Plastic Surgery Revision of Tracheostomy Scars

Tracheostomies frequently result in unsightly neck scars. Their prominent neck location and the temporary indwelling breathing tube commonly leaves a depressed neck scar after its removal. It often looks like a belly button with the skin turned inward. This is known as a tracheal tug although it is the lack of underlying soft tissue that makes it look this way.

An undesired looking scar from a tracheostomy can undergo correction within months after a breathing tube has been removed if so desired. Historically, tracheostomy revisions have been done when the scar is more mature. (greater than six months after tube removal) It is not necessary to wait this long however. The plastic surgery techniques used are not really affected by how mature the tracheostomy scar is. And, for many patients, they would like to eliminate as soon as possible the physical and psychological marks of the experience of why the tracheostomy was there in the first place.

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To get a good outcome from a tracheostomy scar revision, there are three basic concepts that must be achieved surgically. First, the turned in skin edges must be released from the deeper tissues and be completely freed up. Secondly, this release creates a real tissue volume defect between the skin and the trachea which must be filled in. Lastly, closing the skin must create a fine line scar that lies in a horizontal direction along a natural neck skin fold. By far, filling in the lost tissue is the hardest one to achieve but it absolutely necessary if one does not want the final result to have any indentation. Filling in the missing tissue can be done in a variety of ways. If the tracheostomy scar is not that deep and fairly shallow, the surrounding skin edges can be used through a technique known as edge de-epithelization. The thinned skin edges are then turned down for a little tissue fill and the full-thickness skin edges closed over it. For tracheostomy scars that are significantly indented, however, more volume is required. I prefer using dermal-fat grafts which can be quite thick if desired, up to 1 cm. A donor site is needed to harvest it and this will leave a scar elsewhere on the body. However, if one has a scar from a previous surgery elsewhere that is from a favorable area that has some fat thickness, then this should strongly considered. Otherwise, allogeneic dermal grafts (from cadaver skin) can be used which is an off-the-shelf product.

Tracheostomy scar revision is a fairly simple outpatient procedure. All sutures are placed under the skin so there is none to remove. A fine line red scar will exist for awhile afterwards (months) but this will eventually fade into a near imperceptible pencil line thin scar. Again the key to a successful tracheostomy scar revision is to completely resolve the skin tethering to the trachea and replace any missing tissue.

Plastic Surgery Revision of Tracheostomy Scars

Dr Barry Eppley is a board-certified premiere plastic surgeon in Indianapolis, Indiana where he practices at his Ology Spa locations at Clarian North Medical Center in Carmel Indiana and at Clarian West Medical Center in Avon Indiana.(http://www.eppleyplasticsurgery.com) He writes a daily blog on plastic surgery, spa therapies, and medical skin care at http://www.exploreplasticsurgery.com. Dr. Eppley can be heard weekly on his radio show, Doc Chat, on WXNT 1430 AM every Saturday afternoon.

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Plastic Surgery Release of Tongue-Tie Deformity

Being tongue tied is more than just not knowing what to say. It is an actual medical diagnosis (ankyloglossia) that is not that uncommon. (estimates are one in one to two thousand people) In my Indianapolis plastic surgery practice, I have seen lots of them over the years. It is a condition inside the mouth where the tip of the tongue is tethered down to the floor of the mouth. It is marked by an inability to move the tongue beyond the front teeth.....or just barely past them. When there is an attempt to stick the tongue out, a V-shaped notch appears at the tip. Technically, it occurs when the lingual frenulum (on the underside of the tongue) is either too short or anteriorly placed , restricting the mobility of the tongue.

Ankyloglossia occurs as a result of a developmental aberration in utero. Early in fetal development, the tongue is attached to the floor of the mouth. Like how fingers become separate from the initial fetal webbed hand (planned cell death and atrophy), the tongue and the floor of the mouth separate leaving a residual attachment known as the frenulum. Tongue-tie results when this frenulum is short and thus limit the movement of the tongue. This is a condition which can be seen at birth if one looks carefully enough. But it becomes very apparent when the front teeth have erupted. Physical exam will easily demonstrate the short or anteriorly placed lingual frenulum. While the tongue continues to grow until about four years of age, one does not outgrow a short frenulum. Once present, it remains so.

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Tongue-tie most commonly appears as a partial restriction and rarely as a complete fusion. There is considerable controversy as to what functional problems that it may or may not cause. It has been implicated in speech defects, breastfeeding difficulties, and a source of dental problems. While I have seen and treated many tongue-ties in babies and young children, the few I have seen in adults did not appear to be causing any significant problems. The main reason tongue-ties are treated is for better tongue mobility which has a cosmetic benefit and probably some minor functional improvement as well.

The main reason to treat tongue-tie, in my opinion, is the sheer simplicity of doing it without postoperative complications or relapse. One can have a lot of debate as to whether it is medically necessary, but if you can eliminate the problems with a very simple and quick procedure, that debate takes on less significance.

Tongue-tie is released through a procedure known as a frenuloplasty or frenectomy. The frenulum is incised near its midportion until the tongue is fully released. Then it is sewn together with small resorbable sutures creating a long unrestricted frenulum. In babies and children this requires a general anesthetic. In adults, it can be done under local anesthesia in the office.

Plastic Surgery Release of Tongue-Tie Deformity

Dr Barry Eppley is a board-certified premiere plastic surgeon in private practice in Indianapolis, Indiana at Clarian Health Systems. (http://www.eppleyplasticsurgery.com) He writes a daily blog on plastic surgery, spa therapies, and medical skin care at http://www.exploreplasticsurgery.com Dr. Eppley can be heard on his weekly radio show, Doc Chat, on WXNT 1430AM Indianapolis on Saturday afternoons.

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Nipple Deformities - Simple Plastic Surgery Corrections

Nipples are as variable as the size and shape of breasts. No two nipples are ever exactly alike, usually not even on the same person. While much breast reshaping (breast augmentation, breast reduction, breast lift) goes on in plastic surgery, many men and women suffer from nipple deformities as well which also affects their self-esteem. Nipples can stick out too much, can be turned in, or the areola (the colored area surrounding the nipple) can be too large. Some of these nipple problems may affect certain breast functions such as feeling or lactation. The good news is that there are some very simple plastic surgery procedures that are quite effective at improving these problems.

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For the sake of clarification, what most call the nipple is actually two different structures. The true nipple is the central projecting skin area that has both enhanced sensation and milk ducts for lactation. The flatter, almost always more pigmented, skin around the true nipple is called the areola.

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Nipple inversion (shy nipple) affects about 2% of the population, more commonly in women than men. Some nipples can be turned in slightly or to a significant degree. Some people are born with nipple inversion, others occur later often after breastfeeding. In rare instances, a tumor may be pulling the nipple inward and this should be ruled out particularly if it occurs later in life and just on one breast. Correction involves a simple procedure done under local anesthesia. The nipple is released and brought out. The biggest problem with nipple inversion correction is relapse, the nipple losing projection and returning to an inward position. Nipple inversion surgery can also be done at the time of other breast surgery. I usually like to delay repair in the case of breast augmentation until later as the implant may help to push out some nipples, making correction unnecessary.

Enlarged nipples often create visible 'headlights' which can be a source of embarrassment for many women. This can also be an issue for some men. An overly projecting nipple can be easily reduced through a wedge excision or a 'ring' reduction approach. Sensation and the ability for milk production can be preserved with either technique. Done under local anesthesia, nipple reductions are very stable and are not associated with any significant relapse.

"Puffy" nipples can occur in women and are usually associated with the tubular breast deformity. In this nipple problem, the areola and the nipple are pushed outward due to an underlying herniation or protrusion of breast tissue. Correction of this problem is slightly more complex than isolated nipple surgery. It is usually treated as part of tubular breast surgery which involves the use of a breast implant and areolar manipulation. This is treated by making an incision around the areola, removing some of the pigmented skin (if needed), and lifting the areola skin up and decreasing the projection (puffiness). This is a more extensive surgery and requires an operative room experience under anesthesia.

Large or wide areolas are extremely common in big breasts. Usually the size of the areola is related to the size of the breast, but not always. Large areolas are commonly reduced as part of breast reduction surgery. They can be reduced independent of a breast reduction through the periareolar approach. By removing a ring of the outer areola, the circular diameter of the areola is narrowed. Due the tightness of breast skin, there is a limit as to how much the areola can be reduced. This procedure results in a scar at the junction of the areola and skin which occasionally widens and requires secondary revisional surgery.

