Your Questions
Your Questions
Q: Dr. Eppley I´m a 34 year old healthy man interested in enhancing my poor defined jaw line. Have read some awesome reviews of your work and feel really drawn to having this aesthetic implant procedure performed by you. It would be easier and less expensive to go to another country but I really feel you should be the one to treat my case. I would like to know the average cost and the downtime it will require. I´ll be more than greatful for any info you can provide me with.
A: The most important decision in regards to jawline enhancement with implants is whether stock preformed or custom implants would be most beneficial. I can make that determination by looking at some picture of your face from different angles. The critical determinants of whether custom jaw implants are needed are the size of augmentation that a patient desires, whether there is any significant vertical increase needed in the jaw angle (and the chin) and whether a smooth continuity of the jawline from the chin back to the jaw angles is desired. Until that determination is made, it is not possible to give an accurate cost quote. But as general guideline, off-the-shelf chin and jaw angle implant surgery is around $8500 while custom chin and jaw angle surgery will be nearly double that cost. Either way, recovery is the same which is largely about facial swelling which takes about three weeks to go down and look normal again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year old male. Seven years ago I was diagnosed with a right frontal lobe tumor and underwent craniotomy. The procedure went well and all has healed medically well. However the bone flap due to the nature of the cutting process sits slightly lower than my normal skull. Not by a huge amount but about 2-3mm at the most, but is noticeable. I am wondering if cranioplasty can be performed to build a couple millimeters on the flap and thus smooth the forehead/skull? I already have an incision scar in the hair bearing area which starts in the top centre of the forehead and extends to just behind/above the right ear. I presume this can be re-opened. The bone flap is fairly well aligned just above the ear, but towards the top and front, slightly lower. It is the step in the visible part of the forehead which is of most significant in improving. Can you able to advise on possibility, risks, and estimated costs? Much appreciated.
A: An onlay frontal cranioplasty will solve the forehead contour problem of your bone flap very successfully. Using your old scar, the area to be augmented can be easily accessed and built up. While there are a variety of cranioplasty materials to use, and that selection affects costs, I would prefer to use an hydroxyapatite paste material which hardens shortly after application. That would be the most ‘natural’ material to use that would serve you best over your long remaining lifetime. This would be a one hour procedure done under general anesthesia and the estimated total costs would be in the $7500 to $8500 range.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can a temporal implant be placed on top of the temporalis facia instead of under it? Or is the risk it to become misplaced easier on top of the fascia? As the hollowing is deepest just above the zygomatic arch, so can the implants be used to correct this? And can you tell me how much this surgery costs? Many thanks.
A: A temporal implant is usually placed under the deep temporalis fascia. It can be placed on top of the deep fascia, if the aesthetic need dictates, but this does pose some potential risk for nerve injury. The frontal branch of the facial nerve is exposed to risk of injury as it courses through this area under the skin, resulting in either temporary or permanent forehead/brow paralysis. As long as one stays directly on top of the deep temporlais fascia while doing the pocket dissection, this risk is very low. Since the hollowing is usually in the middel portion of the temporal zone, that is exactly why placing a temporal implant under the fascia corrects that area the best. But in cases where the deepest indentation is right up against the zygomatic arch, placement of the implant on top of the deep fascia may be needed to fill out that area. The complete costs of temporal implants is in the range of $5500 which may vary based on what type of implant material is used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want cheek implants to help balance out my face. I have a strong jawline but no cheekbone definition whatsoever. I think that some type of a cheek implant would help balance out my face a bit more. However, I don’t want the implants on the apples of my cheeks but just on the top of my cheekbones to give me a more defined face. Is this possible? I’ve seen some awful examples of cheek implants where the apples of the cheeks have ended up looking way too large for the face they were on.
A: Choosing the placement and size of cheek implants is critically important in obtaining an improved but natural looking result. It would be essential to know exactly what part of the cheek you want augmented and a feel for how much volume you like. If in doubt, you should first try an injectable filler to get the exact location identified and make sure you like the result. The cheek area is one of the aesthetically sensitive facial areas and quite frequently poor results happen because of improper implant style and/or size selection. Cheek implants are a good example where a little volume goes a long way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding the potential complications of performing breast reduction surgery on a breast that has been previously radiated for cancer. I was irradiated for a localized ductal carcinoma five years ago. The irradiated breast has finally softened a bit and the skin appears pink and healthy after significant initial burning at the time of radiation. Six months ago, a plastic surgeon performed reduction surgery on the normal breast (from a size DDD to a size C) in an attempt to alleviate chronic back pain. He unfortunately removed so much tissue from the healthy breast that the radiated breast remains 2 cup sizes larger than the post-reduction normal breast. I am quite upset with the unsightly asymmetric results. The plastic surgeon did not want to attempt reduction surgery on the previously radiated breast due to the risk of poor healing etc. This seems to be good advice but doesn’t solve the current lop-sided result. The plastic surgeon suggested that I undergo a full mastectomy and flap reconstruction but that seems a bit much. Do you know of any reduction alternatives or surgical techniques that can overcome the complications of operating on irradiated tissue? Thank you for any information or advice you might have.
A: In today’s world of early breast cancer detection and treatments, it is no longer rare to see a patient for breast reduction that has had either a biopsy or lumpectomy and radiation. I have performed several cases of breast reduction previously without undue wound healing. This being said, it is important to realize that the effects of radiation on wound healing do not actually improve with time. The sclerosis of the microvascular of the skin actually worsens past the early post-irradiation period, so there is never a completely safe time to operate on an irradiated breast. The risk of wound healing problems is very real and the extensive devascularizing nature of a breast reduction procedure can unmask how compromised the circulation of the breast skin is.
There are two approaches to operating on the irradiated breast for a reduction. The first is to change or alter the surgical technique used. Using a standard breast reduction approach, the inferior pedicle is keep very wide (10 cms) and the raised skin flaps are kept thick. (2 to 3 cms) The amount of breast reduction that is internally removed may be less than that of the opposite breast so ideal symmetry in breast size will not be obtained. But maximal microcirculation is obtained. It is also extremely important to keep the skin excisional pattern conservative so no tension is placed at the intersection of the vertical and horizontal closure. The surgical technique can also be altered to be a free nipple grafting method where the breast resection is through the central mound and the circulation to the remaining skin flaps is completely unaltered. The second technique is the safest and may allow the reduction to be optimally matched to the opposite but the appearance of the nipple-areolar complex will be slightly different and nipple sensation and erection will be lost.
The second approach, and one that is reserved for the most severely radiation-damaged breast, is a two-stage technique. The breast is initially injected with a combination of stem cella and PRP (platelet-rich plasma) to improve the vascular quality of the breast mound. Three months later, the breast reduction is performed.
Which of these approaches is best would be based on how the breast looks and feels and the radiation dose and length of time from when it was done.
I would agree that immediate conversion to a mastectomy and flap reconstruction is overtreatment and should be reserved in case there is a major healing problem…and can always be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 31yr old female looking to improve the side profile of my face. I have a lot of fat under my chin and this causes an awful side profile. It also shows from the front. From what I’ve read about neck liposuction this could be a good option. But I’ve also read that chin implants can be useful for improving one’s profile as well. Which one would be best for me or do I need both?
A: Improving the profile of the neck and jawline must take into consideration whether excess fat and loose skin exists and the amount of bony chin projection. Given your age loose skin is not an issue so any consideration of a jawline tuck-up is not needed. The combination of neck liposuction and chin augmentation can be a very powerful changer of one’s profile, assuming one has a weaker chin to start. The best way to answer whether chin augmentation is beneficial is through computer imaging. See what your profile would look like with neck liposuction with and without chin augmentation. Seeing is believing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, my breasts are slightly droopy and I want them to be more perky. I thought I needed a lift but one doctor that I consulted with said that I needed more volume in my breast instead of a lift. He said this could be done with an implant or fat injections. The length between my nipple to sternal notch is 22.5 cm. Should I have breast lift or breast augmentation? If augmentation is best, which treatment is better an implant or fat injections?
A: The key to knowing whether a lift or the addition of volume can make the breast look better depends on the position of the nipples. If it sits above the lower breast fold, then volume is the answer. While I do not know exactly what your breasts look like, knowing that the distance from your nipples to the sternal notch is only 22 cms tells me that your nipples are definitely above the inframamammary folds. That is essentially a completely normal or ideal nipple position. (the normal range is 18 to 22 cms depending in the length of one’s torso)
Since more breast volume is the answer, the question of whether it can be done with an implant or fat injections becomes very relevant. The use of fat injections for augmentation of a variety of body areas has become very popular in plastic surgery recently. While it is widely accepted for volume augmentation of the face and buttocks, its use in the breast is currently controversial. This is because there already exists an augmentation method that works well and is very reliable, an implant. For overall breast augmentation, an implant works better, is a one-step procedure, and will cost less. If there is just one area of the breast that needs filled in, then fat injections becomes the preferred treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, what is the difference between craniofacial and maxillofacial surgery? I am thinking that they use the same surgical procedures and the same materials like bone cement? I am interested in getting my forehead reconstructed from a dent in it due to an injury but don’t know which type of surgeon to go to. And are you practicing both craniofacial and maxillofacial surgery?
A: Maxillofacial surgeons are usually dentists (with or without a medical degree) that have trained in facial bone surgery below the forehead, mainly of the jaws. Craniofacial surgeons are plastic surgeons that have done extra training in craniofacial deformities and have much greater experience in bone surgery above the jaws. Most maxillofacial surgeons will have very limited experience if any in forehead surgery and cranioplasty.
While there are exceptions to either of these types of surgeons and training and experience can vary by country and geographic region, these are general guidelines. I can speak to their differences quite clearly as I have trained and am board-certified in both specialities. You should seek out a plastic surgeon who has considerable experience in cranioplasty and the various materials used to do this type of forehead surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I want a rhinoplasty and as part of it I’d like a wedge excision procedure to reduce the alar flare without reducing nostril size. However, there seems to be a lot of concerns with the wedge procedure as it leads to some external scarring. I wouldn’t mind this if the scar itself was camouflaged within the alar crease. My main concern is that there might be an obliteration of the facial alar groove with this procedure. Is this a real concern? What is the best way to go about this without obstructing the alar crease?
A: There are two basic skin excisional approaches in rhinoplasty to change the bottom shape of the nostrils. The first technique is the removal of a vertical wedge of skin inside the nostril just next to the lateral nostril wall. This will reduced the flare of the ala with minimal narrowing of the nostril width. This leaves no visible external scar and will not alter the alar-facial groove. This appears to be what you may need. The other technique is where this inside the nostril excision is extended out along the ala-facial groove. This results in significant nostril narrowing as well as flare reduction. This does place a scar in the alar-facial groove which, if well placed, is not a visible scar concern. It does not result in any chance of effacement of the alar-facial groove.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an accident when I was 16 that resulted to a dent between my eyebrows. I had a surgery to elevate that dent 10 months ago and it was done by my neurosurgeon because my frontal sinuses were also indented. My forehead now is improved but I can still see a slight dent which is very acceptable. My question is if the bone cement on my forehead will deplete overtime resulting to a more indented forehead again?
A: What you had sounds like an outer table fracture of the frontal sinuses, also known as brow bone fractures. Because this portion of the forehead has only a thin layer of bone in front of the underlying air-filled frontal sinuses, it can be pushed inward with a significant traumatic force. This buckling inward creates the outward appearance of an indentation of the forehead just above the eyes. When a delayed repair is done, it is much easier to build up the contours of the brow bones that it is by repositioning the displaced bone. This is done using any of the available cranioplasty materials. While I don’t know what type of cranioplasty was used for your brow bone augmentation reconstruction, none of them are resorbable. They all are stable biomaterials that do not degrade over time. So your current result will stay stable throughout your lifetime.
Dr. Barry Eppley
Indianapolis, Indiana