Your Questions
Your Questions
Q: Dr. Eppley, I am interested in paranasal implant revision. I had Medpor paranasal implants placed one year ago. My surgeon told me that it is an implat on each side of the nose.I also had an open rhinoplasty at the same time.
Here are comparison pictures I took around 2 weeks after my surgery last year in June (I was extremely happy with the results) and around a month ago. The lighting is different and I put on around 5 pounds but I feel like since the swelling went down, I actually find the results less optimal (especially the fact that my nose still looks a bit droopy like before surgery and the nasolabial folds came back more than I would have liked)
A: Thank you for sending your pictures and detailing your surgical history. It is not rare that the facial fullness caused by midface implants early after surgery is very appealing due to its wider overall effect. But when the swelling goes down the effect is much less. I don’t know the premise for why you had paranasal implants but the treatment for nasolabial folds would not be one of them. Their primary purpose is to bring out the base of the nose which can have some slight improvement of the triangular fossa at the top of the fold next to the nose. But that effect will usually be very modest. Whether a more profound midface effect could be obtained by paranasal implant revision with a different implant design or size depends on knowing the exact paranasal implants you have in now. If they are Medpor paranasal implants they only come in one size although they may have been modified in surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wasn’t aware that cheekbone reduction surgery was offered in the US as it is rarely heard of and is over shadowed by cheekbone augmentation.
I hope you can help me as I am worried for my face. I’m one week away from being 3 months post op from cheekbone reduction. My zygomatic body was reduced by 5mm on both sides, pushed in and fixed with screws after a temporal cut to the end of the zygomatic arch (also fixed).
Two or three weeks after the large swelling went down after surgery, I noticed that my nasolabial area looked like there was wrinkling. I asked my surgeon about this and he said it was due to all the swelling in my cheeks. This being such a major surgery, I simply nodded and brushed it off and returned to my home country.
Now that I’m so close to the three month mark, I am starting to get nervous. The nasolabial puffiness/wrinkling improved only slightly since that time I consulted with the doctor about it, but they are still deeper than it was before surgery. Specifically, the malar bag area seems slightly puffier than before and I’m not sure if it’s residual swelling or slight sagging as I’m only in my early 20s.
I consulted with two plastic surgeons in my own country, though they do not have experience with zygoma reduction.
One surgeon said that three/four months would generally be the result I’ll have. He explained that the tightness of the zygomaticus minor and major loosened after moving my cheekbones inwards, so the puffiness was not a surprise as they wouldn’t “tighten”. Moreover, a cheeklift was not suggested but adding cheek implants (though it seems counter intuitive to add cheek implants after I went through surgery to make them less prominent.)
The other surgeon said swelling would last up to one year to 18 months, then showed me out with no other suggestions.
I hope you can advise me on what to do, with your experience of performing this surgery. Is it possible that I still have residual swelling at this point and should wait a couple of extra months or would the swelling have dissipated by now?
Or at 3 months is this pretty much the result I’ll have. Would an extra 3 months waiting show any noticeable improvements in your opinion?
A:The short answer to your question is, while it takes 6 to 12 months to appreciate every final detail from any kind of facial bone surgery, what you have is largely the result it will likely be. While cheekbone reduction surgery is effective at narrowing their prominences, the cheekbones are midfacial skeletal structures that provide soft tissue support. As a result in some patients the tradeoffs for such maneuvers are associated soft tissue changes which always is in the downward direction most commonly sagging in the lower cheek areas often seen as a more prominent nasolabial fold.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in thigh implants. I wish to increase the volume of the thighs, the front and the back, I am aware that there are limitations and that everything is not possible at once. The front of the thighs, so that they grow wider would be desirable. I understand that it is probably not possible to do both the front and the back of the thighs at the same time.
A:Thank you for sending your pictures and detailing your thigh implants augmentation objectives. You have now have thigh-calf disproportion after your calf implants. Augmenting the calfs is a very successful procedure because there is one defined muscle belly and the implant-muscle ratio is fairly high. (a lot of implant for the size of the muscle) Thigh augmentation, while it can be successfully done, is not as easy to get such a good result as calf augmentation because there is not one muscle that makes up the thigh and any implant-muscle ratio is going to be much much lower than that of the calfs.
That being said, there are two fundamental approaches to thigh augmentation. The most biologic approach, although not one that produces the most augmentation, is to place the implant under muscle fascia. (which is always preferred in implants if possible) This largely leaves the rectus femoris muscle on the anterolateral thigh which is the largest muscle belly. The other approach is to ignore subfascial placement and place it on top of the muscle fascia. In this way a larger augmentation can be done as it does not have to stay within the defined underlying muscle fascial borders. It has a slightly higher risk of infection and implant show although the latter can be overcome by implant design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, would such 3D custom facial implants still have a risk of asymmetry after they are inserted? I have been told that as the implant is printed to perfectly mold to every crevice and shape of your own bone, there would be no need for fixation.
A:It does not matter how any 3D custom facial implants are made or their material, they all have risks of asymmetry as they still have to be surgically placed through limited access incisions. Such surgery is not like Lego Blocks or mounting the implants on a skeletal model, they don’t just snap into place. It is far harder to do than it looks due to the presence and importance of the overlying soft tissues and the limited visualization to the bone sites that the surgeon has. A 3D design process makes it look ‘easy’ because you are just looking at the bone model but that has little to do with actually doing the surgery to place them.
And, quite frankly, whomever made the statement that they don’t need fixation because they are perfectly made to the shape of the underlying bone has either never done such surgery or has very limited experience as that is simply not true.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about liposuction irregularities. i had liposuction 1one year ago to abdomen, then liposuction to flanks and low back. he second liposuction was done three months ago and has left me with irregularities and lumpiness, I suspect due to over aggressive treatment…can you help me? I am in great shape, muscular, thin and healthy, no meds.
A: Some modest irregularities after liposuction are common based on the quality of one’s skin before the procedure and how agres. But if they are significant they often occur in thinner patients where more aggressive liposuction has been done in an effort to maximize the contouring effect on an already thin subcutaneous fat layer. Once this has occurred it is a very difficult problem to improve as further cannula releases and smoothing efforts often will fail or at best produce a very modest improvement. Ideally the best improvement for liposuction rregularities comes from subcutaneous releases and fat grafting but this is both counterproductive to the original procedure and such patients often have no fat to harvest to do so. I would need to see pictures of the liposuction areas to provide a more qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My mother wanted to know if you would recommend anything for her aging eyes, Specifically the hollowness around the upper and lower eyelids.
A: Thank you for sending your mother’s pictures which shows hollowness (loss of volume) on both the upper and lower eyelids. The question is what type of material/graft can be used to add volume to these area. On the upper eyelids it would unequivocally be fat grafts as the upper eyelids have a lot motion so anything applied there needs to be soft. The only debate there is whether it should be done by fat injections or the open placement of a dermal-fat graft. On the lower eyelids options include fat, tissue bank dermis (Alloderm) or implants. Unlike the upper eyelids the lower eyelids don’t move much so they can tolerate grafts or implants. The one requirement they do have is the skin is thin so whatever is placed there must be smooth. For this reason I would favor cut sheets of Alloderm or autologous dermis to lay under the entire lower eyelid and down into the infraorbital-cheek junctions. Many surgeons inject fat into this area but my experience is that often ends up lumpy and puffy looking.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant put in twelve years ago and I have had intermittent pain and numbness from what I believe was a severed nerve. I read a post that you wrote for another patient’s question that sounded like he or she was in exactly the same situation. You referred to it as neuroma. Can you fix this? If a virtual consultation is better in this situation then I am open to that. Thank you.
A: Being this late out from a mental nerve injury and possible neuroma formation can only be treated one of two ways; 1) neuroma resection and direct nerve repair or 2) neuroma resection and a cross-mental nerve graft. The latter would likely more effective at this late date after the event. Whether either one of these nerve treatment approaches would be reasonable depends on the severity of your nerve symptoms. With symptoms that are intermittent in nature, at the least you should get a 3D CT scan and confirm the position of the wing of the chin amount in that side. I would suspect it is right up against the nerve. With mild symptoms simple nerve decompression can be tried by getting the implant off the nerve for your chin implant nerve pain.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get a sliding genioplasty or maybe shaving plus fillers (on the front, not on the angle of the chin). I want vertical shortening and minimal increased projection (~3 mm) and a bit more definition/chiseling on the front view. I got a rhinoplasty last August, which gives the illusion that my chin is larger. I like my side view way better but the front is worse. I’ve done a lot of research and without a doubt I am going to do something.
A:Thank for sending all of your pictures. As you may or may not recall this is not the first time that I have seen them. Based on your own imaging and desired goals (vertical shortening and increased horizontal projection) the only treatment option would be an intraoral sliding genioplasty if one wants to use their own bone to accomplish both types of dimensional changes. The other alternative would be a submental approach from below with an inferior border reduction with the addition of a small 3mm central chin implant.
But I think a sliding genioplasty would be the bette choice as it addresses both concerns in a single procedure without an implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, are you familiar with or have you ever had experience with Parry Romberg syndrome? I’m a 38-year-old male patient (victim) with this disease. I had a muscle flap surgery in my 20s which failed and have had no other procedures since. There is a significant asymmetry as my right cheek has major atrophy in the soft tissue. I was wondering if a custom implant could be made to improve my looks. I’ve never wanted to go through surgery again but I was hoping new technologies may hold some hope for me.
A: I am very familiar with Parry Romberg syndrome and have seen and treated many cases of it. Thank you for sending your pictures, you did very good with them. It appears most of the atrophic defect is in the soft tissue and not involving the underlying bone.
You have a couple of options that would be far simpler that the initial free muscle transfer that was tried years ago. They include the following:
1) Dermal-Fat Graft placed through a nasolabial fold incision. I can’t tell if there is a scar along the nasolabal fold more not.
2) Dermal-Fat graft placed intraorally.
3) Injection fat grafting to the whole right cheek area
4) Custom midface implant (although the defect does actually involve bone. The concept is to try and push out the overlying soft tissue.
The easiest and probably first option to try is #3, injectable fat grafting. While unknown back in the time when you had your muscle transfer surgery, this is common today and is a standard approach for facial soft tissue defects of almost any kind and location. Its success in Romberg’s disease is variable because of the thing atrophic tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have inquired previously about custom implants however I have my concerns about custom jaw implants such as bone erosion and the fact they negatively impact with age so I am looking toward the chin wing osteotomy surgery option. I would like to know if you can perform a side wing (not increase the vertical size of the frontal part of the chin) but simply increase lateral jaw width and length.
I am interested in having this procedure and then repeating it for further adding width and length to my aesthetic goals. Can you do this procedure and how much does chin wing cost?
A: Besides the fact that your concerns about jawline implants are unfounded, a chin wing osteotomy can add no width anywhere along the jawline and does not make any change back at the jaw angles. It can only provide vertical lengthening to the chin and the middle part of the lower jaw as well as increased horizontal projection of the chin. It is not a jaw widening procedure no matter how the diagrams make it look like it can. A chin wing is really an extended sliding genioplasty with long back wings to the chin segment.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, i am interested in custom infraorbital-malar implant and a custom wraparound jawline implant. I guess the best way is to do them together?
I would be interested in predictions of custom infraorbital-malar implants and custom wraparound jawline implant, does separately and then together.
I am also interested in before and after pictures of patient who had either such custom implants.
I guess it’s irrelevant if I do Veneers before or after?
A: Thank you for your inquiry and sending your pictures. I will have my assistant Camille contact you to schedule a virtual consultation time. In answer to your general questions:
1) Whether one does more than one custom facial implant at one time is a personal decision not a medical one. But it is certainly common to do so.
2) Due to patient confidentiality patient pictures are not distributed without their permission…which is done by very few patients. Any such permitted pictures would be posted on the website, www.exploreplasticsurgery.com.
3) You are correct in regards to veneers, it is irrelevant whether they are done before or after. But because of the intraoral approach for much of a custom jawline implant, I would vote for veneers after that procedue is completed. to avoid any trauma to them.
4) Computer imaging of your pictures will be done after the virtual consultation is completed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am iunhappy with the appearance and shape of my chin. My bite was corrected with braces, and my chin isn’t receding or over-projected, but it is admittedly quite narrow and pointy from the front view.
I have a tapered heart-shaped jawline/face which only serves to exacerbate my self-consciousness about my narrow and pointy chin.
I have consulted with a local surgeon, but I found out you are the go-to expert on facial bone surgeries and chin surgeries through RealSelf. I really hope you could provide some insight onto the options I was provided so that we can have some foundation to go off of during the video consultation.
My surgeon, who is a plastic surgeon with a craniofacial background, assessed my chin at a consult and gave me three options. I would really appreciate your opinion on the suggestions as a medical expert so that I can have the best surgical plan to achieve what I desire.
