Custom Skull Implant

Q: Dr. Eppley,  I am interested in skull augmentation or skull reshaping, I don’t know which is the right term. I feel it’s from the back of my head circumferentially around the sides. When I push fthe ront of my hair up (to increase  volume) I feel my face looks normally. But when I take my hair tightly I feel my head is smaller than my face.

I am really sad and frustrated. I feel there is no way that I can feel normal I even went to a good plastic surgeon for a consultation but after 5 minutes he said it’s genetics and not worth it to be corrected.The only doctor that I found is really supportive is you. 

I think my problem is more than just cosmetic, I  I don’t look normal and I cannot do normal activities like swimming. I always have to use many clips to push my hair up.

I really appreciate your kind support. 

A: Your description of your skull/head shape problem is one that I have heard from female patients many times. The skull size descriptions and their aesthetic concerns and psychological effects are identical. Their is a solution to these skull size concerns and it involves a custom skull implant that adds volume to the head in exactly the areas you feel are most deficient. But there are two ways to use such a custom implant and they will create different results.

Having had patients just like you I have a good feel for the amount of additional skull volume you need. Thus the ideal approach is a two-stage one. The first stage is the placement of a tissue expander for 4 to 6 weeks to create the scalp stretch that is needed for the size of skull implant that will create the ideal result. The second approach is one-stage with the placement of a smaller skull implant without doing scalp expansion first. The way to think about choosing is what type of result are you willing to accept for the effort invested? If you can live with improvement and 50% to 75% of the ideal result then  place a custom skull implant without scalp expansion. If only the ideal skull height/shape increase will do the do the two-stage approach. Be aware that once you have an implant placed you can do not do scalp expansion later. (should one decide afterwards that they want more volume. Obviously the one-stage approach is quicker and costs less…but you have to be prepared to accept improvement in skull size but not perfection.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Lift

Q: Dr. Eppley, Is it possible to do forehead lift to rid of  horizontal wrinkle lines and raise the forehead but not move eyebrow position? Because I have many forehead wrinkles. I have tried Botox but I want a permanent result. I don’t want any movement position in eyebrows. How is it done?

A: What you are asking can not be done exactly the way you want it. You can not permanently paralyze the entire forehead even with extensive muscle stripping. And if you remove all the muscle between the eyebrows to try and achieve it you will need up with a dent or depression between the eyebrows. You definitely can weaken it considerably by muscle resection (glabellar area) but it should be combined with the placement of a dermal-fat graft in the resected area so that a depression  is not created and it will inhibit any muscular reattachments as well.

In reality a forehead lift and a browllift are one and the same. A forehead lift can not be done without some browlifting effect. That effect can be made minimal but no change can be done in the forehead without some potential change occurring in the brow area riught below it.

Dr. Barry Eppley

Indianapolis, Indiana

Occipital Implant

Q: Dr. Eppley, I am a 28 year old male. I was always bothered by a flat spot on the back of my head. It has a profound effect on my confidence and makes me feel very self-conscious about myself. Even though it is not terribly bad, I would still like to get it corrected. Going through similar cases on your website, I would like to know if I will be a good candidate for the minimally invasive closed cranioplasty approach. What is the success rate of such a procedure? Are there any side effects? How long does it take for the scar to heal and will it be visible? How large of an incision will be needed? I have attached a photo of back of my head.  Also, my hair is currently thinning on my crown area. I would like to get an FUE hair transplant. Is it recommended to do the hair transplant first prior to the cranioplasty or vice versa? Will cranioplasty have any effect on hair growth in general?

A: The best and only way I will do occipital augmentation today is using semi-custom or custom occipital implant placed through a low occipital incision. (general 9cms in length)  This has a high rate of success (as long as one is not asking to achieve more than 10 to 15mms of augmentation) and a low rate of revision. A closed cranioplasty procedure has a high incidence of irregularities and asymmetry…which can only be revised then by an open cranioplasty approach.

Occipital implants do not cause hair loss. When it comes to hair transplantation, the impact of occipital augmentation depends on what method of FUE harvest is going to be done. If one is going to have a traditional linear strip harvest then one should have an occipital implant as least one year before the procedure to allow the scalp to relax. But one would be unlikely to get more than one harvest so ideally this FUR harvest method should not be used. If more contemporary methods of harvest are going to be used (Neograft, Artess) then the hair transplant procedure can be done six months after the occipital implant is placed.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery History

Q: Dr. Eppley, why does plastic surgery get its name? Can I assume that most plastic surgery operations work by putting in some form of plastic or synthetic material?

A: While there are certainly some plastic surgery procedures that do employ the use of synthetic materials to create their effects, most commonly that of breast augmentation for example, the vast majority of plastic surgery procedures use the patient’s own natural tissues for either cosmetic and reconstructive efforts. The timeline of plastic surgery history will show that the surgical specialty name and that of synthetic material development are quite different.

By modern day perceptions of plastic surgery, most people would be surprised how old the field of plastic surgery really is. The term plastic surgery can be traced way back to the early 1800s in German surgical texts. This predates the development of synthetic plastic materials by more than one hundred years. India placed a major historic role in developing reconstructive plastic surgery techniques due to the need to rebuild lost noses and lips that had been cut off by local warlords to mark the people that had violated local customs and rules. But it was World War I that catapaulted plastic surgery into an organized and recognized surgical specialty due to trench warfare and the devastating facial and burn injuries that it created. This subsequently lead to the creation of the American Society of Plastic Surgeons in the late 1930s…which still predated the developement and commercial use of plastic materials.

Dr. Barry Eppley

Indianapolis, Indiana

Head Widening Implants

Q: Dr. Eppley, I am an Australian looking for someone who does head widening implants in Australia. I have been researching for some time but you are the only surgeon I can find who performs this surgery! Unfortunately, as a student, I don’t see myself being able to afford a trip to the US any time soon so I was really hoping that you may have an idea/possibly know a college here in Australia who may be able to perform this surgery. I would really appreciate any advice or recommendations you could give me.

A: The surgical concept and the implants used for head widening implants are those that I have developed. This is a new cosmetic temporal surgery that would be unknown to almost all surgeons in the world. Thus I am certain there is no one in Australia or anywhere else in the world at this time that performs this surgery. It uses as dual combination of anterior and posterior temporal implants placed in a subfascial location to create a widening effect from the lateral orbit and forehead all the way back to the anterior occipital region. Since the side of the head is largely made up of temporal muscle it makes sense to augment this large muscular surface area to create greater convexity to the side of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Marionette Fold Excision

Q: Dr. Eppley, I am really feeling confident with what you have advised for other procedures and was wondering if after having everything we discussed whether I could possibly have marionette fold excision. I can’t stress enough how much I detest these lines. They are extremely prominent and appear to take over my face. I have researched my options and I’m not really sold on the filler injection as I would much prefer a permanent solution. And having typed in marionette fold excision your name came up. I have my fingers crossed this may be possible. 

A: Marionette fold excision can be done and is a permanent solution. But it is almost always reserved for older patients with really deep (inverted) marionette lines/folds who are more than willing to trade off a scar for the fold. That can be an easy tradeoff in much older people, usually 65 years or older since they already have many lines and wrinkles. That tradeoff may be more suspect in someone younger…or at least one should give very careful consideration of it. In addition an older person’s facial skin stretches more due to being thinner with less elastic fibers. Thus they scar much better. This is why skin cancer excision and reconstruction has such good results on older people.

Dr. Barry Eppley

Indianapolis, Indiana

Masseter Muscle Reduction

Q: Dr. Eppley, I’m interested in masseter muscle reduction and am aware you offer electrocautery as a treatment. I have a few questions regarding this procedure : 

1) Is it permanent? I understand Botox is used for this as well but it is temporary and radio frequency has also been used but lasts only for a couple years. I am looking for a permanent solution. 

2) Are the effects significant? I have seen the effects of Botox for masseter reduction and I really liked it but as I previously mentioned the effects wear off. Will electrocautery provide the same effects or is it more subtle? If I find the result too subtle could I possibly come in for a second treatment? 

3) Will there be any complications such as nerve damage, eating/movement limitations, premature sagging skin, or asymmetry? 

4)  Also, I have a dental Herbst appliance. Would that be an issue?

I look forward to your response. I apologize for the many questions.

A: Electrocautery is a form of surgical masseter muscle reduction. Somewhat similar to radiofrequency, it is a method of causing direct thermal injury to the muscle resulting in permanent loss of some muscle fibers. Unlike radiofrequency it it done through an open approach intraorally where the undersurface of the masseter muscle is treated. Through a combination of subperiosteal muscle release and direct electrocautery the size of the muscle mass is decreased as it heals. To answer your specific questions:

  1. Those muscle fibers that are directly thermally injured does result in their permanent loss. However, like liposuction which permanently removes some fat cells but weight gain can return by those fat cells that remain undergoing hypertrophy, the same can be said for muscle tissue. If the cause of the masseter muscle hypertrophy persists the remaining muscle fibers can become hypertrophic and muscle volume returns.
  2. Generally the effect masseter muscle reduction by electrocautery are similar to the effects of Botox injections. Further reductive treatments can be done.
  3. Other than some temporary muscle stiffness (trismus) there are no other adverse effects. It is just an aesthetic question of what degree does the overall muscle mass shrink.
  4. An indwelling oral appliance is not a preventative factor for having the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Testicle Implants

 Q: Dr. Eppley,  I have an odd question about testicle implants that I hope you will not think is too weird. I have had great loss of testicular size due to testosterone therapy. Is it possible to get two testicle implants and not disturb the small testicles that I have? 

testicular imlpant sizing dr barry eppley indianapolisA: I think your question is whether you can add two testicle implants while keeping your existing small testicles. Provided there is adequate scrotal sac space, and there most likely is, the answer would be that you could. You would just have to be sure that you can get a testicle implant in the sac that is appreciably bigger than the existing smaller testicle. That way you could have two ‘dominant’ testicles and not just four smaller ones. (aka sac of marbles) The obvious assumption is that you are trying to have a more normal testicle size while keeping the simultaneous function of the existing testicles, small as they may be.

Testicle implants are placed through high scrotal incisions near the groin crease so the final resting place of the implant is not directly against the incisions. This is a procedure that is performed as an outpatient under general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Incisionless Otoplasty

Q: Dr. Eppley, I made a terrible mistake with my son’s otoplasty. I went with the less invasive procedure for his ears. I had a doctor perform an incisionless otoplasty six days ago. The bandages were removed this weekend and I am extremely unhappy with the results. There is virtually no change at all and it looks terrible. I am embarrassed that I made this choice and I now realize I should have gone with your approach at our initial consultation. Is there anything that you can do to help revise this now or should we wait a few months?

A: At just six days after an incisionless otoplasty it is possible that the ears are so distorted with swelling that you may not be really looking at any approximation of the final ear reshaping result. The incisionless otoplasty works on the principle of a closed cross hatching of the cartilage with a needle (to weaken it) and then passing multiple sutures under the skin using the same entrance points. This technique does cause a lot of trauma to ear so I would not rule out what you are seeing as temporary ear distortions due to swelling and bruising.

But it would be important at this early point after surgery to allow the swelling and bruising to subside and let healing take place for the next three months. At that point the ears will have their final shape and you will be in a better position to assess the result. The ears would also be healed enough at that point that I would consider converting to an open otoplasty to get a better result if that is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Bulging Eyes

Q: Dr. Eppley, What can be the most likely solution to my bulging eyes? You can see in my pictures that my eyes stick out. They have been this way since I was little girl. 

A: Thank you for sending your pictures. The first question to answer is whether this is exophthalmos due to a medical condition such as hyperthyroidism. But since your eyes have always been ‘buggy’ it would be reasonable to assume that this is their natural appearance. It looks like you have what is known as pseudoproptosis. (appears like eye bulging when in fact it is not) This is due to a lack of bony rim/fullness around the eye particularly in the superior and lateral orbital rim areas. When the bony rims are recessed or not adequately projected the eyeball will look like it is sticking out when in fact its position is normal within the orbital box. The fact that they have been this way your whole life would support that this is just the way your face developed. Placing custom made superior and lateral orbital rim implants through an eyelid incision or doing it from above through a scalp incision would be the only way to improve this bulging eye appearance.

Dr. Barry Eppley

Indianapolis, Indiana