What Bone Cement Can Be Used For Forehead Augmentation After Tumor Removal?

Q: Dr. Eppley, I had a brain tumor surgery (meningioma) the size of a tennis ball taken out three years ago and I would like to know if bone cements for forehead augmentation/ reconstruction has any after affects. What consequence could the use of this material have on me. Where would the incision be done? How good could the outcome from forehead augmentation be?

A: I assume you had a frontal craniotomy/bone flap done to remove your meningioma and this has results in some contour deformities of your forehead. This is common as the frontal bone settles and heals with irregularities around the burr holes and the plates and screws used to fix them into place. These forehead defects/irregularities could quite easily be smoothed over/augmented by any of the different bone cements. The best bone cement to use would be that of a hydroxyapatite composition. There are no adverse consequences of this material on your bone or the overlying scalp. You would some or all of the same incision for your forehead recontouring that was used for the neurosurgical tumor procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Will Perioral Liposuction Help With My Protruding Mouth Appearance?

Q: Dr. Eppley,  I am a 32-year old woman and I have been searching for a solution to my protruding mouth (or perioral mounds)…I have had this all my life, and recently got some filler in my chin to balance out my bottom lip protrusion and also have Invisalign to correct my teeth. However, none of these treatments will get rid of the fat around the corners of my mouth and under my bottom lip. I saw a great case study on your web site and I’m wondering if I might be a candidate for the corner of the mouth lift and perioral mound liposuction. My big concern is that surgery could affect the muscles, leaving irreversible damage. Also, I wanted to comment on the results in the case study were very appealing to me because it appeared that the mouth lift and liposuction actually gave the patient an illusion of dimples, which I think is very attractive.

A: Small cannula liposuction can be done very successfully on the sides of the mouth, known as the perioral mounds. But it can not or should not be done below the lower lip as, not only will not be effective, but may cause injury to the depressor muscles of the lower lip. (as you have correctly surmised)

Tweaking up the corners of the mouth with perioral mound liposuction can certainly create the appearance of dimples as the mound area goes from convex to concave with enough fat removal.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Jaw Angle Resection Be Reconstructed With Titanium Jaw Angle Implants?

Q: Dr. Eppley, I had jaw resection surgery.But it was overresected. So I am thinking of my jawline reconstruction. In theory would it be possible to have a strong and tough jaw by having my mandible reconstructed with 3D printed customized titanium alloy additive? Usually I heard that silicone or PMMA is often used to make a jaw line but they are not as strong as titanium and don’t have osteointegration properties. I love sports like boxing and I want to know if I can enjoy the sport with my reconstructed titanium mandible.

A: You can have your jaw angles reconstructed by using a 3D method to fabricate titanium implants rather than silicone. However the cost to do so may be prohibitive as the costs of the implants alone will come close to $10,000 and that does not include the surgical fees to place them. While this can be done, I don’t see the advantage of a metal reconstruction over the option of custom silicone jaw angle implants. They offer similar protection, would be easier to place, cost far less to manufacture, provide protection to the bone by acting as a ‘bumper’ and can be securely fixed to the bone so that they would have no problem withstanding any sports activity.

Dr. Barry Eppley

Indianapolis, Indiana

Should My Cheek Implants Have Screw Fixation?

Q: Dr. Eppley, I am getting cheek implants next week but I became worried because my surgeon says he does not use any screws to secure the implants to the bone…just uses a pocket and wait for the scar tissue to hold implant in plance. Should I find another surgeon?

A: Just because your surgeon does not use screw fixation for cheek implants, that does not mean it will not be a successful surgery and outcome. Surgeons do use different techniques in facial implant placement and, as long as it works successfully in their experience, then that technique is adequate. I would say that those surgeons who secure their cheek implants with screw fixation is far fewer than those who don’t. The most common type of cheek implant fixation is pocket positioning that may be combined with sutures or even an external cotton bolster into which the sutures around the implant is passed. (this is generally removed in one to two days after surgery)

Dr. Barry Eppley

Indianapolis, Indiana

How Can I Make My Face Shorter?

Q: Dr. Eppley, I have a long face shape but small forehead. (like Sarah Jessica Parker). I really hate my face shape and would like to make it shorter. My nose is long and I was wondering if it were possible to shorten my nose, raise my mouth and then make my chin a lot smaller so that my face is a lot shorter but still in proportion. I also have a bump on my nose that I would want straightened.

I’m not sure if such thing is possible but if you could let me know if there is anything that could be done. I have attached a picture of what kind of thing I would like done. The picture on the left is what I look like now and the one on the right is kind of how I would like to look like after. The third picture is of the bump on my nose and whether this would be able to be corrected as well. Thanks!

A: Based on your pictures and goals, I would say that two of the three facial changes you would like are achievable with fade shortening surgery. A rhinoplasty can be done to eliminate the bump on your nose and provide some further refinement. A vertical reduction genioplasty can be done and the bone removed behind it back to about the mid-body of the mandible through an intraoral approach. It can achieve the amount of vertical reduction you are showing on our imaged picture but it is the most that can be done. probably about an 8mm reduction in anterior chin/mandibular height. Lastly, it is not possible to surgically raise your mouth (lips).

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Face Be Shortened?

Q: Dr. Eppley, Can you tell me what the cost of jaw surgery would be to shorten and recontour the face? I attached photos which show my face length.

A: The concept of facial shortening by double jaw surgery is based on whether you have vertical maxillary excess and a gummy smile. If one does not, then shortening the lower facial bones is going to bury your teeth under your upper lip which has a very negative aesthetic outcome. The pictures you sent do not show you smiling but I suspect you do not have true vertical maxillary excess as, even with non-smiling, one would have an open mouth posture or show evidence of mentalis muscle strain when the lips are together. Without true vertical maxillary excess, one has to look at a variety of other compensatory facial procedures like vertical chin reduction, subnasal lip lifts and rhinoplasty (that shorten the facial look) and potentially procedures that increase facial projection. (e.g., cheek augmentation) To determine the potential impact of any of these procedures on your face I would need to see some better pictures for computer imaging. (front and side views that are non-smiling)

Dr. Barry Eppley

Indianapolis, Indiana

Can A Reduction Of My Sagittal Skull Ridge Be Done?

Q: Dr. Eppley, I am interested in skull reshaping, specifically a reduction of a sagittal ridge. Not sure what to expect, I got a high top ridge at the back of my head (covered by hair, so a photo does not really show it) – rising maybe 2.5 cm above the rest of the skull top, which looks strange. Would you have reduction experience for that kind of surgery? Can one expect a great change in appearance. (assuming only 5-7mm can be reduced)? Thanks for your advise. :-)

A: With very high sagittal ridges in which bony reduction alone can not make it confluent with the parasagittal skullbone, one can consider a combined sagittal reduction with augmentation of the areas right next to it. However, the first question to answer is really how much bone can be reduced. In very high ridges the bone may be quite thick and more than the typical 5 to 7mms could be reduced. This would require a CT scan to determine the sagittal ridge thickness and what type of reduction change to expect. It is also possible that in many sagittal ridge reductions I have seen that the bone is much thicker than normal and more may be possible to be reduced. This will be seen in a CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Way To Have A Jaw Angle Implant Revision Done?

Q: Dr. Eppley, I wanted to ask you a quick question regarding jaw implants revision. I  am a 29 year old male and have had silicone jaw and chin implants placed previously. I am very happy with them, however, as time has gone on I feel like the jaw implants could be slightly larger in width(1-2 mm each side at most). I am perfectly happy with the chin implant.  I know you had said this desire for further augmentation is a common occurrence among young men and clearly you were right. I guess my question is a two part question. The first question is if fillers can address the slight augmentation desired, and if so which filler should be used? Any risks associated with this since there is a pocket and an implant already there? The second question is that were you to suggest surgery, would it be a very difficult procedure to remove just the jaw implants and replace them after nearly 3 years? I would of course like to do this as minimally invasive as possible. 

Thank you so much for sharing your knowledge and providing this valuable advice.

A: Whle you certainly can have fillers done, I dount they will be very satisfying in the long run. Since you have jaw angle implants in place, it would be important to make sure that the injections avoid violating the implant capsule under the muscle. I don’t think the type of injectable filler used matters , they all will work. The injection technique is more important that want is placed.

For a permanent increase in jaw angle width, you can either replace the implants you have or use a wafer or wedge technique to augment what is in place alreasy. It is much easier that the first jaw angle implant surgery as you have an established pocket to do either. The simplest, and probably the most the most effective to do what you want accomplsih is the wafer method. This is where a wafer of implant material is put behind the existing implants to create the increased thickness. This does not necessitate the need to remove the implants, merely lift them away from the bone to slide the wagfer of extra material.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Cheek Implants Do I Need For High Projection Near The Zygomatic Arch?

High Cheek Bones Mads Mikkelsen Dr Barry Eppley IndianapolisQ: Dr. Eppley, I’m 21 years old and I have average sized cheekbones. I’ve always dreamed of having very prominent and chiseled cheekbones, such as those of Mads Mikkelsen (even though I’m a girl) that have more projection on the outer corners of the zygomatic bone as opposed to the classic apples in the area below the eyes. I would like to augment a good part of the bone, yet pay much more attention to the area adjacent to the zygomatic arch. Many people would recommend me to aim at a natural and light outcome, but I want a very noticeable difference. I’m also a bit confused about the procedures. So far I’ve read a fair few articles regarding PMMA bone cement as well as Kryptonite and something about Medpor, still I have no clues whatsoever which one would suit my needs best. I would like something that is permanent, that endures time, that is at least as strong as the bone itself and that doesn’t get loose. As to the volume to be added, would it at all possible to have a 7mm or over projection.

A: When it comes to cheek augmentation, it is very important in any patient that the correct zone (s) of the cheek or zygomatic bone is augmented or highlighted. You have described exactly where you want the maximal augmentation to be done (posterior malar) as opposed to anteriior submalar which, as you have corrected stated, is the usual highlight augmentation zone for a female. That is is very helpful as then the correct cheek implant style can be chosen.

When it comes to cheek implant augmentatation material, no form of bone cement would be appropriate. What is used are preformed implants made of either silicone or Medpor material. Both are permanent materials that will never degrade or change shape and when fixed to the bone will be just as strong as the bone underneath it. Their ability to stay in place is more about how the pocket is made and how they are secured than it is about the material. There are advanatges and disadvantages to either solid silicone elastomer ot medpor, but my preference is for silicone as there are many more styles and size options and it is far easier to revise should that ever need to be done.

As for size of the cheek implant, 7mms would be a very strong change and may or may not be too much. Such thickness numbers may seem small but when it comes to putting an implant on your face, it can easily end up being much larger than one would have initually predicted. When  it comes to facial implants,  a slightly too small change is always better than one that is too big…as that will always lead to revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

How Soon After Breast Feeding Can I Have Breast Augmentation?

Q: Dr. Eppley, I’m breast feeding now. How long should I wait after I stop before I come in for a breast augmentation consultation? How soon can I have breast augmentation after breast feeding?

A:You should wait for breast augmentation surgery until your breasts have returned to their natural size after breastfeeding. By so doing you can gauge properly the implant size you need and the type of breast lift if necessary. But one can come in even while breastfeeding to get an initial evaluation and some general information about the combined breast lift and breast augmentation procedure. That will answer most of your questions and help you prepare for the surgery when your breasts are ready. Then you just have to stop in for a quick implant sizing appointment right before the anticipated surgery date. While there is no hurry to get the ball rolling so to speak, you certainly can if you desire.

It is also important to note that many women who have breast augmentation after breast feeding may note that they have some milk production after the surgery. This is due to the pressure of the implants on the milk glands that can cause additional discharge from the swelling of surgery.

Dr. Barry Eppley

Indianapolis, Indiana