Your Questions
Your Questions
Q: Dr. Eppley, My question is about the limits of a lip lift and the use of one in a postoperative Lefort patient. In most of the pictures I’ve seen it looks like a surgery that merely helps make the vermilion more visible but it doesn’t really “lift” the lip if it’s really hanging. I received orthognathic surgery years ago to make my face shorter and since then my upper lip has been hanging lower than usual. It also looks flat and dead instead of curled up and reactive to facial tension. I was wondering if a lip lift could help in this case and if one with muscle hemming (a technique that I rarely see talked about) would be a better option. Thanks.
A: Your correct in that a subnasal lip lift primarily exposes more vermilion (and reduces the skin distance between the nose and the lip) bit does not lift the bottom edge of the lip vermilion any higher. A subnasal lip lift is largely a static procedure not a dynamic one. Many upper lips after an intraoral vestibular incision used for a LeFort 1 procedure become somewhat less animated due to the stripping of the collateral muscle attachments. I can’t see, however, how a muscle hemming procedure of a subnasal lip lift would improve that problem. It would likely cause other adverse effects on upper lip movement and smiling which is why it is not written about much and is largely shunned today.
If you want to raise the upper lip with a subnasal lip lift it should be combined with a horizontal horizontal mucosal resection on the inside of the lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had eyebrow transplants done 3 weeks ago with 50 FUEs to each brow area, I’m looking to get a rhinoplasty with a silicone implant done a month from now. Can I just check and see if it will be fine to do so or will my grafts be damaged if I get a rhinoplasty done so soon after? My surgeon says it is fine but I wanted to get some additional expertise from someone of your professional caliber.
A: The follicle of a hair transplant has taken by two to three weeks after being placed. The hair shaft will have exfoliated by then but the transplanted follicle lies deep to the skin surface where it will be unaffected by any external forces. It will cause no harm to recently transplanted follicles to have a rhinoplasty done one month after the hair transplantation procedure. In fact hair transplantation could be done at the same time as a rhinoplasty if it were not for several logistical issues. (e.g. time of the procedure and the typical environment (office ) where most hair transplantation procedures are done) Rhinoplasty even using a silicone implant will have no negative impact even on hair transplants that are so new.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Three years ago I had a functional rhinoplasty with adenoids were removed and turbines shrunk which has dramatically changed my voice. My nose and face have changed. The flesh all around my nose, the triangle from under my eyes down my cheeks and under my nostrils / tip of my nose has completely sunk. It is fixed and depressed against the bone of my skull. My top lip has flattened and hangs lower over my teeth. The nose tip is also thinner and lower. I am interested in a pyriform implant a surgeon here recommended that might support the base of the nose off of my skull again and lift the flesh up with it. It is a concave depression right now I keep poking out with my tongue over my teeth. Also my cheeks have sunk either side of the nose so I have folds and have lost my natural volume over my naturally high check bones. I had a young face but have aged over night. My eyes look sunken and everything pulled down as if the implants fixed my cheeks inwards and down. I have seen different surgeons and there is no consensus between implants or fat grafting but I also feel as if my cheek and lip muscle around my nose need lifting back into place. I keep being told I am attractive and too young for a face lift. I feel as if no one is listening. I seem to be researching similar treatments as cleft palate patients. Between the nose and lip and around the nostrils up to the eye are indented.
Please find attached some pictures for your review. You can see how my lips jutting out under the lip and the front of the cheeks is flat, particularly indented on either side of the nostrils and where the mouth cheek folds are. I look forward to hearing from you.
A: Thank you for sending all of your pictures. You have a classic central midface deficiency. It is really a combined per maxillary-paranasal-maxillary deficiency which is commonly seen is certain ethnic groups. (e.g., Asians) The whole central part of your face is flat. While a peri-pyriform midface implant will be somewhat helpful it is inadequate in both design and size for your needs and its benefits alone will be woefully inadequate. By itself it will not provide fullness (more like bumps) to the side of the nose. What you ideally need is a custom midface implant made that will build up the entire deficient mid facial area from around the base of the nose up along the sides of the nose and out onto the maxilla. In addition the tip of the noses not going to be lifted up by any augmentation done at the bone level including the premaxillary region. Deprojection and lifting of your nasal tip will require a tip rhinoplasty to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a skull implant for my child. What is the youngest age you would fit a pediatric skull implant to a child? Can it be done under local anesthesia?My son is three years old.. He has plagiocephaly of 6mm and 92% brachycephaly. Would he be suitable for a skull implant? Would he need more surgery as he got older? How many children have you fitted with head implants? Many thanks for your time.
A: I have done onlay cranioplasty surgeries in children as young as 4 years of age using hydroxyapatite bone cements. I have yet to use a silicone skull implant in someone that young although there is no specific medical reason not to do so. It is just a request I have never had. An onlay skull implant would grow with the child as the bone underneath it expands outward. There may or may not be some settling of the implant into the bone a e] millimeters as the skull grows but this is a passive process not an active inflammatory or ‘erosive’ biologic event. If his occipital deficiency is 6mms I would preferentially consider preferentially consider bone cement but I am not opposed to an implant. Either way these are not procedures done under local anesthesia in children. Please send me a picture which shows his occipital plagiocephaly deformity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 35 year old man interested in a cranioplasty procedure. I haven’t been able to find a plastic qualified surgeon who is capable of performing cranioplasty in my or neighboring countries. There is a clinic in Korea. However their method is not predictable since reshaping given by surgeon at the time of operation by using bone cement requires a bigger incision. I have to undergo skull reshaping surgery due to a flat back of my head as well as the top head which is also flat head on top. In addition forehead recontouring and hair line lowering needs to be done. These procedures must be done in same session because of scalp efficiency concerns. In my case I guess scalp tissue expansion is gonna be first stage prior to skull augmentation in order to achieve maximum silicone implant thickness and to allow the hairline to come forward. I have copies of 3D CT scan in my hand so would please let me know which steps will be taken from now on? Kind regards.
A: You are correct in that those cranioplasty or skull augmentation areas and hairline lowering procedures would require a first stage scalp expansion procedure. I would need to see some pictures of your head as well as eventually a CD of your 3D CT scan. Given that you desire a combined hairline lowering and skull augmentation, the custom designed skull implant would need to be placed through the frontal hairline incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I practice plastic surgery in Chicago. I attended a cadaver course on facial implants last year in Las Vegas where you gave a superb number of lectures on a variety of facial implant procedures. I have a question regarding temporal implants and which tissue plane to place it in, I can not remember exactly what you said. From what I remember, it was placed under the superficial layer of the deep temporal fascia (on the temporalis muscle). Is that correct? Also, what would be the reason to not place it on the fascia? Thank you for your time.
A: Temporal implants should always be placed in the subfascial tissue location. (under the deep temporal fascia and on top of the temporalis muscle. Temporal implants should NEVER be placed above the fascia. Placing temporal implants in this area is what has caused them to be described as a bad procedure due to complications. When temporal implants are placed above the fascia the outline of the implant will be seen when the swelling goes down…not to mention the potential risk of injury to the frontal branch of the facial nerve in placing it in this more superficial tissue plane.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been interested in upper lip advancement (vermilion advancement) for a few years. My lips are full but very narrow toward the outer third. is there a maximum measurement of lip advancement that can be done in this area?
A: A vermilion lip advancement can be done to any part of the lip or its entirety. The only limits to vermilion advancement are aesthetic…you do not want the sides of the lips obviously fuller than the central part. Vermilion advancements of the outer third of the lips are not rare in my experience as many people have adequate central upper lip fullness but it tapers quickly down the sides into the mouth corners. This vermilion arrangement creates a mismatch between the vermilion fullness across the upper lip. Advancing only the sides of the vermilion upward is a simple and permanent solution to this aesthetic lip shape imbalance problem. It is done in the office under local anesthesia. There is usually minimal swelling and no bruising with a very quick recovery. The change in the vermilion shape is instantaneous and permanent. The only trade-off is the small fine line scar at the vermilion-cutaneous junction which certainly needs to be carefully considered.
Dr. Barry Eppley
Indianapolis, Indiana