facial atrophy look with aging.
In trying to create a more sculpted face, it is also important to look at other potentially useful procedures such as chin augmentation, neck liposuction, and maybe even mild cheek augmentation. When put together with buccal lipectomies in the right face, a signficant more defined facial look can be obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am writing to you because I have a very troublesome scar on one of my cheeks. The scar has been there for a long time since I was 5 years old. At that time I had some type of cyst removed which left a bad scar. It has bothered me for over 20 years and has very negatively affected how I see myself. I have tried the best that laser resurfacing (Fraxel) has to offer as well as Botox and filler injections, all with no visible improvement. I have paid good money for these treatments and I was really disappointed to see that they did not make a difference. What do you recommend?
A: Your question has me at a disadvantage as I can not see your facial scar. Having seen and operated on children for facial nevi and other tumors, however, it is like that your scar is plagued by multiple adverse scar factors including being wide, is deeper or more depressed than the surrounding skin, and is positioned over a prominent facial area. I can say that with some confidence because you were still young when the scar occurred and your face has grown much since that time. Facial growth always causes scars to stretch and be thinner than the surrounding skin.
The only hope of any improvement is actual scar excision. Cutting all or part of the scar out and then re-closing it can narrow it. Often this takes two stages to get the scar narrowed as much as possible. Thereafter laser resurfacing may be beneficial but may not be needed at all. When one considers serial scar revision, including healing and scar fading time, this is a process that easily can take a year or longer to get to where you want to be. A patient must be prepared to make such a time commitment. You are still young so such lengthy efforts will still have a long lifetime of benefits.
Dr. Barry Eppley
Indianapolis, Indiana
