Brow Bone Augmentation

Q: Dr. Eppley, I have a few questions in regards to brow bone augmentation.

1. In most of your work in this area of face, a more pronounced upper brow bone area can be noticed from the profile view, which actually is the main purpose of the procedure. However, I feel that the lower part of the brow bone (where the upper eyelids and the brows meet) isn’t affected much except in this case where bone cement was used.

Does this bigger augmentation amount (compared to other patients’ results) in the upper brow area have to do with the material used or with the soft tissue anatomy of the patient?

2. I’d pursue brow bone augmentation to mostly augment the part of the brow bone I talked about before. Is this the right operation for me? If yes, are injectable fillers a good yet temporary alternative to achieve similar augmentation degree to your result that I previously linked?

A: In answer to your brow bone augmentation questions:

  1. Actually the differences between using a custom implant or bone cement are exactly opposite of your supposition. It is far more predictable and effective for lower brow bone augmentation to use a custom implant if it is designed to do so. It is very hard to get bone cements that low due to the working properties of the material.
  2. Injectable fillers are always a reasonable test for any form of brow bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Hip Implants after Buttock Implants

Q: Dr. Eppley, I am interested in hip implant augmentation and have some questions for you.

1. Knowing that I do not have enough fat for the Brazilian style fat injections, what are the relevant considerations when selecting either synthetic injections or the silicone implants? (Everything I have read suggests that the synthetic injections are likely to be more dangerous, provide less certain results, are of limited life, and more expensive, but would like to have a first hand professional assessment.)

2. Going on the assumption that you recommend the silicone hip implants, is the 2″ addition to each hip achievable?

3. Would a silicone implant move with the body and look reasonably natural in all positions and further how would such an implant feel?

4. Are your silicone hip implants customized for your client and how specifically are they crafted?

5. How secure are these implants after insertion, are they held by a muscle like a butt implant?

6. Do you have pictures showing the before and after of this specific procedure without accompanying injections?

7. What would the normal life of such an implant be?

8. From your website the procedure is listed at around $5500-6500, does this still seem reasonable in light of the details provided and are there any other fees that she should be aware of?

9. Given that a Silicone butt implant is already in place would there be any issues with adding a hip implant or in customizing the shape to work with the butt implant?

10. As noted, the butt implant took place Sept 29, 2017. How long would it be advisable to wait before undergoing a hip implant surgery?

11. What will recovery look like generally? Specifically, she will be coming via a 4 hr flight, how long must she plan to stay in Indiana after the surgery before being able to fly back. (Additionally, how many follow up visits will be required, particularly if after the flight is allowed?)

12. On some sites this surgery is connected with the need to wear some sort of structured garment during the healing phase, is such a shaping garment required for your procedure, and if so how long must it be worn.

13. How long is it generally recommended before returning to work following the procedure?

14. Probably aligned to the flight question, but how long before she will be able to drive?

15. How long before more restrictive clothing like jeans may be worn?

16. Reviews and other information about your practice seem very positive, but just as a point of clarification, where your site lists “board certified in the specialties of Plastic and Reconstructive Surgery” does this mean board certified by the American Board of Cosmetic Surgery?

17. Will you personally be performing the procedure?

A: In answer to your hip implant questions:

1 The concept of using synthetic materials and injecting it into body areas for augmentation is a fundamentally dangerous one. While it may be successful for some people without complications, some patients will suffer foreign-body reactions which will be both difficult to treat and will end up in various amounts of tissue destruction. In essence such injections are not truly reversible. Conversely hip implants are completely reversible without ill effects on one’s health for either medical or aesthetic reasons.

2 The amount of hip augmentation achievable by implants depends on numerous factors include the thickness of the soft tissues and their ability to safely stretch and accommodate the implants. Probably 2” or a 5 cm thick implant is too much particularly in a thin person.

3 Hip implants are ultrasoft and very flexible so they do not interfere with movement and feel about as natural as an implant can feel. (no implant can ever feel perfectly natural since it is an implant not natural fat tissue)

4 All hip implants are custom made based on measurements taken on the patient for surface area coverage. (aka implant footplate)

5 All implants, regardless of body location, are held in place by the initial tissue pocket made and the scar capsule that ensues.

6 Patient pictures are confidential and are only released by the permission of the patient.

7 All implants last a lifetime as they are made of a non-biodegradable material. 

8 The cost of the procedure will be forwarded to you by my assistant.

9 With a buttock implant in place, it is importantly that the two implant pockets do not connect. If the buttock implants is intramuscular this is not a concern. But if the buttock implant is subfascial, the design of the hip implants must take its location into consideration.

10 Three months should separate the placement of buttock and hip implant surgeries.

11 Most patients can fly home in 3 to 5 days after surgery but such travel is really based on how the patient’s comfort. There are no specific followup visits scheduled unless there are urgent issues. All followups are done on a virtual basis.

12 A compressive garment is helpful in the first few weeks after surgery to help the implant pocket heal around the implant.

13 Depending on how physical one’s work is, one should able to return in two to three weeks after the procedure.

14 Driving after hip implants surgery is based on one’s comfort.

15 Jeans can be worn as soon as one is comfortable in doing so.

16  My board certification is by the American Board of Plastic Surgery. The American Board of Cosmetic Surgery is not a board certification recognized by the American Medical Association. 

17  I am the only one available to perform the surgery under my name.  

Dr. Barry Eppley

Indianapolis, Indiana

Dental Treatments after Jawline Implant

Q: Dr. Eppley, When is it ok to go to the dentist for a deep cleaning and root planning after my custom jawline implant ? And should I tell them about the jawline implant?

A: Dental treatments in the patient with certain types of facial implants (cheek, paranasal and chin and jawline implants) pose issues that make telling your dentist that such implants exist. If screw fixation was used with the implants these will be visible in some dental x-rays. (e.g., panorex) The need to perform local anesthetic injections into the tissues overlying the implants is the most significant consideration.

A deep dental cleaning should not be done for three months after the facial implant procedure. If they are going to perform any local anesthetic injections, whether it is for cleaning or other dental treatments, they need to the aware that an implant exists along the jawline. Inadvertent needle penetration into the implant’s capsule has a high risk of causing an infection. The needs can track bacteria from the mouth into the implant’s surface. Fortunately local anesthetic injections can still be successfully done with some modifications (avoiding deep injections down to the bone) when a complete jawline implant exists.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Implants

Q: Dr. Eppley, I am not quite ready for a facelift but would like to restore the fullness to my face/cheeks through cheek implants. Here are my pictures. I am interested in your thoughts about cheek implants for me. Thank you in advance.

A: You are an excellent candidate for midfacial volume restoration or augmentation through a combined malar-submalar shell style cheek implantas. You are spot on in terms of what would have the greatest anti-aging effect on your face. Such as implant is really like a ‘deep plane facelift’ for the midface. By elevating the cheek tissues off of the masseteric fascia they are allowed to float upward and are supported by the ‘spacer concept’ of the cheek implants.

Like all facial implants proper selection of cheek implant style and size is essential. Particularly relevant is the surface area that they cover in the midface, The aging face with sagging cheeks requires that the implant pocket extend down over the origin of the masseter muscle on the cheekbone.

I would agree that you are not only not ready nor would a traditional facelift produce the type of facial rejuvenation change that would most benefit you in the midface.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Forehead Implant Revision

Q: Dr. Eppley, It’s a pleasure to meet you. Do you mind if I ask you some question about custom forehead implant surgery? I have read many times about your surgeries on the site.

I have done a bone cement surgery on my forehead and my eyebrow. (custom forehead implant) Can I get more bone cement added onto the current implant? Because I don’t want to remove the current implant. I am happy with the shape, just want to add more. If not, can you take the implant out and reshape it? Or do you have to make a totally new one?

I have got the surgery based on my exact skull model with the 3D printer. So the implant is really well shaped based on my forehead and brow bone. So I just want to add little bit more bone cement on the current implant.

Like one the first photo, there are some gaps between my real bone and the implant . I want to fill those gaps if its technically possible. (Glabella, brow bone) If I need to remove the current one and get a new one , is it possible to make the implant model like the second photo?

Also i found that photo model on your site. Is it possible to add extra bone cement on the part that I circled with purple color?

Thank you so much !

A:  The answer to your fundamental question is that it is not possible to just additional cement to your existing forehead implant to create a result that will be perfectly smooth and even in the areas you have highlighted. Although you did not state what exact material your implant is I would wager that it is PMMA, an acrylic bone cement which is commonly used in Asia but not the U.S. for custom forehead and brow implants.  I have removed and replaced many such forehead implants as their design is often identical to yours and the patient’s desires for an improved implant shape is also identical to yours as well.

Dr. Barry Eppley

Indianapolis, Indiana

Pectoral Implant Revision

Q: Dr. Eppley, In regards to my pectoral implant revision, I googled PowerFlex 1pectoral implants and it took me to the Implantech web site. I took a look at all their pectoral implant styles. The shape is what I am looking for although the projection is 3.9 cm. It is tempting although I think this would be too large. I noticed on the Implantech site there is a PowerFlex Pec Implant (Novack style 2) that may work for me. It states that this implant is “coming soon”. The shape looks excellent although I am not sure if this would be large enough. The dimensions are 15.2 x 12.4 x 2.2 cm and the volume is 345 cc’s. Do you think this would fit well for me? Not sure what my chest dimensions came to that you took on my last visit. The pectoral implants I have now are 2.8 cm in projection although I would not mind going a little smaller to the 2.2 cm. This time I think the definition and shape are more important than the volume. Also, on the Implantech site they show the original Novack implant that is 15.3 x 12.6 x 2.3 cm and the volume is 300 cc’s. This is a little confusing since the Novack original which is a little larger then Novack style 2 implant although the volume is 300 cc’s (original) and 345 cc’s (style 2). Can you double check the dimensions for the PowerFlex Pec Implant (Novack style 2) with Implantech? 

A: In looking over all the pectoral implants from various manufactures I think the conclusion is the right shaped one is a little too big and those with the right volume don’t quite have the right shape.

The ones you have in now are too big in terms of surface area coverage and could also stand some more projection particularly in the inner and upper poles of the implant.

Given that you have a reasonable acceptable result, albeit with its own issues, the only reason to have pectoral implant replacement surgery is to make a really substantial improvement. To do so it would be best to get the best shape, projection and volume of the implant based on the measurements and numbers that we know would be better….aka just make custom implants for your pectoral implant revision..

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Horn Removal

Q: Dr. Eppley, I was wanting to know if there is anything you could recommend to remove what I have heard are called forehead horns.(forehead horn removal) They are wide and stick out of the left and right side of my forehead. They get bright when light shines on them and I feel more insecure as I grow older and they grow. My idea is that I have a large forehead so smoothing out the bone (forehead horn reduction) and bringing my hairline forward so the hair closer to the top of my head moves towards my front face. (forehead reduction)

Thank you please help!

A: Thank you for sending all of your pictures. What you have are classic forehead horns. The incision location of a hairline advancement procedure would be the only way to access them for forehead horn removal. While a combined hairline advancement and forehead horn reduction is a logical set of procedures to put together, the incision location must be carefully considered in a young male as the long-term stability of the frontal hairline may or may not be assured. In essence you don’t want to trade off one aesthetic problem for another….horns vs scar in a male with closely cropped hair.

Dr. Barry Eppley

Indianapolis, Indiana

Medpor Facial Implant Removal and Replacement

Q: Dr. Eppley, I have had off the shelf Medpor chin and mandibular angle implants in for the last decade and desire a greater degree of augmentation and resolution of underlying asymmetries that could only be achieved with custom implants.

My two questions are; 1) can 3D CT modeling be done with the current implants in place, and 2) will removal and replacement of current Medpor implants really carry a large risk of disfigurement?

Thank you in advance for your reply.

A: In answer to your Medpor facial implant removal and replacement questions:

1) Your indwelling chin and jaw angle implants are not a problem for designing new custom implants as they are digitally removed to do so in the designing process. Having existing jaw implants in place does help in designing new implants as having a known effect guides what an improved effect should look like. 

2) Having removed and replaced many Medpor facial implants I am not certain where the concept of causing facial disfigurement emanates. Certainly their removal poses greater difficulties than if they were silicone implants, but their removal does not cause facial disfigurement/deformity that I have seen. Their removal often causes greater temporary swelling due to the more extensive tissue dissection needed from the adherence of the soft tissues to the implant surface.

Dr. Barry Eppley

Indianapolis, Indiana

Male Breast Implant Revision

Q: Dr. Eppley,   I just underwent breast implant revision with new and larger implants. I just wanted to follow up with you on my revision. No pain to complain about. No pain meds needed just the antibiotic. I was a bit worried about the shape of the right implant as it still looked a bit odd in shape. However they are gradually taking on a very nice shape. The projection is perfect. I am very pleased with your work. Thank you!

I have two questions:

1) Will these implants drop and fluff during the next 6 months or will they hold the current shape. I really like the shape and strong projection. There does not seem to be much swelling.  

2) There seems to be a lot of “gurgling” going on. I assume this will absorb into my body over the upcoming weeks.

Dr Eppley, thank you again for your outstanding work and patience with me.

A: Thank you for your early breast implant revision followup. I did debate with myself in surgery as to whether to go with the 350HP or the 400HP. The latter gives more projection but would also make the breast mounds overall bigger…so I went with our previously discussed 350s.

In answer to your questions:

1) Now that the lower poles of the breasts have been released there will be a lowering of the implant (dropping) as they heal as the scar impediment to do so has been removed. This generally takes about 6 to 8 weeks to finalize.

2) The gurgling you hear is some irrigation fluid used to wash out the pockets before placing the implants as well as an ‘air space’ existing between the implant and the overlying soft tissues. The fluid will be absorbed and the tissues will shrink back down over the implants in the next few weeks of further healing.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jaw Implant

Q: Dr. Eppley, I’m thinking about having a custom jaw implant or a custom wrap around jawline implant. I’m a male who has a round short chin with a smooth jaw. I want my lower third of the face to be longer and wider. Not so much of a horizontal projection on chin but a significant vertical height and definitely a square,defined chin. So I roughly measured the projections I want myself. They are:

Chin width 4cm – 4.5cm not mm

Chin vertical projection 8mm – 10mm

Chin horizontal projection 3mm

Mandibular vertical projection 1mm – 2mm

Mandibular horizontal projection 5mm

Do you think this dimensions are realistic or achievable? And thank you for your consideration!

A: In answer to your questions about your proposed jawline implant dimensions I would make the following comments:

Chin horizontal projection – 5mms (yes)

Chin vertical increase – 5 to 10mms (5mms is more realistic)

Chin width increase – I not sure whether you mean in addition to your natural chin width or that this is the amount you want added. The former is very possible, the latter is too extreme as the side tissue can not be stretched that much. (Maybe 1 cm per side)

In the chin area of the jawline the soft tissue chin pad is much more restrictive in allowing it to be expanded than in the back part of the jaw. This is particularly relevant in vertically dropping of the chin. If you want a 10mm increase with the other chin changes, I would also consider doing an opening vertical bony genioplasty of 10mms (this carries the soft tissue chin pad down better) and placing custom extended jaw angle-lateral chin implants to accomplish most of the other changes.

What I would also say about the chin width is that most patients, understandably, can’t appreciate the impact of measurements that they take on the outside of their face for what an implant size should be. That often over estimates the impact of such skeletal augmentations on the face. In my experience, if patients were left alone to devise the implants based on measurements they believe would work, all such implants would be too big. One of my tasks in custom facial implant designing is to help avoid that aesthetic problem or other more significant problems that can come from very large implant dimensions.

Jaw angle width increase – 5mms (yes)

Jaw angle vertical increase – 2mms (yes)

Dr. Barry Eppley

Indianapolis, Indiana