Your Questions
Your Questions
Q : I had gastric bypass surgery about six months ago and have already lost 65 lbs. At the pace I am going, I will reach my goal of 100 lbs within one year after surgery. While the weight loss is fantastic, the amount of loose hanging skin that has developed is disgusting. I want to get this loose skin removed as soon as I can. How soon once I reach my weight loss goal can I have plastic surgery?
A: It is understandable that most extreme weight loss patients want to enjoy the benefits from their efforts as soon as possible. While the weight loss is the first step, most patients will require some skin removal through a second stage body contouring surgery to really see the body that they had hoped for.
Despite the enthusiasm of pressing forward as soon as possible, it is important to wait until some point after you have reached your weight loss goal. Your body needs time to recover and adjust to the new weight. This also allows you to learn new eating habits that will help keep the weight off but also have you become more nutritionally sound.
Body contouring surgery places major stress on one’s body and requires a lot of nutrients and energy to heal properly. You also want your immune function to be functioning as best as possible. In short, you don’t want to be malnourished going into major surgery. It has been that many post-bariatric surgery patients have protein-calorie malnutrition as well as various vitamins and mineral deficiencies.
While there is no standard waiting period after bariatric surgery, it is best that one have a stable weight for at least three months before considering elective body contouring surgery. Patients who have had gastric bypass, due to intestinal absorption changes, aren’t usually ready for body contouring surgery for six months or more afterwards. Lapband patients lose weight at a much slower rate and it may be much longer than a year after their procedure before they are ready. Extreme weight loss patients who have done it on their own without surgery can be done sooner because their intestinal absorption of nutrients has not been altered.
Dr. Barry Eppley
Q: I have one breast that is quite a bit larger than the other one. I am way too embarrassed to wear a bathing suit or even go out with men for more than a couple of weeks. (I don’t let my relationships, go to the next level so to speak, in fear that the guy will totally freak out and embarrass me even more if that is possible because I already feel pretty bad about myself!) Anyway I was wondering if you could enlarge just one of my breasts?
A: While few women have breasts that are perfectly symmetric, congenital or developmental breast asymmetry is another matter. In this condition, one breast is significantly larger than the other often by several cup sizes. In its most severe form, there is a medical condition known as Poland’s syndrome where the breast and the underlying chest muscles on one side fail to develop much at all.
All forms of breast asymmetry can be significantly improved through modern breast surgery methods. In some cases, the smaller breast may be merely enlarged by the placement of a breast implant. In other cases, differential enlargement of the breasts will different implants sizes may be better.
Often times, however, the differences between the breasts is more than just that of volume. The larger or more normal breast will have more skin and a different size and position of the nipple on the breast mound. Optimal correction may require adjustment of the more normal breast as well through a lift or nipple elevation.
Dr. Barry Eppley
Q : I am interested in getting breast implants. I have been saving for years and am so excited to be close to actually getting it done. One worry I have is about the time to recover. I can’t be out of work too long. I have read from some doctor’s advertisements that it can be done with no recovery whatsoever. Is that true? How can that be possible since it is surgery?
A: Breast augmentation is definitely real surgery. While it is a cosmetic operation, it does involve lifting up your main chest muscle (pectoralis) to insert the implant underneath it. Lifting up any muscle in the body is not pain-free and does involve some recovery.
There has been a general change amongst many plastic surgeons over the past decade about what to do after breast implant surgery. In the past, there was the belief that restricting any motion of the arms and chest muscles improves healing around the implant and helps control discomfort. There has been a 180 degree change in recovery philosophy with the recognition that the fastest way to recover from a ‘pulled muscle’ is to use it rather than restrict it.
As a result, contemporary recovery techniques after breast augmentation use an aggressive physical therapy approach. Early and frequent arm range of motion and a ‘get up and go’ approach is now used. Pain medications are either not used or restricted and one begins immediate use of non-narcotic anti-inflammatory medications. From a marketing standpoint, these have become known as ‘no recovery’, ‘rapid recovery’ or ‘easy aug’ breast augmentation methods. Suggesting that there is no recovery is a bit overstated but it is certainly much easier than it used to be.
It is certainly possible today to be sufficiently recovered after breast implants to be back at a non-physical job within a few days. A heavier labor position may take a one week or two to have sufficient recovery to work unrestricted and relatively pain-free.
Dr. Barry Eppley
Q : I would like my brow bones reduced. I am now 20 and until about 12 years old my brow areas looked normal as best as I can remember. Since then they have continued to grow, or at least seemed to, to the point that I look like a Cro-Magnon man. My parents took me to get evaluated by an endocrinologist around age 14 or 15 to see if there was some reason and to make sure I did not have acromegaly or some other hormone problem. Those tests were normal. I feel like a freak with the way I look. How is this surgery done?
A: Prominent brows are not due to excessive bone growth of the forehead per se. Rather it is due to the overdevelopment or pneumatization of the frontal sinuses. The frontal sinus is an air-filled space between the inner and outer bone surfaces of the forehead brow bone. They empty into the lower portion of the nose through long ducts. Sometimes they exist as two separate cavities above each brow. Other times, they connect across the middle and are just one big frontal sinus.
The frontal sinuses do not even begin to develop until age 8 or older. They do not stop forming until well after puberty. When the airspace gets too big, it causes the bone on the outer side of the sinus to bulge out. Why some people’s brows remain flat and others ’overdevelop’ is not known. While there can be a medical reason, such as a pituitary tumor, most cases are idiopathic. (they just happen for no apparent reason)
Brow bone reduction surgery involves taking off the bulging outer plate of bone and reshaping it. During the operation, the cavity of the frontal sinus is widely exposed and the reshaped outer plate of bone is put back with tiny plates and screws. While this sounds like a gruesome operation, it is not. In many ways, it is a glorified brow lift using the same scalp incisional approach. It is the same operation as a frontal sinus fracture repair.
The sticky issue for men is the need to create a fine line scalp scar behind the frontal hairline. Based on hairlines and density, this may be a concern for some men.
Dr. Barry Eppley
Q : I am interested in scar revision. I have had three hair restoration procedures and this has now left me with a very wide donor scar that is quite noticeable on the back of my head.
A: Hair restoration, also known as hair transplantation, is a true ‘robbing Peter to pay Paul’ type of surgery. Hair grafts are harvested in a horizontal excision pattern in the lower portion of the occipital scalp. (back of the head) The donor site is brought back together so that the scar, hopefully, is just a fine line that can not be easily found in the remaining scalp hair.
Harvesting scalp skin (and hair) is quite easy and the donor scar usually looks quite good since the scalp is very flexible and comes together without much tension. Since most hair transplants require more than one session to get the maximal hair density, this same donor site must be used consecutively. The scar will usually stay quite narrow even after the second time of graft harvesting but the scalp closure is definitely tighter.
The third scalp harvest, which is often not advised and even done, will likely run into a wider donor scar problem. One of the most important contributors to how all scars will eventually look is tension. The tighter the closure, the more likely the scar will end up being wide. Tension wins over time and it relieves itself through widening of what is an initially narrow-looking scar. Also contributing to the scar widening is the inavoidable horizontal orientation of the scar which is repeatedly pulled downward with neck flexion.
Wide occipital scalp scars can almost always be improved by excisional scar revision. Unlike the donor harvests, however, the skin is closed with the aid of significant tissue undermining at the galeal plane level. This helps reduce the tension on what would otherwise be a very tight skin closure. In addition, I have occasionally incorporated a geometric skin closure pattern with a running w-plasty series. The interdigitating limbs of skin closure are another method to change the tension lines on the skin closure.
Dr. Barry Eppley
Q: Can facial implants help to fill in a cheek region, where collagen injections have been beneficial? I have a large depressed scar from dermabrasion and laser treatments on an acne scarred region of my face. I would be glad to email pictures of the region to assist in the answer.
A: Facial implants work by pushing out from the underlying bone on the overlying soft tissue. This how they create more highlights or volume to specific facial bony prominences. While a facial implant can be placed anywhere on the facial bones, they work best on convex or flat surfaces such as the chin, cheeks, and jaw angles.
The treatment of most depressed scars would be either some form of surgical scar revision (cut out and re-closure) or skin resurfacing. In some select cases, such as yours, actually filling in the underlying soft tissue helps flatten the outer appearance of the scarred area. Injectable fillers can work well for that type of depressed scar but they are not permanent and must be repeated.
You have correctly pointed a very uncommon but potentially beneficial approach to depressed cheek scars. Having proven that soft tissue expansion makes the scar look better, it is insightful to ask about whether a cheek implant can create the same effect. Since the cheek bone is convex, an implant will definitely push outward on the skin, helping flatten a depressed scar. I have done such an approach twice in my Indianapolis plastic surgery practice and it can work well as you have surmised.
The key to the successful use of an implant for a depressed cheek scar is two-fold. The acne or traumatic scars must be directly over the prominence of the cheekbone to get the most benefit from the underlying push of the implant. And you must consider the opposite cheek prominence as well from the perspective of balance. (one-sided or both sides for cheek augmentation)
Dr. Barry Eppley
Q: When I was younger, around 14 years old, I was punched on the left side of my cheek which caused my left side (cheekbone) to be larger than my right side. I did not notice this until my ex-g/f, then current, informed me of this. It’s maybe 4 to 6mms bigger than the right side. I didn’t get it fixed since I didn’t realize there was a problem until the bones had already repaired itself. I suspect a lot of it is bone growth making my cheekbone larger. Could you tell me if this is possible to fix?
A: This is an unusual reaction to a traumatic facial injury. Usually the cheekbone would have gotten fractured causing the opposite problem long-term, cheek indentation or flattening. The observation that it got bigger would indicate that an actual fracture of the bone did not occur.
It is more likely that you sustained a traumatic hematoma (blood collection) to the tissues. This could result in either extra bone being deposited on the outer surface of the cheekbone (appositional bone development with blood as the stimulant which could happen in a growing bone such as a teenager) or scar tissue which has thickened the soft tissue.
The question is how do you make that determination as to which it is? A plain x-ray (Water’s view) would be a simple and useful diagnostic test. Or you could just treat the problem the only way you can which is cheekbone reduction. Even if it is soft tissue thickening, bone reduction would still be the treatment method. Through an incision inside the mouth, the outer surface of the cheekbone would be burred down. If the difference was greater, a cheekbone reduction osteotomy could be done. But for 5mms or less, simple outer cortical burring of the cheekbone is the best way to go. Because it is done through the mouth, there would be no scarring and just a temporary period (four to six weeks) before you would see the final result,.
Dr. Barry Eppley
Q: I am 42 years old. I have always had large breasts. I have permanent indentations on my shoulders from bra straps. I currently wear a 40F bra. I have had back and neck pain for as long as I can remember as well as rashes under my breasts which become unbearable in the summer. I had an MRI to rule out spine problems as a cause for my back pain and it was normal. I am extremely uncomfortable in a bathing suit (in fact, last summer I wore a bra under my suit) and I have a difficult time finding clothes that fit properly. I am unporportioned. I wear a size 18 pants, but a 3x top. I would love to be able to run. I currently weight 190lbs and am uncomfortable exercising but want desperately to lose weight. Please help me.
A: One of the real benefits to breast reduction surgery is how consistently it improves, or alleviates, the musculoskeletal pain from large breasts. While the size and weight of large breasts is often believed to be the sole reason for musculoskeletal pain, the sag of the breasts is just as important in contributing to the pain. Like a rope around the neck attached to several lbs of sugar in bags, this creates a downward pull on the neck and shoulders. Breast reduction surgery works because of weight reduction and resuspension of the remaining breast tissue back up on the chest wall. (thus eliminating that rope around the neck effect)
In a patient with these symptoms, breast reduction will reduce the back and shoulder pain, eliminate completely the rashes, and will enable her to exercise and run better. For many patients so afflicted, breast reduction surgery can be life-changing.
Dr. Barry Eppley
Q : I am writing because I am bothered by bags under my eyes. Since I was a teenager these bags have been there but are now much more prominent as I have gotten older. I don’t expect my eyes to be perfect but I shouldn’t look this way at only 38. I have tried every cream out there and nothing seems to make them better. Is there a plastic surgery for this problem?
A: Lower eye bags are the result of herniated eye fat. Most of the time they appear as a result of aging. But some people have it appear much sooner in life, even during their teenage years. One occurs as a result of weakening of a lower eyelid membrane with age, teenage eyebags are the result of a congenital weakness in the same membrane.
To understand lower eye bags, one must know that our eyeball sits in a bed of surrounding fat for padding and protection. The lower eyelid is like a gate in which fat underneath the eye is held back by a membrane between the lower eyelid margin down to the lower edge of the eye socket bone. When this membrane is weak, eye fat can protrude through like a hernia through an abdominal wall defect. This is easy to demonstrate by closing your eye and pressing on the eyeball. You will see that the tissues underneath the eye bulge out as you press in. This is eye fat being pushing out.
Lower eyebags can only be removed by lower blepharoplasty surgery. No topical treatments or other external treatments will cause the fat to go away. If there is no significant extra skin which is common in younger patients, the fat can be removed through an incision from inside the lower eyelid. (trasnconjunctival blepharoplasty). If there is extra skin from aging, the fat and skin are removed through an incision right underneath the lashline. (external lower blepharoplasty)
Dr. Barry Eppley
Q: As I am getting older, I don’t like my neck which is getting looser and lower. I think I may need a facelift but am scared to death to go through it and it will likely cost more than I have. I have read and seen pictures about the Lifestyle Lift and that really interests me as it doesn’t look like surgery is needed and the results are great. Do you think that will work for me?
A: As we age, the very common signs of facial aging is in the development of a saggy neck and jowling. These loose facial skin issues are exactly what a facelift treats, contrary to what many patients believe that a facelift is.
Facelifts can be done in a variety of ways but fundamentally there are two types, limited and full. For smaller neck and jowl issues, a limited facelift can be a very good rejuvenative procedure. For larger neck wattles and jowls, a full facelift is often needed to get the best result.
The Lifestyle Lift, a tradename and franchise approach to delivering cosmetic facial surgery, is a variation of a limited facelift. Many patients have commented to me that they did not think it was surgery based on the ads and the TV commercials. But a Lifestyle Lift is surgery and can be combined with a wide variety of other facial procedures and injectable treatments. Usually a combination of ‘small’ procedures can collectively create a significant facial improvement.
The limited facelift approach has been around for a long time, dating even back to the early part of the 20th century. It has re-emerged in popularity today because younger patients are seeking facial improvements. They don’t want to wait until they need a complete facelift and have such a dramatic change. Plus, they want to maintain a more youthful appearance as they are in their prime work years. About half of the facelifts I now do are of the limited variety because it fits many patient’s age, lifestyle, and budget.
When you see a good before and after picture of a significant facial change, you should know that is not possible without some form of surgery. There is no magical cream, laser, and other ‘magic’ that can create what a facelift operation can do. We all would like there to be but it does not exist. Remember a basic plastic surgery rule…’small changes require only small procedures, big changes come from big procedures.’
Dr. Barry Eppley
Q: I’ve read your article on calf augmentation using fat transfer. Since 2008, have you performed this procedure? I have finding very mixed feedback on this. Some surgeons are saying this is high risk and will be unsuccessful because the fat will all be absorbed. Another doctor in NY I’ve been in contact with says he has had great success and with little side-effects. Appreciate your feedback.
A: Calf augmentation is most reliably done with implants. There are specific silicone rubber implants made for the calf and they are placed through a small incision on the back of the knee. (popliteal fossa) Because an implant is used, the result is stable and consistent in the amount of size increase obtained. Conversely, because it is an implant there are the associated issues of the risk of infection, malposition and asymmetry as well as a significant recovery and discomfort.
Fat injections, no matter where they are considered and what they me be used for, always have the same appeal. Using a natural tissue that has virtually none of the risks of an implant-associated procedure. Despite those benefits, fat injections have one significant downside…their volume retention is unreliable. At this time, there are no standard techniques for fat preparation and injection and the science behind its survival once transplanted remains to be discovered and utilized for more stable outcomes.
Because of the differing techniques and injection methods, fat injections for larger volume areas (breast, buttocks, calfs) have widely variable results. With these inconsistent results come quite discrepant surgical opinions about their effectiveness. There is now to reconcile one plastic surgeon’s experience vs another at this time.
Calf augmentation with fat injections is relatively ‘new’ and the worldwide experience is still evolving. The issues with the calfs are no different than the buttocks or breasts. It is a very safe procedure with minimal downtime. But one has to accept the reality that how much fat survives is the risk of the procedure. And more than one session may be needed to get the best results. (more likely than not) My experience has been with just a few cases and the early results have been acceptable. But the key is patient selection…don’t ask the fat to do what an implant can do better. (mild enlargement, not big enlargement)
Dr. Barry Eppley
Q: I am inquiring as to whether you perform tracheal shaves? I have been bothered by the bulge in my neck caused by my Adam’s apple. As a female, it does not give my neck a very nice profile and looks too manly. I have read that the protruding cartilage can be shaved down. Is there much scarring and what is the recovery like?
A: A tracheal shave, known medically as a chondrolaryngoplasty reduces the size of the thyroid cartilage through a small horizontal incision in the neck. While often thought of as only a transgender procedure (facial feminization), I have performed more of these procedures on men and women who are merely just uncomfortable with the prominence of their Adam’s Apple.
The procedure is actually fairly simple and does truly consist of shaving down the protruding cartilage with a scalpel. Through a small horizontal incision in a favorable or prominent skin crease near the thyroid cartilage, the vertical strap muscles are separated to get direct access to the protruding cartilage. It is shaved down as much as possible to get a throat line that appears smoother and less angular. One must be careful to not take too much cartilage away which can de-stabilize the attachments of the underlying vocal folds, risking potential hoarseness after surgery. While the goal is as smooth a neckline as possible, sometimes it can merely be reduced significantly but not made completely flat. The small neck incision will go on to heal very nicely with little scarring.
Recovery is quite quick with minimal discomfort. I do not place patients on any type of restrictions after surgery. There are no sutures to remove. There is some mild swelling and bruising which goes completely away in two weeks. There may be some temporary discomfort on swallowing. Usually, there is little to no change in the pitch of a patient’s voice. There are some topical scar treatments that can be done beginning three weeks after surgery to optimize the fading of the fine line scar.
Dr. Barry Eppley
Q: I am writing you because I need information on gynecomastia reduction. I have been battling with fat around my chest ever since I was young. I am now 28 and not the least bit out of shape. Actually I am a certified personal trainer and have participated in body building contests. Even when dieting down to as little as 4% body fat I still have this fat on my chest. It is very humiliating and I have never been comfortable with my body because of this reason. I am completely happy with my body except for this part. Being a trainer and a single man my appearance is important. Can you help me?
A: Male breast enlargement, known medically as gynecomastia, comes in all forms. How it appears in different men is as variable as breasts are in women. While many people may think that gynecomastia presents as an actual breast, that is only partially true. About half the men I see today in my Indianapolis plastic surgery practice have what I call ‘minimal gynecomastia’. Their stories are all very similar. They are younger (under age 40) men who are in extremely good shape (many are trainers and body builders) who just can’t get off that little bit of fat on their chest. While a lot of other people may not think it significant, they are extremely bothered by it due to their understandable sensitivity to their body shape. I suspect in some patients their extraordinary focus on conditioning and body shaping may be a compensatory response to their self-image issues with it.
Such smaller amounts of gynecomastia are easily treated and resolved with simple liposuction techniques. This leaves essentially no significant scarring, can be done in one hour of surgery, and there is minimal recovery. Because of its effectiveness and skin tightening potential, I prefer to use laser or Smartlipo as the liposuction method. Men can return to full chest exercises in two weeks.
Dr. Barry Eppley
Q: I had a car accident in February 2009 that resulted in the need for big operation on my stomach. This has left me with a long big scar. I want to know what percent of it can be removed? I want to remove this scar for me because don’t want to get naked in front of my husband or any person because of the scar. It is so bad that I cry a lot about it as I picture how good my stomach looked before the accident. I am 23 years old, been married two years and have no kids.
A: Scar revision is about scar reduction, not scar elimination. While I wish as a plastic surgeon I could wipe them away for patients, that is not currently possible. Therefore, the judgment about the merits of scar revision are about the degree of improvement. Is the result worthy of the efforts is the consistent question about scar revision.
The answer as to whether scar revision is meritorious for any patient lies in the physical characteristics of the particular scar. There are several features of scars that can be consistently improved by surgical methods. Scars that have surface texture problems such as being wide, raised (hypertrophic), or depressed (indented) are good candidates. These type scars can be cut out and reclosed in a variety of ways whose objective is to make them flatter and narrower. Scar features that are difficult or impossible to improve include lack of pigment (normal skin color) and visible flat narrow scars.
Without even seeing a picture of the scar on this patient, one can be fairly certain that it is a wide vertical scar running down the middle of her stomach area. Such scars often get quite wide and indented as they have healed. Scar reduction can most certainly be done with the goal of making a much narrower and flatter scar. While that will not make it invisible, it will provide at least a 50% or greater degree of improvement.
Dr. Barry Eppley
Q: I am a male and am interested in the direct neck lift and want to know more about it. I don’t want a complete lift and think this may be my answer. How much of a scar remains visible and will it last a long time. Also, do you tighten the muscles and remove some of the fat?
A: The direct necklift is an alternative to a facelift for a select number of men and women that are interested in getting rid of their neck wattle. A facelift works out excess neck and jowl tissues by chasing them back towards the ears and placing the scars there. A direct necklift cuts out the neck wattle directly, placing the scar right down the middle of the neck. It is a highly effective procedure that produces neck results that are just as good, if not better, than what a facelift can do particularly in men.
In the direct necklift, not only is skin removed but fat and muscle tissues are changed as well. With the skin cutout, the underlying fat is removed as well right down to the muscle. The split platysma muscle is widely exposed with the overlying tissue removed. Because of the excellent visibility, it can be sewn together from under the chin right down to the thyroid cartilage with superb tightening achieved.
The direct necklift is not for everyone but for just a select few patients. In my Indianapolis plastic surgery practice, I reserve it primarily for older men (55 years and older) who either do not want to undergo a facelift or have a very poor hair pattern and density around their ears. The occasional woman is done but they are almost universally 65 years and older and are choosing the direct necklift vs a facelift because of its lower cost.
The obvious issue with a direct necklift is the scar. Generally these scars are quite thin and the only widening that occurs in them is in the middle of the neck where the tension is the highest. For this reason, I usually place a z-plasty scar orientation in this area to avoid hypertrophic scarring there. I have performed no scar revisions on them to date which speaks to patient acceptance of their final aesthetic appearance.
Dr. Barry Eppley
Q : I have a weak chin that has bothered me my whole life. I am so self-conscious that I turn away so people can not see me in profile. I also think my entire jawline is weak, it overall looks too small for the rest of my face. Can my jawline be improved with different types of implants?
A: Historically, most people think of jaw enhancement as that of the chin only. Chin implants have been around for over fifty years and have evolved today to include a wide variety of different chin styles and sizes. For horizontal jaw shortness, a chin implant can provide a simple, quick and permanent method of significant profile improvement.