Nipple Deformities - Simple Plastic Surgery Corrections

Dr Barry Eppley is a board-certified premiere plastic surgeon in private practice in Indianapolis, Indiana at Clarian Health Systems. (http://www.eppleyplasticsurgery.com). He writes a daily blog on plastic surgery, spa therapies, and medical skin care at http://www.exploreplasticsurgery.com. Dr. Eppley can be heard on his weekly radio show, Doc Chat, on WXNT 1430AM Indianapolis on Saturday afternoons.

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Plastic Surgery Techniques For Reshaping the Round Face

Not infrequently I get requests from patients for the desire to transform a round face into a more shapely appearance. One cause of a round face is that the patient is overweight. A full neck, round cheeks, and a lot of subcutaneous fat throughout the face creates a generalized fullness that creates a fat and round face. These patients know full well that they are overweight and some liposuction of the neck and buccal lipectomies may make some difference. But weight loss will probably make the most difference in these cases. And these procedures should not be performed until some weight loss has been achieved.

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But the overweight patient is not what usually makes up the 'round face' patient. Most commonly these are younger patients that are not significantly overweight and are usually closer to being more height and weight porportionate. They may have some mild fullness in the cheeks and neck but often their bony prominences (cheeks, chin, or jaw angles) may be somewhat deficient. The approach to these patients must deal with both hard and soft tissues issues to be effective at improving the face's angularity and definition.

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In addition to the fullness of the cheeks and neck, the next most important consideration in facial shape improvement should look at the chin. Often it may only be midly short in the horizontal dimension but the width of the chin is also important, particularly in the male patient. Chin implants today can provide more projection as well as width in many different sizes. Placed through a small incision under the chin bone, a chin implant can lend more definition and squareness to the lower face from subtle to dramatic results.

Upper facial fullness, more specifically midfacial fullness, can be achieved through cheek implants. Placed into position by incisions inside the mouth under the upper lip, cheek implants can provide good highlights through three-dimensional enhancement of the bone as it wraps around the area below the eye. An amazing aray of cheek and midface implants is available to provide a lot of enhancements around this important facial landmark. When paired cheek implants are combined with a chin implant, an upside down triangle of change is created that directly opposes a more round or oval facial shape.

Jaw angle implants are always a possibility but these are rarely needed in most really round faces. They can produce some lateral facial fullness but this is not usually helpful in 'de-rounding' the face in most patients.

The procedures of buccal lipectomies, neck and jowl liposuction, chin and cheel implants make up the usual plastic surgery tools for facial rehaping. Which one or a combination of procedures is most helpful for improving facial definition is best determined by careful computer imaging study during the consultation with your plastic surgeon.

Plastic Surgery Techniques For Reshaping the Round Face

Dr Barry Eppley, board-certified plastic surgeon of Indianapolis, operates a private practice at Clarian North and West Medical Centers in suburban Indianapolis. He writes a daily blogs on topics and trends in plastic surgery at http://www.exploreplasticsurgery.com

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Creating Cheek Dimples Through Plastic Surgery

Dimples are depressions in the cheek skin which appear when one is smiling. They usually are not apparent when one is not smiling in those have them naturally. Cheek dimples are an inherited trait and are reported as a genetically dominant one. Cheek dimples are most always on both sides and rarely on one side of the cheek only.

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The cause of cheek dimples has been anatomically studied. It has been found to be the result of an abnormality of the major muscle elevator of the upper lip and corner of the mouth, the zygomaticus muscle. This muscle runs from the cheek bone down to the corner of the mouth. When a cheek dimple occurs, it is due to a split or hole in this muscle. When one smiles, the muscle contracts and this hole gets bigger, sucking down the overlying skin into it so to speak. This explains why a cheek dimple may not be seen when one is not smiling but is when one is.

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Some people desire to have cheek dimples as they view it as an attractive facial feature. In my Indianapolis plastic surgery practice, it is possible to make dimples (cheek dimple creation surgery) through a small operation. This is done by making a small incision on the inside of the cheek opposite the desired location of the dimple. Dissection is carried through the zygomaticus muscle and a small permanent suture is placed between the underside of the skin and the muscle. It is important not to overtighten this suture since it isn't particularly natural to have dimples when one isn't smiling. The procedure definitely creates some bruising and it's biggest complication is that the dimple may not be permanent if the suture pulls through in the first few weeks after surgery. Usually small to moderately-sized dimples can be created but large or deep indentations require tissue removal which I don't advise. It is best to do this procedure with the patient awake so I can see how the dimple looks when one smiles.

This procedure is reversible if one doesn't like the results. It is relatively easy to cut the sutures within the first month or so after surgery which is in the time frame when one should know if the result is acceptable.

Creating Cheek Dimples Through Plastic Surgery

Dr Barry Eppley is a board-certified premiere plastic surgeon in private practice in Indianapolis, Indiana at Clarian Health Systems. (http://www.eppleyplasticsurgery.com) He writes a daily blog on plastic surgery, spa therapies, and medical skin care at http://www.exploreplasticsurgery.com Dr. Eppley can be heard on his weekly radio show, Doc Chat, on WXNT 1430AM Indianapolis on Saturday afternoons.

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Plastic Surgery Treatments For Lip Wrinkles

I read a recent article that reports that drinking directly from water bottles can cause just as many upper lip wrinkles as smoking. I wouldn't doubt it as any activity that makes your lips pucker, which activates the orbicularis oris muscle which encircles the mouth, can cause wrinkles to appear on the upper lip. The development of such wrinkles is a function of both the activity and how often it is done. Drinking water these days for some people is about as frequent as a regular smoker who does one or two packs per day.

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As a general principle, wrinkles form on the face perpendicular to the direction of action of the underlying muscle movement. For example, horizontal forehead wrinkles are the result of their vertically-oriented and moving frontalis muscle which extends from the brows upward into the scalp. Since the mouth's main muscle (like the eyes) is a sphincter or encircling muscle which lies parallel (horizontal) to the upper and lower lip (except at the corners), it is no surprise that the lips (particularly the upper) develops vertical wrinkles in some people. The other factor that highly contributes to lip wrinkles is the thickness of your skin and the size of your lips. (which is interrelated) The thicker your skin, the less likely you will ever develop them. You rarely see lip wrinkles in people with thicker skin such as African-Americans and people of Middle Eastern descents for example. (and they have larger lips to begin with....as their skin is thicker)

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Treatment of lip wrinkles is a challenging problem. I tell patients to think of it as improvement as there is no complete cure in most cases. For small and fine lines that are mainly located at the junction of the skin and the lip, an injectable filler can make a nice improvement...provided you find it acceptable to have a larger lip size. (whichever you desire) When the lip wrinkles are deeper and run higher into the upper lip, the concept of skin resurfacing comes into play. This typically means lase resurfacing and the question is how deep to go with how long of a recovery that will be acceptable to the patient. When the lip lines and wrinkles are more severe, I usually use a combination of making the lip bigger with injectable fillers and resurfacing the skin with a laser. This is usually done under local anesthesia in the office unless the patient is having other major facial surgery, such as a facelift, where the procedure would be then performed in the operating room. There is some current debate between the laser techniques of resurfacing or peeling and the use of fractional (fraxel) laser treatments, but there is no hard clinical evidence at this point to say conclusively that fractional laser treatments are better. In the more severe cases, a small amount of Botox to help reduce the amount of muscle movement can also be helpful when done with fillers or laser resurfacing but you must be careful to not use to much lest you make your smile have an unnatural appearance.

Alternative treatments for lip wrinkles through skin modification are currently being evaluated. One method is to combine laser resurfacing with the use of sandpaper (yes I said sandpaper), known as laserbrasion. With laserbrasion, a combination of upper skin removal is done first with the laser and the deeper skin areas are taken down with sandpaper. The concept here is that the use of sandpaper causes less trauma (no heat) and will heal faster without the prolonged redness. And it is just as effective as the laser but safer and with less complications than if one used traditional dermabrasion. The other method is known as percutaneous collagen induction therapy. (PCIT) Like aerating your lawn, making very tiny holes throughout the upper lip with a small wheel lined with microscopic needles cuts into the deepest portions of the skin. As this heals it causes the skin to thicken which helps reduce the amount of visible wrinkling.

Upper lip wrinkles in some women are unavoidable and can be very troubling. Injectable lip fillers, laser resurfacing, and Botox can help but there is no permanent cure. The alternative treatments of fractional laser treatments, laserbrasion, and collagen induction therapy are interesting but it is too early to know if they will offer better results.

Plastic Surgery Treatments For Lip Wrinkles

Dr Barry Eppley, board-certified plastic surgeon of Indianapolis, operates his private practice at Clarian North and West Medical Centers in suburban Indianapolis. He writes a daily blog on topics and trends in plastic surgery at http://www.exploreplasticsurgery.com

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