Jaw Angle Implant Removal

Q: Dr. Eppley, I had jaw angle implant removal surgery last year, and they were removed early this year. The biggest issue is the disruption of my pterygomasseteric sling which is most noticeable when I clench my teeth.

Anyway, after a fair bit of research online, I’ve since accepted that it is not possible to fully fix this. My question is – could fillers be used to camouflage or minimize the disruption? If so, would Radiesse or Sculptra be suitable fillers? Finally, what would be the longevity of these fillers and how much will they cost?

Thank you!

A: Reattaching a contracted masseter muscle after jaw angle implant removal is certainly a challenge and usually only partially successful. How well the masseter muscle can be pulled down is a function

Filling in the muscle defect below the new level of the masseter muscle can be done by injectable fillers or fat injections. The first thing you want to do is to use a hyaluronic-based filler (e.g., Juvederm XC, Voluma) as this has the least risk of irregularities and has an assured dissolution time or can be reversed by hyaluroidase injections in the event that you do not like the result.

Dr. Barry Eppley

Indianapolis, Indiana

LeFort 1 Osteotomy

Q: Dr. Eppley, I had orthognathic surgery last year. (LeFort 1 osteotomy) This has left me hanging soft tissue, no jaw line, crooked nose, enlarged nostrils, flared nostrils, toothless smile, thin bottom lip and can’t even close my mouth without feeling pain, as though someone is pulling my chin backwards through my skull.

A: While I am just looking at a front view picture, you have many of the potential sequelae from the intraoral incision used for a LeFort I osteotomy which includes flared nostrils, widening of the nasal base and upper lip sag. This occurs because of the degloving incision and detachment of the facial musculature to the bone…not because the bone was moved back too far. (although that may be a contributing issue of which I can not speak since I don’t know the skeletal movements done) The nasal asymmetry can arise from a septal deviation caused by the bony movement.

Given that you are nearly a year after this surgery the soft tissue changes are stable. There are a variety of procedures to deal with these nasolabial changes from nostril narrowing, lip lifts and rhinoplasty surgery. Unless there is a significant bite issue, I would focus on the soft tissue issues and leave the jawbones where they are.

Dr. Barry Eppley
Indianapolis, Indiana

Orbital Rim Implants

Q: Dr. Eppley, I have been looking into various procedures for augmentation of the upper face as the area surrounding my eyeballs is recessed in relation to the eyes. It is my understanding that the area surrounding the eye is comprised of the brow ridge (superior orbital rim), the lateral orbital rim (bone that extends from the edge of the brow ridge) and the inferior orbital rim (area under the eyes). One area which I am not sure about is the boney area that stretches around the side of the eye before joining the inferior orbital rim area, what is this bony area called?

I know that this entire skeletal area can be mobilized with the Le Fort 3 procedure, however this is not something that I would like to pursue due to the risk factors involved. My question is to what extent the effects of a Le Fort 3 can be replicated by the use of custom made implants? I know that implants can be used for anterior projection of the inferior orbital rim and the cheekbones, and that custom brow ridge and custom lateral orbital rim implants can be made. However, is there any way to advance the area of bone directly horizontal to the outside corner of each eye, to ‘encapsulate’ the eye so to speak from that side? Also, to what extent can the inferior and lateral orbital rims be reasonably advanced without it looking unnatural or proving problematic? Finally, what is the most economical way of combining custom implants to provide a total augmentation effect? So can a combined brow ridge and lateral orbital rim implant be fashioned etc.?

A: The inner orbital area is not a rim area per se. Rather it is comprised of the nasal and lacrimal bones as well as the frontal process of the frontal bone.

A LeFort III procedure does not change the entire orbital rim area. Rather it is a naso-maxillary-inferior orbital rim skeletal advancement. While this can be good procedure for you get children and even some adults that are affected by congenital craniofacial conditions, it is not an aesthetic procedure nor appropriate at any age for non-craniofacial anomaly problems for a host of reasons including its risks.

Custom onlay orbital rim implants would be the only way to safely and effectively augment all of these facial areas. The design of these type of orbital risk implants must take into consideration primarily how they would be placed (access incisions) and to make the augmentation look natural. That usually means not having them too big and having smooth transitions to the surrounding bone off the implant edges.

Such a ‘mask’ custom facial implant would be put in a segmentalized manner. How that would be divided is based on the access by which they are placed. Thus brow bone/lateral orbital rim, inferior orbital rim-molar, and maxillary-nasal base would be a three-piece approach to such a custom facial implant placement.

Dr. Barry Eppley
Indianapolis, Indiana

Chin Ptosis Repair

Q: Dr. Eppley, I am interested in chin ptosis repair. I had a surgery for chin implant one year ago. It was a silicone implant and surgery was done from inside my mouth. I also had a dimple in my chin which I asked the doctor to get rid of. He put the implant, but it was too big for me so the wound from inside my mouth wouldn’t heal. I had to get the implant removed just after two  weeks of getting it done. He said I would have to wait six months until I could put a new one in. Somehow the dimple i had in my chin is not there anymore and my chin looks completely different from what it was before. It has been a year and a half now and I’m not happy with it. But during this year and a half, it seems that it got uglier from what it was before from when i just got it removed.

I only had the implant for two or three weeks as the wound wouldn’t close. The doctor tried to stitch it back a couple times but the stitches wouldn’t stay and I could literally see the implant when I opened my mouth. I luckily didn’t get any infection. He told me that I could get a chin implant again in six months but obviously I never went back to him since then my chin keeps getting a worse look, I don’t know what to do.

A: Thank you for sending your picture. What you have is true chin ptosis as you initially suggested. You have four chin ptosis repair options at this point:

1) Do an intraoral chin ptosis repair. This is usually marginally successful because you have both detached and some stretched out chin tissues.

2) Do a submental chin ptosis repair. This is done from below by removing the soft tissue overhang. It is very successful because it removes loose tissue but does so at the expense of a submental skin scar.

3) Do a combined intraoral ptosis repair with a small chin implant. This is more successful than #1 because it adds support low on the chin bone for the resuspended chin soft tissues.

4) Do a sliding genioplasty. This is like #3 but uses your own bone and not an implant to create the support for the uplifted soft tissues. This probably offers the most successful outcome of all options listed but is the most ‘invasive’.

The reality is that it will be difficult to go ‘back home’…meaning going back to where you started before the chin implant was placed. That is probably a complete impossibility. Options #3 and #4 offer the combination of creating a chin augmentation effect that you were originally seeking and also solving the chin ptosis problem.

Dr. Barry Eppley
Indianapolis, Indiana

Implant Rhinoplasty

Q: Dr. Eppley, I had a L-shaped silicone implant rhinoplasty donea year and a half ago. There have been no major complications, but I’m looking for a revision for a better aesthetic outcome. My biggest issue is that the implant seems too ‘narrow’, and I’m looking for a new implant that’s wider and longer to give me a more masculine nose. My questions are:

– I know that many surgeons favor rib cartilage, but I’m honestly not fond of such an invasive procedure and lengthy recovery (especially the scar). If I only want a synthetic implant material, which one would you recommend (silicone, Gore-Tex etc.)?

– Apart from my bridge, I’m hoping for a more pronounced radix and glabella. Could this procedure be done at the same time as the rhinoplasty?

– Finally, I’m looking to increase my nasolabial angle. Could a small implant be placed under my nasal spine to bring the base of my nose forward?

Thank you!

A:  In your revision implant rhinoplasty the question is whether any standard nasal implant would suffice for your needs or whether a custom nasal implant would need to be made. I would need to see some pictures of your nose to make that determination. I believe all of your revisional nasal objectives can be achieved with a new silicone implant that has the right dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Body Implants

Q: Dr. Eppley, I am interested in bicep,tricep, deltoid and pectoral implants all done in one procedure. I have a couple of questions about these types of body implants.

1. Are the solid soft silicone implants you use “gummy bear” (cohesive gel) style implants or more solid than that?
 
2. In your experience approximately how long would it be before someone (including intimate partners) would not generally notice the scar? A week (after the hair regrows?) or many months?

Thanks,

A: In answer to your body implant questions:

1) Body implants are made from a very soft (low durometer) silicone that is in a solid implant form. They are not gel-filled like breast implants which is very low durometer silicone put into a bag because it can not maintain a solid form. Body implants feel just slightly firmer than a contemporary gummy bear breast implant but only slightly so, They are design in feel to be like muscle tissue.

2) While you will always have fine line scars from the insertion sites they do got through a period of redness from which it takes months to settle down and look their best. Thus you should think of it a several month process, not one of a few days or weeks.

Dr. Barry Eppley
Indianapolis, Indiana

Sliding Genioplasty Revision

Q: Dr. Eppley, I am interested in sliding genioplasty revision surgery. I had a sliding genioplasty done five years ago for aesthetic chin contouring. A subsequent fat injection was done over the lower margin of chin for further chin contouring a year later. Afterward, I have functional disorder of the lower lip and chin so I took my doctor’s advice on removal of miniplate and screw via intraoral incision. The disorders of the lower lip and speech persisted. So I took my doctor’s advice on steroid injection for scar adhesion release which provided no improvement and made it even worse.

Now I feel tight while talking and eating. There is a line between my lower lip and chin. Muscle below the line will rise and stick to the line while talking, therefore I have difficulty talking smoothly. Some doctors said since I have had two surgeries via intraoral incision, there may be something wrong with my mentalis muscle and scar adhesion. Please diagnose my symptom. If there is something wrong with mentalis muscle or possible scar adhesion or else, please help me, because you are a master in this field. I need your help. In fact, I don’t know what to do next. I hope to talk smoothly. I pray to God for it. Hope you can help me. Hope to receive your e-mail as soon as possible.

A: While I have not seen any pictures of your chin, your story is not unfamiliar to me. This sounds like scar adhesion/contracture in the chin soft tissues. This is particularly evident in the tight and deep labiodental fold. This is a problem of both and now lack of supple tissues in this area. In my experience treating this problem, I advocate for your sliding geniplasty revision releasing the intraoral adhesions over the chin bone and muscle and placing a dermal fat graft. This now only releases the tight tissues but brings in new and unscarred tissue to make the tissues more supple/soft.

Dr. Barry Eppley
Indianapolis, Indiana

Corner of Mouth Lift

Q: Dr. Eppley, I am interested in a corner of mouth lift. On one side of my mouth as I have an asymmetrical smile. The corner is low when I am not smiling but it gets worse when I smile. I have attached two pictures which show the asymmetry both smiling and not smiling.

A: Thank you for sending your two pictures. Your mouth at rest and when smiling show that the root cause of your mouth asymmetry is weakness of the zygomatic major facial muscle. This muscle is responsible for lifting up the corner of the mouth when smiling. Since the muscle is weaker on the one side, the corner of the mouth droops down slightly when not smiling but becomes really magnified when asked to animate. (smile) Thus the mouth asymmetry is much more apparent when smiling.

A corner of mouth lift is a static procedure that is done on a structure at rest. Since your problem is much more of a dynamic nature, a corner of the mouth lift will provide better symmetry at rest and less so when smiling. But despite its limitations a corner of the mouth is all you can do for your mouth asymmetry concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Augmentation

Q: Dr. Eppley, I am potentially interested in some form of a forehead augmentation procedure. So this is what I’m working with the last picture shows an example of what I’m looking for in regards to a forehead change . I’ve scheduled a hairline lowering procedure but my forehead will still “slope” backward obviously. I don’t know if this is because of my eyebrow bone or what but I have no clue where to start or what would be the best course of action. Hairline lowering and eyebrow bone shaving? Hair transplants? I really don’t want to do the whole cement implant thing and was hoping there were other options. I’d really like your honest opinion because I’m impressed with what I’ve seen on your website in regards to forehead augmentation. Thank you and best wishes. Let me know if you need better pictures please.

A: With you modest backward inclination to your forehead the result you demonstrating/seeking definitely involves upper forehead augmentation. There is no other way to augment the forehead without adding something to it.

The alternative is to reduce the brow bones (and leave the forehead alone) which in your case is actually a viable idea. With even 4 to 5mm brow bone reduction you will go a long way to achieving that look. Augmentation is still preferable but brow bone reduction is not a bad alternative if you are strongly opposed to any forehead augmentation material.

Either way, forehead augmentation or brow bone reduction, it is best to do it with the hairline lowering procedure. Otherwise you are going to have to go through the hairline scar twice which may not lead to the best scar outcome.

Dr. Barry Eppley

Indianapolis Indiana

Sliding Genioplasty

Q: Dr. Eppley, I’m contacting you because I believe you may be able to offer some advice on my sliding genioplasty procedure.I recently went through with a revision genioplasty and I am currently recovering, it has been 1 week since the surgery. The surgery went well however I am concerned and merely certain that my surgeon did not move the chin forward enough to truly support the loose skin on my chin and the mentalis muscle. I specifically asked him to put the chin back in the same position that it was in prior to any revisions and I provided numerous X-rays and pictures, however I can see and feel that it’s not in that position. I raised my concerns to him but they are telling me to give it more time because it’s swollen and I cannot tell the final result right now. 

I am aware that it is swollen, and I do have a follow up visit on Tuesday with the doctor where x-rays will be done. If I find for certain in the x-rays that the chin position is still off from the desired projection to support the mentalis muscle, what do you think is the best way to proceed forward to revise it? I would really like to get it revised immediately before the bone starts to heal back up. I’m just not sure about how to go about requesting this from the doctor and avoiding additional fees. My surgeon clearly mentioned that his precision will be within half a millimeter of the desired outcome. I’m concerned that it’s not but I do not know if I will be able to get them to correct it even if the X-rays prove that it’s further off. I believe it is about 2 millimeters from the projection of the original position but another issue is that I can feel that the chin bone points slightly up  instead of down which would be inline with the rest of my jaw. A simple 2 millimeter plate increase seems like it will fix the angle and projection issue. 

I understand that some of these questions don’t really have direct answers, but if you can offer me some advice/recommendations, that will be useful. 

Also I’m wondering, if the doctor agrees to increase the projection and the surgery is done within say 3 weeks of this original surgery, do you think it would be possible to do it under local anesthesia? I’m wondering because it seems like it would be a easy procedure as no bone cutting should be necessary and just exchanging the plate size should suffice. 

Thank you for your time, I will look forward to your response.

A: Thank you for the detailed information on your recent sliding genioplasty surgery. However I do not provide advice or recommendations on patients who are under the active care of another physician. That would be inappropriate as I can only comment on what I would do, not what another surgeon would or should do. Your questions are best handled by addressing then directly with your surgeon who I am sure would appreciate that you are having that discussion with him.

Dr. Barry Eppley

Indianapolis, Indiana