Medpor Facial Implant Removals

Q: Dr. Eppley, I am interested in Medpor facial implant removals. I had a Medpor chin implant and angle jaw implant done ten years ago. Is there a way to have the implants removed or shaved down to be smaller? I would prefer removing. The jaw implants has two screws and the chin implant one screw. I have read that Medpor is challenging to remove because of potential sagging but suspension can be done. I wear a beard and don’t know if this could be hidden behind beard. Both were done through the mouth not externally. Thank you.

A: Medpor facial implant removals are challenging because of the significant tissue adherence that they have. But they can be successfully removed and I have removed many of them. An important issue with any chin implant removal, particularly when done from inside the mouth, is the risk of chin or lower lip sag thereafter. Even with good muscle suspension this is still a potential issue because what the implant has done is create an overall tissue expansion effect. When you remove the support (chin implant) there is a relative soft tissue excess that may not be overcome by an form of tissue suspension. This depends to some degree on what size the original implant is. But knowing this is a Medpor chin implant, by definition, this is a larger implant with long wings on it. So this issue is probably very relevant to you. This why ideally such implant removals should be supplemented with some residual chin augmentation whether it is a much smaller implant or a small sliding genioplasty subtotal replacement.

Such issues are less pertinent to jaw angle implant removals as they are not anterior projecting structures.

It is best to think of total implant removals, not in situ implant reshaping. This is a recipe for facial asymmetries and implant irregularities.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Augmentation and Defibrillators

Q: Dr. Eppley, I was diagnosed with Congestive Heart Failure at 19. I’m now 29. I’ve had 3 defibrillator surgeries, the last one being the 2nd of this month. They implanted a subcutaneous defibrillator which goes in your side and the lead runs under the breast and up in between. It does not have contact with the heart it is like a camera that just watches it. My defibrillator has only ever went off once in 2010, it’s pretty much just a precaution. My ejection fraction is low, like 20%. I’m 90lbs so this particular defibrillator is VERY noticeable and makes me very self conscious. I have like no boobs lol, literally. I’m hoping to possibly get a breast augmentation to make me feel better and make my machine and lead less noticeable. Do you think it’s safe?

A: The two relevant questions are whether breast augmentation is both safe and effective given your medical condition and very thin frame with little body fat. From a safety standpoint this is really a question for your cardiologist and whether he/she would ever give medical clearance for this surgery. The safety of surgery relates to whether you could have general anesthesia which is typically how breast augmentation surgery is done. Another consideration would be to have the surgery under local anesthesia with the breast implants placed above the muscle.

The other question is whether breast implants would provide some camouflage for your debrillator. I have done a few breast augmentations in defibrillator patients and it has been helpful.

Lastly it is important to know where the leads run so they are not damaged during surgery. A chest x-ray is needed before surgery to accurately know their location.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty Imaging

Q: Dr. Eppley, I love the rhinoplasty imaging predictions, they look great!  I was wondering however if you could possibly send me a few more.  I know I asked for a concave look, but could you show me what it would look like if my nose were made to be a little less concave.  Also, what do you think about possibly shortening my nose and nostrils?  Would it become too short for my features then?  I’m nervous and want to ensure I love the end results, so could you show me a few possibilities for what these two separate end results might look like, one with my nose just a little less concave, and another with my nose a little less concave and shortened. 

A: Thank you for your feedback on the rhinoplasty computer imaging. What is important to remember is that computer imaging is just a prediction and and not an exact replica of what can or will be the outcome. It is a good goal and a road map for the surgeon but no one ends up looking exactly like the imaging. It may be close but never exactly like the prediction imaging shows. Rhinoplasty surgery is not ala carte. You can’t dictate the fine details of the change to your nose like getting your coffee at Starbuck’s.

That being said, you should decide to have rhinoplasty surgery based on what you have already seen. If that is enough then the surgery will not disappoint. But if you have to have some change this is more than what is shown then you will find fault with any rhinoplasty surgery and will end up disappointed and always finding fault with some aspect of the result.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Slimming Surgery Revision

Q: Dr. Eppley, I am seeking a facial slimming surgery revision. I had cheek bone and jaw angle reduction six months ago in Asia. This seemed to result in cheek bones that dropped, became assymetric and disjointed. As for the jaw bones, the left mandible broke and seems fixed with screws. Could these screws be affecting my nerves and affecting my smile because now when I smile, my smile is crooked. I also have dental maloclusion and cannot chew normally. Please can you look at my CT scans:

1. What has happened to my cheek bones? What needs to be done for corrective surgery?

2. What has happened to my jaw bones? What needs to be done for corrective surgery ?

3. Please give me feedback or input as to what could be causing the problems I am experiencing regarding my crooked smile.

