Your Questions
Your Questions
A: You have wisely thought through the always delicate balance between the amount of facial bone removal vs the risk of postoperative soft tissue sagging. It is always better to be more conservative with cheek and jawline facial bone removal as I have done many more secondary surgeries for rebuilding back removed bone than I ever done for more bone removal later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year old male, and I am interested in getting custom zygomatic implants to augment my cheekbones. Reading through your site, I’ve come to learn that the key to the chiseled, high cheekbone look is to augment the zygomatic arch. So this is what I want to do. I also have a lack of projection in all directions of my zygomatic body and my infraorbital rim, so I want to cover those areas too.
However there are a few things which I’m not clear about when it comes to cheek implants, and I thought you might be able to help clear them up for me. I’ll number the questions. I hope they aren’t too long.
1) Angularity. I wanted to ask you how much the shape of the implant contributes to achieving the ‘angular’ look that a lot of models have. The angularity I’m referring to is where the zygomatic body progresses posteriorly into the zygomatic arch. A lot of models have an angular transition here. Would making the implant more sharper (slightly more square shaped) as it wraps around the zygoma help achieve this, or will this look unnatural?
2) Anterior projection. I wanted to ask for your opinion on giving more anterior projection to the zygomatic body. In your opinion does this an anteriorly protruding zygoma look feminine? Basically I don’t want to divert attention away from the zygomatic arches by making the zygoma too big anteriorly, but at the same time I don’t want to miss out on the benefits of making my face look more anteriorly developed.
3) Lateral projection of the zygomatic body? I’m confused as to whether it is desirable to laterally project the zygomatic body, or just the zygomatic arch. Would you be able to explain to me the aesthetic effects of projecting the zygomatic body along with the zygomatic arch, compared to just the zygomatic arch alone?
4) Will it be possible to modify the implant at a later date by burring/shaving if there are some minor imbalances?
5) The cheekbone ‘pop’ underneath the outside corner of the eye. A lot of models have this definable pop/prominence in this area. I’m trying to figure out how to achieve this. Am I right in saying that we would need to take into account the balance between the infraorbital rim and the zygoma, ensuring that the zygomatic prominence sticks out relative to the infraorbitals? I’m concerned that this will leave me with infraorbital hollowness.
6) Frontal process of the zygomatic bone (inferior portion of the lateral orbital rim). Is it possible to include this area? I’m concerned that building up this area might make the zygomatic prominence look less developed (protrude less). Is this concern justified?
A: In answer to your questions about custom infraorbital-malar implants:
1) The shape and dimensions of any custom facial implant are a major reason for the external facial shape seen. I would not make any such implant with a square shape as that would appear unnatural.
2) A high anterior zygomatic projection never looks feminine, you are referring to a low submalar anterior projection which does so.
3) You can not separate the lateral projection of the zygomatic body from the zygomatic arch. They are closely linked.
4) Revisions of custom facial implants are not rare since there is not accurate method to correlate the actual implant design to the desired outcome.
5) The implant design would extend up onto the lateral orbital rim.
6) answered in #5.
Dr. Eppley
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found you on RealSelf and noticed you have a lot of experience in this area. (cheekbone reduction reversals) I had my cheekbones reduced in Korea over a year ago. I’m very disappointed with the results and incredibly depressed with this surgery. My question is:
1) Is it possible reverse this surgery by pushing the zygomatic arch and malar bone back out?
2)if bone graft is needed is there a computer program tthat can make a mold of my cheekbones ad estimated how much bone graft is needed?
3)Have you done this or met anyone who reversed this surgery with pleasing results? Thank You.
A: In answer to your cheekbone reduction reversal questions:
1) Cheekbone reduction osteotomies can be successfully reversed. The anterior osteotomy is almost always more important than he posterior osteotomy site.
2) The most precise way to do is with virtual planning. A 3D CT scan can be done and the cheekbones moved out digitally from which the bone grafts can be digitally created in design to be used for the surgery.
3) Most cheek bone osteotomies reversal that I have done (by osteotomy and one grafting or custom cheek implant augmentation are usually happy to be back ‘home’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, a friend of mine has had large prosthetics and augmentation in his entire forehead region and even supraorbital a while back. He doesn’t care for them now, however, and in fact, finds that his forehead is too prominent now and wants them removed. He is wondering what will happen to his upper eye area when this happens. Will his eyes become more hooded and his eyebrows descend? He actually prefers this because he feels his upper eyes at the moment are too hollow and eyebrows are too high at the moment
He is also considering a hairline lowering procedure but was told by a doctor that his scalp was too tough. Would the removal of these implants also make it possible for him to achieve a hairline lowering without the usage of a tissue expansion?
A:I think it is fair to say that removing a large forehead augmentation will result in some potential brow ptosis and even upper eyelid hooding….which sounds like what he prefers anyway.
Whether he could get any significant hairline lowering without tissue expansion I can not say given that I have no idea what he looks like or have felt his scalp. Suffice it to say that hairline lowering is most effective when a first stage scalp expansion is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have asked you questions before and I read your boards here and you seem very knowledgable in implants. I had a right cheek implant replaced from silicone to Medpor two weeks ago. Have Medpor in the left side as well. My Dr is well known and well versed in implants but not a good communicator and I really don’t want surgery with him again. My question is about pain. I have some swelling but not significant and some redness but not much, no fever and no heat at the site. However, I have a significant amount of pain. I will do an MRI to look for possible low grade infection. I think this is unlikely but possible. My question is, could things down the road be okay possibly? I mean, could things settle down and this pain be from swelling and tissue/nerve disruption of the infraorbital nerve? It is placed mid cheek (slightly higher) It is very bothersome (obviously). I don’t want to remove it, but also could not live like this the rest of my life either…Thank you for your input.
A: I think the fundamental question you are asking is whether the cheek implant is impinging on the infraorbital nerve…as this would be the only reason to have more than the typical pain associated with cheek augmentation which usually is not very significant. The best way to check cheek implant positioning, or any facial implant positioning, is to get a 3D CT scan. That will answer that question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a cartilage chin implant for 13 years and it was ok. A doctor convinced me to replace it for a silicone implant which I had for 15 years and caused bone loss and chin ptosis. I didn’t want a replacement but no plastic surgeon would remove it without a replacement. I had a plastic surgeon replace it with a Medpor chin implant which was AWFUL so three months later it was replaced with another Medpor chin implant with four screws. I have had two chin pad resuspensions as well. Now seven years later I am seeing my chin get pointy and believe it is due to bone loss. My body is not liking this implant. Would you be able to remove this Medpor chin implant without another synthetic chin implant. Do you do cartilage chin implants or is there something else I can do as my chin might look deformed?
Thank you.
A: While I don’t know what you look like or the size of your existing chin implant, a synthetic chin implant can be replaced by either an autologous (your own tissue) or allogeneic (cadaveric) cartilage or bone grafts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am strongly considering a temporal reduction in the near future due to my wide head, but i have a few questions.
1. Is this procedure dangerous in any way?
2. Will the temporalis muscle grow back once it is reduced?
3. With my age being only 19, am i too young for this operation?
4. How often do you perform these procedures?
5. Roughly, what is the cost for this procedure?
I hope I am not asking for too much, but a response would be greatly appreciated. Thank you.
A: In answer to your temporal reduction questions:
1) This is a very safe procedure
2) The muscle will not grow back
3) Age 19 is not too young for the surgery
4) I perform Temporal Reduction surgery on a regular basis
5) My assistant will pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it looks like I’ll be moving forward with the custom infraorbital-malar and jawline implants next year.
I am seeking temporary improvement before I see you. I find that when I pull my skin in an upwards/diagonal vector, I see large improvements in the nasolabial area and my overall appearance. Would a PDO threadlift (I know its effectiveness is debated, but the nurse I’d be seeing uses a newer thread and had compelling before and afters) be contraindicated given implants with you in May?) My understanding is that most of the effects of the threadlift would likely dissipate by May, but there is a chance some of the sutures won’t have completely dissolved.
A: Pulling your skin upward by fingers is not representative of what a thread lift can really do. It will have a much less significant effect than that simulation and will never make the nasolabial folds appear less deep. Such digital manipulations way over estimate what is possible with any thread lifting procedure.
Otherwise any threadlift done now will not impact any custom facial implants planned for next year. The effects of the thread lift will long be gone by then.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I really dislike the lower-mid portion of my face, which seems to be getting worse (sagging) as I age…the area closest to the nose around the nasolabial fold.
I’ve asked many doctors about this bulge and they all suggest cheek implants or filler. I’ve had filler in the cheekbone area and while that helps to hide it, I still want to address the bulge because with the filler in the cheekbone I just end up looking too bloated for my liking.
No one seems to have an answer for how to address the fullness in those areas. I’ve gotten a couple of mid face lift suggestions but from what I understand, the lift will move some tissue up over the malar area but not really attack the bulge because the incision too far away to reach that area of correction. An I correct here? Could a modified lift be done with your ingenuity with an incision closer to the area?
I consider myself a highly motivated patient and would be willing to undergo a two or three or multiple stage surgery where after the fat or muscle or whatever it is removed, then the area and skin is tightened and then scar revision done if the scar is more visible to my liking in a young patient like myself. I wear make up and am fine with revising scars with lasers, injections and even scar revising surgeries if I can get a good aesthetic pay off.
Also do you think it’s more muscle, skin, or fat that is there?
Thank you.
Attached are photos of the issue I’m speaking of and following photos circled are areas where it is flat and in my opinion, ideal
A: Thank you for sending your pictures and detailing your concerns. Unfortunately the facial area (lower midface fullness reduction) to which you refer is a very difficult if not impossible area to significantly improve. While some slight reduction of it is possible, if your goal is the male picture in which you have circled, such a result is not remotely possible with any surgical method. While small cannula liposuction can be done in the nasolabial fold/perioral mound area I would expect the result to be very modest. This is a facial area in which the buccal branches of the facial nerve exist eliminating the possibility of any excisional approach regardless of a lack of concern about scars..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i’m looking to do skull augmentation and I noticed you often use PMMA material for implant but other doctors refuse it saying it causes inflammation in 40% of cases and only use PEEK. In your experience how safe is PMMA and do you overcome its sterilization issues when prepared? My target is large skull augmentation since my problem is small head/face.
A: Thank you for your inquiry. Let me provide you with some clarifications on some of your skull augmentation biomaterial statements in your inquiry.
1) For elective aesthetic skill augmentation today, I primarily use custom made silicone skull implants from the patient’s 3D CT scan. That is a far superior method to the use of any form of bone cements or PEEK material for a variety of reasons.
2) When I did use PMMA bone cements I never see any problems with inflammation or infection…and I have used it in hundreds of cases.
3) You should not confuse aesthetic onlay skull augmentations with reconstructive cranioplasties which are done to fill in a removed or lost full-thickness skull defect. These are completely different patient populations which have different risk profiles and tissue makeups. It is that population to which other surgeon’s comments are most likely directed.
4) If large skull augmentation is your aesthetic goal, you will require a first stage scalp expansion followed by a second stage skull augmentation with a computer-designed skull implant. That is the only effective way to achieve that kind of skull enlargement in a safe and predictable way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was under the impression that there would be some discussion regarding the testicular enlargement implants, especially regarding sizing and fit, before surgery. Maybe that is not necessary? I assume they are ordered since they require three weeks to manufacture.
A: The timing to determine the design of any custom testicle implant is about six weeks before the surgery so your email is timely.
The two dimensions that are needed to determine the design of custom testicular enlargement implants is the outer and inner diameter. The outer diameter is the desired final size of the testicular enlargement. This is typically between 5 and 6 cms as measured in the north-south or longitudinal direction. The inner diameter is the relief need to accommodate the existing testicular size. Most men are in the 3.5 to 4 cm range. You simply need to measure your own and let me know what it’s measurement is. Most testicles are slightly different in size but that doesn’t matter since the inside of the custom testicular implant is modifiable during surgery. The outer diameter, however, is not. (or should not be as its smooth surface will be lost)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a unique ear condition that I can’t seem to find anyone with a similar case. I always had prominent, asymmetrical ears that made me slightly self-conscious, but grew to live with them and be comfortable. The prominence was due to me not having an antihelical fold on either ear. In January of this year, I was diagnosed with a cholesteatoma in my left ear which required a mastoidectomy and reconstruction. The surgeon used cartilage from my concha bowl to reconstruct my ear canal which worked fine. What I wasn’t prepared for was the cosmetic toll this would take on my left ear. The surgeon removed a large part of my concha bowl, and I also suffered from post-surgical bleeding due to the amount of trauma from the surgery that left me with some additional scarring/shrinkage of my concha bowl.
This left my left ear almost flush with my head and created massive asymmetry between my prominent right ear and stuck to my head left ear. In May, a plastic surgeon performed an otoplasty on my right ear to bring it more in line with my left ear. He also performed a scar release on my left ear to bring it out. Both of these procedures were successful. My right ear looks great and my left ear did come out some from my head with the scar release, but I’d still like a little improvement. I’m curious if there is a type of implant that can be placed behind my ear where my concha is located to bring out my ear a few more mm. I’m not looking for perfect symmetry as my ears have always been asymmetrical, I’m just looking for more improvement. I don’t want a big jump, as I like my ears closer to my head, since my ears protruded a lot. Since there is no antihelical fold on my left ear that needs to be released and the concha just needs to be boosted, is this easier than a typical reverse otoplasty? Can this be done under local anesthesia? Thanks in advance.
A: Based on your description I suspect that a ‘wedge’ placed behind the ear to help push it out is what is needed. This is probably done best by a cadaveric cartilage graft rather than an implant. This would required that there is adequate soft tissue cover to do so. I would need to see pictures of the left ear to provide a more qualified answer. Regardless of how it would be done, it could be done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana