Your Questions
Your Questions
Q: Dr. Eppley, I have some questions in regard to temporal implants:
1. Are there standard implants for augmenting the whole temporal complex? or just the anterior portion?
2. What the procedure be should the implants become infected post operative or years later?
3. How many days would I need to stay in Indiana for recovery?
4. Could an endoscopic brow lift be preformed at the same time through the same incisions?
A: In answer to your temporal implant questions:
1) Standard temporal implants only exist for the anterior temporal region. There are special design or custom temporal implant options for the posterior temporal region.
2) I have never seen a temporal implant infection. But if it would ever occur, like all implants, it would occur within the first month or so after surgery. It would not occur years later. The standard treatment for implant infections is removal.
3) 1 to 2 days at most would be all the time you would need to be here before traveling home.
4) Endoscopic browlifts require more superior scalp incisions to perform not lateral temporal incisions. As a result an endoscopic browlift could be performed at the same time as the placement of temporal implants. In fact the same high temporal incision could be used to perform both of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m needing some information on the ultra-soft testicale implants you talk about in you blogs. I have had a semi-solid Promedom implant placed three weeks ago. Now I find it is a bit harder than my other natural one, so are the soft implants you mention softer and more natural feeling than the Promedom semi-solid elastomer ones? Are they silicon gel filled or just a much softer elastomer? Which company makes and supplies them and how could I purchase them here in my country?
A:I can not speak to how the Promedom testicle implant compares to the ultrasoft testicle implants that I use here in the U.S. since I have never felt that implant before. I also have no knowledge of its silicone composition or properties. But due to the lowest durometer silicone that is used in my custom testicle implants and I have yet to see a patient state that it is too firm, I would guess that it is a softer solid silicone material that what you have currently in place. The testicle implants that I use are exclusively provided to U.S. surgeons based on FDA requirements and guidelines. How to get them in your country is a question for the manufacturer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, let’s say a patient is interested in permanent lip augmentation. From research, Ive found the only permanent options are a lip lift, fat graft to the lips (but it’s controversial as many have reported it deflating too soon) and the silikon 1000 injections. My concern with the lip lift is the scarring, especially because I have olive-dark tone skin and have read that those with darker pigmentation are more prone to keloid scarring. If I were to treat my skin to become lighter, does that help with the issue of dark skin = keloid scarring? I’d really like a lip lift as it seems the only permanent option.
A: For the sake of clarification, there is also two other permanent lip augmentation methods, a lip or vermilion advancement and internal mucosal V-Y advancements. So there are a few other options of which the concerns about scarring exist with the one (lip advancement) but not with the other. (mucosal rollout)
I have done many lip lifts on dark-skinned patients and I have never seen any adverse scarring issues such as keloids. So this would not be a major concern based on my lip lift experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I am currently 6 months after my rhinoplasty and chin implant and I am unfortunately more than disappointed with the results. I went in with my nose being my main concern and my plastic surgeon was very adamant about giving me a chin implant, as a lot of surgeons suggest doing with rhinoplasties. Because I trusted him and his work, I agreed to it. I wanted to wait to do the implant at a later time, thinking it would be too much all at once, but he thought it would be best to get it all over with at one time. Well, I should have stuck with my gut, because I was right- the results are too much. I wanted a new nose, not a new face- and with the two, I just don’t feel like myself anymore. I realize I had a small chin and maybe the way my chin is now, might be aesthetically perfect to others, but it is not me and I wish I could have loved myself for what I was. I went to my 3 month post-op appointment to voice my concerns with my plastic surgeon, because not only am I not pleased with my implant, but I am going to need a revision rhinoplasty. He looked at me in disbelief, telling me he was disappointed in me and that anyone else would be thrilled with their results- that what I’m seeing is psychological. I can assure you, I am not feeling good about myself, but I know I am not seeing things. When telling him I didn’t like my implant, he told me getting it out would be the biggest regret I would ever make and that the procedure is extensive and complicated. Right now, I just want to get back to feeling and looking like me again. Being that I am so early in my recovery for my nose, having this implant removed is all I can do and I really would love your input. I have done a good amount of research and I am terrified that I’ve made a huge mistake. I keep reading about people getting their implants removed and their lips/chins being permanently numb, hard, or they can’t move their mouth properly.. or they have the sagging skin, dimpling, etc. A big dislike I am having with this implant is that it has changed the way I talk, amongst other things. I had such a petite face/chin before and although this may be a small implant, it was enough to change my look completely. And to me, not for the better. I have tried to look into doctors who specialize in implant removal and did not have a lot of luck- it seems like a lot of doctors are able to put them in, but are not as experienced in taking them out. I just really want this done the right way, or not at all. I don’t want to be stuck like this for the rest of my life, but I really can’t handle dealing with anymore bad results. You were one of less than a handful of doctors that popped up right away in searching the removal of chin implants- Can you please give me some insight?
A: Thank you for your inquiry. It is always disheartening to hear of unsatisfactory aesthetic outcomes from any form of plastic surgery whether it is my patient or another…so I do feel your psychological pain. I always do preoperative imaging on any facial reshaping change to be certain that the patient likes their predicted new face. That may or may not have been done in your case. But either way it is irrelevant now. You have done the definitive test, you have worn this chin augmentation result long enough to know whether you like it or not.
A silicone chin implant removal is very straightforward and far less ‘complicated’ than putting it in. While the implant is small and has not been in for very long, and the risk of any soft tissue sag is low, it may be beneficial to do a little soft tissue tightening internally when it is removed. But based on how you feel, just get it removed ASAP and get back to the lower facial shape that you know.
The picture being painted that a chin implant removal is complicated and will lead to other adverse issues is not accurate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know that facial fat is a very difficult thing to address.
If you are young and have exhausted both options of Buccal fat removal and facial liposuction and still have an unacceptably fat and heavy face, how feasible would it be to get a face lift to address the deeper and superficial layers of fat by dissection? I know In older patients who get face lifts often everything is opened up and can be fully accessed and at times fat is taken out. I know the issue with taking out fat in the face is that it can’t be accessed easily since a lot of it is intermingled in different soft tissue layers. Wouldn’t a full face lift allow a surgeon easy access to all of it to dissect, remove and split carefully?
Can this be done with a younger patient who desperately wants a leaner face even at the expense of face lift scars?
Also what’s your opinion on Kybella for facial fatness beyond by chin?
A: In answers to your questions about facial fat reduction:
1) Kybella will be useless for our facial reshaping concerns.
2) A lower tuckup facelift will offer improvement. You are correct in that regard. But it is not really the result of fat removal, it exerts its effect by tissue lifting/tightening along and above the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested to read your comments regarding augmenting the skull area: ‘Kryptonite Bone Cement, can be injected through a very small incision (10mms) and shaped until set from the outside. ‘m (injectable cranioplasty) Would this procedure be suitable for expanding the cranium, beginning from above the forehead, top of the cranium ending at the back of the top of the head, as this is where I would require augmentation, the highest area to be approx 3cm in height? Also, what would be the cost? I look forward to hearing from you at your earliest convenience.
A: In answer to your question, both Kryptonite bone cement material and the concept of an injectable cranioplasty using it have been abandoned. While there may one a role for injectable cranioplasty for very small cranial defects, it is a technique that will not work for larger skull augmentations due to irregularities and lack of contour control.
While I commonly do large skull augmentations, this is done today using custom designed skull implants from the patient’s 3D CT scan. This ensures control of the surface area coverage and shape of the skull augmentation in a precise manner. In larger skull augmentation, like the 3cm thickness to which you refer, this would require a first stage scalp expander to generate the soft tissue coverage required of such a large skull augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in rib removal. I was wondering how much of the 11th and 12th ribs you remove during the procedure? Also, what is the risk of post-thoracotomy pain from the procedure? And what do you do with the intercostal nerves that run below the ribs when you do this procedure? Thanks very much.
A: In answer to your rib removal questions, the ribs are removed back to the lateral or outer border of the erector spine muscles. More medial resection towards right spine has no aesthetic benefit. There is zero risk of pneumothorax in removing ribs #11 and #12. The pleura of the lung sits higher than at these rib levels in most patients. I have only see the pleura one time during surgery at the level of the 11th rib. The intercostal neurovascular bundle, located on the inferior side of the rib in a bony groove, is dissected out and preserved throughout the extent of the rib resection out to their cartilaginous tips. Intercostal nerve blocks with Exparel anesthetic are administered at the end of the procedure prior to wound closure to help with decrease the immediate postoperative pain during the first few days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, in Europe and Australia, PEEK has recently come into use as a facial implant material, particularly being advertised for its ability to be custom manufactured/shaped for the patient.
One of the supposed benefits of this new material is that it is very similar in density and hardness to bone. However from reading your blog posts on Medpor vs silicone or ideas like titanium implants, it seems to me that this is irrelevant and that silicone remains both cheaper and easier for surgeons to use?
Would there be any advantage at all to this material or is it just a case of people trying to reinvent the wheel?
A: PEEK and any other firm rigid polymers as a facial implant material have a role to play in reconstructive surgery but not so much in the aesthetic patient for two primary reasons. First and foremost there is the surgical access needed to place the material. A rigid implant requires wide open incisional access or, at the least, longer incisions and a much bigger implant pocket. This is a major disadvantage over more flexible materials like silicone which can be placed through smaller incisions and then acquire the feel of bone when the backing on which they rest is bone. Secondly, custom designing of a PEEK implant is far more expensive than that of other materials like silicone often being 2X to 3X more expensive.
In conclusion, there are numerous other technical issues than can overtake whatever theoretical material advantages a facial implant material. (ease of placement and removal as well as cost being major considerations) While feeling ‘like bone’ may seem advantageous, that very material property is equally if not more potentially disadvantageous.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i had my chin implant revised last year as it had shifted after ten years. A surgeon repositioned the implant intraorally but i did not like the look. I subsequently had it removed a thereafter as it got infected as well. The surgeon who removed the implant saw fit to inject me with HA filler on my chin as i was afraid that it might lose its shape once the implants was removed. Another doctor gave me another injection of HA filler last year as well.
All in all everything seems to have been one mistake after another. I am now diagnosed with ptosis of the chin. i have good lip competency but it is not without some effort. i also feel the shape of my lip quite different from before and it feels sort of loose, like it’s been stretched out and is a little bit slack. It has been recommended that either a Medpor chin implant or a genioplasty should be done although all the doctors I have seen say they haven’t seen many cases like mine though.
So I went reading on the internet and it seems you have a lot of experience with cases similar to mine. Might you be able to help me with. chin implant replacement?
A: What you undoubtably have after having a chin implant removed is exactly what you described…a stretched out soft tissue chin pad. It is being partially supported now by the HA filler but that is not the same as a chin implant replacement as either a new chin implant or a sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana