Subj: Ear Pain
Date: 05/12/2001
To: beppley@iupui.edu
Dr. Eppley:
I appreciate your response and am sorry for both of us that this has been a problem. I just finished writing the following message to you when I saw your e-mail come in. I know there is nothing that you can do from there, but the change in the quality of the pain in the right ear today has me very concerned. It's just that I have always snapped right back after every kind of operation I had before and don't know what to think of this pain.
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My nurse practitioner tired to get me an immediate appointment with an ENT-facial plastic surgeon yesterday and he could not give me an appointment until May 21. My pain was not sharp and intense yesterday, just pain and ringing in both ears that has been present since the day of surgery and has become progressively worse each day. I thought it would be better by now.
Today I have severe, intense pain in my left ear that is stabbing when I open my mouth. I have noticed that canals of both ears are nearly closed by what seems to be pressure pulling the ear downward from the tension on the SMAS. The only way I can get a bit of relief from the intense pain is to lift my ear up (with a Q-tip from inside) in a way that opens the canal to the position it was in prior to surgery, which relieves the pressure somewhat.
Needless to say, I cannot do this more than a few seconds or so. I have a high painthreshold and would rather not take pain med. I have taken Tylenol, which does nothing. I guess I just need reassurance that it can't possibly be something that requires immediate attention. I do plan to ask the ENT surgeon to see me first thing Monday because it IS that serious.
I have not been able to return to anywhere near the level of activity that I should have by now and have continuous headaches, tinnitus, dizziness, and nausea. Everything seems to stem from the pressure pulling on the ears. I have to force myself to eat because chewing gives me sensations in my ears that make me nauseated. I am just afraid about the left ear because the quality of the pain changed so much today.
As far as healing goes, my incisions look fine and I did not have any more bruising than what you saw the day after surgery. I have been sleeping with my head elevated still and have used silicone sheeting on the incisions at night which I found helps develop a nice, neat scar, so that is at least something positive.
Lucille
Subj: Re: Ear Pain
Date: 05/16/2001
To: beppley@iupui.edu
CC: arlmulley@hotmail.com, lucilleiacovelli
Dr. Eppley:
I started writing you the message below but did not finish it because I am in such dreadful pain and insatiable ringing and pressure in my ears has me nearly incapacitated. I can hardly think straight to explain what I KNOW is causing the problem, but it doesn't matter much anyway. It occurred to me that the ENT specialist I will see next week is a doctor who never believed my face stretched out from the rhinoplasty when I consulted him before and is not about to take me seriously now, particularly in light of the fact that he was a bit put out because I did not have HIM do my surgery and he wanted to know WHY I found it necessary to go out of state. The only other ENT and facial plastic surgeon I saw was Dr. Mack Cheney at Mass Eye & Ear in Boston who also wanted to operate on me and seemed to think my sagging face was just skin and said the platysma and sagging were "simple" to correct. I think you know that was not the case. I trust Dr. Cheney more than I do Dr. ####, who is the ENT/facial plastic surgeon in Hyannis I am supposed to see and the only one qualified down here in plastics as well as ENT. But seeing either of these doctors will be useless unless YOU are willing to describe the condition of the tissue you had to operate on and whether you will relate to them that what I said happened with the stretching from the swelling after the rhinoplasaty POSSIBLY caused the hypoelastic state of the SMAS and skin which is why things are now healing as they are.
I feel totally helpless and at the mercy of doctors who never believed what I was telling them in the first place. Now I am asking them to help me with a problem from s surgery they did not perform when they already had an "attitude" regarding me.
All I know is my ears never stop ringing and it is getting worse. The pain in the ears is triggered by chewing, swallowing, and other animation. Smiling is excruciating and pulls my lower face downward MORE than before. Swallowing causes the same contortion and I also cannot tilt my head back at all.. EVERYTHING IS PULLING DOWNWARD TIGHTER AS IT HEALS. There is no opposing tension UPWARD. which, if fixated before the rest of the face, would have gone a long way to correcting most of my problems. This is not something that is going to "loosen up" . The tension and shortening of SMAS in the direction it is fixated with the platysma invagination without benefit of myotomy will just thin everything out more and I will nave a neck without any angle .. there is already no angle to the mandible because the platysma is PULLING straight from the sides of my face downward.
I don't know what information you can provide to these doctors that will help them help me.. IF there is any help for me at all. I only know I didn't realize how lucky I was before to just LOOK awful.
I feel totally helpless in this plight.
Lucille
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In a message dated 05/12/2001 2:26:22 PM Eastern Daylight Time,
beppley@iupui.edu writes:
>>The pain that you are experiencing sounds like it may be from the tightening of the SMAS both above and below the ear, although I have never heard of this putting pressure on the ear canal since it is sutured a far amount away from the canals. <<
The pressure seems due to a pulling downward (tension on SMAS pulling structures around the canal down and placing pressure on whatever is in there that causes this unceasing ringing and headache.) If I pull UP on the ears, producing a counter tension, it seems that would help if it could be sustained. The problem is I cannot do that because it is pulling in opposition to the tension on the SMAS. Now consider this: IF you were dealing with a face in which the tissue planes were intact and integrity of tissue was what you could consider "normal" for someone who has had a previous facelift, the tension placed on the SMAS as it is fixated at present should not have the ability to pull down the structures in and around the ear to this degree. HOWEVER, due to the COMPLETE DETACHMENT AND HYPOELASTIC state of ALL AREAS (which in my case was face from the lower lids to the nasolabial fold, submental, submandibular and platysma area as marked in intra-op pictures from Mass General), what you have left is a mass of unsupported soft tissue simply hanging on the facial bones and muscles with the new "support system" you provided with this last surgery bearing the entire burden of the "unsupported" tissue.
Now, consider the areas in which you lifted and supported these layers of tissue that have their own characteristics (hypoelastic, unyielding, no support - SMAS & skin - and its contiguous transition into the muscular quality of the platysma and the attachments of all this to the deep muscles of expression, function and mobility. What you have is the support provided by your surgery trying to hold up the entire "detached" areas with their own gravitational pull and tension or lack thereof when the face is animated...- smiling, chewing, swallowing, moving head back, etc.-
THEREFORE, if support were provided where necessary, to include ALL areas undermined in the previous facelift that were later detached and stretched from the subsequent rhinoplasty swelling, the burden of holding up the face would be evenly applied and undue tension would not be placed in limited areas only (as it is now). The burden of support is now placed so that the ears and the dissection which excludes the mid face and nasolabial area are trying to hold up the whole deal and something has to give. You did such a good job of the internal sutures that at least they are not giving way, however, the burden of the rest of the face WHICH HAS NO SUPPORT is placed in that area (ears) and thus pulling whatever is least resistant. As I said, I have no idea how this pressure is causing the ringing, I know nothing about ENT things.
About the platysma: Again you have a stretched, hypoelastic sheath of muscle that used to be attached to the structures beneath. I think you realize by now that all the sagging stuff that looked as if it were only skin was actually skin & SMAS/platysma. The reason it was so thin, (as you mentioned to me it being the thinnest SMAS you ever saw) is because it was so stretched out after the rhinoplasty swelling... (which brings us back to HOW that could happen and the only answer is the changes in the structure of both skin & SMAS from the hydrodissection under high pressure that was employed in BOTH the sub cutaneous and sub SMAS dissection of previous facelift). One can say this is merely conjecture, but let's face it, Dr. Eppley, one must also give way to common sense and the obvious. While there may not be solid proof of this phenomenon and accompanying data to substantiate the condition of my facial soft tissue as you found it, it should not be difficult to determine through the many photos of my face at different stages from before the facelift in '1997 through every phase up to my surgery last month that things are exactly as I have stated from day one after the rhinoplaasty. The only pictorial "evidence" missing is the extent of the swelling, and for that I can provide a reasonable facsimile. If a person has a nasty fall and comes to the ER with a broken bone, one does not have to witness the fall to validate that the leg is broken, though one does have the advantage of an x-ray.
You have been inside my face; handled the tissue for yourself. I am sure there are sophisticated ways to determine tissue thickness (ultrasound?) and integrity (biopsy?) that I don't know about that would show the difference in unaffected areas of my face directly adjacent to the effected areas included in the hyrdodissection and swelling/stretching. From the very beginning I was told my "theory" was nonsense, ridiculous, impossible and was called everything from being a crazy person to a just plain nasty, belligerent patient.
Every doctor I consulted before contacting you, including the doctor who removed my sutures and the ENT facial surgeon I am booked to see and several other very good surgeons ALL said my face did not stretch out from the rhinoplasty.. which is why I refused to have them operate on me. Everyone EXCEPT YOU refused to even consider what I was saying happened to my face and the damage it caused to the tissue was real.
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