Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a custom skull implant replacement. I am a patient of yours from 2014. You performed a successful skull implant surgery on me and I am extremely grateful. There certainly has been some improvement in my life – it usually takes a bit less time for me to get ready, etc. However, as I know that you offer 2 stages of the custom implant – one which entails using a spacer to enlarge the implant area, and I opted for the one-time only option, I was wondering if there is any ability to have a second surgery? I guess I am wondering if the first implant itself might have acted as a spacer of sorts, creating more room for a larger implant now? I truly don’t mean to sound vain or ungrateful, as the first implant surgery has absolutely helped! But I am still struggling more than I would like… I understand if this is not an option or simply a procedure you do not perform, but I thought it was worth asking before I gave up. I am not a body dysmorphic person or someone who will continue to seek the “next thing.” It’s really just that I am still relatively young, and with the efforts I am still having to make with my hair, to get ready, go swimming, etc, it makes me sad to think of spending the rest of my life this way. I was hoping to achieve (if possible) another few mm at the top and upper sides of my head. Thank you for your time, Dr. Eppley. I know you are very busy and I hope this email doesn’t find you rolling your eyes at someone who is ungrateful. Please know that is not the case.
A: Good to hear from you again. Your supposition that an indwelling scalp implant can act as a spacer or tissue expander is completely correct. A second skull implant (custom skull implant replacement) can be placed that is usually double the thickness of the first one (9 to 18mms in your case) as the scalp has had time to stretch and relax to accommodate its volume. Placing the second jmplant is usually a bit easier on the patient since much of the pocket (separating the scalp from the bone) has been done from the first surgery. As you may guessed, this is not the first time I have had this request so there is no eye rolling occurring. In reality this is just a different form of a two-stage skull augmentation approach…it just occurs over a longer period of time. And the good news is that I have not yet had anyone want to go on to a third skull implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: D. Eppley, I have some technical questions about custom jawline implants. The implant looks like solid silicone. Do you divide it in the midline for insertion? Do you use any screw fixation or just close the periosteum over these implants? Is your incision strictly transcutaneous or do you incorporate buccal incisions as well?
A: In answer to your questions:
1) All custom jawline implants require a three incision placement technique. (2 posterior vestibular and 1 anterior, submental or intraoral) It is a biggest facial implant that can be placed and requires multiple incisions to be inserted.
2) If the implant has large jaw angles, it needs to be divided in the midline and inserted in a posteroanterior approach to eliminate the risk of mental nerve injury. The key to a single for split custom jawline implant is the size of the jaw angles and how easily they can be folded during insertion.
3) If the implant has smaller jaw angles that can be easily folded it can be inserted as a single piece in an anteroposterior method.
4) The implants are placed in a completely subperiosteal pocket.
5) A three point microscrew (1.5mms) fixation is used at the chin and jaw angles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a second custom jawline implant. I should have listened to you with my first implant when I asked you to reduce in surgery the size of the implant. I regret that decision now two months after surgery as what I have now is too small. I would like to potentially proceed with the procedure, but I have some questions first
1. What are some potential risks of doing a revision?
2. Is the risk of infection higher?
3. Is the risk of the surgical wounds not healing higher?
4. Are there any extra risks with nerve damage?
5. Do you remove the screws from the previous implant or do you leave them in there?
6. How much would it cost to remove the revision implant, clean and reinsert if I was to get an infection? And when this does happen, what are usually the percent chances that an infection happens again?
7. What is the recovery like for the revision compared to the initial procedure?
8. Are there any permanent risks associated with doing a jaw implant or a jaw implant revision?
9. Would you consider a jaw implant revision easier or harder than on the surgeon compared to the initial procedure? And why?
10. Do you normally reopen the same wounds or create different wounds inside the mouth?
11. How long do you recommend waiting to let the initial wounds heal before doing a revision?
A: In answer to your custom jawline implant revision questions:
1) The surgical risks as identical to the first custom implant procedure as it is the same operation.
2) The risk of infection is the same as the first time.
3) The risk of intraoral wound dehiscence is the same as the first time.
4) No
5) The screws are removed as they have to be to remove the implant.
6) The risk of facial implant infection is around 2% to 3% every time one is inserted.
7) The recovery will be identical to the first time.
8) A custom jawline implant revision surgery incurs the identical risks as the first time, they are no higher or lower.
9) It is the same surgery so it is equally ‘hard or easy’ as the first time. This is not a surgery I would ever consider easy no matter how many times it is done.
10) The same incisions are used the second time as the first time.
11) I advise 3 to 4 months before proceeding with any secondary implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip reduction surgery. In your experience, what is the revision rate for lip reductions done on natural (no foreign material) lips? One office I called gave an estimate of “1 in 4 (25%)”, which I think is shockingly high! What has your experience been, and what is the most common reason a revision is requested by patients?
Also does the lip’s overall shape change much with the surgery? I would like mine to be more M-shaped and curvy, as it’s currently lacking any definition. Or does that require a different procedure entirely?
Thanks.
A: The revisions rate for lip reduction at 25% to 33%, which I consider to be a very realistic and honest number, may seem shockingly high to you but that is the reality of doing aesthetic procedures on the lips. The most common reason for as revision is the desire for more reduction that can be achieved in a single procedure or some minor issues with the scar. In male lip reduction patients, which make up the majority of lip reduction procedures, I would put that revisions rate of 50% or higher. Young male face patients, of which my practice has an enormous experience, are the most challenging and particular of all aesthetic surgery patients.
A lip reduction is a debulking/volume changing procedure not a lip reshaping one. It can not or should one expect any shape change in their lips.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw surgery and genioplasty almost a year ago to correct my recessed upper and lower jaw, which was fairly successful. However I still have a few remaining issues. One being that I have pretty significant notching along my jaw line where the cuts were made (14mm advancement). I also need to add length and width to my ramus. I figure I would have to go the custom route due to the asymmetry I have and large notching from my sagittal split jaw osteotomy.
A: Deformities of the mandibular ramus are not uncommon after sagittal splits osteotomies particularly large advancements. By your description a custom jaw angle implant would have the best success rate insect cases of jaw asymmetry. The first place to start is to send me some pictures of your face for my assessment and I will have my assistant contact you to schedule a virtual consultation time. Ultimately a 3D CT scan will be needed to not only show the anatomy but it designing the custom jaw angle implants for insertion. The 3D Ct scan can be done where you live and I can place the order for it.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, , I am interested in doing a scrotal lift procedure. I am 32 years old and I have family genetics with large scrotums unfortunately. I want to know the risks for having this procedure.
A: The scrotal lift is am aesthetic genital procedure that tightens and lifts the scrotal sac through a midline excision of tissue along the raphe. Such a reduction lifts the lower edge of the scrotum by a wide removal of scrotal skin and deeper tissues that raises the level of the bottom hang of the scrotum. It leaves a fine line scar that often looks just like the raphe itself. The scar is really the only ‘risk’ of a scrotal lift other than standard ones like infection or hematoma which are very rare in this type of surgery. Because the tissue excision is in the midline it has no impact on the function or position of the testicles which are to the side of the midline
.The aesthetic ‘risk’ is the outcome of the procedure which is obviously important. There is always the question of whether the degree of improvement (reduction and lift) meets the aesthetic expectation of the patient. In my experience it is a highly satisfying procedure and the revision rate is very low.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for all the info you generously gave me on midface implants. I came across this image on your website. I wonder if it’s a combination of premaxillary implant and cheek implant. In addition, I feel a bit nervous about having this surgery. It seems like you are the only doctor who talks about it. When I look up premaxillary implant, there is a poor amount of info found on Google and all that info are written by you. I found absolutely nothing else other than the posts you wrote, not the info nor any before-and-after photos. I tried to search in a different language too but nothing. Other doctors seem to work on only cheek implants. Did you ‘invent’ this surgery? Or does this surgery go by another name? Or is it just that this surgery isn’t popular?
I honestly feel weird about this and feel more anxious when no info can be found on the internet. On one hand I really want to improve my appearance, on the other hand, I can’t just have a surgery if i don’t feel well-informed. Is there anything about this you can tell me?
A: The custom implant image to which you refer is a total midface implant that covers the paranasal, premaxillary, anterior cheek and infraorbital rim areas. Implant augmentation of the base of the nose (premaxillary-paranasal region) has been around for decades. It is not ‘popular’ because it is not commonly requested and almost all surgeons have no experience with it. In my experience midface implants have moved beyond trying to use various implant materials not specifically designed for it to try and make it work. The use of custom implants designed and fabricated from the patient’s 3D CT scan allows for midface augmentation results around the nose that have previously been unattainable in any other reliable way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, regarding jaw angle reduction or removal (traditional jaw angle amputation) where the surgeon cuts off the jaw angle at the mandibular ramus. Will the masseter muscle also be cut? (looks like the masseter muscle covers this area of the bone) If the masseter muscle gets cut, then what will happen and what will be the potential consequence?
A: In jaw angle reduction surgery the masseter muscle is first lifted off the bone through subperiosteal dissection. Then the bone is cut and the muscle falls back into place during closure. Thus no muscle is cut unlike that of the bone.
While no muscle is cut during jaw angle reduction surgery, the muscle will retract upwards to the new lower border of the jaw angle when it is amputated or removed in an oblique full thickness bone cut fashion. This does not affect its function or mouth opening/closing. But between the bone removal and muscle retraction the shape and support of the soft tissues will change over the angle area. Facial width will definitely be less and hopefully there will be no soft tissue sag as a result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wrote to you before about my chin implant removal problem but I wanted to wait a little bit more to have a surgery. I am 22 years old and had a bad chin implant surgery six months ago. The chin implant was the extended anatomical type, Implantech brand, small size 5.5mm. The incision was submental and implant stayed in only 2 days and was removed due to not liking it at all. It was a big mistake for my face. Its been is months and even though it improved with time, its not exactly how it was before both the shape and size of my chin. My chin is wider, longer, and bigger than before and it feels squashy inside and not tight as before. But now I see that,my jaw is also larger. My jaw was never touched in the surgery but somehow it effected it too. My jaw is obviously larger than before and its square. My jaw used to be V shaped and my face is now more square. My lower face looks heavier and not lifted. What can be the reason for my jaw to be larger? Is there a solution for that? Since you are one of the most qualified chin surgeons in the world, i thought maybe you know why and maybe you have seen something like that before. I am sending my pictures. Thank you so much.
A: I do remember your chin implant removal case and patients have come forth before with similar findings. While not common it results from the tissues being lifted off the bone for implant placement and they never reattach like they were before the implant. It should not have affected your jawline per se since those tissues were not lifted off of the bone as the wings of the implant does not go back that far. But that is the effect of the tissues along the chin and backward having an inferior descent creating the change the shape your jawline from the front.
Options for improvement are either a submental chin tuck, a jowl tuck up or a combination of both.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 30 year old male and have been debating about a skull reshaping procedure for the past five years. Attached are some profile pictures of my head shape and two pictures of my expectations. I was hoping to round out the back of my skull and shape it in a way that makes my jaw line more prominent/visually appealing. I’m sitting here wondering about the following factors:
1) Are my expectations reasonable/attainable?
2) Am I even a good candidate for this?
3) Is the scarring blatantly noticeable?
4) Will altering the back to improve the profile affect the frontal view (eg…head on)?
A: Thank you for your inquiry and sending your pictures. In answer to your skull reshaping questions:
1) The morphed images of the back of your head are fairly realistic, being able to achieve 80% to 90% of that change as a one stage skull augmentation procedure.
2) One is a good candidate for this surgery if their expectations are in line with what can realistically be achieved.
3) The implant is placed through a small horizontal incision low in the occipital region. This is a scar that is barely detectable without hair and undetectable with hair.
4) Changing the back of the head will have no effect on the front of the head/face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I thank you for your pre surgery notes in relation to the psychological effects of living with a new jawline implant have become apparent this weekend. I think the initial panic set in and I’ve had to take a step back and think about your comments again. I think the initial feeling is that the implant is way to big – but again I’ve taken onboard your comments around swelling and the amount of time that should be allocated to allow this to subside. Aside from this I’d like to ask a few questions:
1) Can you advise how long I should wait to shave the area under the chin – where the stitches are placed (these dissolve naturally right?)
2) Will I have a noticeable scar from the skin were the stitches are?
3) If after a number of weeks the implant still looks out of proportion and I decide to have it removed what are the implications? Would the current implant cause a permanent change to my facial features?
4) How quickly could we move from making the decision to remove the implant to actually removing it ? (i’m not suggesting this at this point, I’d just like to understand the process)
A: in answer to your custom jawline implant recovery questions:
1) It is important to realize that you are just less than 4 days after your surgery…when things look their worse. A lot will change in the next 2 to 3 weeks when you will feel much more comfortable with the way your face will look.
2) Having done hundreds of custom jawline implants there is no way this design would ever be considered too big. Conversely, in a month or so you will likely feel the other way….thinking maybe I should have gone a bit bigger.
3) You may shave under the chin at 7 to 10 days after surgery.
4) Implant removal will likely have no adverse effects on your preoperative facial shape, particularly when it is this small size.
5) Any removal of the implant before 8 weeks after surgery, when you have had time to fully see the actual facial changes and adjust to them, would be capricious.
6) Implant removal could happen within a week if one decides to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial implant revision surgery and fat grafting.Three months ago I underwent surgery with the following facial concerns/objectives, a weak chin (needed more projection and wanted in squarer in appearance), a weak jawline (wanted very strong, defined jaw line), hollow eye area and wanted slightly wider mid face. For those concerns I had a Terino Square – Style I chin implant, buccal fat reduction and fat grafting to under eye area and temples.
Although I can see an improvement in the projection of my chin in side profile I would have liked the chin to be wider. The chin implant alone has not provided me with the jaw line enhancement I wanted – disappointed with the results. The fat grafting carried out in the eye and temple region was very conservative and provided minimum results/very subtle improvements and my understanding is that the areas treated could further diminish as the fat reabsorbs. However I am happy with the buccal fat reduction.
After evaluating the outcome of my procedures and completing extensive research (including your website and case studies) I feel I have a much better understanding of what I want to achieve and treatment options available. I I would like my chin to be slightly wider in front view and feel that the going up a size (Terino Square Chin – Style I – large) could achieve this effect. I would like a much stronger and more defined jaw line. I feel my jaw angle is very high and that I have a vertical deficiency. I am very interested in the Vertical Mandibular Angle implant. I am open to custom implants if it will provide me with a better outcome – I am seeking a straight line back from the chin to the jaw angle point and after reading some of your articles understand that the potential dipping between implants needs to be considered. I would like to add more volume and increase width slightly through implants or fat injections. For the temples, I feel my head is narrow and would like it to be fuller and wider (smooth surface with gentle curves). I think further fat injections could help.
A: Thank you detailing your recent lower facial surgery history as well as your objectives. In reading through them I can make the following comments:
1) A Style 1 square chin implant lacks adequate width (45mm) for most men that seek a more square chin look. It almost has to be out to 50 to 55mms to have a more square effect.
2) A chin implant by itself is never going to create a jawline effect as the chin is but one-third of the total jawline.
3) Fat grafting in younger men of average or thin body frames rarely has much persistence and, at best, produces subtle/minimal results.
4) The only way to have a straight line from the chin back to the jaw angles is with a custom jawline implant.
5) I would have little confidence in fat grafting to the temples. It is a broad area and requires a lot of fat just to have just a little result and would not likely ever end up ‘fuller and wider’. Temporal implants are far more effective and have an assured volume augmentation result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m not sure if I’m a candidate for a custom jawline implant. If I have symmetrical jawbone structure I don’t see why I should need it. In addition, I don’t have the capital for custom one. From my point of view, I have a very weak lower jaw, my chin is very behind plus it is narrow, as you can see from my smiling picture it looks like I have no connection between my ramus and my mental protuberance. In addition, my jaw is narrow as well plus it is not prominent at all since the whole jaw is short. What I’m looking for is both horizontal and vertical improvement in my jaw with non-custom jaw implants that will bring balance to my lower face. I’m not worried about my chin at this moment because I don’t have the resources.
A: Based on your initial stated objectives of improvement, you are speaking to a total jawline approach. You can’t bring the chin forward, length the jaw angles and make the jawline wider all at the same time unless it is a total wrap around jawline implant.
The most common reason for a custom jawline implant is not asymmetry, it is primarily used when the patient’s dimensional jawline needs exceed what standard implants can achieve.
Standard vertical jaw angle implants are an option if you just want to limit the change to the back part of the jaw only. (jaw angles) But with a revision rate of over 25% using standard jaw angle implants, it would be important to only consider this surgery if your resources are sufficient should the need for revisions surgery arise.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question, and it involves customized facial implants for the cheeks and chin/jaw. In college I played for the football team and and broke my face. My nose was shattered with an effort made to fix it several times. My cheeks and jaw were damaged and there is a lack of harmony between these facial features (cheeks, jawline, chin) that they once had. That may have gotten worse due to the fact that I was still growing. But I was wondering if these customized implants in both areas could “put me back together” and really give me more confidence. I know you place your cheek implants higher so as not to create a rounded face and to achieve angularity and do CT scans to create a perfectly conforming chin/jaw implant with the degree of jaw “flare” or width and verticality desired. I know very few people choose to have their photo put on the website, but with these tools is it basically possible to create the best/patient desired jaw angle/width and cheek implant/placement? Even “male model quality”? Because I know fillers are always another option but they are not permanent.
My last two questions are these:
1.Would a chin implant eliminate my chin dimple? I would not want that. If it was softened a little, that would be fine, but I wasn’t sure exactly where the implant was placed and how it would effect the soft tissue.
2. What is the infection rate on jaw implants? I know it is higher than chin implants, but thought maybe the CT used to make customized facial implants “custom build” would help reduce the instance of infection and subsequent removal. Thank-you for your time.
A: Thank you for your inquiry and detailing your facial concerns. First and foremost I would need to see pictures of your face for my assessment and computer imaging to see what may be possible. Second, while custom facial implants can be designed to any shape and dimensions, how to make those dimensions create any specific look is more an art than a science and is not a completely predictable process. Third, a chin implant will not efface or eliminate a chin dimple. Lastly, of all facial implants, any implant that involves the jaw angles has a high infection rate. While the overall rate of facial implant injections is around 1% to 2%, that increases to 3% to 4% in the jaw angle region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had rhinoplasty done five years ago and developed a recurring abscess on top of my nose several years later. It was needled and cultures which turned out negative. I noticed a suture coming out but swelling with pus still builds up every week . I have been on Augmentin a few times but with no relief. What should I do? Is surgery needed?
A: Your descriptive history suggests that there is a foreign body in the nose that needs to be removed. Whether this is from a permanent suture or from an implant I can not say since I do not know what was specifically done during your procedure. If there was an implant placed in the dorsum of the nose then there would be no question about the source of the infection
But with recurrent swelling years after the original procedure and failure to resolve completely with antibiotics suggests that open exploration is needed to determine the source. Infection after rhinoplasty surgery are fairly rare particularly when autologous cartilage grafts are used. But sutures used inside the nose in rhinoplasty can be a known source of tissue irritation particularly if there are of the non-resorbable composition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had spoken to you a few weeks ago about the tightness I had from my chin implant. You had recommended a 3D CT scan to make sure the implant was in the correct position. Before I could make the appointment, I started to carefully feel the implant and noticed that the right wing of the implant is heading up in the direction of the right corner of my mouth! This area is where I am feeling the numbness and tightness. I had put botox to relax the muscles but now that I have felt the position, do you recommend to remove the implant to help with the symptoms I have been having? I’m of afraid of another surgery to reposition it and having to deal with the long recovery again. I’m thinking the removal won’t be as bad as the implantation. Do you think the tilt in the implant is causing my symptoms?
Please respond when you can. I appreciate any help I can get and you seem to be the only one with the answers.
A: A malpositioned chin implant can certainly be the cause of various postoperative symptoms, which include tissue tightness. The way to answer the question of whether the implant is the source is to have it removed. On the other hand there is a reason you had the chin implant in the first place and it would be shame to abandon its original objective. (the argument for chin implant repositioning)
The best way to answer the question of chin implant malposition is with a 3D CT scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I started taking Accutane exactly one month ago – the dose is quite low, at 20mg once daily. I now have a problem / query. I realized I should have had surgery before starting on Accutane. I had an infected jaw implant removed earlier this yea and have terrible asymmetry as the jaw implant on the other side is still in place. I cannot wait 12 months to have this corrected (I say 12 months as the plan was to be on Accutane for 6 months followed by 6 months being Accutane-free)
My question is – how soon can I have surgery (custom wraparound jawline implant at least) seeing that I’ve been on 20mg Accutane daily for the last 30 days?
A: It has long been believed that wound healing may be compromised in patients taking systemic isotretinoin. The cellular basis of this potential adverse effect is that his drug affects the synthesis of collagen which is essential for normal wound healing. Despite this contention, animal studies have failed to show adverse effects in wound healing at doses of 4 mg/kg per day. Case reports and cohort studies looking at facial skin laser resurfacing, facial chemical peels, laser hair removal, rhinoplasty, tooth extraction and ENT procedures have failed to show any demonstrable or consistent increase in wound healing problems.
Does this mean that the purported adverse effects on wound healing by isotretinoin are a myth? It is fair to say that most of the clinical studies reported have very low numbers of patients which makes it difficult to really know if those findings are valid. Equally relevant, none of these clinical studies have involved the use of implants which have natural higher risks of complications and is always the ultimate test of wound healing.
Given that most of aesthetic facial surgery procedures are elective and there remains some doubt that isotretinoin has no adverse effects on wound healing, one should not have surgery while actively on the drug. If you stop the medication now, having been on it for just two weeks, the risks a wound healing problem from having facial implant surgery a month or two from now should be very low.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty several months ago and have muscle strain in my chin and my lower lip no longer functions the way it use to. My lower lip will not meet my upper lip without force and ends up tucking up under my upper lip when I chew, almost disappearing. My chin bunches up when I close my mouth and now I’m stuck with this open mouth expression all the time. My lower lip has also thinned and falls well below my lower teeth as if it’s being pulled down. My surgeon told me he projected my chin out by 4mm but not sure on the hight. I’ve read message boards of patients with the exact issues as me and say time has not corrected this. Is there anything that can be done to correct this Dr. Eppley? I asked my Surgeon to reverse or adjust my procedure but he will not. I am very distraught and not sure what to do.
A: To have such a cascade of perioral symptoms from a small 4mm horizontal advancement sliding genioplasty is very uncommon in my experience and is more likely with much larger bony chin movements. But that issue aside the question is why you have such symptoms…it is because of the bone movement or does it have to more with the soft tissue closure/adaptation to the new chin position? To give an informed answer it would be helpful to see before and after pictures of your face and any after surgery x-rays if your surgeon obtained them.
But in refractory cases like yours where the symptoms did not improve with time, a reversal procedure would be the most logical approach to improving your current symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question for nipple lift surgery. I am considering redoing my breasts implants. If I did, in what scenario could we use the gummy bear tear drop implant? Could it be the same 250cc or would we have to increase it, and by how much? Also, if we put in a new implant (I would prefer medium profile and I currently have high profile) would we have to use my armpit incision or could we use the nipple lift incision? And if we use the nipple lift incision, will it cause a worse scar? Please let me know, thanks!
A: If you were to replace your breast implants it would be possible to use your existing axillary scars, particularly if the implant size is not going to increase by any significant amount. While a tear drop shaped implant can be used, they are highly prone to rotate when placed into a pre-existing pocket. So their use in an existing pocket should be approached with that risk in mind. (the textured surface really only grabs fresh pocket tissue not that of a smooth capsular surface that has been created from an existing implant) You would be better served to use a lower profile round smooth which would naturally develop profile closer to that of. tear drop but with no risk of shape malformation with implant rotation.
The nipple lift incision is too small for implant insertion. And even if it weren’t it would end up with a worse scar than would be created from a nipple lift alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I started taking Accutane exactly 2 weeks ago – the dose is quite low, at 20mg once daily. I now have a problem / query. I realized I should have had surgery before starting on Accutane. I had an infected jaw implant removed in August 2017 and now, in my eyes, have terrible asymmetry as the jaw implant on the other side is still in place. I cannot wait 12 months to have this corrected (I say 12 months as the plan was to be on Accutane for 6 months followed by 6 months being Accutane-free.) My cheek implants are also contributing to asymmetry (they are visibly misplaced).
My question is – how soon can I have surgery (custom wraparound jawline implant at least) seeing that I’ve been on 20mg Accutane daily for the last 2 weeks?
A: It has long been believed that wound healing may be compromised in patients taking systemic isotretinoin. The cellular basis of this potential adverse effect is that his drug affects the synthesis of collagen which is essential for normal wound healing. Despite this contention, animal studies have failed to show adverse effects in wound healing at doses of 4 mg/kg per day. Case reports and cohort studies looking at facial skin laser resurfacing, facial chemical peels, laser hair removal, rhinoplasty, tooth extraction and ENT procedures have failed to show any demonstrable or consistent increase in wound healing problems.
Does this mean that the purported adverse effects on wound healing by isotretinoin are a myth? It is fair to say that most of the clinical studies reported have very low numbers of patients which makes it difficult to really know if those findings are valid. Equally relevant, none of these clinical studies have involved the use of implants which have natural higher risks of complications and is always the ultimate test of wound healing.
Given that most of aesthetic facial surgery procedures are elective and there remains some doubt that isotretinoin has no adverse effects on wound healing, one should not have surgery while actively on the drug. If you stop the medication now, having been on it for just two weeks, the risks a wound healing problem from having facial implant surgery a month or two from now should be very low.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year old male from Europe looking for a surgeon who has experience with facial implants, in particular with cheek implants. I had Medpor cheek implants placed one year ago but I am not happy with how the result turned out. They are placed too low on my face and the size of the implants is way too small for the result that I was looking for. I wanted to have bigger implants placed more on the “outside” of the face to make my narrow face wider and give it more of a feminine and oval shape. Since I think that the standard range of silicone/medpor implants will not fit my expectations regarding the size of the implant, I was looking for custom cheek implants with a very big/important projection.
As I said before, I am not from the US – could you maybe explain to me how it works for international patients to have surgery with you. Do I need to come for a pre-operative consultation or would a consultation via Skype be sufficient? and plus, since I am looking for custom made implants, would it be OK for you to have a 3D scan of my face and discuss the options via Skype and email?
Thank you very much in advance for your assistance.
A:Thank you for your inquiry and your detailing your history. By your description it sounds like what you are looking for are what I call ‘malar-arch’ cheek implants that extend much further back along the zygomatic arch. This produces a much more dramatic sweeping effect to the cheek augmentation result. These type of cheek implants are best made in a custom fashion from a 3D CT scan. All subsequent discussions and preoperative planning can be done in a virtual fashion (Skype and email)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in elbow lift surgery. In reading online one of the surgeons on there said: “Realize that a scar on the elbow does not heal very well. The scars tend to go wide as the area bends so much and separates the scar.” Is this true even if I take say a month and don’t bend my arm all the way? Another wrote: “I have found a combination of Sculptra and radiofrequency treatments like Venus legacy and Thermage help increase the tightening in this area. Fractional laser like Fraxel added, can help increase collagen as well.”
What’s your experience been with those modalities?
A:The key to a successful elbow lift is ultimately how the scar does as one does not want to tradeoff one aesthetic problem for another. The key to a limited width elbow scar from a lift is the zone of excision, where it is placed and how much is removed. This is determining by preoperative markings with the elbow in BOTH extended and 90 degree flexed positions. If the surgeon only takes into consideration the amount of tissue removed in the extended position, it will be too much and a wide scar will result. It is first marked in the extended arm position and then checked and reduced in the flexed position so not too much skin is removed and tension is placed on the wound closure. This is a basic plastic surgery concept but often overlooked. The name of the game is maximal skin removal with the best scar result. In aesthetic surgery the scar result takes precedence over the maximum skin removed.
For excess skin around the knees, and any joint for that matter, non-surgical modalities will be only of benefit to the provider of them. While most of these non-surgical treatments are largely harmless, only surgical excision can really get rid of loose skin just above the elbow
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you could answer a few questions regarding the custom wrap around type jaw implants I came across on your blog. I had a BSSO, Lefort 1 and sliding genioplasty about 8 years ago. Following that, I had custom medpor jaw implants placed to correct some significant notching that had developed around my jaw angles and along the genioplasty site. These implants added no length and very little width, only enough to make my jaw symmetrical. My bite is now perfect, and from a functional standpoint the surgery was a success. However, I have been extremely unhappy with the aesthetic results. First, my jaw remains very steep and narrow, giving the lower portion of my face an elongated, weak shape with an odd shaped protruding mouth that looks as if I have to strain to keep it closed. Also, my chin has a bit more horizontal projection after the genioplasty, but still looks relatively long and weak, especially when viewed from the front.
I am interested in the wrap around type implants because it seems to me that my lower jaw is deficient in all three dimensions. Also, I am not looking for anything too drastic, I would just like a more balanced, masculine lower face shape. I would like to know if I am a candidate for this surgery, given my previous procedure. Second, I noticed that you typically use silicone implants. My current implants are Medpor, and I really like how they feel completely natural, as if it’s my own bone. I don’t know if this has anything to do with the tissue ingrowth seen with the Medpor material, but I was wondering if there are any major differences in sensation when using silicone.
A: By your very own description you are the exact patient who is only going to get a much improved jawline result by a custom implant approach. Your history of prior jaw surgeries does not preclude you from having a jawline implant but the scar tissue and implant removals do make it more challenging than the patient who has never had any prior surgery. But in my practice your history is common and about half of custom jawline patients have a prior history of bone or implant surgeries.
The perception that Medpor implants feel ‘more like bone’ than silicone is a myth. There is no biomaterial or biomechanical basis for it. With bone as the implant backing, all currently used implant materials will feel the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I get hip implants if I have PMMA injections already in my hips? is it best to have it removed or just some of it removed beforehand? Because my hip area is already tight and some days I am in pain. These hip implants were not heard of when I got the PMMA injections. It still was not enough to make a difference that I don’t still get told I look like a man from the waist down and I still barely fit into trousers so it didn’t exactly make me curvy for how much was injected. I am meant to be petite, and that is fine, but I still wanted better proportion. I’m 5’m 2” and 103 lb. I do have a doctor that will try fat grafting although I’m thin. He said he could also remove some or most of the PMMA. But I had big indentations without the PMMA so that might leave me looking worse, especially with really not enough fat to maybe fill it back up, let alone to get bigger than I am now. The only thing that could still be worthwhile about that is he would be trying to slim my waist more and that would help my waist to hip ratio, but won’t change fact I have big shoulders so I would still look manly without bigger hips and only a smaller waist.
A: If you have PMMA material in the area of potential hip implants and the tissues are tight and it has some pain associated with it, you would not be a candidate for hip implants. There would be a substantially increased risk of infection. It is never wise to put implants in any tissue bed that is not in a near pristine condition, does have foreign material in it and has inadequate subcutaneous fat thickness. If your hip areas are pretreated with fat injections and the tissues become softer, you may then become a potential candidate for hip implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana