Your Questions
Your Questions
Q: Dr. Eppley, I am getting closer to making a decision about extra large pectoral implants. I currently have Implantech’s Power Flex Pectoral Implants. (ACPI-4, 17.6 x 13.4 x 3.2cms) I am looking for something much larger, particularly in projection…hopefully at least double or much larger with greater upper fullness and deeper separation/cleavage. I know my pecs will be out of proportion to the rest of my body but that is OK. ou sid I could get pectoral implants as large as possible that would fit in the tissue pocket. How would you be able to judge their maximum size. Didn’t you say you had used custom implants as big as 6.5 cms projection? Thank you so much for your kind attention to this matter.
A: When designing custom pectoral implants, several considerations go into considering their dimensions based on the restrictions of the submuscular implant pocket. First and foremost you have indwelling implants which have created a solid surrounding capsule. Unlike submuscular breast implants, the capsule of pectoral implants is harder to release much because of the limited access from the remote axillary incision from which the implants were initially inserted. The one area that most needs to be released is the sternal or medial edge of the pocket as well as the superior edge of the pocket since this is where you need the most expansion with new pectoral implants. Because you have the Powerflex pectoral implants (ACPI) that are more oblong rather than rectangular (PowerFlex II, ACPI2), your greatest area of ‘aesthetic’ deficiency is closer to the sternum. Any new pectoral implants must have a shape that is more like the PowerFlex II rather than the PowerFlex I that you have now.
Changing the height and width of your indwelling pectoral implants to 19 cms x 14.5 cms would be what I would advice. Any increase in pectoral implant surface area is going to come in the sternal side. Unlike the height and width of the existing pocket the ability to stretch the projection is more generous. Thus doubling their projection should not be a problem from a tissue stretch standpoint.
The only issue that bears consideration, and a possible limiting factor, is the insertion process of large custom pectoral implants. Pectoral implants are inserted through an axillary incision and are done so because they are folded onto themselves. The thicker the implant becomes the harder it is to roll it (fold in half) for insertion. This is why in very large pectoral implants the concept of double stacking implants rather than one single large implant is often considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask, in a Lefort 1 osteotomy, is it possible to lengthen the nose along with that part of the maxilla. Part of my problem with my midface is a nose that is short vertically compared to the distance between eye to eye horizontally. So is it possible to lengthen the nose within the Lefort 1 osteotomy? I am asking because I saw this Lefort 1 osteotomy example, and wanted to know if the bone grafts also applied to lengthening the nose vertically? And if so, by how much?
A: While diagrams and actual LeFort I osteotomy down fractures (vertical lengthening) do show the pyriform aperture (nasal base) being opened up and/or bone grafted, this will not vertically lengthen the nose. The shape of the external nose is largely controlled by the cartilaginous support system. (septum, upper and lower alar cartilages) This to vertically lengthening the nose cartilage grafts must be placed on TOP of the existing cartilage support. Nothing done underneath it will lengthen the external nose shape. In fact, vertical lengthening of the midface will actually create a relatively greater deficiency of the nose, more of a potentially saddle dorsal line appearance rather than the opposite effect which you desire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin reduction three weeks ago. My chin always made me feel self conscious because I felt it was too long and wide for my face. Also, I had a dimple in the center of my chin that also really bothered me. My surgeon preformed a sliding genioplasty and shortened by chin 5mm. I was also concerned of the width of my chin after surgery so he tapered the sides of my jaw/chin to create a more narrow appearance.
I understand that there is considerable swelling still but I am so unhappy with how I look at this point I can’t even leave my house. The first thing I noticed was instead of dimple being in the middle of my chin, it’s at the very bottom and looks much deeper. I thought my dimple would be greatly diminished if not gone. This is what he told me. Also, my chin looks incredibly round. I feel like he should have addressed my skin and tissue instead of just addressing the bone alone. The sides where he burred to make it more narrow have this big hard knot or bulge on each side. What is this? When I smile I feel like I look awful. My lower lip looks thinner and is still numb. My lips when I smile look lopsided as well. I absolutely hate everything about my chin. I want a v shape appearance with my dimple gone or at least diminished. Now I feel like he made everything worse.
I want you to preform a revision but how long would I have to wait? I have included some pictures from 2 days ago. I would love to have a skype interview with you ASAP.
I appreciate your time and I look forward to hearing from you!
A: While I lack some specific information about your exact chin reduction surgery (type of osteotomy), I can tell you some very specific information about the recovery process from any type of reductive chin surgery. While three weeks seems like an eternity, the full recovery from chin reshaping takes a full three months, The swelling from chin osteotomies can be massive and, at three weeks, I would expect considerable chin distortion and roundness and it may not even be back to its normal size yet. Between resolution of the swelling AND soft tissue contraction back down to the smaller reshaped bone, it really does take a full three months. Other issues such as hard knots/spots, lip numbness and abnormal lip movement and smile are also normal at this point and will take the three months or longer to completely resolve.
If I am to interpret your pictures correctly, I believe some of them are before surgery (glasses) and the after surgery are those without. Based on these pictures I see a chin that do not considerable abnormally enlarged at this point after surgery.
From a chin dimple standpoint, No bony surgery is going to change the dimple. Its location may change because of the bone reduction but it will not go away. This is due to the fact that a chin dimple has a soft tissue etiology not a bone one. To decrease its appearance requires soft tissue management such as fat grafting.
The type of osteotomy used will determine whether a more v-shape will be the final result. This almost always requires a combined horizontal osteotomy and vertical ostectomy to achieve that change. I obviously have no idea what type of chin osteotomy was done in you although I am suspicious that it may have been a horizontal one only with some shaving on the sides. This does not usually work that well to effect that change. A simple panorex x-ray would answer that question.
Based on the chin osteotomy type and the presence of the chin dimple would determine whether staying the course until complete swelling has resolved would be best or whetehr earlier intervention would be more appropriate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For purely cosmetic reasons, I wanted to know if it was possible to lengthen my midface by performing a 1-2mm dual sided vertical ramus distraction of the mandible? Also a 1-2mm LeFort 1 osteotomy vertical elongation similar to the fashion of that provided in the attached photo that had featured the osteotomy and bone grafts. And if so, what would be the likely maximum cost after taxes and hospital bills?
A: What you are seeking is vertical elongation of the maxillomandibular complex. If all that is needed is a few millimeters of vertical lengthening of the maxilla and mandible, there would be no reason to undergo any form of distraction. This can be done by using conventional orthognathic surgery operations such as a LeFort 1 osteotomy with interpositional bone grafting and a sagittal split osteotomy of the mandible. I would not do a LeFort 2 osteotomy as this is associated with an incraesed difficult factor that requires a coronal scalp incision to complete. Whatever aesthetic benefits that may come from a LeFort 1 osteotomy vs a LeFort 2 osteotomy, the added surgical risks and effort are not worth it. Such bimaxillary orthognathic surgery will cost in the range of $40,000 to $50,000 to undergo.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tummy tuck surgery. Can you please tell me the cost of tummy tuck surgery in your practice? Also what is the recovery time from tummy tuck surgery?
A: Thank you for your inquiry. There are eight different types of tummy tucks with differing associated costs. I would need to see some pictures of your abdomen to give you a very specific cost figure. Most women are type 4 so I will have my assistant pass along the cost of that version to you. That may or may not be the type of tummy tuck that you need. There are three different levels of recovery and it depends on what you are defining as your recovery point. (up and about, back to work, working out, final recovery) Since full recovery from a tummy tuck takes a complete eight weeks, I am assuming you are referring to some level of incomplete recovery where you can get at least back to that type of activity. Working backwards then it would six weeks for working out/running, four weeks for any job that has a significant physical components to it, two weeks for a sit down job and seven to ten days to be more up and about.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope you will respond to my question. I am scheduled for temple augmentation with your designed temporal implant and was curious to know the recovery time? I have had cheek augmentation recently(2 months ago) and found the swelling stayed longer than anyone explained. Should I expect the same swelling with this implant? How long? Are there any photos of temple implant recovery?? Is this a new type of implant?
A: Since you are not my patient, my first answer to your temporal implant augmentation question is that these should really be answered by the surgeon you are trusting to do the procedure. He/she should be able to fully explain these questions if they have had experience with the procedure.
That being said, temporal implant recovery will be quicker than that of cheek implants. As you have now learned, full recovery from any type of facial skeletal augmentation will take a full two to three months. Your surgeon should have made that clear before your surgery. Any form of facial implant surgery always takes longer than any patient believes or is told. However since temporal implants are not a bone-based surgery but a muscle one, the recovery is much quicker with a faster resolution of swelling and to get to the point of seeing the final result.
Due to patent confidentiality, patient photos are not shared.
The temporal implant is not a new implant as defined by just coming out. It has been commercially available now for over three years.
Best of luck with your surgery,
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested surgical reduction of the occipital nob. I have a large bump on the bottom of the back of my head that causes constant pain and headaches. It hurts to sleep on it and wearing protective head wear at work is almost impossible. I have read that you do a reduction of the occipital knob. Is this strictly a cosmetic procedure or can it be deemed a medical issue for insurance coverage?
A: The occipital knob deformity is an abnormally large hump of bone at the bottom of the occipital bone in the midline. Why it develops more prominently in some men than others is not known. It has become more of an aesthetic issue today since more men shave their head or have very closely cropped hairstyles.
Tthe size of the bony knob can be a source of discomfort when flexing the head backwards or in certain headwear/headgear. This is also where some of the neck muscles attach and the large hump of bone probably signals strong muscular attachments as well. The occipital knob can be reduced by burring it down through a small horizontal incision over it. This is a cosmetic procedure and not one covered by insurance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have two questions about rhinoplasty. First, is there any leeway in the 7 day recovery time? And the second one is I have seen that if you have trouble breathing, insurance may pay for some of the procedure. Is that true? I ask because my nose is a little crooked to the right and I feel like there is a big difference between the left and right side as far as breathing goes.Thanks.
A: Depending upon how one chooses to define recovery, only the first phase of a rhinoplasty is done at one week after surgery. That is when the nasal tapes and splints are removed. But that is far from when one has a full recovery from the procedure. But that is certainly the most obvious appearance part of it due to the external nasal dressing.
If one has breathing problems in which deranged anatomy is evident in a CT scan, then a predetermination with your insurance can be filed to see if they will pay for the functional or breathing part of the surgery. An insurance predetermination can not be filed without a recent CT scan report. The purpose of a predetermination letter is to provide your health insurance carrier with the information so they can determine if you qualify. But insurance does not cover any part of a rhinoplasty that changes the external shape of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a rhinoplasty. I’m looking for mostly tip narrowing and some nostril narrowing for when I smile, and also don’t like how close the bottom of the nose is to my lip when I smile. I’m wondering what you suggest.
A: It is important to recognize that rhinoplasty, like almost every other facial plastic surgery operation, is a static and not a dynamic procedure. The rhinoplasty operation is designed to fix anatomic problems in the shape and function of the nose that exist when one’s face is at rest and not smiling. Thus your nasal tip can be significantly narrowed and shortened and the nostrils narrowed, and that will have some positive impact on the appearance of the nose when smiling, but not to the degree that you may ideally like. The distance between the base of your nose and upper lip when smiling is a dynamic one that rhinoplasty will not really improve per se. Lifting the nasal tip may provide some illusion that it is improved but not by actual measurements between the nose and lip. That area of improvement is not an achievable or expected outcome from any rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana