Do I Need A Custom Temporal Implants?

Q: Dr. Eppley, I am interested in making my forehead wider and more squarer to balance out the width of my new custom jaw implants that will be placed in about a months time. I have booked in for temporal implants at this stage but not forehead as I don’t think my doctor or any doctors here are quite familiar with the procedure. I wanted to know if it is ok to request to my doctor to use Medpor temporal implants? This is because I had a look at the Medpor catalogue and have found that the Medpor brand offered a significantly BIGGER size compared to the silicone ones offered my Implantech (which my doctor will use). Medpor ones go up to 20mm in augmentation. I’ve read your resource millions of times (very helpful) and want to know do temple implants sit only on top of the soft tissue or can the implant itself be placed higher if the implant overlaps onto the bone? Or is that something a custom made forehead implant would fix? If so are there any off the shelf forehead implants available on the market to widen the forehead? 

I also wanted to know if I was certain that I need a forehead augmentation in future are temporal implants necessary? Or are they needed along WITH forehead augmentation. I just don’t want to waste my money on temple implants if a custom made forehead implant will fix both areas.

A: I would never use Medpor temporal implants myself. They are too big, are very difficult to modify and are very difficult to remove should that ever be desired. (and there should be a high probability that they would) No one ever needs a temporal augmentation that requires a 20mm thick implant. They are simply too big for most cases and were initially designed for patients that suffered significant temporal muscle atrophy from neurosurgical procedures not for patients that want a pure aesthetic augmentation with a normal tenporalis muscle.

If you are seeking a temporal augmentation that reaches the high temporal region to make the forehead wider as well, only a custom designed temporal-forehead implant can achieve that aesthetic change. No current implant style, Medpor or silicone, are made to create that look as a ‘catalog’ item.

Dr. Barry Eppley

Indianapolis, Indiana

How Is Ear Helical Rim Reconstruction Done?

Q: Dr. Eppley, I know that the two most common surgeries in cosmetic ear plastic surgery are to 1) remove cartilage from behind the ear and move the concha closer to the head and 2) reform the antihelix. In my case, the size of my concha and antihelical fold are OK. In my opinion my main problem is that the outer helical rim is short and dipped in. What I am asking is whether you have the ability and experience of building up the helical rim? In my self diagnosis, I think that we don’t have to fix the helical rim all over the ear, we can just fix something like a one centimeter area at the top of the ear. In my self diagnosis it gives me my ideal result.  Thank you very much.

A: What you are suggesting by self-diagnosis for your ear helical rim reconstruction makes sense and is possible. The helix exists as an outward curl of cartilage distinctly different than that of the anti helical fold. How to build out the helix at the top of the ear comes from knowledge of performing microtia, cryptotia and other congenital ear deformities. Based on the attached pictures of your ears, this is going to require the placement of a cartilage graft which could be harvested from the backside of the concha with no change in its appearance. The only question is whether this is best done by placing the graft on top of the existing helical rim or by placing it into a cut below the helical rim as an interpositional space to push the height of the helical rim higher. In my opinion this would best be done with the latter technique to prevent graft show through the very thin overlying helical rim skin.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Lip Advancement Create Less Tooth Show?

Q: Is the V-Y plasty the same thing as a lip advancement? If so, is that a procedure that can raise the height of the lower lip to have less tooth show? That is an option that I am exploring. 

A: A lip advancement and a V-Y advancement are two completely different operations with varying effects on the lower lip. A lower lip advancement removes a horizontal strip of skin on the outside so the vermilion can be rolled outward making the lower lip look bigger. It will not raise up the lower lip but is done to make the lip look fuller. (have more vermilion show) A V-Y advancement is a internal vertical mucosal procedure done on the inside of the lower lip. It is designed to try and lengthen the height of the lower lip and/or release any contracture or shortening of the anterior mandibular vestibule.

Raising the height of the lower lip is challenging and there is no one single procedure that can consistently do so. It usually require a combination of procedures through mucosal lengthening and vermilion augmentation to create such an effect.

Dr. Barry Eppley

Indianapolis, Indiana

How Do You Treat Cutis Verticis Gyrata?

Q: Dr. Eppley, These are a few pictures of my crown and a short video of my head. The hair on the ridges is sparse but in the furrows there is some. I’m not sure if I’m losing hair in this area due to mail pattern baldness or the cutis verticis gyrata. I just want to know my options for conceiving this. Wether it be a hair transplant over it or cutting it out.

A: Thank you for sending your pictures and the video. What you should do is based on how large of an area is involved in your scalp and how progressive or stable the cutis vertices gyrate is. If the area is small and stable and is not causing any other symptoms, it be left alone. I do not think it necessarily is causing hair loss but may just be spreading the follicles out further as it expands. (although I can not say for sure whether it is) The involved scalp area should only be excised if it can all be removed and should first have tissue expansion. The scalp is not very flexible and will leave a wide scar if it is all removed at once. If the scalp area is larger and it seems to be growing, then excision would not be advised. You may consider fat injections or PRP injections in an effort to treat it although such treatment is theoretically beneficial but not yet proven.

Dr. Barry Eppley

Indianapolis, Indiana

What Are The Options For Forehead Reshaping?

Q: Dr. Eppley, I’m wanting to find out more about the different options available for forehead reshaping. Are there alternative procedures to the shaving technique? For example are there any kinds of forehead implants, fat injections that can be used to smoothen the forehead. I will also be sending pictures within the next week or two for a more accurate price range, but can you tell me the average price range for these kinds of procedures? Thank you very kindly.

A: There are numerous different options for forehead reshaping including bone cements, custom implants and even fat injections. (not my preference but an option) When it comes to brow bone reduction, bone removal and reshaping usually works much better than shaving/burring for any significant reduction. As you can see between manipulation of the brow bone and the forehead above it, there are a variety of techniques. Which one may work best for you and what trade-offs you are willing to accept in doing them are issues to yet be discussed. It is better to determine first what methods you would choose and then an accurate cost for the surgery can be given. There are no ‘average’ costs for possible combination forehead procedures that we yet don’t even know what they would be.

Dr. Barry Eppley

Indianapolis, Indiana

Will Remicade Impair Sliding Genioplasty Healing?

Q: Dr. Eppley, I have been reconsidering a sliding genioplasty procedure recently due to the great deficiency my chin has. As I stated in my last email, I am on Remicade and there is a good chance I will still be on that medication when then time comes for the procedure. Does it concern you doing a sliding genioplasty procedure while I am on this medicine? I assume healing may take longer. You have also mentioned that a sliding genioplasty with a chin implant overlay may be necessary. Will this have any negative effect on healing or increase the risk of infection?

A: I have operated on numerous patients who have been on Remicade for Crohn’s disease and I have not seen any healing problems. Such surgeries have been much bigger in surface area trauma and operative times than a sliding genioplasty. The face is uniquely well vascularized and unless there is direct impairment of the blood supply through prior radiation it will not inhibit healing difficulties. The orthopedic literature supports that major bone surgery and joint replacements can heal uneventfully with patients on this medication.

That being said, it is important to work around the dosing of the medication to reduce any risk of adverse healing. Given that Remicade is a TNF blocker and is done by infusion, it would be important to do the surgery about 3 to 4 weeks after the last infusion. This is will than allow a few weeks before the next infusion. With such an approach for a sliding genioplasty I do not envision any difficulty with healing or a prolonged recovery time.

Dr. Barry Eppley

Indianapolis, Indiana

Is Perioral Mound Liposuction Risky?

Q: Dr. Eppley, I am a 40 year old male who had my buccal fat pads removed about 10 years ago. My issue went unresolved however as the puffiness was closer to my mouth. There was no information online at the time and I have just lived with it. Recently, I came across the term ‘periorial mounds’. I went to see a local plastic surgeon about it and he admitted that he had never heard of such a procedure, that it would be much too risky and that there is no fat there regardless. I came across your name when further researching it. You seem to be alone in addressing the needs of people with this issue. I have attached photos of my condition and would love to get your feedback. I should mention, it is not only the visual aspect I am hoping to change, but also the constant weight I feel around my mouth. My questions are:

1. do I qualify for perioral mound reduction?
2. do I risk damaging nerves?
3. will the amount you are able to reduce have a noticeable effect physically?
4. will a reduction aid in reducing the fat on my jawline?

Thank you so much in advance for any further knowledge you can bring me,  I really appreciate it.

Perioral Mound Reduction in Round Face Dr Barry Eppley IndianapolisA: The perioral mounds are a well known collection of subcutaneous fat that exists at the level of the corner of the mouth that is distinctly different than that of the buccal fat pads. It can be reduced by very small cannula liposuction and even a 1cc to 2cc fat reduction can make a noticeable difference. Although some plastic surgeons make not be familiar with its treatment, that does not mean it does not exist nor is it risky to do. In answer to your questions:

  1. You do have a fullness in the perioral mound area with an overlying skin fold which presumably is due to aging. (descent of the midfacial tissues) It is impossible to know beforehand how much the skin excess or subcutaneous fat is contributing to that appearance. But in my experience removing the subcutaneous fat through perioral mound liposuction can make that skin fold ‘lay down’ so to speak.
  2. This is a very safe facial area to do liposuction in. The buccal facial nerves run above it and the marginal mandibular nerve lies below it. This is a safe facial triangle for subcutaneous fat removal.
  3. There is no way to absolutely predict the change but I have yet to see a patient who did not get some improvement in their perioral fullness.
  4. The liposuction can and should be carried down to the jawline to maximize the procedure’s effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Does Ear Lifting Really Work?

Q: Dr. Eppley, I have low set tilted back ears. I want to know if it is possible to bring the ears forward, thus raising the top vertically? In other words, is it possible to rotate the right ear clockwise, the left ear counterclockwise;  thus, rotating the top of the ear forward.  I obviously do not know anything about this, but it would seem that the rotation would result in the top of the ear being ‘higher up’ five millimeters or more depending on what is possible. I understand the canal cannot move upwards. If this is possible, how much vertical increase in the top of the ear would result from the forward rotation? Is it possible to rotate them forward so that the top of the ear is the eyebrow level without relapse? 

I also desire the lobes to be shortened and the ears pinned so they do not stick out so much.  Attached at the bottom are pictures. Lastly, if this is possible, is this an otoplasty procedure that you perform?  Thank you for your time and consideration.

Otoplasty with Earlobe Reduction result left sideA: I have done numerous ear lifting type otoplasty procedures, some with moderate success and some with little vertical change at all. You are correct in your assessment that the fixed point of the cartilaginous ear is the canal which prevents any significant cartilage relocation. Whether the upper half of the ear can be moved upward at all this depends on the flexibility of the superior helix. Any lifting effect at all comes from relocating the area behind the anterior crus of the helix upward. By suturing this cartilage area up higher on the temporal bone with microscrew fixation, some vertical lengthening of the upper ear can be achieved. That effect can be maximized with setback of the upper helix since this also can cause a rotation effect if desired and appropriately sutured. Putting the two together can help raise the vertical height of the ear but not to the level of the eyebrow however. A vertical reduction of the earlobe will also help not only shortening the vertical length of the ear but may also help create the illusion that is actually higher.

Dr. Barry Eppley

Indianapolis, Indiana

Who Are The Best Sliding Genioplasty Surgeons?

Q: Dr. Eppley, I am asking an identical array of questions of different surgeons both to become more knowledgeable on the topic as well as making a decision on choosing a surgeon. If you were to undergo sliding genioplasty, which five top surgeons would you choose based on experience and reputation.

A: This is an excellent question and I wish I had a similarly good answer for you. There are many surgeons of different specialities that perform sliding genioplasty but who would be ‘top five’ would escape me. Since I have never seen another surgeon actually perform this procedure other than myself (and that was decades ago in my training), all that I have to go on is whom writes clinically and scientifically about the procedure. And because it is an historic maxillofacial procedure of which there is little new, few surgeons today publish on this procedure. Thus creditable knowledge of who performs a sliding genioplasty technically well I do not know. That does not mean they do not exist, as obviously they do, but I could not honestly give you a list based on useful knowledge of them.

Dr. Barry Eppley

Indianapolis, Indiana

Am I A Good Candidates For Vanquish Treatments?

Q: Dr. Eppley, I was interested in getting a consult for myself for the Vanquish vs. Exilis for several areas. I was also going to potentially buy a gift for my significant other as he is very concerned about abdominal fat. He also is considering Liposuction, so I looked that up. In your article about Liposuction you indicated that non-surgical, non-invasive fat removal methods are often not realistic and over hyped. Now, I am not sure whether to pursue the consult for the Exilis and/or Vanquish.

Vanquish Body Contouring Dr Barry Eppley IndianapolisA: Any non-invasive body contouring procedures can not be compared in results as to what surgery can do. (e.g., liposuction) They rarely are even close. In general, there is a often a disconnect between patient expectations and what these types of treatments can do. Between a patient’s hopefulness and device marketing (by both manufacturer and practitioner), there is ample opportunity for patients to be disappointed. This does not mean that these devices are not beneficial and can not create moderate body contouring results, but each patient needs to be assessed individually to determine how non-surgical vs. surgical ROI (return on investment) compares. That requires a thoughtful and honest discussion which I regularly do for many potential patients seeking such treatments. I own both Vanquish and Exilis, so I have great insight into their potential value, but I also have no interest in patients making a ‘poor investment’ either if they are not good candidates for them. I would recommend that you and your husband come in and talk to me about it.

Dr. Barry Eppley

Indianapolis, Indiana