A: Thank you for your inquiry and sending your pictures and x-rays as well as telling your surgical history about cheekbone and jaw angle reduction. In reviewing your CT scans, the answers to your questions and facial slimming surgery revision needs are as follows:

1) The front end of your cheekbone was plated in an inferior (low position) rather than being put back at the correct horizontal level, albeit in a more inward position. I have never seen such a bone positioning of the cheekbone. But this would explain why your cheeks sag.

2) As you had previously stated, you sustained a fracture of the mandibular ramus during the jaw angle reduction procedure. (this also I have never seen before) There are plates sand screws at two levels to fix the fracture. It is possible that the screws from the lower plate could be impinging on the mental nerve which could cause numbness of the lower lip. The fracture could also be as source of bite issues since fixing jaw fractures are a well know source of postoperative malocclusion. (bite is off) Your smile is crooked because your have sustained an injury to the marginal mandibular branch of the facial nerve. This is the nerve that controls the depressor movement of the lower lip. When it does not work the lower lip on he affected side elevates when you smile rather than being pulled down. This is the source of your crooked smile. If the function of this nerve has not returned in one year after the injury, it will not recover.

Dr. Barry Eppley

Indianapolis, Indiana

Widening Genioplasty

Q: Dr. Eppley, I am very interested in having a chin implant removed while having a genioplasty in its place. However I noticed your article in which you state that the genioplasty can be altered through a midline incision to narrow the bone. Can this midline incision also be used to widen the chin? Therefore augmenting my chin forward with the genioplasty while making it wider with the midline incision? 

Thank you

A: A sliding genioplasty can be done where the bone is expanded through a midline sagittal bone cut and the placement of an interpostional bone graft. (allogeneic bone is usually used) This requires more than one metal plate for fixation because of the two independent bone segments (unlike a typical sliding genioplasty which just uses one central plate) but such a widening bony geniplasty can be done. Whether it can achieve the exact effect you are trying to accomplish in the amount of chin width expansion would require computer imaging assessment before surgery. The amount of chin bone expansion by this technique is limited to 1m or less. This would not be enough to replicate what the width of a square chin implant could achieve in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Male Model Cheek Implants

Q: Dr. Eppley, I am looking to receive male model cheek implants. The type of cheeks that I would like to achieve are the high cheekbones that are visible on male models. Now my issue is this: my zygoma is set too low on the face. I believe that this is a particular growth pattern because the same is true about my infraorbital margin. When I trace the infraorbital margin with my hand, it feels too low relative to the position of the centre of my eye. 

So my issue is that my zygoma is too low, which has two salient aesthetic consequences: 1) that the malar prominence is too low relative to the rest of the midface, and 2) the lower border of the zygoma is situated too low. My question to you is whether we can manage this issue and replicate a higher zygomatic bone with implants. My thoughts here are that we would: a) reconstitute the malar prominence with the shape of the custom implant, placing it higher on the face. And b) bone reduction/burring of the lower part of the zygoma, thus raising the lower border of the zygoma. 

The reason why I believe that this particular part is important is because faces with high set zygomas tend to have a ‘hollowed out’ area that starts where the zygoma stops. Unfortunately the lower part of my zygoma sits too low, meaning that this area is ‘filled out’ in a feminine way rather than the masculine ‘hollowed out’ appearance. 

c) My only other question is whether the actual infraorbital margin can be raised as part of an infraorbital extension to the same implant? My thoughts here are that we would both raise and bring the infraorbital margin forward, causing the ‘mew’ margin to sit both higher and more forward relative to the iris.

Thank you for your time, Dr. Eppley

A: I can’t ever say that I have seen anyone whose zygomatic body sits too low with the exception of certain congenital craniofacial deformities. (e.g., Treacher Collins Syndrome) But that comment aside, with custom implant designing you can make infraorbital-malar implants anyway you want. How to achieve the desired external cheek appearance (so called male model cheek implants through such designing, however, remains an art form and not an exact science. Also, It is not rare that such custom infraorbital-malar implants raise the level of the inferior orbital rim.

Dr. Barry Eppley

Indianapolis, Indiana

Temporal Artery Ligation

Q: Dr. Eppley, I lost a fair amount of weight a few years ago after giving birth to twins, and suddenly my superficial temporal artery on the right side of my face started bulging. Now, 5-6 years later, I have another one on my left side. They are bothering me on a daily basis even though I’ve just cut my hair to cover them. I am wondering if anyone has ever experienced permanent hair loss or scalp problems as a result of ligating these arteries? I had a dermatologist tell me once that there was nothing you could do to them without “going bald”, which obviously caused me great concern. But from all that I’ve read in my research, I have never heard of this happening. I really appreciate your response. Many thanks.

A: In my experience with the temporal artery ligation, I have never seen any adverse scalp effects….nor would I expect that to happen. The scalp is a tremendously interconnected vascular system that it would be very difficult, if not impossible, to cut off the blood supply to any one area without long incisions. I do not consider scalp or hair loss a risk with the procedure. But if or really wanted to ‘hedge your bet’ so to speak about the potential hair loss concern, just do ligation on one side at a time.

On a side note, of all the temporal artery ligation patients I have treated they have all been men. I have yet to see a wome

Dr. Barry Eppley
Indianapolis, Indiana

Cheekbone Reconstruction

Q: Dr. Eppley, I am interested in cheekbone reconstruction. I had an injury to my right cheekbone 11 years ago it left my face asymmetrical. My right cheekbone is flatter now than the other side. It’s appears to be protruding at one point. The orbital looks out of place. I didn’t have insurance or money at the time to fix it so I allowed it to heal on its own. It obviously healed very poorly. I have not been happy with my appearance ever since. I was wondering what can be done to fix this and achieve a natural symmetry to my face I once had. I fear I may have broken the my zygomatic arch and since I didn’t fix it right away stuck with there results. I have gone to a few surgeons that recommended fillers although my cheekbone it flat in some areas that may help I’m concerned where it appear to protrude will upset that balance. I already have fairly large cheekbones and I don’t want them to appear larger. This is my concern about the filler. Most of the surgeons I went to downplayed the injury and were more interested in convincing me to live with it. This is not an option I’ve tried for 11 years and there hasn’t been a single day that I’ve been overcome by the disappointment in my appearance. This was never the case before the injury. I’m always researching and looking for surgeons that may be able to help. I saw you website and decided to make an inquiry. Thank you.

A: Thank you for sending your pictures. If I understand your concerns using the pictures as a guide, you have three right zygomatico-orbital concerns:

1) Right mid-zygonatic arch depression

2) Right posterior zygomatic bump (may just appear this way because the arch is indented)

3) flatter right inferolateral orbital rim-anterior zygoma

These three areas could be treated by cheekbone reconstruction consisting of the following :

1) small ePTFE zygomatic arch implant (max 3mms thick)

2) rasping down posterior zygomatic bump

3) small hand carved ePTFE inferolateral orbital rim implant

All done from inside the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Orbital Rim Implants

Q: Dr. Eppley, I am interested in custom orbital rim implants. What is the amount of depth, in mm, that you would consider going for the orbital area as this area, in my opinion, would need more than a few mm? Also if it is a combined orbital rim-submalar this can also include the paranasal area too? I have seen on your blog the custom midface implant  and they look great.

Please would you have your secretary send me prices for custom orbital rim only and also for the combined orbital rim-submalar-paranasal implant.

Many thanks,

A: With a custom implant design you can make it cover whatever areas the patient wants or even the entire midface as you have seen in other patient implant design examples.

For the orbital rim area its thickness would vary based on where on the rim it lies. But as a general rule it is thinnest in the tear trough (2-3mms) and thickens as it goes out into the cheek region. (5-6mms)

The actual implant cost of a custom facial implant is the same no matter how it is designed to the surface are it covers. Where the cost varies is in the time it takes to surgically placed. I will have my assistant Camille pass along the cost of the two different options to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Bicep Implants

Q: Dr. Eppley, I am inquiring about bicep implants on both of my arms as a result of two traumatic injuries from playing football. Several years ago I suffered a left distal bicep tear and had unsuccessful surgery to repair it. Then, my right bicep–the short head muscle–suffered what my surgeon called a rare trauma (partial tear) one year later and subsequently was unsuccessfully operated on. As a result of these injuries, I feel and look “deformed” and would like to cosmetically improve this since I am still relatively young and tend to my health very well.

I am able to provide current pictures of both of my arms as well as a “pre-trauma” one. To note, my entire life, aside from OTC supplements, I have been 100% natural and aside from limited alcohol use, never have either tried or experimented with tobacco or illegal drugs. While there are other doctors in various parts of the country who do this type of surgery, after researching you it’s apparent you are one of the top ones. 

A: While I will ultimately need to see pictures of your arm, both flexed and extended, what you undoubtably have is muscle atrophy from the tears from the bone. They may be different, one proximal and one distal, but their treatment is the same…the placement of subfascial subtotal bicep implants. Most likely the incisions used for your unsuccessful muscle surgery could be used for their placement.

Dr. Barry Eppley

Indianapolis, Indiana