What Type Of Skull Reshaping Do I Need?

Q: Dr. Eppley, I’m very interested in pursuing skull reshaping surgery to fix a congenital defect involving the right side of my skull. For as long as I can remember, it has been both a cosmetic concern and one of comfort. (causing pain/discomfort with prolonged lying on the right side or with wearing helmets of any sort). From reading your web-based article, I believe I may be a good candidate for your procedure. I’ve attached a few photos of the affected area for your review; of course it’s difficult to capture the magnitude and dimensions of the defect (a bulging, sharply angulated defect) with mere photos. I thank you in advance for your time and consideration.

A: As best I can tell from your pictures, the location you are referring to is the right parietal/posterior temporal region. You describe it as a congenital defect but also call it bulging. I suspect you mean a lifelong bulge in this area which is painful. This is very consistent in my experience with more of a temporalis muscle problem in that area. Most patients and even physicians have little appreciation of how thick the temporalis muscle is in that area and how far back it goes. It always feels like bone but there is a 5 to 7mm layer of muscle under exactly where you point. Having done a far number of temporalis muscle reductions/resections (temporal reduction) in this area for symptoms described just like yours, I can attest that your concerns are more likely muscular based than being a bone problem. A CT or MRI will show how thick the muscle is in this area. However, I often make the decision to do muscle resection/reduction based on the description and physical examination only.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Lip Lift Or A Lip Advancement?

Q: Dr. Eppley, I am interested in a lip lift. I have very thin lips and a long upper lip. I want them to have more shape and size although I don’t want them to be too big. I have read about lip lifts but am not sure what I really need. I would like your opinion. I have attached a front and side view of my lips for your recommendations.

Vermilion Lip AdvancementA: Thank you for sending the pictures. What they show to me is that unequivocally need a vermilion advancement and not a sub nasal lip lift. Your lips are very thing from corner to corner, has little cupid’s bow shape and there is a long distance between the base of the nose and the upper lip. This is a contraindication to a subnasal or bullhorn lip lift as it will only move up the central third of the upper lip but leave the rest of the lip behind, potentially creating an unusual and unpleasing shape. Only moving the physical location of the vermilion-cutaneous border, from corner to corner, of both lips can you make a significant improvement in the size and shape of your lips. I have attached an example of upper and lower lip vermilion advancements although this patient is older and she wanted a more dramatic change. The change from a lip advancement procedure is adjusted by the vertical size and shape of the skin excision and can be in any degree desired. The ‘test’ of the change a patient wants with a vermilion advancement is done by having them draw on the new border and shape of the lip with an eyeliner pencil. Then that becomes how much lip advancement is done.

Dr. Barry Eppley

Indianapolis, Indiana

Will Custom Cheek Implants Restore My Face?

Q: Dr. Eppley, I am interested in custom cheek implants.  I has severe sleep obstructive apnea and it took maxillomandibular advancement surgery where both jaws were advanced about 8 MM) to finally cure me.  As you can from the attached photos the maxillomandibular advancement surgery changed my face for the worse. Some people do not recognize me, others say I really aged and others say I look totally different. Other people on the internet that had maxillomandibular advancement surgery for sleep apnea say that they got there face back by having cheek implants put in. I would like to augment my cheeks in the best way and have other procedures and/or fillers to get me looking at least as good as I was before the sleep apnea and maxillomandibular advancement surgery.

A: The current state of your facial skeleton/appearance is rather classic when the upper and lower jaws are significantly moved forward when there is no natural malocclusion. These osteotomies are done below the level of zygomas (cheeks) and thus they create a relative state of upper midface/cheek deficiency as there is now a big forward step off between the zygoma and the maxilla as opposed to the reverse step off that normally exists. Cheek and/or cheek-infraorbital rim implants are the logical solution for this induced facial skeletal deformity. There are arguments to be made for either using preformed or custom cheek implants for your midface restoration. But the very altered bing anatomy does make an argument for the custom approach.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Cheek Implants Do I Need?

Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I  also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.

A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.

I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.

Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place  getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Method Of Lip Augmentation For Me?

Q: Dr. Eppley, I’ve been looking for a more permanent solution for a lip augmentation. I was looking into fat grafting, but I understand that that procedure may not turn out as well as I would like if not done by a surgeon who is very experienced in that procedure. I’ve also been looking into permalip, but I don’t know if that would be for me because my top lip is uneven (as you can see in the picture I’ve attached). In your opinion, which procedure would be better for me? Roughly, how many times have you done each procedure? And what are your prices for both procedures?

Upper Lip V-Y Lengthening Dr Barry Eppley IndianapolisA: There are multiple options for lip augmentation from fat injections, implants and mucosal advancement procedures. (V-Y lip lengthening) There are advantages and disadvantages to all of these procedures and none of them are perfect. They all have flaws such an unpredictability of volume retention (fat injections), asymmetry and palpability (implants) and longer recovery. (mucosal advancements) While they all can be effective, it simply depends on which of their flaws you find most acceptable. I have performed many of all of these and I think the ‘safest’ (less risk of complications) is fat injections. Permalip implants are the easiest and can always be replaced by fat grafts should one not like their feel.

Dr. Barry Eppley

Indianapolis, Indiana

 

Will Complete Mentalis Resuspension Surgery Help?

Q: Dr. Eppley, I have a problem with the mentalis “balling up” when I try to elevate my lip after having a genioplasty. Prior to the genioplasty I had an indentation (not really a cleft but a small ridge) in the lower middle of my chin, this since is gone and simply looks like a ball of tissue when I elevate my lip (at rest it looks okay). I did consult with a local surgeon over a year ago who then performed a mentalis resuspension. This showed some improvement but afterwords, due to still having the “balling” found out that he never fully released the mentalis and he’s recommending releasing the entire mentalis and resuspending again. I’ve been doing some research about mentalis resuspension. One technique goes intraorally to do a wide release of the mentalis but also makes a small incision under the chin until the mentalis is completely released. Once the mentalis is fully released it is suspended intraorally and then the chin pad is anchored rom below. Do you think this will work? My main objective is to reduce (or eliminate if possible) the balling effect, hopefully returning that nice indentation (which I feel is the main reason the area balls up) and hopefully reducing my lower teeth show (full competence would be nice however I’d be happy with a mere improvement). Please let me know if this is something that you perform and if it’s something you’d feel comfortable with.

A: As you know there are different variations and extent of mentalis muscle releases. Depending upon how much the mentalis muscle is released will determine how much it can be resuspended. The mentalis muscle has its origin on the bone in the incisive fossa of the incisor teeth superiorly and inserts inferiorly into the skin of the chin. (not really the bone on the bottom of the chin) It is the insertion point of the muscle that actually contracts and pulls the skin upward. Thus when you are talking about a balling up of the muscle when you elevate your lower lip, that suggests that the problem may be exactly the opposite of what you think. I would question with your history if releasing the whole insertion of the mentalis muscle from below is really going to correct this balling up issue. Rather that anatomically suggests that the balled up area of muscle may represent the fact that the insertion point of the muscle in that area has been lost. However given that it is very difficult to re-establish a long-standing disinsertion point of the mentalis muscle (chronic scarred muscle contracture) the only real effective option may in fact be complete mentalis muscle insertion release. This does require a submental incision to really fully release it properly. Once fully released then it would have to be resuspended intraorally.

That is a long answer to say that this full mentalis muscle release and resuspension would be the only hope of eliminating this balling up issue even though it is ‘anatomically incorrect’ when you look at how the muscle moves and its origin and insertion points. That most certainly could be done under a sedation and local anesthesia approach like before.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Buccal Lipectomy Help Slim My Face?

Q: Dr. Eppley, After doing some more research, I’ve also wondered about the possibility of facial liposuction or a buccal lipectomy with my vertical chin lengthening procedure.. I know that buccal lipectomy has to be done selectively, because it can cause a gaunt look. Do you think that buccal lipectomy or some cheek liposuction would help me? The fullness of my cheeks bothers me a lot and so I thought the genioplasty would help elongate my face to reduce the roundness or fullness. Basically my question is if some sort of facial liposuction may be a better option, or if it should be done in addition to the genioplasty? (I’ve had one other doctor mention that my chin height isn’t really lacking and that not much vertical height would need to be added). I’m interested in getting your opinion on this.

A: It would not be rare to do further facial derounding by a subtotal buccal lipectomy as a complement to other procedures. A buccal lipectomy produces a subtle effect so it alone would rarely create significant facial slimming. As long as it is not done overaggressively, it will not ultimately produce the gaunt look and will reduce some fullness right under the cheekbones.

By aesthetic measurements, you vertical chin height may be fine. But in the spirit of what you are trying to achieve, vertical chin lengthening is needed. Rather than rely on numbers or what looks right to someone else, use computer imaging to see what facial look is created with and without vertical chin lengthening.

 

Dr. Barry Eppley

Indianapolis, Indiana

Will Jaw Angle Implants Help Widen My Lower Face To Match My Cheek Width?

Q: Dr. Eppley, I feel my chin is strong and I like my cheekbones, but they are wider than my jaw rami. I would simply like to add width to the lower third of my face by jaw angle implants. How can that be done? I have attached some pictures of my face so you can see what I mean.

A: I can see by your pictures as to exactly what you mean by narrow jaw angles compared to the rest of your face. Since I do not know what your jawline looks like from the side, I can not tell if it is just a width issue or a combination of width and some vertical lengthening. That distinction is critical in choosing the right style/design of jaw angle implants. Your have stated that you only need width so I will assume for now that is the only jaw angle dimension increase that you need.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Get A Custom Medpor Jawline Implant?

Q: Dr. Eppley, can I get a wrap around jawline implant made of Medpor material?

A: There are two basic types of wrap around Medpor implants depending upon how you choose to have them preoperatively prepared. There are preformed implants (a variety of chin and RZ angle styles (also known as the Matrix system) and then there are custom implants. Due to the extremely high cost of custom implant fabrication from Stryker ($15,000) I do not consider that a practical option for most patients. Thus with Medpor it is a matter of selecting amongst the various preformed ‘parts’ to create a wrap around jawline effect. A true custom wrap around jawline implant prepared off of a patient’s 3D scan can only really done today economically if it is made of a silicone material.

Dr. Barry Eppley

Indianapolis, Indiana

 

What Is The Cost To Build Out A Flat Back Of The Head?

Q: Dr. Eppley, I came across your website in search of a surgical procedure that would add more volume to the back of my head. (occipital augmentation) I have essentially a flat head, and would like to change that. My question is; what is the average price (I know they are not all the same) for this procedure.

A: The typical occipital augmentation procedure uses about 60 grams of bone cement (which is just about the extent that the scalp can stretch to accommodate the underlying bone expansion) placed over the flat area on the back of the head through a scalp incision. In most cases of occipital augmentation this produces a satisfactory result. However there are a minority of cases where this volume addition may not meet the aesthetic expectations of the patient based on the degree of flattening that they have. Thus it would be helpful to see a picture (side view) of your head to determine if this one stage approach would be enough. In more severe cases, a two-stage approach can be used but obviously we would like achieve a good enough improvement that only a single surgery is necessary.

As a general number, the average total cost of a cone-stage occipital augmentation procedure (all expenses included, surgeon’ fee, operating room and anesthesia and bone cement material costs) is around $8500.

Dr. Barry Eppley

Indianapolis, Indiana