Today, jaw enhancement has progressed to consider changes along the entire jawline from back to front. Besides chin implants, the use of implants to accentuate the jaw angle have become popular. Designed to increase the width of the jaw (and some designs will lower the jaw angle as well), they increase bigonial width and create a stronger and more masculine.
Chin implants are most commonly done as a stand alone facial augmentation procedure. Jaw angle implants can also be done by themselves if an adequately projecting chin already exists. For cases of an overall weak lower jaw, the combination of chin and jaw angle implants together can make for a more dramatic change in jawline appearance. This combination (the ‘jawline trifecta’) is increasingly popular for those men who have a congenitally shorter jaw or for those want to make a stronger jawline out of an otherwise normal sized one.
Dr. Barry Eppley
Q: I have a rib graft on the bridge of my nose which I would love to have removed. The surgery to place it was 12 years ago. At the time, the doctor thought my nose would be better off with the bridge higher. I liked my bridge before the rib graft. Is it possible to remove this graft? Is there any hope for me because I also dislike how it feels, not to mention how it looks which is not good?
A: Rib grafts to the nose are usually done for dorsal augmentation (building up the bridge, the distance between the top of the nose and the tip) secondary to prior trauma or rhinoplasty surgery or for altering certain ethnic noses. Whether dorsal augmentation is aesthetically beneficial, like all rhinoplasty changes, can be determined prior to surgery with computer imaging. The harvest of a rib graft and changing the dorsal line of the nose is not an insignificant adventure and everyone needs to be sure that it is a worthwhile procedure.
I have not found most rib grafts that hard to remove or manipulate in my experience, provided that they are completely composed of cartilage and are limited in location to the nasal bones and middle vault. Cartilage grafts to the dorsum, while wonderfully biocompatible, heal with a surrounding capsule and never truly integrate into the underlying structures like a bone graft would to bone. As a result, they can be usually be removed without as much difficulty as one would think.
The exceptions that make removal more difficult is if the rib graft was more bone than cartilage (which it usually isn’t) or if it was an L- strut configuration extending around the tip and down along the columella. It is not that the removal is that much more difficult, it is that it is more destructive to do. (more of the nose has to be taken apart to do it)
The description of a rib graft to the bridge of the nose done for aesthetic purposes suggests two things. The graft is small and probably all cartilage and that its location is just to the dorsal line of the nose. Both of these qualifiers would indicate that’s its removal is both possible and minimally destructive. Its removal, however, should be done through an open rhinoplasty approach even though it may have been placed initially through a closed or endonasal incision.
Dr. Barry Eppley
Q : Is umbilicoplasty recommended only after you’re done having children? I heard the procedure could be ruined during pregnancy.
A: As a general rule, changing the shape or form of the umbilicus (belly button) is a simple procedure that is usually permanent. However, pregnancy is well known to affect the umbilicus due to its expanding effects. The usual way it can change the umbilicus is to convert an ‘innie’ to an ‘outie’. This is the result of an actual hernia coming through where the umbilicus attaches to the abdominal muscle wall. One must remember that the umbilicus is really nothing more than a scar that goes all the way through to the underside of the muscle wall to the peritoneum. This can be appreciated during a mini-abdominoplasty where the umbilicus is often released and repositioned lower. Once it is cut off at the level of the abdominal wall, a small hernia is immediately apparent.
Because of the potential negative effects of pregnancy on the umbilicus, one should usually wait until after pregnancy for a female umbilicoplasty procedure. If you are converting an outie to an inner, it is possible with the increased abdominal pressure from pregnancy to have it change back to an outie after surgery. The one exception to this id if one is not planning to get pregnant for years. Adequate healing and scarring will then have occurred and it will be able to better resist stretching forces. But if one thinks it is possible to get pregnant within the first year after repair, then one is better to wait.
There are some umbilical changes that may be not be so adversely affected by pregnancy. Removal of skin tags, small scars, nevi, and a ‘pseudoinnie’ (looks like a partial outie but is just a lump of scar tissue) can be done with a low risk of post-pregnancy change.
Dr. Barry Eppley
Q: Hello sir, I did my first rhinoplasty for a minor problem. Initially I had a thin and pointed nose but overall it was not too bad looking. I went to this inexperienced surgeon because me or my parents didn’t know anything about surgery at that time. He made my nose shorter with a round tip and I got very bad dark circles under my eyes for a year. My nose is still short, fat and twisted. After three years, I have gotten the courage to consider another rhinoplasty surgery to make it look better. What do you recommend to be done?
A: Most likely what has happened is a fundamental problem that is reminiscent of rhinoplasty from days of old…removal of too much cartilage structure. This results in collapse of the nasal tip due to loss of support as well as wound contracture. Almost certainly, this rhinoplasty was done through an endonasal approach where removal is what can largely be achieved. Only the real masters of rhinoplasty can do significant restructuring that has predictable outcomes through the limited access of the endonasal approach.
For a revisional rhinoplasty such as this, the open approach needs to be done. The tip cartilages and nasal septum can be separated, cartilage grafts placed and reshaping done through suture techniques. It may also only require an onlay cartilage graft but that must be precisely placed. Only the open approach offers this degree of visibility. The cartilage grafts will likely come from the ear (conchal) due to the size and shape needed.
At three years from the initial surgery, the nasal tissues are more than soft enough to allow for good manipulation and healing.
Recovery from the short nose problem in revisional rhinoplasty is usually quite good, but access and cartilage grafting are the keys.
Dr. Barry Eppley
Q: I am interested in getting breast implants. I am 34 years old, have had three children and my breasts are just not what they used to be. They are smaller and now droop. They are disgusting to look at and are nothing like they used to be when they were nice C cups and round. I want to get implants so my breasts can look like they did before. Is this possible?
A: The concept of looking like you did before is an understandable one but may not always be possible. The reason is that the breast skin and breast tissue you now have is different than what it used to be.
Women considering breast augmentation almost always fall into two main types; those who have always had little breast tissue whether they have ever been pregnant or not (type 1)…and those women who have lost their natural breasts and have developed droopy smaller breasts due to childbearing and nursing. (type 2) The results of placing a breast implant will be different for each type of patient. Type 1 patients will do fine with a breast implant alone and will often get the more ideal breast shape result. Type 2 patients may need a breast lift in addition to an implant to get a better shape with a good nipple position. It is this consideration of a lift and breast mound scarring that will often catch the Type 2 patient by surprise.
It is important to appreciate what a breast implant can and can not do. Implants do a superb job of making the breast mound bigger. But they have very little ‘lifting’ ability. The only lift effect that can occur is from inflation of the breast mound and this will move the nipple up a little. The operative word here is…a little. Significant movement upward of the nipple for most breast ptosis patients is a matter of at least several centimeters, not millimiters.
Dr. Barry Eppley
Q : I am 52 years of age and my upper lip seems to be getting longer. When I was younger my upper lip didn’t seem to be as long. When I smile I barely show any upper teeth at all anymore. Is there some form of lip surgery that can help me?
A: A long upper lip can develop in some patients due to the natural process of aging. The upper lip can literally lengthen due to shrinkage of the vermilion (pink portion of the lip) which gets smaller and actually rolls inward. These age changes of the lip can be accentuated by tooth loss. Loss of lip volume combined with other falling facial features makes the skin portion (between the base of the nose and the vermilion) of the upper lip a bigger percentage of upper lip length.
There are two specific procedures for shortening the upper lip. Both involve removing skin in a horizontal fashion at either the top or bottom skin portion of the lip. The subnasal lip lift, also known as the bullhorn lip lift, removes skin from right under the nose and truly is a lifting procedure. Removing skin just above the pink lip line is known as a vermilion or lip advancement. This advances the pink part upward directly. Both result in fine line scars although the subnasal lip lift places the scar in a more hidden location in the crease under the nose.
While both of these procedures are effective at creating a slightly shorter upper lip, both will increase the amount of vermilion show. The subnasal lip lift is limited to increasing only the central pout of the upper lip with lip shortening. The vermilion advancement moves the entire pink portion upward from one corner of the mouth to the other.
Which procedure is best for any patient depends on the anatomy of their upper lip, specifically the shape and thickness of the vermilion.
Dr. Barry Eppley
Q: My boyfriend is concerned about the size of his areolas. Do you offer areola reduction surgery? He is very interested because he feels his nipples stick out too far and his areolas are too wide. They stick out when he is in t-shirts and some clothes.
A: The nipple and areola, known in plastic surgery as the nipple-areolar complex, is a two-tiered structure. Surrounding a central protruding and darker pigmented nipple, the areola is flat and much larger in diameter. The size of this complex can be quite variable with significant amounts of nipple protrusion and very wide areolas. But the extent of these variations is largely in women since this is a functioning gland that changes as a result of pregnancy. Men rarely show such variations in size as it serves no functional purpose.
Todays’ fashion and styles, however, have placed a little more focus on the nipple-areolar complex. Men do not like when their nipple protrudes through clothing and, rarely, a few men feel that their areola is too wide. Most wider areolar concerns are in patients with gynecomastia where the breast is also larger. But wide areolas can occur when gynecomastia is not present. In women, the typical areolar diameter measurement is around 38 to 45 mms. In men, those numbers are usually half those amounts.
Both nipple and areolar reductions are simple procedures. The nipple protrusion can be flattened by a simple wedge excision without any visible scarring. The areolar diameter can be narrowed by a circumareolar excision. This does leave a fine line scar at the junction of the areolar and skin. Both can be done under local anesthesia in an office setting.
Dr. Barry Eppley
Q: I had rhinoplasty over one year ago for a small bump on my nose and a tip that I thought was too wide. While it looked absolutely perfect for a few months, an indented area on the right side of the bridge of the nose appeared. When I brought this to the attention of the plastic surgeon, he told me to let it continue to heal and wait and see what it looks like at one year after surgery. I just saw him earlier this week and, although that indent is still there, he said it is not worth trying to improve it and I should just live with it since the rest of the nose looks fine. Do I have any other options at this point?
A: Like all forms of plastic surgery, the risk of a less than perfect result afterwards always exists. Rhinoplasty surgery is no exception and secondary aesthetic deformities are not uncommon. The risk of the need for revisional surgery in rhinoplasty is estimated by some to be 10% to 15%, although that risk varies based on the difficulty of the initial nose problem.
In my Indianapolis plastic surgery experience, I find that the dorsum or bridge of the nose is one of the most common areas where irregularities can eventually appear. It is the least precise area in rhinoplasty because it is the least visible and involves bone edges. Because of small amounts of persistent swelling and the months that it takes for the skin of the nose to shrink back down and adapt to the modified underlying bone and cartilage framework, any asymmetries of the bridge area will usually take three to six months after surgery until they become visible.
The recommendation to wait until one year after rhinoplasty before considering revision is generally a sound one. The reason is two-fold. First, you want to be sure that the area that needs to be improved is a ‘stable target’ so to speak. Because of the length of time it takes for all of the swelling of the nose to go away, operating too early may underestimate what needs to be done. Secondly, the nose needs to soften up so that dissection is easier once the scar tissue has settled down. While this is usually one year or so after surgery, a better estimate is how the nose feels. If it is still stiff, it is too early. It should feel soft and flexible again for the best revisional results.
Dorsal irregularities may only need to filed or rasped to smooth out a rough edge, but often indentations require some form of graft augmentation. Many graft options exist but I prefer diced cartilage because it is both a natural and easily moldeable augmentation material.
Dr. Barry Eppley
Q: I am a 23 year-old graduate student and former college athlete. My breasts are so large I am miserable all the time and can’t even run anymore. I wear a 36DDD bra and this puts too much strain on my body. My shoulders hurt all the time. I have been in physical therapy for my neck and back, have migraine headaches and asthma. I am 5’ 10 and weigh 190 lbs. Will insurance pay for my breast reduction?
A: Breast reduction surgery is commonly covered by insurance but not always. There are certain very specific qualifications that all health insurances require that a patient must meet to be eligible. These include being within 20% to 25% of their ideal body weight (not being too overweight), having a documented history of physical therapy or chiropractic treatments for three months that did not result in sustained pain relief (emphasis on being documented), failing other non-surgical therapies such as anti-inflammatory drugs and support bras (all patients meet these criteria), and having your plastic surgeon document the specific amount of grams that will be removed that meets the minimum amount based on your body surface area calculations. (estimated by your plastic surgeon) All of this information will be put in a letter by your consulting plastic surgeon and sent in with photographs of your breasts to your insurance carrier for their determination.
Generally, if all of these criteria are met a patient will be approved for breast reduction surgery. The most common reasons patients are rejected coverage is because they weight too much for their height, have not tried some form of physical therapy, or not enough grams of breast tissue are estimated to be removed. (in this patient based on height and weight, the BSA is 2.05 with a requirement of at least 1,000 grams removed per breast)
While any amount of breast reduction provides relief in all patients, and a patient’s weight or amount of breast tissue to be removed has not been proven to matter for pain symptom relief), these are the insurance criteria. Debating their merits with the insurance company is not a productive endeavor.
In patients where insurance coverage has been denied, breast reduction surgery can always be done on a fee-for-service basis. Your consulting plastic surgeon will be happy to provide you with a cost estimate.
Dr. Barry Eppley
Q: Hi. As a baby/kid I had misaligned teeth due to sucking my thumb. I sucked my thumb pretty much up to 15 years old or so. At about 15 years old I went to the orthodontist to get braces. He decided along with the braces to install this thing in my mouth called a “herbst appliance”. Cant find anything about on Google. Maybe it was to push up my chin due to my some what recessed chin due to sucking my thumb? I finally got all the stuff out of my mouth removed last summer. I was always a little self conscious about my jaw line , but the past couple of months i’ve started to notice tremendous asymmetry between the right and left side of my jaw. The right side looks like I have a Brad Pitt Jaw and the left side is nothing, barely a jaw line showing. I’m tremendously discomforted inside due to the straight forward appearance of my face shich is crooked. What can I do to address and fix this problem?
A: Undoubtably what you originally had was a short lower jaw or mandible. In an effort to help the lower jaw grow during your early teen years, the orthodontist put in a growth stimulting appliance for the lower jaw, known as the Herbst appliance to which you refer. It is a well known device that has been used for several decades now. Now that the device has been removed and you at are the end of your facial growth, the final position and shape of the mandible can now be seen.
When looking at facial symmetry from the front view, the important issues on the centric position of the chin and the amount of flare of the jaw angles. These three points give the visual impression of the overall jawline appearance. When one has jaw asymmetry, provided that the teeth are in a good bite relationship, manipulation of these three points can be surgically done.
The chin can be adjusted with an implant or an osteotomy. The jaw angles can be accentuated and lowered through implants. Any combination of these numerous options exist. Which one(s) or combinations can only be determined through photographs of your face, a panorex x-ray, and computer image manipulation of proposed changes.
Between chin and jaw angle surgery, a tremendous improvment can usually be obtained and a much more symmetric and pleasing jawline can be realized.
Dr. Barry Eppley
Q: Hello, I have a few questions.I’m interested in getting my leftover fat from my entire body put into my boobs. I’d like to get my bmi to be just at 18, although it is at a 20 right now. I was just wondering if anyone would be willing to even work with me since I weigh around 115 and am 5’3″.
A: Breast augmentation using injectable fat rather than a synthetic implant remains in an ‘experimental’ or an investigative phase currently. Since it does not involve an implant and uses your own natural tissue, it is understandable to think that it is a safer and perhaps better procedure.
While fat may be natural, it is not a predictable implant material particularly in the volumes needed for breast augmentation. No standard techniques exist for fat preparation or injection methods and very different results can occur in various hands. At the least, much if not all of the fat can be absorbed rendering it a waste of time. At the worst, the fat may make the breast lumpy with cyst formations or develop sterile pools of liquid fat. What impact fat injections have on mammogram imaging and breast cancer detection remains unknown and not studied.
While much of this discussion sounds negative, the concept of using fat for breast augmentation has appeal and work is ongoing in this area. The only FDA-approved clinical trial that I know of is with the BRAVA system in which injectable fat is stimulated after surgery with an external low-level suction device. Otherwise, any clinical work that is being done is occurring in an independent fashion as an individual-precribed surgery amongst a handful of practitioners.
With the low BMI and body fat that this patient has, she would not be a good candidate for the procedure even if it was proven and widely used. A simple breast implant is so much easier and more predictable that fat injections, which for now, remain as a more complicated and morbid approach for breast augmentation.
Dr. Barry Eppley
Identity theft is a growing problem that now threatens just about everyone, even if you don’t spend a lot of time online. It is a huge problem with risks that are estimated to place most Americans as having a 1 in 4 chance of being victimized in the next five years. With credit card and social security numbers flying around in cyberspace by the billions, it is a wonder that those risks are not even higher.
Plastic surgery faces its own identity theft problem but of a different nature. In the most noteworthy case of plastic surgery identity theft to date, an American in the Middle East was recently arrested posing as a renowned U.S. plastic surgeon. Shockingly, he had operated on scores of patients in his Dubai villa. There he allegedly performed numerous cosmetic surgery procedures with primitive surgical equipment and lack of any sterile conditions. To no surprise, several of his patients (victims) have suffered serious complications requiring additional surgery and medical care.
This former Oregon physician was impersonating and using the good reputation of a plastic surgeon in Washington, D.C. who performs several surgeries per year at the American Academy of Cosmetic Surgery Hospital in Dubai. Aside from facing legal charges in Dubai, this fake plastic surgeon is wanted in the U.S. by the FBI and Interpol on charges of drug trafficking and numerous other crimes from when he held a medical license in Oregon.
While this identity theft story seems remote and far from the American medical scene, plastic surgery identity theft occurs more regularly here…but it is of a more subtle and insidious nature. With the ongoing erosion of medical fee reimbursements and increasing practice revenues and regulation demands (which is only going to continue to worsen, particularly with the passage of the new Health Care Reform Act), some physicians search for methods of cash only services. No seemingly ‘riper fruit’ currently exists than that of cosmetic services. (although weight loss is a close second) Between public interest and the all-to-willing drug and device manufacturers to sell to anyone with a medical license and a credit card, there is a dearth of cosmetic surgery providers with quite dissimilar education and training backgrounds.
While many of these cosmetic surgery ‘adopters’ are largely involved in office-based injection and laser treatments, some perform invasive surgery which is within their legal right as a licensed physician. As long as you hold a valid medical license, you can do almost anything in your office which is largely unregulated unlike a hospital or surgery center. A great illustration of this phenomenon can be read in the April 7th issue of The New York Times where a California physician (non-plastic surgeon) was interviewed touting his breast augmentation surgery technique under local anesthesia. Claiming that patients can now have a say in the breast implant selection process, he teaches weekend courses to physicians of any background (the articles states mainly family practice and Ob-Gyn docs) who are willing to pay.
The argument that women want to be awake and watch their surgery being performed is fundamentally flawed. I know of no female patients who want to sign up for that experience. But the underlying premise for such surgery under local anesthesia was not revealed in the article. Without proper training and credentials, an uunregulated office environment is the only place he could ever perform such procedures. And without an anesthesiologist, the only option is local anesthesia. Hardly good reasons for choosing a surgical method or even offering the procedure.
Dr. Barry Eppley
Q: I have a fat nose and would like it to look slimmer. It doesn’t seem to fit the rest of my face which is actually very thin. But I don’t want to have my nose broken as I like the rest of it. Are there different types of rhinoplasty surgeries?
A: Like all operations in plastic surgery, it is important to tailor it to the specifics of the problem. Most plastic surgery procedures do not use a ‘cookie-cutter’ approach but modify certain details of the operation to a patient’s specific needs. Rhinoplasty surgery is the pinnacle of this philosophy as every nose surgery is uniquely different.
Despite the many variations of rhinoplasty, they can be divided into two main types, a mini- or tip rhinoplasty and a full rhinoplasty. The fundamental difference between the two is that a full rhinoplasty treats all three sections of the nose, often breaking the nose bones (upper third) to narrow them. A tip rhinoplasty treats only the lower one-third which consists of a paired set of cartilages which meet in the middle to create the tip of the nose.
When one has a fat or wide nose, it is because the cartilages in the tip of the nose are big and protrusive and often don’t quite meet in the middle. Through a tip rhinoplasty, these cartilages can be reduced in size, reshaped and brought closer together. Using suture techniques, a remarkable change in the nose tip can be done making it thinner and more in proportion to the rest of the nose.
Dr. Barry Eppley
Everyone knows the phrase…’beauty is skin deep but ugly goes to the bone’. While commonly said, this phrase is only partially correct. Beauty is also bone deep as the outward appearance of the face begins down at this foundational level. How the face looks at the outside has a lot to do with how it is shaped on the inside. Any forensic scientist can attest to it. Many have seen on TV shows how an unidentified corpse’s face is ‘rebuilt’ with clay layers on top of the skull and facial bones based on established soft tissue measurements. Like a roof on a house, the outer appearance of the face is highly influenced by the shape of the bone underneath it.
Treating facial bone problems has a long history in plastic surgery. Since World War I, when trench warfare created a large number of severe facial injuries (sticking your head up out of a trench was usually not a good idea), plastic surgeons have been rebuilding, rearranging, and enhancing facial bones. Today’s plastic surgeons pay particular attention in cosmetic surgery to how the skin, fat and muscle of the face redrapes over the bones, knowing full well its influence on the final shape. Whether it is a facelift, nose job,or making one’s face more masculine, being aware of and changing the shape of the bone can lead to a better balanced and more attractive face.
Facial bone changes can be done by building the bone up with synthetic implants, or in some cases, actually moving select facial bones themselves. A remarkable array of changes in the forehead, nose, cheeks, midface, lower jaw and chin are now possible.
Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you down deep inside the face on a tour of its palpable architecture. Learn how many of the commonly known, and some less commonly known, cosmetic facial bone procedures work and help make for more beautiful faces.
INSIGHTS FROM ‘BEHIND THE NEEDLE’
In the past, plastic surgery was all about having operations to reverse the effects of aging on the face. Time was, once you could no longer stand to see yourself in the mirror or in pictures…facelifts, eye tucks and the like became appealing with all of the associated swelling and bruising, recovery, and expense.
Over the past ten years, non-surgical injectable treatments have become popular for men and women of all ages…and have become part of mainstream society in ways that rival Starbucks, energy drinks, and iPhones. The concepts of muscle paralysis, plumping fillers, and fat dissolving agents have made it possible to have smooth foreheads, fuller lips and softer laugh lines, and maybe some subtle tightening of the jowls and neck in a few simple visits to the doctor’s office. Unlike surgery, injectable facial treatments are as much about the prevention of the effects of aging as they are about reversing what has already taken place.
Along with this explosion of available injectable treatments have come the inevitable, unbelievable marketing claims, and so-called ‘expert’ injectors. But, like much of what you may read on the internet, in popular magazines, and hear in commercials , what can you really believe? How do you separate reality from marketing hype? How can you decide where-or if-injectable treatments are for you? And if so, which ones??
Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a broad tour of every injectable treatment option. Providing insight into Botox®, the many injectable fillers, and lipodissolve, Dr. Eppley provides the current science behind the treatments, and talks plainly about his experience and observations. These insights from ‘behind the needle’ about these incredibly popular injectable treatments are available nowhere else.
Whether you are just researching Botox® or fillers, or are a seasoned expert with an upcoming consultation about the next new option, Dr. Eppley gets you ready for Injecting Youth!
