Your Questions
Your Questions
Q: Dr. Eppley, Here you have some pictures 3 months post op from my custom malar-infraorbital and custom jawline implants. As you can see all (or almost all) of the swelling in the jaw and chin area has subsided. There is still some swelling (or puffiness) under my eyes but that is slowly improving. To this date is a bit better than in the pictures. The scar under the chin is almost imperceptible and I can shave without feeling anything.The blepharoplasty scar at the corner of my eyes are less noticeable. I am happy with the result and I think it definitely is an improvement. I’d like to ask you about your opinion on a second implant advancing my chin still a bit and pushing the jaw angle a bit backwards (I am happy with the width of the jaw but I wonder how feasible it would be to take it a bit lower and backwards)
A: Thank you for the followup. In looking at your before and after pictures, I would agree that there has been overall improvement in both the eye/cheek area as well as the jawline. It looks natural and not overdone. I would also agree that we certainly did not overdo the jawline (which was an initial concern) and there is room for further chin and jaw angle improvement through a redesigned implant. The good news is that a new custom jawline implant is so much easier the second time because there is already a pocket in place so the trauma of extensive soft tissue dissection is over. Also we have the advantage now of knowing what the existing custom jawline implant does and that makes it much more predictable in terms of how to redesign a new one for added augmentation benefits.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve given it a lot of thought and done some research over the internet. I’ve been having problems resulting from a previous jaw/chin reduction. And I really want my face bone structure to go back to where it was, or close to my original chin/jaw line. I need help and really want a chin/jaw implant(s).
See my chin in 2013 CT scan. A surgeon reduced my chin in 2013, I had a CT scan in 2014 and realised the surgeon took off about 4.27 mm. Until this day, the soft tissue (chin area) just has never felt right. It feels out of place, uncomfortable. I’m always pulling my chin skin down. The chin skin dips down when I smile. (side profile) I have 2 new dimples. My chin area, just right below my lower lip(right side), protrudes when I smile. (very noticeable) I hope this is not to do with mantalis suspension. The stitching line which the surgeon has done does look lower than my original mantalis line along the gum line right below my lower teeth. Saliva also drips, when I sleep, drips down the corner edge of my right side lower lip (I’m not so bothered. But I don’t know if it’s implication of any issue?
I really want my old chin back with a chin implant; hopefully it will solve some problems. I’d rather have chin implant incision under my chin, it sounds like the incision inside the mouth can affect the muscle or tissue affecting the lips?
1. Is it possible, that I have my chin augmented so that it will be the same as my original chin in 2013 CT scan? (Unfortunately, the CT scan in 2013 is all pictures, no raw data, so I don’t know if that CT scan can help in making a chin implant to achieve the original chin size or length?)(However, my new 2014 CT does have the raw data needed to make custom jaw/chin implants. But my chin has been reduced on 2014 CT)
2. What kind of chin implant will I need, vertical or horizontal? (I dare not do chin sliding osteotomy.)
3. Logic tells me I will also need to do a jaw line augmentation to line up with my desired chin. I’m thinking it’s best to do a custom chin/jaw implant. So will this be 3 pieces implant or 1 implant that wraps around? For best results.
4. What material will the implant(s) be made of? If silicone, what kind of silicone exactly? Heard of silastic but usually associated w/ chin implants.
A: Thank you for sending the pictures and a detailed description of your chin concerns. Based on the pictures I assume your chin reduction was done through an intraoral approach. An intraoral approach to a vertical chin reduction should be done by a vertical wedge ostectomy through the middle of the chin bone (vertical reduction bony genioplasty) to preserve the attachments to the bottom of the chin bottom to prevent soft tissue ptosis. (or an empty soft tissue pocket as the chin tissue will fail to adhere to the bone) In looking at the CT scan, and it may be a function of your drawing, it looks like just the bottom of the chin was cut off. (a lower chin ostectomy) That would be a very unusual approach to a vertical chin reduction but would account for many of your current symptoms. This you have two current problems, an aesthetically shorter chin (which perhaps may not be a concern for you) and soft tissue chi ptosis/mentalis sag.
The optimal way to correct these chin concerns is a custom chin implant with a jawline extension as a one piece implant. (one could argue that a vertical lengthening bony genioplasty would also be appropriate but you have excluded that option. While there is no true way to know exactly match your previous chin (since the DICOM data is not available), the design could be reasonably guessed. It is only a question of how far back along the jawline one wants to go. This looks like it would be a pure vertical lengthening chin implant. Such custom chin implants are made of solid silicone material. The term silicone and Silastic are synonymous. The name Silastic was trademarked in 1948 by the Dow Corning company for their silicone polymer product and it is name that is still occasionally used today been though the Dow Corning company no longer makes any aesthetic silicone products.
This custom chin implants should fill in the loose tissue at the bottom of the chin and eliminate that feeling of looseness of the soft tissue at the end of the chin. The only residual concern is that of your salivary drooling and that raises the question of whether mentalis muscle resuspension should be done at the same time. If you have lower lip incompetence/sag I would say yes. But if not I would leave it alone and see effect the chin bone restoration achieves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an otherwise very thin healthy 42 year old female searching for a forehead augmentation solution to my upper forehead contour defect. I had what would be considered minor trauma in 2010 (struck forehead on breakfast bar) with a resultant depressed skull fracture. To fix the resultant indentation I have had 2 fat grafts and several Radiesse injections with no resolution. Is there any hope of a repair with a closed procedure; something akin to Artefill w/o Bovine Collagen (allergic)? Bone graft? Stem cells? Can frontal bone be shaved down to create a smoother contour endoscopically?
A: I am not surprised that your frontal defect in the upper forehead could not be adequately contoured/restored with any of the injectable methods that you have had. They simply will not work for a bone contour defect nor is there are injectable material like fat or any other synthetic filler that will work.
There are a variety of minimally invasive procedures, however, that will work for your type of forehead augmentation. Through a small incision in the scalp (3 to 4 cms) done endoscopically, a variety of implant materials can be introduced to smooth out the upper frontal bone depression. These can include PMMS or HA bone cement or even a small semi-custom or custom implant. These are all procedures that can be done under local anesthesia/IV sedation. The most economical approach would be PMMA bone cement. I will have my assistant Camille pass along the cost of the procedure to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, about four years ago I emailed you with questions surrounding an injury I sustained to my eye and cheek area some 20 years ago. Again briefly, I was assaulted and never had my cheek and eye fixed. Now I would like to because of the appearance I see in the mirror of a flattened left cheek and slight drop under my left eye. I could not have the procedure done when I first contacted you because of the finances and then the collapse of the economy. But now I am in a position to have the work done and I think and feel you are the best doctor qualified for the job. Can you please provide me again with what would need to be do be done as far as if a CT scan is needed, measurements need to be made and things of that nature. In the light, up close and when I smile, I look fine. But when the lights are dimmed and looking at my face from a distance, the obvious damage and asymmetry is noticed. It is as if I can see the imprint of a fist on my face. I want the left side of my face to be even, full and balanced like my right side. I have included some new pictures. Thank you for your time and please respond and help me if you can.
A: I remember your inquiry and your face problem quite well. You obviously had a cheekbone fracture that resulted in flattening of your cheek bone area as well as along the infraorbital rim. Fortunately your eyeball position looks fairly even with the right side (at least based on the pictures) so no orbital floor or lateral canthal work needs to be done. I think cheek augmentation alone should suffice and the cheek implant needs to be put up high on the flattened cheek bone. Fat injections also need to be done to build up the cheek area where the implant will not reach. We could get a 3D CT scan but that will probably not change your surgical needs unless we decided that a custom made cheek implant would be used for the reconstruction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it’s been almost one year since my rhinoplasty. Today I wore snow goggles for about an hour and now I have a red small bump on the bridge of my nose. I’m pretty concerned. I iced it for a bit and it hasn’t gone down. Is there anything else I can do? I don’t want to ruin your beautiful nose work. Thanks!
A: Being a year after a rhinoplasty with hump reduction and osteotomies, your nose should be sufficiently healed to handle any type of eyewear. It is not possible that snow googles would cause any change in the underlying nose structures. It is important to realize that snow googles press on a broader area of the nose than regular glasses and thus cause more pressure. I would suspect that by tomorrow or even later today the red area on the nose will be gone. It may be a year after your rhinoplasty but your nose skin is probably a bit sensitive still. So the pressure from large snow goggles may cause the temporary skin deformity that you are seeing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year old woman. I have attached some pictures for your reference. I would like you to give me your opinion on what you could do to make my shape more curvy. (widen hips, increase buttock projection and decrease waist, back and arms size) I think liposuction to the abdomen, flanks and back plus re-distribution to the buttock and hip area is certainly something I would like to consider.
As you can see in my pictures I also have had a breast augmentation and have been told that these are polyurethane, so they may be hard to remove. I would like your thoughts on what you may do to make my breasts slightly smaller and less projected, but more natural and rounded.
Could you tell me how long I would need to stay in hospital, then in the area before I fly home ( and details of how soon I can fly) Thanks!
A: Thank you for sending your pictures and providing your body contouring objectives. I believe you are correct in the approach to improving your body shape through a combination of aggressive liposuction of the abdomen, waist, back and arms with redistribution of the fat aspirate to your buttocks. That combined procedure has a name and is the well known Brazilian Butt Lift with assured body contouring benefits from the fat harvest and buttock augmentation from the liposuction ‘discard’.
In regards to your breast implants, these are harder to remove than smooth silicone shell implants but let’s not confuse harder with impossible. Most likely they have some degree of encapsulation which makes them look very ‘stuck on’ and firm due to the encapsulation. Removing the implants and their capsule with a slightly smaller volume implant should make them softer and a little less projected. It would ultimately be helpful to know what the implant volume is when planning their replacements and I would probably drop the volume down by about 50cc.
This type of body contouring surgery is done in my private surgery center, not a hospital, where the costs are much lower. Given that you are from afar, I would keep you overnight but you could go back to the hotel the next day. I would anticipate you flying home within 5 to 7 days after the procedure at most.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal and jaw angle implants. But when I get really old would it look like this if I have implants in my face? See the attached picture of breast implants where one is able to see all the edges of the implants. This is a scary picture.
A: It is important to separate what can happen with facial implants vs that of breast implants with aging. The show of breast implants can become more obvious when one loses weight or has very little subcutaneous fat cover from aging. Breast implants are ultimately only covered by the thickness of the breast tissue and if they are partially under the muscle. (which the lady’s implants in the pictures are not) Facial implants are placed next to the bone with a soft tissue cover that is not as influenced by fat loss. (more muscle cover) Thus, facial implants will never get as skeletonized or develop implant edge show as breast implants can. Facial implants are bone implants while breast implants are soft tissue implants. That is a fundamental anatomic difference. Because facial implants add support to the overlying soft tissues they often are a positive additive feature rather than a detraction from aging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do temporal implants for people after craniectomy/craniotomy? Or only for those with wasting from other nonsurgical issues. I had a craniectomy after brain surgery after fractured my skull in a car wreck. Despite the severity of the injury I have made a full neurologic recovery.
However the neurosurgery itself caused a massive amount of temporal hollowing. My neurosurgeon for the last year has said I’d be eligible for 3D custom implants. However after waiting a year and consulting with another doctor who is supposed to specialize in 3D custom implants he told me he had only donetwo temporal implants which both had to be removed and would not do them on me. I’m not sure if there was a further scientific based reason for this as my appointment with him only lasted five minutes. He also said he would not recommend me to get the implants done by anyone else.
I understand these 3D custom implants have been around only shortly since 2013 but I know regular temporal implants have been around for decades. I feel trapped in being disfigured like this and don’t know where to really look for a solution. I’m not sure why my neurosurgeon would recommend me for 3D custom implants for a year and then I’d not be eligible for them or for any cosmetic solution to my temporal hollowing.
Do you take patients from Canada? I would really be relieved to find a solution to this as Canada does not have many plastic surgeons in total and then even fewer that have dealt with cranioplasty let alone anything with soft tissue replacement implants.
A: I have done temporal implants for years for both aesthetic purposes as well as for reconstruction after neurosurgery due to temporal muscle wasting/detachment. The key factor in success in neurosurgery patients is whether they have had radiation to the temporal region or not. With your trauma history, you clearly have not received temporal irradiation. I can not give you a good reason why two separate surgeons would not do a 3D temporal reconstruction on you. Unless there is something that is not clear to me, I can not envision the circumstances where it is not possible. Can you send me some pictures of your temporal deformity and any CT scans that have been done since your surgery. I know the CT scans may or may be available and are not important right now. If based on your pictures I feel you are a good candidate then we would need a new 3D CT scan anyway.
The success of any craniofacial implant reconstruction is the quality of the overlying soft tissue cover. Adequate thickness and good vascularity of the tissues are important for long term success.
I have patients that come from all over the world and Canadian patients, because of proximity to the U.S., are some of the most common international patients I treat.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to remove fat from both sides of chin and redefine my jawline and make my face symmetric again. I had a procedure 3 months ago to remove fat from my cheeks (bichat fat) in order to make it look thinner. I did not attain the expected results as my face doesn’t look thinner but is now asymmetric and it looks like I have a lot of fat on both sides of my chin (makes me look older!). Can you please help?
A: Often surgeons think that taking out the buccal fat pads will make a face thinner when the fullness problem is actually much lower. There are two separate fat compartments between the cheek and the jawline, the well encapsulated globular buccal fat pads located just under the cheek bone and the more superficial and less volume perioral mounds located just under the skin besides the corner of the mouth and extending down to the jawline. Since I have no idea what you looked like before their removal, I can not say whether removing the buccal fat pads was truly the main cause of your facial fullness concerns. But the subcutaneous fat around the mouth and chin (perioral mounds) now looks fuller because it remains unchanged as the area above it where the buccal fat pads are is now thinner. It may be that microliposuction of this fat area would complete the ‘project’ and should help. Whether any fat should be replaced due to the asymmetry above caused by the buccal fat pad removal may be a solution to also consider. It is either that or do further removal on the fuller side. That choice is a matter of your aesthetic judgment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was reading the information over skull reshaping in the site and I noticed that the procedures for narrow skulls are usually done with infants or toddlers but my question is if it were anything that could possibly be done to a 20 year male skull? My skull isn’t exactly large but very narrow and long.the reason I’m asking this question although I am aware that this procedure is most common for toddlers is because I research a few before and after pictures on give and I noticed that some of the males appear to be in their mid 30’s or so. I’m praying that anything could be removed or reduced from the front or back of my skull to make it appear at least close to normal if I am fortunate enough to have this procedure done. Please feel free to contact me anytime of the day. Thank you
A: While the most common treatment for a congenital long and narrow skull is complete calvarial remodeling or suturectomy of the sagittal suture, that is for the infant condition known as sagittal craniosynostosis. That type of surgical approach has nothing to do with treating a long and narrow skull in an adult. Such treatments can only focus on camouflage efforts on the outside as the brain is no longer growing and occupies a fixed space on the inside of the cranial ‘box’. Whether these adult efforts at skull reshaping can be done with frontal and occipital bone reduction (which is limited) and/or widening in between the front and the back awaits analysis of your skull shape. PLease send me some pictures of your head at your convenience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implant replacements. I currently have 400cc saline breast implants in and the plastic surgeon I went to suggested replacing them with 650cc smooth round silicone implants. Based on where I am now and where I want to be (I attached a bunch of ideal breast augmentation results) I do not think he and I are on the same page. I don’t think he understands what I mean when I say extreme breast augmentation. Can you look at all my pictures and tell me what you think. Your reputation as a plastic surgeon precedes you so your opinion would mean a lot to me. Thanks!
A: Thank you for sending all the photos of your breasts and that of your ideal result. Based on how your breasts look now with 400cc implants and their degree of sag and nipple position, none of those ideal results are achievable for your breasts. Your breasts have too much skin and sag to look that high up on the chest or to be that round…regardless of the size implant used. All that can be done is to make them bigger and somewhat more round but getting enough implant volume in place is the key. It is clear to me with these goals that 650cc is not going to adequate. more likely it is somewhere between 800ccs and 1000ccs to be able to fill out your breasts for a rounder fuller look. No silicone implant is made over 800ccs and its weight will make the breasts bigger but not as round as you would like. Only overfilled saline implants will create a more rounder effect as they naturally sit higher and rounder when overfilled. Most likely an 800cc saline implant filled to 960cc to 1000cc will be needed. It would also be important to use an areolar incision when placing such large breast implants to keep the incision at the top of the mound and away from the skin stretching effects as the base of the breast mound. Anytime one gets over 800ccs in implant volume that would fall into the classification of extreme breast augmentation or the use of very large breast implants.
Dr. Barry Eppley
Indianapolis, Indiana