(1) A laterally widening genioplasty. I was advised this would be an option as only a minor widening effect was needed.
Would this bone widening make my lower facial shape more rounded and less angular, or would it just make my chin flat and square? Would I still have a natural curve to the chin? I’m a little worried it will make my chin more masculine looking.
(2) Hydroxyapatite on the sides of the chin. As a craniofacial surgeon, he mentioned he had quite a bit of experience with this material and that it could be placed on the sides of the chin and shaped.
However, from looking through your blog, this material seems to be quite unforgiving for augmentation purposes. I’m worried about potential asymmetry and not being able to remove the material if the shape is bumpy or doesn’t achieve what I want.
With your experience of the material, should we even entertain this option? It does seem less invasive than a bone-cutting surgery but there seems to be so much more that could go wrong (eg. asymmetry, not the right shape.) Can this material get infected?
(3) Lastly, the surgeon mentioned an implant but he did mention that off-the-shelf implants wouldn’t be suitable for my case, considering that no other dimensions of her chin need any augmentation.
A custom implant was possible but it added on thousands financially, and for such a minor augmentation it just didn’t seem worth it.
I am not sure what is the best option out of what I was advised. I would really appreciate your insight and I thank you for your time.
A: Thank you for your inquiry. Since I have no idea what the chin/face in question looks like nor have any knowledge as to what the aesthetic chin change goal is (I assume computer imaging has been done to determine the exact amount and extent of the chin/jawline widening effect), I can only make the following general comments:
1) Widening of the chin is accomplished by creating more width from the center of the chin back a certain distance along the jawline. That posterior widening extension will need to be longer than one would think and its shape as to be fairly precise to end up with the desired effect that is both a adequate and symmetric.
2) There is little question as to what is the best treatment option to create the desired chin widening effect…computer designed implants based on the bone on which it is intended to augment. Having precise control of their design simply can not be beaten, that is not the actual question you are asking. Because of cost considerations the actual question is what else can she done that costs less that may come close. to their effects. From that perspective I will address your current options.
3) The use of hydroxyapatite granules is very prone to irregularities and asymmetries, it is just not a precisely controllable contouring material in the unforgiving projection of the chin.
4) A widening genioplasty will make the sides of the chin wider…to a point. But there may be step offs along the back ends of the wings of the bony genioplasty when the bone flares out at its back ends when the center of the chin is widened, creating a contour deformity along the jawline without a smooth transition. You are also correct in that it may have more a chin squaring effect than a rounding one and it does seem to a ‘solution that is bigger than the actual problem’.
5) There are standard prejowl implants that add some width to the side of the chin without increasing its horizontal projection. Whether this should be adequate I cannot say since I don’t know the exact aesthetic chin widening goal based on computer imaging. These can also be made by a special design process for whatever the desired width increases are needed.
6) There are also ePTFE (Gortex) blocks and sheets that can be handmade and carved to create one’s own intraoperatively fashioned ‘custom chin widening implants’.
In conclusion, trying to cut and move the bone to create the exact chin widening effect one wants is harder than it seems. The chin bone can be cut and centrally widened but precise control of the resultant shape is not assured. Placing granules into a. subperiosteal tunnel and them molding them from the outside is not an assured method of bone contouring with both symmetrym, smoothness and an exact shape is desired. The best method for such minor chin widening, in my opinion, is to get a preformed implant shape to do it. As discussed there are various implant options in that regard.
Dr. Barry Eppley
Q:Dr. Eppley, I am very interested in the Lip Lift procedure and was wondering if you have experience with patients who have a slightly gummy smile? I have found that some doctors say it can make a gummy smile worse and some say it won’t affect it at all.
A: A subnasal lip lift, in the face of a gummy smile, certainly has the potential to make it slightly worse. (more gum exposure) Whether it would have no impact at all on it or whether it would slightly exacerbate it depends on how the lip lifing is being done. (% of vertical skin distance being reduced) Obviously the less lip lifting being done or a vey modest change will minimize its impact on your gummy smile but its aesthetic lip lifting effect would also be very modest. More aggressive lip lifting most certainly will as there will more likely be an elevation of the upper lip smile line. The bottom line is that any effort at lip litfing incurs the risk of making the gummy smile worse, there is no assured way to every say it can not happen. The only way to eliminate that potential risk is to either not do the procedure or do a some gummy smile correction at the same time.
Dr. Barry Eppley
Indianapolis, Indiana