Do You Prefer Silicone Or Medpor Facial Implants?

Q: Dr. Eppley, from my research and various consultations, I believe Medpor facial implants is the way to go. I have heard that with silicone it will eat away the bone’s density as it has shown on my latest CT scan. (which was sent to you also)  Over years will the bone keep deteriorating from the silicone? What is your opinion on both types? pros/cons?

A: Whatever you have heard about silicone facial implants is both inaccurate and untrue. It does not cause any deterioration of the bone. That is an occasional passive phenomenon in the chin where the implant may settle into the bone from the pressure of the overlying muscles if the implants are placed too high on the chin bone. It is a simple passive phenomenon and not an active inflammatory process, It is never seen beyond the chin area in my experience.

I have used plenty of both silicone and Medpor facial implants in both primary and revision work. I could detail all of the advantages and disadvantages of each but, in short, if I never could place another Medpor implant I wouldn’t. (I still do when patients want but I have yet to see any advantages with its use and there are plenty of disadvantages) It costs more, has a higher rate of infection (as any textured surface implant does anywhere), is difficult to place, requires longer incisions to insert, is harder to modify, and poses a real problem when it comes to revisional surgery. (and remember even with custom implants the revision rate is not insignificant in the young male face patient) Whatever benefits they may be to some tissue ingrowth are overwhelmed by all of these disadvantages and screw fixation easily eliminates its only one advantage. (tissue ingrowth = implant stability) Over the years I have come to one conclusion about Medpor… it is an implant material that is really a poor choice for facial implants but it has been around so long and is an alternative to silicone that doctors keep trying to make it work.

But some patients are very emotional in their decision for Medpor although the logic of its use does not meet the scientific test for being any better than silicone. (and is a much worse handling material) But if that is what the patient wants, I will use it most of the time unless I feel it really compromises the ability to get the desired result.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need Facial Implants Or Fat Grafting?

Q: Dr. Eppley, I have some questions about facial implants.  I had a square chin implant and paranasal plus midface rim implants placed one month ago. I’m happy with the augmentation they’ve provided, but they haven’t exactly addressed the areas I really wanted augmented. I’m aware that there’s still quite a bit of swelling, but the parts of my face that were initially deficient now look worse in relation to my augmented mid-face and chin. Here are my questions:

1) It has been 4 weeks since I had these implants placed. Given your experience, what % of swelling is there still remaining?

2) The paranasal implants have given me mid-face volume, but the area that I really want augmented is the areas under the nose and above the upper lips. I’m looking to make that region more convex to obtain a ‘step off’ between the upper mouth and the mid-face. I’ve done a bit of research, and I suspect I may need premaxillary implants. 

3) I had this weird issue of there being some kind of ‘jowl lines’ from my lower lips to the sides of my chin. The chin implant does seem to have exacerbated it, and I don’t think implants are going to address the issue. I’m not sure what has caused it, but the region below my lower lips appears to be more convex relative to the areas to the side of it, which is what gives the appearance of jowl lines.

Anyway, do you think that fat grafting to the perioral and upper chin region will address it? Further, if I’m getting fat grafting done, should I consider getting fat grafts placed in the premaxillary region too? Could you kindly give me your professional advice on my options to augment these areas?

A: At just four weeks after facial implant surgery, you probably have about 75% of facial swelling reduction. But the remaining 25% of facial swelling and soft tissue adaptation to the new facial contours will take several months to resolve.

Facial implants are generally designed to provide augmentation of facial skeletal areas that are flat or convex in nature. They are not effective for concave facial areas that are not supported by bone. Thus, premaxillary augmentation is best done by an implant while the jowl areas above the jawline are better augmented by fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Can Facial Implants Help Rejuvenate My Face?

Q: Dr. Eppley, I am considering facial implants to rejuvenate my young but old-looking face. I am 37 years old and underwent gastric bypass surgery two years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye. I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows .I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change…not me… I want a drastic change. I lost over 1090 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.

A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

How Soon Should I Revise My Facial Implants Again?

Q: Dr. Eppley, I had custom chin and jaw angle implants placed four months ago and then I had them revised with new implants two months ago. While it is much improved and is almost what I want, I think I need another surgery. How soon should I have another jawline implant surgery again, I am ready right now?

A: While I am not your plastic surgeon, I do not agree with any patient changing their facial implants repeatedly over very short times. Making facial structural changes before 9 to 12 months short of some major aesthetic problem is often premature. You have been through two surgeries over a short postoperative period of time and now you want to change the look again…before you have ever truly seen the final result and before you have had time to psychologically adjust to your new look. Perhaps you have learned that, despite all the preoperative predictions and planning, that it really isn’t the look you want or maybe achieving that look isn’t even possible. I am not looking for an explanation nor do I want one from you as to the logic of the desire for another surgery, it is just this decision just seems very hasty sitting from my perspective.

The other equally important reason that I advise against prematurely jumping in and changing facial implants is that each surgery carries risk and the more surgery you have the greater likelihood that one of those risks will occur.  Every surgery always involves some form of a trade-off and each new surgery creates the opportunity for a new problem to appear. The dreaded one, of course, is infection. Just because it has not occurred before, each new surgery involves a new spin of the wheel so to speak, and repeated surgeries increases that risk.

I say all of this because a patient’s decision to undergo any revision should be based on the severity of the problem versus the degree of risk involved. There does come a time when the balance between those two should give one pause for reflection.

Dr. Barry Eppley

Indianapolis, Indiana

Does The Thickness of Facial Implants Create The Same Change On the Outside?

Q: Dr. Eppley, you have written in regards to facial implants that the translation of bone augmentation to an exterior soft tissue facial change is not a 1:1 ratio. Does this mean that a 3mm malar implant may not necessarily provide 3mm of augmentation? If so, do implants tend to give more or less augmentation than their specified dimensions? Additionally, what is the reason for it not being a 1:1 ratio?

A: The reason that augmentation of bone (a hard substance) does not translate exactly to the exterior surface of the overlying soft tissue is the compressibility factor between the two different types of tissues. If the enveloping soft tissue was as hard as bone then augmenting the bone would create an exact 1:1 ratio translation. But the soft tissue of the face has varying  thickness and is soft, thus pushing on it from below is somewhat ‘blunted’. Thus the ratio of bone surface change to external soft tissue change would be less than an exact 1:1 relationship. This would be influenced by the thickness of the overlying soft tissues. The thicker it is, the less is the 1:1 relationship, the thinner it is (less fat) the closer it is a to a 1:1 relationship. This phenomenon is well established in orthodontics and orthognathic surgery where these hard:soft tissue relationships have been studied by cephalometric analysis.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Facial Implants Will Help A MIdface Deficiency?

Q: Dr. Eppley, I have been diagnosed with a mild midface deficiency.  I would like to have this corrected to end up with the most aesthetic appearance possible. I have been reading about facial implants and the work you have done with them. I would like to achieve a reduction of the depressions on either side of the nose, reduction of the heavy creases going down to the corners of my mouth and better projections of my face to make it look less wide and flat. In addition I am also interested in lip implants. I already have some lip implants placed. They were the type that look like spaghetti and the size was 4mm top and bottom. I would like to add to these to make my lips bigger. Specifically I would like to show more of the pink lipstick area rather than just make them stick out more. I would also like to bring the implants out to the edges of my mouth to make the lips and mouth appear wider.

A: When it comes to facial implants, there are a lot of facial changes that they can make…and there some changes that they can not. For a mild midface deficiency, consideration can be given to paranasal implants to bring out the base of the nose and anterior submalar implants to provide some upper midface projection. The lower nasolabial folds as they approach the corners of the mouth will not be affected by any bone-based implant. This area is best treated by fat injections.

In regards to the lips, you either have more recent Permalip silicone implants or older style Advanta lip implants. Either way it is not a good idea to double stack lip implants as there will be a great tendencey to have them roll or twist on one another. You may exchange them for the largest 5mm implants but, for the sake of a 1mm increase, that is not likely to make much of a difference. Furthermore, some of the lip changes you desire can not be achieved by lip implants. No implant will increase the vertical height of the vermilion (pink lipstick area) nor will they make the corners of the lip appear fuller or wider, they are too thin in this area. To make these kind of lip changes, you will need to consider a vermilion or lip advancement procedure which directly changes the location of the vermilion…which is what is needed to make the type of lip changes you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Will Facial Implants Help Rejuvenate My Face After Weight Loss?

Q: Dr. Eppley, I am considering facial implants to rejuvenate my youthful face. I am 27 years old and underwent gastric bypass surgery 4 years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye..I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows..I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change..not me I want a drastic change. I lost over 160 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.

A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Medpor Facial Implants Be Removed Without Causing Problems?

Q: Dr. Eppley, I had Medpor infraorbital rim and paranasal implants placed last year. The recovery was uneventful, but I’m hoping for further augmentation that’s more suitable for my face. This is why I’m contemplating getting a custom made implant for the entire mid-face region. However, my biggest concern is with removing these implants. I understand that Medpor removal comes with its risks. Assuming that I’m willing to undertake these risks, can I just check if it will at all be possible to remove the infraorbital rim and paranasal implants? If so, what kind of soft tissue damage can I expect? Would any tissue resuspension be necessary, especially if I were to replace them with the custom made implants in the same surgery? Thanks!

A: Having done a lot of Medpor facial implant removals, I have yet to see an implant that could not be successfully removed. There really is no risk with their removal other than the swelling which naturally occurs afterwards which usually isn’t worse than the original implantation surgery. I don’t think there is any risk of soft tissue sagging with their removal particularly if replacement implants are being simultaneously inserted.

Dr. Barry Eppley

Indianapolis, Indiana

How Likely Do Facial Implants Need Further Surgery After They Are Placed?

Q: Dr. Eppley, I have been looking into getting facial implants, specifically chin, cheek and jaw angle implants, now for quite some time. During my time researching these procedures I have come across many reputable sources of information, like yourself, and millions of internet experts professing to know the ‘truth’ of some sort of another regarding facial implants. Nowhere amongst all this are clear and unambiguous answers to some of the most basic questions. Hopefully you can provide these for me. My questions are as follows: 

1. If a chin, cheek or jaw angle implant is placed, the surgical wound heals, all is well and the patient loves the result several months after the operation, what is the likelihood that the implant will become infected years or decades later.

2. In your experience, if an implant is placed uneventfully can the patient then go on to live for decades having ‘forgotten’ about the implant, so to speak? I don’t want to have to come back to any implants later in life, I want to have my first cosmetic surgery and then forget about it forever.

3. Is the removal of an integrated Medpor jaw angle implant as difficult as it is said to be? Also, is there a silicone jaw angle implant that can provide the so called drop down effect?

4. There is a lot of confusion regarding cheek implants for men who want their cheekbones to flare out laterally. Do you think it is a deficiency in zones 1 and 2 of the malar-zygomatico complex that needs to be corrected in order to achieve the male model look? If so, are custom cheek implants capable of achieving this in the right individuals 

5. Individual implants will not make a person look radically different. Is this something that can happen, for good or ill, when several implants are placed at once?

A: In regards to your questions about facial implants ( cheek, chin and jaw angle implants), my answers are as follows:

1) The risk of implant infection is greatest in the perioperative period (first month or two after surgery) usually as a result of implant contamination during placement. Delayed facial implant infections are very rare. not impossible, but it would require contamination into the implant capsule like from a dental local anesthetic injection. Delayed infection risks are so rare that they are almost case reports for the literature.

2) If one has uncomplicated healing and is pleased with the size and symmetry of the facial implant result, having them will quickly become a ‘natural’ part of one’s anatomy and they will be forgotten as being a synthetic extension of one’s face.

3) Medpor implants,including those of the jaw angle, can be removed and I have removed many of them. They are much more difficult to remove than silicone implants but that is an issue of relativity. Silicone facial implants are so easy to remove that anything that is more adherent seems difficult.

New styles of vertical lengthening silicone jaw angle implants are now available. I designed them to provide a better implant material to that of Medpor. They are much easier to insert and replace/modify if necessary.

4) The concept of getting cheek implants to achieve any type of facial look is more ambiguous and harder to achieve that most would think. The cheek area is a complex four-dimensional structure and the interpretation of what is a pleasing shape is as variable as the anatomy of each person’s cheek bones. It frequently is not as simple as just pulling an implant off the shelf, regardless of its style and size, and the desired look is achieved. Even using custom designed implants is not a guarantee that the desired look can be achieved as the ability to translate a design to what it makes the outside of the face look like is not a mathematical one. Many men seek the so called ‘male model’ look which often but not always means a high angular skeletonized cheek look. You would have to define what cheek look you are after by using model pictures as examples. While all of them are models, many of their cheek shapes are quite different.

5) The more facial implants that are placed, if they are not properly sized, the more different one can look.

The one caveat I would add to all of this is a basic fact based on my very extensive experience with male (almost always young) facial skeletal augmentation surgery…such patients have a remarkably high revisional surgery rate which approximates 50% or greater in the first six months after surgery. These revisions are almost never because the implants have any medical problems but because many young men are impatient of the healing process and often are uncertain if they like the aesthetic outcomes of their procedures even if it is exactly what they thought they wanted. Thus, when you think about getting facial implants this revisional surgery issue is what you need to consider, not all the other concerns that you have mentioned which are fairly irrelevant compared to this consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Will Facial Implants Give My Face A Model Look?

Q: Dr. Eppley, I am interested in getting facial implants and am gathering information about getting plastic surgery. My intention is to improve my facial features with facial implants and cosmetic plastic surgery. I would like to get your professional impression and advice to enhance my look. 

The areas that I would like to improve are: 

- Jawline. I think I have an elongated face. So, I am looking for a more square and strong jaw.

- Cheeks and Eye Hollows. I am starting to notice some eye hollows. I think I do not have a strong features in this area, they are somehow “flat”. At this time, it is not bad, but I believe with time they will get more pronounced. 

- Upper Eyelids. I notice that I have extra skin on my eyes lids, especially on my left eye.

-  Any suggestions to make the face more aesthetically balanced and harmonious with the rest of the face.

Concerns:

- I am concerned about the scars and the surgery around the eyes. I do not mind internal scars but external incisions concern me.

- What is the material used for the facial implants? I read about Silicone, Medpor and Gore-Tex. I would like to know your impressions about these materials, and their pros and cons, and why you use ones over the others.

- Asymmetry, implant shifting and/or misplacement (due to position, scarring, etc.)

- Final look. I would like to look natural and not “done”. 

- Revisions. What is your policy in case of revisions?

- Complications during and/or after surgery. What is your policy in case of complications during the surgery and/or after the surgery? nerve damage?, secondary effects?, responsibility, cost, etc.

- Bone erosion with implants over time. What is going to happen with the implants when I get older. I am 30 years old at this time. What is going to happen with the implants and the bones when I am 85-90 years old? the implant, the screw, the bone. Is there any research done about this? 

Ideal:

- I can imagine you have heard this before, but I would like to get the “model” look. Strong, symmetrical, pleasing features. I attached some photos of some ideal looks, by all means I don’t want to look exactly like a specific “celebrity” or “model”, it is just an idea of the look I am looking for. 

Questions:

- Could you provide me with your professional impressions about the surgery/ies that I will be benefiting from, their related costs and results?

- Do you provide any imaging about the possible results. I attached photos of my face in different angles. 

- What are the difference between conventional and custom designed implants? what are their costs?

- How long will I have to stay in Indianapolis after the surgery? 

- When would I be able to return to my normal life work, exercise, being in public, etc?

- How much discomfort should I be expecting in the surgery?

A: I have done some computer imaging on your face for the various facial implants for the following procedures:

1) Square chin augmentation

2) Vertical lengthening as a well as width expansion jaw angle implants

3) Cheek implants

4) Fat injections to the lower eye hollows/tear troughs

In answer to your questions:

CONCERNS

- there would be no external incision with fat injections

- implants would be silicone, best because of better shapes and easily reversible or modifieable

- all implants would be screwed into place

- natural comes from not using too big of implants, particularly when multiple implants are being used.

- we have a complete page of the revision policy which you would get to read before surgery.

- bone erosion is a non-issue. The implants will look the same decades from now as they will one year after surgery.

IDEAL

- you are correct in assuming that every male who wants this kind of surgery wants the ‘male model’ look. Those who have a chance to come close to that look have to have thinner faces and some decent underlying facial bone structure…you are the uncommon one that actually fulfills these criteria.

QUESTIONS

- I have attached some imaging predictions for your review. I will have my assistant pass along the costs to you in a day or two.

- you should be fine with standard implants. Custom implants are always ideal but at the additional costs of $7500 they had better provide a real difference…which in your case they do not.

- 2 to 3 days, all based on how you feel.

- that is based on how you feel and look, somewhere between 10 and 21 days after surgery.

- jaw angle implants provide the most discomfort, the other procedures are much less.

Dr. Barry Eppley

Indianapolis, Indiana