Your Questions
Your Questions
Q: Dr. Eppley, I had buccal fat removal a few months ago. That helped a little but I want an overall smaller face so I would like to get liposuction around my neck area, neckline my lower cheeks, areas surrrounding my jowl and chin area. I want all the fat that I have from my mid face down, ear to ear, to be all 100 percent removed.I just don’t like the fact that I have fat on my lower face instead of in my upper cheeks. When I smile I feel like the muscles or perhaps the fat pulls my nostrils out making them look wide. I thought that may be fixed with liposuction or it might just be fixed with rhinoplasty.
A: When it comes to facial liposuction, the reality is what you are asking for can’t be done with the result that you want. There is no such thing as ‘removing all of the fat’ no matter where on the body liposuction is performed. Facial liposuction is particularly unique because the fat is in very select and limited compartments, thus limiting how much facial slimming can be achieved. There are several discrete compartments of the face in which face can be reduced and includes the buccal space, perioral mounds, submental, lateral neck, lateral face and jaw angle area. Liposuction can help provide some refinement and mild sculpting to the face but it is best not to overestimate its facial slimming potential. Facial contour improvement is possible but removing all the fat is the face is impossible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just had my cleft chin reduction surgery on this past Thursday October 11th. I’m having a difficult time opening my mouth and am wondering if this is normal after this kind of procedure. It feels like there is some kind of resistance on the left side of my jaw (which is the same side of my mouth where fat was taken from) whenever I try to open my mouth past an inch or so. It doesn’t hurt, it just pulls.
A: What you are experiencing is perfectly normal. For your chin cleft correction a small buccal fat graft was harvested through a small incision high in the maxillary vestibule. This requires going through the buccinator muscle and then closing the incision with a few dissolveable sutures. This will definitely make in the first few weeks a sensation of tightness when opening your mouth widely. That is because the intraoral mucosa and buccinator muscle stretch when opening and now have a little constriction. This is a temporary minor problem which will be self-solving in a few weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t live in Indiana but I haven’t been able to find a plastic surgeon in my state that does the type of procedure you do. I have for my entire life had an extreme amount of fatty tissue in my mons pubis region, even when I was 125 pounds (I’m about 140 pounds now) it was just insane how big of a bulge I have down there. I am in a situation financially where I might be able to afford some type of financing arrangement, some type of payment plan… and if that were a possibility I would be more than happy to make the trip out there to Indianapolis to speak with you! I just want to be able to wear a swim suit or tights or just tight jeans without this source of embarrassment! 🙁 I am 26 years old and this has been a major issue for me ever since I was about 10 or 11. I’d give anything to finally have it reduced and just look in the mirror and feel ‘normal’ although I hate that term. I know nobody else would notice a difference because I’ve gone to such extents to hide it but just for myself I know it would give me something that I need more than anything right now in my life. It would give me the peace of mind to just wear whatever I want to wear, to do things that other people do without thinking about how to hide this part of my body… please, if there is any forseeable way you think I could work out the financial aspect of this pleasse let me know if I can meet with you! I would so appreciate it. Thank you for your time, I hope to hear from you soon…
A: A large suprapubic mound is not uncommon in many women although it is more unusual in thin women. But its presence in an otherwise non-heavy woman suggests that it is here to stay and will not be eliminated by any amount of diet or exercise. Surgical reduction by liposuction can be remarkably effective and a lot of ft can be quickly removed, In some patients, a suprapubic lift with the liposuction may be needed if there are any excess skin issues, But that would seen unlikely with someone of your weight range and stability.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, for nasal surgery can you use calcium phosphate cement to build up the nose? Please advise.
A: As you may know there are a large number of materials, both synthetic and autologous, that are used for nasal augmentation. The term, nasal augmentation, can be used to describe a variety of dorsal nasal procedures but in most cases refers to a build-up from the nasal bone area down to or just behind the tip. It is important to realize that the underlying anatomy changes along the dorsal line. Only the upper third of the dorsal line is comprised of bone, the lower two-thirds is cartilage. Therefore, when considering a bone cement material for nasal augmentation it would need to be restricted to that of the upper third where the cement can actually attach to the bone. Bone cements would not be good for any other dorsal line area because it will not attached to the underlying cartilage.
Can hydroxyapatite bone cements be used for nasal augmentation? Yes but it would be restricted to very limited nasal augmentation indications. Does bone cement offer any advantages over the wide variety of other more commonly used nasal implant materials? That is a matter of debate and would highly depend on the specific need and indication. But, in general, it is a very uncommonly used nasal implant material even for the bony bridge area of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in getting a jaw reduction surgery done. I am a 25- yr old female with a jawline significantly wider than cheek bones area. My jawline alone is wider, adding to that strongly developed mandibular muscles makes my lower face evidently out of proportion.
1) Do I need anything additional done besides the jaw reduction surgery?
2) For how many days would I ave to remain hospitalized?
3) I live out of state, so how could the follow up appointments happen?
4) how many follow up examinations does Dr Eppley usually do? And what is their time frame?
5) what is the approximate cost I would be looking at (including hospital stay)?
Thank you!
A: In answer to your questions:
- I would need to see some pictures of your face to determine what, if anything, else make be helpful in achieving your goal of a more narrow lower facial width.
- This type of facial surgery is done as an outpatient procedure. There is no reason to be hospitalized for jaw angle/jawline reduction surgery.
- As a general rule, my out of state/country patients follow-up by e-mail, phone or Skype. There are no regularly scheduled in-person follow-up examinations needed. When it comes ti changing appearance what matters is how things look and that can be discerned with modern technology from afar.
- as per #3 above
- I will have my assistant pass along that information later today or tomorrow. Although be aware that this is a cost estimate for a procedure on a face that I have not yet seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow and forehead augmentation. I feel like my eyes are very flat. I would really love deeper eyes. I believe deeper eyes are the most attractive eyes there could ever be. I love Adriana Lima’s eye. Her eyes are very deep and I believe that is what makes her very beautiful. I believe having deeper eyes will give my profile a better definiton. I have the thing that changes the feature of your face on my Iphone, so I played around with it and structured my face with deeper eyes and I actually really how it came out and I can only imagine coming out better in the actual procedure.
A: In looking at your pictures, I would agree that you have a relative lack of any brow bone prominence and a vertical forehead inclination. I have done an imaging picture based on what I think the general changes can be with brow bone and forehead augmentation. The brow bones need to be augmented at least 7mms (if not more) and the forehead shape needs to be converted to a more convex and less straight vertical inclination in profile. The amount of brow bone augmentation is open to discussion as more or less can be done based on your preference. The amount of brow bone augmentation will determine how deep set your eyes will look. In looking at the one model’s pictures which you have shown, she not only has more brow bone but it is very horizontally-oriented, a key feature of brow bone augmentation to get deeper set eyes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants but don’t know if making the breast bigger will also lift may nipples up. They have a little sag but not bad. I have read about a nipple lift but am not sure what it does or how it works.
A: A nipple lift, also known as a superior crescent mastopexy (SCM), is the simple removal of a half moon-shaped piece of skin above the nipple. This allows the nipple to move up higher based on the amount of skin removed. This leaves a very fine line scar that is usually imperceptible along the upper areolar-skin margin. A nipple lift is almost always an adjunctive procedure when placing breast implants if the patient has some mild breast sagging. An extra 1/2 to 1 inch of upward nipple repositioning can be helpful. But a nipple lift is not a replacement for a formal breast lift in cases of more significant breast sagging. In breast augmentation a nipple lift is usually done for one of two reasons. First, in women with very small amounts of breast sagging, a breast implant alone may not provide enough of a lift and the nipple lift is insurance that a more centrally positioned nipple on the breast mound may occur. Secondly, in women who really need a more formal breast lift with their implants (such as a vertical breast lift) but are very apprehensive about the scars, they may initially try a nipple lift and see how much improvement they get. One can always proceed with a fuller breast lift later if enough improvement is not obtained. A nipple lift is not the same and should never be thought of as a form of a breast lift although many call it such. It is nothing more than raising up the level of the nipple on the breast mound, it does not change the shape of the breast mound.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 24 years old and I have scaphocephaly that I would very much like to have corrected. Frontal bossing is apparent, and I also display temporal hollowing, as well as depressions along a prominent saggital ridge (as long as I have hair on my head, these features are not a significant concern for me). What is a significant concern for me — something that I would sacrifice a lot for in the hopes of even a modest correction in appearance — would be the protruding occipital bone. In my case, the premature fusion of the saggital suture caused the occipital bone to form something of a pointed cap, which extends from the base to the top of the skull; as such, the posterior fontanel is located high on the skull, and from a top down view, it mirrors the anterior fontanel. Are there procedures available to address this? Perhaps the occipital bone could be reshaped (shaved?), or would it be possible to perform a craniectomy in order to correct the appearance with a prosthetic? Thank you very much for your time, Dr.
A: The protruding occipital and posterior sagittal skull areas could be modified by burring reduction (shaving) not a craniectomy. Craniectomies are not going to be performed in adults for cosmetic concerns. But significant skull burring and reshaping often can be accomplished. How much reduction could be obtained would ultimately be determined before surgery by a few simple plain x-rays. But it is likely that the protruding occipital bone, particularly in the midline, is fairly thick and thus capable of being significantly reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, if a patient seeks to duplicate a jawline of an existing person via the use of custom implants, assuming their current structure and soft tissue allow for that look, how closely do you work with the patient to design the implant? What sort of process do you use to make the implant provide a look as close to the desired person as possible?
A: When it comes to designing custom facial implants, I have done it from numerous different approaches. Many patients do not want to participate in the details of their implant design, but some patients do. I do not profess to have an exclusive skill or knowledge in how to predict how any implant shape and size may affect the way the face will look once it is implanted, so I am always open to input. I have even done a few cases where I let the patients completely design their own implants out of clay, only providing input as to details that may make a certain design or size difficult to surgically place. Obviously I have tremendous experience in seeing how different implant shapes and sizes affect the face. But I appreciate that a patient providing input about their implants does empower and invest them in the process. On the flip side of that investment also comes partial responsibility in the outcome of the facial implant procedure, particularly if the results are less than desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get brow or maybe forehead augmentation. My eyes pop out too much and I would like to have deeper looking eyes. Do you think this will help?
A: I would need to see some pictures of your face to determine by imaging whether this would be a good procedure for you. A side view of your face would be particularly useful. By definition, increasing the prominence of the brow bones and forehead will make the eyes appear more deep set and less ‘protrusive’. Brow bone augmentation makes the superolateral orbital rim bigger and, in some cases, patients may also benefit by infraorbital rim augmentation as well to get a circumferential deeper look to their eyes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper and lower eyelid surgery and a muscle needed to be stitched in my eyebrow where a cut injury once existed. I have just had Botox for frown lines. The doctor (different doctor) hurt me when injecting into that muscle. Within a few hours my eyelid is heavy, dropped eyebrow and when I raise my cheek in a winking jesture the whole of my cheek quivers very badly. Will the effect of the Botox go away and the lid raise? Does this sound permanent? Has the muscle been damaged by the Botox as it was scared tissue and stitched in 2008 in order to raise the eyelid? I would be so comforted by your response as I need reassurance before i return to my doctor for correction.
A: The workings of Botox is based on two fundamental principles, it affects the neuromuscular junction of the muscle causing weakness or paralysis and its effects are TEMPORARY. The biggest advantage and disadvantage to Botox is that its effects are not permanent. Patients who get good results with its use wish it was permanent while few patients who develop an undesired aesthetic effect are happy that it is only temporary. In addition, Botox has no adverse effect on long-term muscle function regardless of whether it has had prior surgery on it or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting my forehead reduced, now I know there’s only a certain point your eyebrow ridge can be reduced but how about the glabella and the upper third part close to your hairline? Also I would like my hairline lowered but was wondering If the price would be combined all into one or do I have to pay separately and how much do you think it will cost me about?
A: When one uses the term ‘forehead reduction’ that could mean a vertical skin distance reduction by hairline/scalp advancement, reduction of forehead/brow bone bossing or a combination of both. The hairline incision needed for advancing the scalp forward can also be used for frontal bone recontouring as well. The forehead bone including the glabellar area can be burred down. How much it can be reduced would depend on the bone thickness and the location of the underlying frontal sinus. Some people have frontal sinuses that cross between the eyebrows and other have a separate sinus-free zone in the glabellar area. A simple frontal and lateral skull x-ray will show the location of the frontal sinus and the thickness of the frontal bone. This will show how much bone reduction can be done in these areas. One could expect to pay in total surgical costs around $ 6500 to $8500 for a combined hairline advancement and frontal bone recontouring.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year-old man who is interested in getting cheek implants for a more chiseled look. I guess some call it the male model look. Whatever it is called, I just want higher and prominent cheekbones. What are the risks of cheek implant surgery? I know there is the risk of infection but the onke that I am most concerned about is nerve damage. How likely is the risk of paralysis or nerve damage?
A: Like all facial implants, there are some general risks such as infection but each implantation site has its own unique set of considerations. For cheek implants, the most common aesthetic risks are asymmetry because they are usually done as a pair. While it seems easy to place two symmetrical implants, because one is doing the exact same thing on both sides, the results are not always perfectly symmetric however. The other aesthetic risk is obtaining the patient’s exact aesthetic result. The cheeks are a unique three-dimensional structure that defies an exact quantitative method to determine the amount of augmentation needed in all dimensions. The implant style selection and size is purely an art form with little exact science behind it. When you factor in the unique underlying bone structure of each patient’s face, it is easy to see why achieving the ‘male model look’ cheek augmentation result is not always easy or assured. When it comes to the risk of nerve injury, you are referring to the infraorbital nerve. This is a sensory (feeling) and not a motor (moving) nerve. So the risk is one of temporary vs permanent loss of feeling in the upper lip and side of the nose. Fortunately, the infraorbital nerve is big and easily visualized during surgery so the risk of cutting it is virtually zero, thus permanent loss of feeling is very unlikely. Most patients will have some temporary numbness due to exposing the nerve with traction on it but this is rarely ever permanent. The surgeon must be very careful during cheek implant placement to not have the implant impinge on the nerve as this is often a likely source of persistent nerve numbness and pain after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do the pinch blepharoplasty? I only need skin tightened under my eyes and don’t have bags so I don’t think I would need fat removed. I read about the pinch procedure and it sound like what I would like to do because it seems fairly simple and less invasive.
A:That is a lower eyelid procedure that I do all the time. As long as one does have significant bags, this can be a good lower eyelid tightening procedure that often is combined with either a chemical peel (25% or 35% TCA) or light laser resurfacing to get the best results. You are correct in your assumption that recovery is very quick. This is because the lower eyelid skin is not undermined and a skin-muscle flap is not raised. It can be an ideal procedure for the younger patient who has a small skin excess of the lower lid or an older patient who may have had a prior lower blepharoplasty and just needs a touch-up or some additional skin removal. The pinch lower blepharoplasty is often combined with a transconjunctival approach to fat removal to create a dual effect when one has bags but little skin excess of the lower eyelids.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lower face lift done along with neck liposuction. The doctor did a skin only lift and pulled it to the side and incisions were made by ears and in back of hairline. He redid 4 months later because it was not correct. It is better but I think my cheeks need pulled up, more like a vertical lift. I feel like my cheeks are hanging down by bottom of face. I have already invested $8,000 into this and wondered if I could now just have some vertical pull in cheek area?
A: A facelift (aka neck-jowl lift) never changes or rejuvenates the cheek area on its own in most cases unless a more extensive procedure was done. A neck-jowl lift moves sagging tissues obliquely back towards the ear while sagging cheeks require a more vertical lift as you are aware. However, in looking at your pictures I can not see a great benefit for such a procedure in you. A cheek or midface lift is a very technique-sensitive procedure to do since it often involves incisions along the lower eyelid and there is always the risk of lower eyelid malposition/sagging afterwards. Therefore, one should have a compelling reason to do the procedure. Cheek lifts can also be done endoscopically with a combined incision in the mouth and in the temples in more mild cheek sagging cases.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I want to undergo chin implant along with lip reduction . I have some doubt in my mind if the result of the chin implant is permanent and will last for the whole life of a person. Also, I do wrestling . Does it not affect the implant if there is a injury to the chin? If there is a problem will I have to visit the plastic surgeon or can it be handled by normal doctor?
A: The chin implant is permanent and will never dissolve or degrade it anyway. The position of the chin implant is fairly assured because I secure it to the bone with screws. In young men who participate in sports, I make it a point of emphasis to screw the implant to the bone in multiple places. In the rare event of a chin implant problem due to trauma, a regular doctor will not be of much help. You need to see a plastic surgeon who is familiar with chin implants.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am currently looking for doctors who have experience with and are willing to place larger saline implants (900-1600cc overfilled). Please let me know if you are experienced in working with larger sizes, what the largest sizes you’ve worked with are, what your technique entails and if you have any example photo.
A: As you may know, the largest saline breast implant that is manufactured for U.S. use is an 800cc implant. If you follow the manufacturer’s recommended fill volumes, the maximum fill should be 960cc. That is a fill volume established by the manufacturer based on the long-term tolerances of the silicone shell. I have filled 800cc implants up to 1200cc. At that point they start to become very hard due to the pressure of saline and the stretch of the implant shell. I would not recommend going any bigger than that given the high risk of shell rupture. It is important that you understand that anything beyond a 960cc fill volume would also nullify any warranty from the manufacturer once you exceed their FDA-approved fill volume.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 5’9” weigh 146 pounds and am a 36D. I had breast implants that were placed three years ago and were 500cc moderate silicone gel implants. Although I like the size, they look flat to me. My breasts are very wide and require a push up bra, otherwise they look flat in my shirt. They have given me reasonable cleavage but they are just so flat. What is the best way to improve their shape? What type of new implant do I need?
A: Moderate projection/profile implants have the lowest projection and widest base of any of the breast implants. Because they are so wide, I actually never use in my breast augmentation patients. Changing breast implants to a more narrow base with higher projection seems logical. It would also be important to go up in volume somewhat so you get more outer and upward push of the breast mound. Therefore I would change to a high projection implant with a volume of 600ccs. This will provide more upper pole fullness and may even narrow your existing width somewhat. With your body frame, a 600cc implant would not be much bigger than your existing breasts…just more towards the shape you want.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my left calf muscle is 2 to 3 inches smaller than my right. I do have muscle in my leg but it just will not enlarge with exercise. I am interested in getting calf implants. I was wondering how long I would need to stay after surgery.
A: Calf augmentation is done as an outpatient procedure. You could go home the same day, but if you live far away, you consider going home the next day.
A calf implant will help the size of the smaller calf but will not be able to make it match identically to the opposite normal side in shape or circumferential measurement. The tightness of the skin is the limiting factor in congenital calf asymmetry, the most challenging use of calf implants. In an ideal world congenital calf deficiency would be treated by a two-stage approach, a first-stage fat injection augmentation followed three months later by the placement of a calf implant. This is the ideal approach because the fat injections and the associated stem cells in it allows for some soft tissue expansion and a thicker soft tissue bed to ultimately receive the implant. But because of cost considerations, most patients have to go immediately for the implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I currently have breast implants which are inflated to 1200 cc’s. On the Purlz website there are references to 2000 cc implants and I am wondering if that is something which you actually do, since I am looking for extra-large implants near 2000 cc’s. In the seven years since my last surgery my skin has stretched enough that I think 2000 cc’s might be able to be achieved. Please reply with any information that you might be able to provide. Also, I am wondering if the sizers on the Purlz website fit nicely over breasts with existing implants? Thanks for your help.
A: I believe that you are confused about the Purlz products. These are breast implant sizers, not implantable breast implants. The only three manufacturers of FDA-approved breast implants for human implantation are Mentor, Allergan and Sientra. Only Mentor and Allergan offer saline breast implants that can be overfilled at the plastic surgeon’s discretion. Purlz offers presurgical sizers to be inserted over one’s breasts in a bra to help with surgical decision making about breast implant size for eventual surgery. They can not be used to be implanted either alone or over one’s existing breast implants.
Currently, the largest FDA-approved saline breast implant sizes are 800cc which are recommended from the manufacturers to have a maximal fill of 960cc. They can be inflated to more than that and around 1200cc , as you have, is around the maximum fill after which they get unnaturally very firm. Outside the U.S. larger saline breast implant sizes exist and are used but those devices are illegal to import into this country for use. The breast implant manufacturers are working on bringing larger breast implant sizes to the market but I could not tell you when that may be in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year-old transgendered woman who is interested in more of a feminine face. I do believe that my jawline and chin is what needs to be changed and would be the most beneficial to me. I have been living full-time as a woman since my gender transition eight years ago. At this time, other than having two teeth extracted and dental work, I have no other facial surgery or injuries. As a woman, I do have occasional passability problems. I feel that my face currently absolutely needs improvement and will boost my self-esteem and self-worth.
A: In looking at your pictures, I do agree that your jawline from the chin back to the jaw angles, is the most masculine appearing part of your face. Softening your jawline would be a beneficial step towards your aesthetic facial goals and is a potential part of many facial feminization surgeries. Reducing the entire jawline is never as easy as making it bigger but there are procedures that can help your its prominence. The jawline angle can be reduced by angular ostectomies where the sharpness and prominence of the angles are reduced along with some width reduction. This is done through an intraoral approach where a saw is used to removed the bony jaw angles (makes them less square) and taking the outer cortex of the mandibular ramus to make it thinner as well. Your chin needs to be vertically reduced and narrowed combined with lateral prejowl ostectomies to make the whole front part of the jaw more narrow. This also is done from inside the mouth where the chin bone is downfractured, shortened and narrowed and put back together. Then behind the chin osteotomy the body of the jaw is then narrowed by outer corticotomies. I have attached some predictive imaging of those potential jawline reduction results.
Dr. Barry Eppley
Q: Dr. Eppley, I would like a consultation for a breast augmentation. I have pectus excavatum and didn’t realize this until early adulthood. At this point in my life I would prefer cosmetic surgery as opposed to a more invasive surgery to correct my deformity.
Thank you and I look forward to hearing from you!
A: Breast augmentation can do a good job of masking/hiding minor to moderate degrees of a pectus excavatum deformity. When the chest plane is fairly flat with minimal breast mounds, a inward curvature or depression of the sternum (pectus excavatum) can be very noticeable. One would think that increasing the size of the breast mounds would make the sternal depression more obvious…but it doesn’t. Conversely it has the opposite effect and makes it ‘disappear’. This is because enlargement of the breast mound with an implant pushes up the inner aspect of the breast mound and part of the skin that makes up the edges of the pectus deformity. With two mounds emerging right next to the sternum, the deepest part of the pectus deformity now creates a natural cleavage effect and the sternal depression has now ‘disappeared’.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am having a tummy tuck and liposuction and am concerned about the risks of a deep vein thrombosis (DVT) and pulmonary embolism. (PE) Do you ever prescribe blood thinners in addition to sequential compression devices (scds) for the legs? I likely am being overly cautious but as a nurse who audits charts all day long I see DVTs and PEs as common problems in the hospital.
A: The prevention of DVTs is of utmost importance in any procedure but particularly in women who are having abdominal/pelvic surgery, which is a higher risk group. During any plastic surgery procedure and in recovery SCDs are used. After surgery early mobilization/ambulation is encouraged. A tummy tuck with or without liposuction is not a procedure one wants to lay around for any extended period of time. Fortunately, I have yet to have a DVT in a tummy tuck patient. Because of the increased risk of bleeding and hematomas, any form of blood thinner (such as heparin or lovenox) is not used unless the patient is a known risk with a prior history of DVT or a diagnosed abnormal blood hypercoagulopathy.
It is important to recognize that a hospitalized patient with a medical problem is a different situation than an otherwise healthy person having elective plastic surgery…so this would explain the dramatic difference in incidence of DVTs in these two populations. But they can happen in any surgery patient so SCDs and early ambulation are the established standard of care in tummy tuck patients.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am getting a tummy tuck and flank and thigh liposuction done in a few weeks. Honestly, I don’t have much of a pain tolerance so I am concerned most about that issue. I know I will be getting oral pain medication but my plastic surgeon didn’t mention a pain pump. Should those be used?
A: Pain pumps are a common method employed by some plastic surgeons for postoperative pain control after a tummy tuck. I have not found them particularly useful, however, in my experience because I infiltrate the muscle prior to closure. The main source of pain after a tummy tuck is due to the midline rectus muscle fascial plication, not what is done with the skin. I prefer to place 50cc of a Marcaine and epinephrine solution into the muscles during the procedure. This seems to be as effective as using a pain pump, saves the patient about $250 and avoids additional skin exit holes for the pain pump tubing. That being said, there is absolutely nothing wrong with using pain pumps also has an additional preventative measure of postoperative pain control.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m hoping that the full facial laser ablation will help greatly with my acne scarring. My only concern is that I have a few scars on my cheeks that are noticeably larger than the rest (they look more like “boxcars” whereas the others just look like large pores) Would you recommend doing the full facial laser ablation first then tackling any punch excisions if needed? Or would it be better to do punch excisions on the few larger ones immediately prior to full ablation in order to maximize success? Of all of the aesthetic goals I’m trying to achieve, having a beautiful “poreless” face is of the most importance.
A: The most important concept about laser resurfacing of facial acne scars is that perfectly smooth and poreless skin is not possible. Improvements in skin texture and irregularities can be obtained, it is just about how much improvement can be obtained and whether one treatment alone is adequate. This can not be specifically gauged beforehand in any patient and more in that regard will be known after the results of the laser treatment is seen. Acne scars that are amenable to excision (ice pick scars, not boxcar scars) should be done beforehand. That way those scar revisions get the benefit of the laser resurfacing as well.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I know a tummy tuck focuses on the abdomen below the belly button. However, I have two fat “dumplings” immediately above and to the left and right of my belly button. If this skin gets pulled down because the lower skin is excised, I was worried that these two fat “dumplings” would look like a new pannus. (if that makes sense).Is liposuction ever being performed on the area immediately above the belly button during a tummy tuck also?
A: In a tummy tuck, the excision of full-thickness skin and fat in the lower half of the abdomen results in an advancement or stretching of the undermined upper abdominal skin flap. This will ‘unravel’ much of the upper abdominal fullness and irregularities because this tissue unit must now stretch out and cover twice the surface area that it used to. Liposuction is never done on the upper abdominal skin flap during a tummy tuck because of blood supply and healing concerns. By doing so there is a very significant risk of causing skin necrosis and wound healing problems of the tummy tuck incisional closure. Once the upper abdominal skin flap is undermined to allow it to stretch out, the perforating vessels feeding the tissues are cut off from the underlying muscles. The skin is now surviving on the more superficial vessels near the skin that comes in from the sides. Liposuction will injure those vessels and make the central upper abdominal tissue have jeopardized vascular perfusion. The small increase in aesthetic improvement is not worth the risk of major tummy tuck wound healing problems. But those areas you are referring to above the belly button are not going to be carried lower as they now exist. They should be completely flattened out for the most part.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m having surgery in a few weeks consisting of a full tummy tuck and liposuction of the, flanks and outer thighs. How much fat did you estimate in inches that can be removed from each of these areas? Particularly with my outer thighs, I was hoping that whatever amount of fat was removed would be visibly noticeable to the eye.
A: While I don’t have the advantage of knowing what your body/thighs look like, there would be little purpose in having the procedure if the change was not noticeable. I never like to use inches as a circumferential measurement outcome for any liposuction-treated area or a tummy tuck because the visible change can be substantial but the circumferential measurement change can be less impressive. This, of course, highly depends on the body type and the size of the original problem. But you have to remember that only one section of the thigh (outer) is being treated not the circumferential thigh so that measurement will never be impressive as the outer profile or silhouette view. For a tummy tuck, only the front half of the body is being treated so the amount of ‘inches’ reduction will depend on the existing size of the frontal abdominal fullness and/or overhang.
While in many patients, inches do come off from a tummy tuck, that can be avery disappointing assessment criteria when looking at outer thigh liposuction…that is rarely an inchess off procedure.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I recently had a breast augmentation with 175 cc implants placed under the muscle.. I went round and round with the surgeon, who had never placed implants that small. I showed him an “A” bra that I was interested in filling (I was a double A) and he assured me that that was where I would end up. No such luck. I am a very full B, and very much doubt that waiting for swelling to go down, drop and fluff, etc, will attain the very, very, very moderate look I wanted: again, an A cup. I had explained to him that I was looking to acheive an “A”, no more, to restore my former breast before the 20-lb weight loss. I am very upset to be so thin (5′ 10 and 120) and have much bigger breasts than I have ever had in my life! Would you deem me a good candidate for revision?
A: It is true that breast augmentation with implants under 200cc in volume is very rare. But yet they do make them as small as 125cc in volume. But most of such implants are used as an adjunctive component of breast lifting surgery.
Had I seen you before your desired breast augmentation procedure what I would have said is that no size of existing breast implant will make you an A cup, no matter how small you started. Even putting in a very small breast implant is going to make most women some form of a B cup even if it is a small one. Granted you are very tall and thin, but even a small breast implant will make some degree of a visible mound which is by definition a B cup.
That being said, where you do go from here…how do you revise what you have to reach your size goal? It would be extremely helpful to know whether you have saline or silicone gel implants and what projection/profile they are. For the sake of assumption, let us assume that you have silicone gel implants. There is no where to go in terms of size as the smallest silicone gel breast implant is 170cc, regardless of the manufacturer. If you have saline, then there is the possibility of downsizing particularly if the 175cc are overfilled. The smallest saline breast implant made is 125cc in the lowest or moderate projection style. By switching to this smaller saline implant, you would realize a 30% reduction in size (maybe more if they are overfilled) and perhaps some less projection if they are anything higher in projection than a low profile implant.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am writing in reference to what I have read in a posting on your site: Case Study: Lower Buttock Lift for the Saggy Derriere from Friday, July 20th, 2012. It seems as if the procedure you perform is one that sutures de-epthelialized dermal flaps to the gluteal fascia, thus redefining the infragluteal fold. My situation is that I lost about 15 pounds a few years ago, resulting in a saggy buttock. This is also likely age related as I am 45 years old. I am happy enough with my buttock per se, which although small might be redefined by the removal of the offending skin, I’m thinking. If I send you pictures would you be able to tell if this procedure would work for me? Thank you in advance for your time and responses to my question.
A: Pictures of your buttocks will do quite nicely in determining your eligibility for a lower buttock lift. Please send a picture from a full back and side view of your buttocks. You are correct in how a lower buttock lift is performed, de-epithelization of the excess buttock fold skin in a horizontal orientation and then suturing the skin edges down, if possible, to the buttock fascia. All skin sutures are placed in a subcuticular location and are of the barbed dissolveable variety so no suture removal is necessary. The only dressing used is glued on tape. There usually is very little discomfort after this procedure. One just needs to avoid bending over at the waist beyond 90 degrees and strenuous exercise for 3 to 4 weeks after the procedure.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had scar revision on my knee area. The surgery helped my scar to look thinner but there is still this image of a straight line cut. I had my operation last September 5, 2012. I am planning to undergo laser treatment for my scar. Can I have it done by December of same year?
A: While you certainly can treat your scar revision by laser resurfacing in the early months after a scar revision, I would not expect it to change how it looks. (like a residual straight line cut) Laser resurfacing is almost always perceived as if it is a ‘magic eraser’ but that is not how it works at all. Lasers do not have the capability to wipe away scars and often are overused and overhyped.
A scar, no matter how thin, is a full-thickness layer (most of the time) of abnormal tissue that is largely white and unpigmented tissue. Laser resurfacing removes a layer of the top of the scar but doing so will only reveal more of the scar. Only in the most superficial of scars can laser resurfacing reveal more normal underlying dermis which then can re-epithelize. Thus in full-thickness scars no improvement will be seen. And after surgical scar excision, your scar is most certainly full-thickness.
Dr. Barry Eppley
Indianapolis,Indiana
