Your Questions
Your Questions
Q: Dr. Eppley, My nerve was damaged in my shoulder and killed my front deltoid muscles. I would like to get this to match my other shoulder.
A:Thank you for your inquiry and sending your picture. What you have is a classic example of deltoid muscle atrophy due to a motor nerve injury. It appears based on this one picture that only two of the heads of the deltoid muscle or involved (anterior and central) and that the posterior deltoid muscle head may have been spared. This is why you referred to it as the ‘front’ deltoid muscle.
That being said an implant would be the only way to restore as much as possible the volume from the lost muscle. Such implants can be designed several ways but the most common method, given your geographic separation, is by having you take measurements of its length and width from which I can make the computer design for the implant.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am scheduled to have clavicle lengthening surgery next month. I wanted to ask about the possibility of permanent loss of motion and function in my arms. An orthopedic surgeon friend recently warned us against this surgery, stating “this does not ‘simply make your shoulders wider’–it permanently rotates your shoulders into an abnormal position and you will loose motion and function.
A:Thank you for your question. In my experience that statement by the orthopedic surgeon is unfounded. That might be true if the clavicles were significantly lengthened by many inches per side, which I doubt that would happen even then, but that is not the amount of lengthening which can be done. I don’t know the basis of the orthopedic surgeon’s statement but unless he has done the actual surgery and seen that happen that is a conjecture and not a documented outcome.
Rather than that expressed concern the real potential complications of the surgery are nonunion of the lengthened bone, hardware loosening, and secondary surgery for these potential problems. Clavicle lengthening is very different from clavicle reduction due to the limitations the soft tissues of the shoulder. Thus the gains to be had, with a low risk of potential complications, is not to try to do too much lengthening. This means keeping the lengthening per side 2 cm or less based on how much the soft tissues of the shoulder will allow the bone to be lengthened. I suspect the basis of the orthopedic surgeon’s comments come from the belief that much more clavicle lengthening can be accomplished then what can actually be done.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley ,Hello! I have tear trough implants that are not the same size. I was wondering if there was a way to have these implants removed and replaced with cheek implants.
A:The tear trough implants that you have are undoubtably made of silicon which makes their removal fairly straightforward. They can be removed by the same pathway in which they were placed. It is possible if they were sutured into place and not screwed into place that they can be removed intraorally. This would be compatible with your stated desire of cheek implants replacements in which most standard cheek implants are done intraorally. However if it is a custom infraorbital-malar implant, which is a typical midface augmentation area for men, it would need to be done through the lower eyelid which is probably how was your original teardrop implants replaced.
These are some general comments in regards to your questions but more specifics as they apply to your exact aesthetic midface needs requires a picture of analysis and further discussion.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I have a jaw contouring/ jaw reshaping concern. My right side lower jaw is bigger and draws the right side of my face downward. This is clear when seeing my lips, as the right side of the lips are pulled in a downward angle. It’s fairly clear to me that the right-side lower-jaw is overly large and extends excessively downward. Please let me know your thoughts!
A:As you have correctly surmised your jaw asymmetry is due to the right side being lower. This is a very typical form of Joel asymmetry and, for whatever reason it is usually the right side which is lower. The only effective treatment is an inferior border shave on the right side. This requires some x-rays for proper planning. At the least a Panorex X-ray will clearly show how much lower the right side is from the left as well as the location of the nerve as it runs through the lower jaw. This is known as the inferior alveolar nerve which supplies the feeling to the lower lip and teeth. This runs directly through the bone in the middle of the lower jaw and exits anteriorly through the mental foramen. Usually when the Joel is lower so is the nerve in the bone and we have to know exactly where that is to avoid injuring it in any type of bone removal. Most likely given where your jaw overgrowth is the nerve is probably got a safe distance away. But it is obviously important to know rather than to guess.
That issue aside the more relevant issue is the approach needed to remove the jawbone. The Jolla angle poses considerable technical challenges for proper access. Since what is needed is a specific linear cut of bone from the back of the jawline forward to the point where it matches better to the opposite side the only way to do that is an external approach. This requires an incision at the back end of the jaw angle. The alternative is an intraoral approach but this places the bone cut at an odd angle, a nonlinear cut, and it is very hard to be exactly specific as to the resultant bone shape that is created. It creates a curved shape unless the bone cut is placed very high which would then make your right side higher than the left and just cause the reverse problem.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m interested in paranasal implants. My goal is to normalize the central part of my face having an aesthetic outcome.
A:Thank you for sending your pictures. I would need to know exactly what you are hoping that paranasal implants can improve or resolve. When one says normalize the central part of my face that suggests to me to provide some additional projection around the lower central mid face which paranasal implants can certainly do. If the goal is to sit softener significantly reduce the presence of the nasolabial folds in that regard I would not be as optimistic in terms of the effects.
That being said, provided the primary goal is increased projection for undergoing the procedure, is whether one should use standard or custom implants. That decision requires a more in-depth conversation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I need to know if taking bisphosphonates (alendronic acid, specifically) would be a problem when it comes to getting an otoplasty done, even if it’s just an upper ear setback via sulcus reduction, as well as a head width reduction procedure, whether it be by removing muscle or bone.
A:Biphosphanates potentially affects bone healing from surgery not cartilage (otoplasty) or muscle tissue (temporal reduction).
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I was thinking of having a facial augmentation, which would include the zygomas and the chin. I tried to make some implants to get an idea of what the result might look like. What does the doctor think of the ones I made. Could the design and thickness be like this.
The goal is to have more projection and width of the lower midface; I would like to know if the doctor could digitally place the implants I have designed onto my skeletal scan/model.
Or better I have already made a physical project of the implants on a skeletal model. What I need now is for this project to be transferred into a digital format, like a 3D simulation, so it can be used for further development of the implants.
So that I can see the project in a professional and more clear way.
A:What your pictures demonstrate is how I used to make custom facial implants prior to 2010. Back then I made the implant design using plaster or wax on the patient’s 3-D skeletal model. Since 2010 this method has become obsolete since I now design implants by computer design on their 3-D CT scan.
But regardless of the method used to obtain any implant design there is no method to determine exactly what the external facial effect will be… which I believe is what you’re asking. That is as of yet an impossibility with any accuracy. Whether it is the old method or the new method custom facial implant designing is done to make the best guess of what the result may be. The basis for any implant design should be morphed pictures of the patients before and after desired result… at least then the implants are designed based on a specific target. What it appears you have done is make an implant design and ask what aesthetic effect it would have. Besides being an impossible question to answer, as I have already stated, this approach is doing it backwards. The implant design should be based on a known target which is the patients morphed desired outcome.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, A year ago, I had Medpor infraorbital implants placed to correct hollowing under my eyes. Unfortunately, I feel that the implants were not well suited – my facial proportions have changed, and the implants are visible beneath the thin skin of the lower eyelids. I have also noticed a deepening of the nasolabial folds, which I suspect may be related to their position being too close to the inner corners of the orbits.
Later, I underwent a temporal lift intended to cover the implants with soft tissue, but it did not bring the expected results – the implants are still visible. Another maxillofacial surgeon suggested that the best solution would be to remove the implants through an intraoral approach, the same way they were originally inserted. After the implant surgery, I also experienced prolonged swelling in the nasolabial fold area, which still concerns me.
I would like to know, after reviewing the photos of my face, whether the best solution in my case would be complete removal of the implants, or possibly replacing them with a different type positioned more laterally – in the zygomatic area. I am also concerned about the removal procedure itself, although I understand that it is performed in another tissue layer and should not lead to skin loosening.
It is very important to me to receive professional guidance, and I am considering entrusting this procedure to you, given your experience with similar cases. I am attaching photos taken before the surgery as well as recent ones, along with CT scan images (unfortunately, the implants are not visible there). In two weeks, I will also have an MRI done, and I would be glad to send you those results for additional assessment.
Thank you very much for your time and opinion.
A:Thank you for your inquiry and sending all of your pictures. I have seen this problem many times and it typically occurs with the more bulky Medpor or PEEK implants because they are machined and do not have fine edges or contours. I don’t know whether these are standard and custom Medpor implants but the issue is the same as you have already correctly surmised… they are not well fitted for your face. The lower eyelid is a very unforgiving area due to the thin tissues and it doesn’t take much implant excess to have them appear as they do in you. You are, however, incorrect about the reason deepening of the nasolabial folds. It has nothing to do with implant location but in rigid Medpor implants it takes extended soft tissue tissue detachments for them to be placed. The need to detach all of the surrounding tissues has resulted in heir subsequent soft tissue descent resulting in the now more apparent nasolabial folds.
The concept of performing a temporal lift to provide more soft tissue cover over the implants was a flawed concept from the beginning…it never had any chance to be successful. The problem lies in the implant shape and design not the lack of adequate soft tissue cover.
When it comes for how to move forward there too obvious options. First there is complete removal of the implants which would solve the protruding appearance of them but I would have concerns that there will be more significant hollowing then you had initially. There undoubtably was a reason they were put in, which I assume was due to undereye hollowing, and that problem will likely be worse due to the trauma to the tissues as well as the stretch and detachment of them. A good rule to remember about implants placed anywhere in the face and body is that once removed one never returns completely back to what it was before they placed. I do not know where your concept comes from for implant removal as it is performed in the exact tissue layer in which they were placed and it will definitely lead to more skin loosening due to the expanded stretch of the tissues. The question is not whether there will be more skin loosing but only how significant it may or may not be
The second option would be to have better design and implants with improved contours and edging. Ideally it would be helpful to see the implants on a 3-D CT scan as then a custom design could be made using that information… As the old motto in facial implants goes…. when you know why something doesn’t work you know how to make it work better the second time. In other words if you could see the implants you have in place it would be easy to design something better to solve the current problems you have. However the Medpor implant material can simply not be seen on a CT or MRI imaging from a 3-D viewpoint which is the only information that would be helpful. I would not waste the effort on getting an MRI. I do not understand why that would be ordered or what is to be gained by getting it.
The most important imformation would be o know exactly the Implants that are in you which would be obtained from your surgeon by the operative note and/or a record of the implant style and size. The operative record is usually the most helpful.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a bimaxillary osteotomy to fix my bite 2 years ago. My bite is now fixed and both jaws have been moved forward and up but I feel like my midface is still pretty flat. The screws in my upper jaw have been removed already. (photo is older) Is there a possibility to add volume only under my nose to lift the base of my nose and around it?
A: It is quite common to have some residual midface projection issues after an isolated LeFort I osteotomy or double jaw surgery advancement. In these instances nasal base augmentation by implants would be the method to do s o now that the bone position has been maximized.
The only debate is how much more nasal nose projection is needed and what is the best implant method to do so…standard or custom implant designs.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, Id like to ask about a step off after genioplasty. I had 2 step off sites right after my sliding genioplasty (6mm forward only) one side is worse than the other. I did a revision 7 weeks post-op to set the bone back to its original position but the step offs are still there. They are better but still there. I’m very stressed now. I thought that a revision would fix this problem. Could you please advise if these step off will go away with time or I need some sort of surgery to fix it? How to fix it please? I’m really stress about it and you seems to be the most knowledgeable doctor about genioplasty . Thank you very much in advance.
A: If you really wanted to know now, rather giving it months, to determine if the bony stepoffs willl go away or persist, you get a 3D CT scan which will provide the definitive answer. Such a visual assessment will also explain why they are there if they do persist.
The only reason they would persist is if the bone was not set back all the way. But A 3D CT scan will answer that supposition accurately.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, Hello doctor, in skull aesthetics, screws are used. What happens if these screws get infected, and is it a risky surgery?
A: Skull reshaping is as safe as any other aesthetic surgery.
Screws don’t get infected, never seen it in 35 years of doing the surgery.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, I attached before and after photos for a procedure called FaceTite with microliposuction of the perioral mounds. I’m wearing very little makeup in these photos, and overall I’ve been bothered by my perioral mounds since I was a young adult. I’ve had them since I was even a child/teenager.
I’ve consulted three different plastic surgeons, the last of whom was able to offer me that procedure. I do notice that it made a difference, but I was told that any further improvements could only be done via a deep plane facelift. I haven’t met a surgeon yet who has been able to offer targeted perioral mound debulking because of anatomic constraints. If Dr. Eppley could take a look and consult with me I’d appreciate it. I’m turning 36 this yeat, and since the surgeon that did my FaceTite procedure is open to a deep plane facelift, I’m strongly considering getting one within the next couple years.
A:I have never been impressed with the results for any Face Tite procedure and I don’t really know what exactly is done with ‘microliposuction’ of the perioral mounds. In other words what size cannula was used, how aggressive and how much surface area was done in the procedure etc. I simply don’t know how thorough the liposuction was done. Microliposuction could mean an aggressive and extensive area was done using a miniature cannula to do so. It could also mean a very limited amount of area which traded hence the term micro.
When it comes to perioral mounds there really are no anatomic constraints. Anatomic constraints in the face typically means where are the branches of the facial nerve. But in the perioral mounds in the lateral facial area on a line between the mouth corner to the ear and down to the jawline there are no facial nerve branches in this area. While this is basic facial anatomy it seems to escape many plastic surgeons as they frequently tour anatomic constraints as to why it cannot be treated or or not treated much beyond the area right at the corners of the mouth.
That being said the real question is whether you would benefit by a more thorough treatment of your area of facial concern. It is hard for me to say, not knowing exactly what was done previously, as to whether further liposuction efforts have merit. I can only make the comment in reverse in relation to considering a deep plane facelift at your age. That is a bit like using a shotgun to remove an annoying fly in your house. The solution seems to be far greater been the problem. In that regard it may be worth trying something far less in magnitude before committing to that type of effort.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Interested in midface augmentation to address some recession and rhinoplasty. Possibly minor bone reduction and implants to resolve some asymmetry. Attached a mockup of what I’m looking for, but it looks kinda unnatural in the eyes.
A:Thank you for your inquiry and sending your pictures. I have toggled back-and-forth between the before and afters and your perception of why it looks unnatural around the eyes is that it’s augmentation effect is greater than that of the midface below creating an aesthetic mismatch. It’s not that there is not benefit to infraorbital-malar augmentation, just a balancing that with her mid face augmentation below it can be challenging.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am very interested in learning more about the Iliac Crest Reduction procedure that your clinic offers. I would greatly appreciate it if you could provide me with information regarding the following:.).
- The expected recovery time and any lifestyle restrictions following the procedure.
- Whether this surgery can be combined with other contouring procedures (such as liposuction or body sculpting).
- Potential risks or limitations that patients should be aware of before undergoing this operation.
Thank you very much for your time and assistance. I look forward to your reply.
A:In answer to your questions about iliac crest reduction surgery;
1) Recovery from iliac crest reduction involves some stiffness with walking in the first few weeks which then completely goes away due to the trauma to the TFL fascia which has its attachments to the iliac crest. Once full recovery is achieved there are no physical limitations.
2) iliac crest reduction can be combined with other body contouring procedures.
3) in my experience other than a small scar I am not seen any other significant risk or limitations from the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m emailing you wondering if I would at all be a candidate for cosmetic skull reshaping. When I was born I was delivered with forceps that unfortunately shaped my head in an odd way. There’s an indent on the back left side of my head that has pushed the front right side forward. Making my skull look ‘pointy’ when viewed head on. I’m curious to know if there is any kind of surgery to make it look more rounded and not a point ridge like it is now?
Thank you for taking the time to read this.
A:Thank you for your inquiry and sending your picture. Regardless of the origin, at least seen in this one front view, you have a classic scaphocephalic head shape….meaning the top has a midline peak and the sides of the head are narrow. One can argue which of these two issues are the greatest, the the midline top of the head is too high or the sides of the head are too narrow, and it is a combination of both but the narrowness of the head shape is really the majority of the problem.
When it comes to treating this type of head shaped there are three options based on how far does one want to go for what degree of correction. These options include: 1) sagittal crest reduction alone, 2) sagittal crest reduction with para sagittal augmentation (between the sagittal crest and the bony temporal line, or 3) sagittal crest reduction with para sagittal and temporal (side of the head) augmentation. As can be seen in the attached three images there is a progressive improvement in the head shape the greater the surface area of the problem is treated.
There is considerations for these options given the shaved nature of your head (incisional access). But initially it is important to consider which aesthetic outcome looks the most favorable to you.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had cheek implants that I initially liked and then replaced them with new cheek implants that I thought would be better…but they weren’t. I now realize that I like my original cheek implants much better. I would also like some paranasal augmentation as well. My question is whether I should go back to my original I should go back to my original standard cheek implants or, because of the desire for paranasal augmentation, go with a completely custom midface implants approach.
A:I think the debate is whether to replace your current implants with the standard ones that you had previously of which you have good aesthetic satisfaction, along with new standard paranasal implants, or to take a completely customized approach to the midface area. That decision, quite frankly, is an economic one. One could make arguments for either approach. For standard implants, which will be the most economic approach, you were happy with a standard style previously and the paranasal area generally works well with a standard paranasal implant. Conversely a custom implant approach can be done where implant designs are made specifically for your bony anatomy to cover these areas. When one is in a position to have a viable debate between standard and custom implants the ultimate question is how much better will the aesthetic result be with a custom approach versus a standard one. For example if you could accomplish 90% of your desired asthetic results with standard implants why would you pay more for custom? However if you could only achieve 50% or less of your desired results with standard implants then the more economic approach would not be prudent in the long run.
That being said the other argument for a custom implant approach, which I have seen many times in patients where standard implants will produce an acceptable result, is that the patient feels better with implant designs in which they can see what they are beforehand and have confidence about what they look like and where they are going to be placed. This is almost always true in the patient who has had one or two prior standard implant surgeries.
The other decision that may sway a patient towards the custom implant approach is if they are having another facial area where a custom design is absolutely needed. This may be applicable to you since for your chin, in which a prior bony genioplasty has been done, a custom implant approach would be the most assured method to achieve very specific augmentative changes.
This is a long answer to a short question, I’ll be at an important one, which implant approach do to take?
Q:Dr. Eppley, What is your experience with treating negative orbital vectors with custom implants. Is it favorable? Also I want enough of a result to be seen but I don’t want to look unnatural so something conservative.
A: In answer to your questions:
1) My experience is favorable one. Compared to any other treatment methods it is the most effective. I didn’t say perfect but it produces a positive improvement
2) I understand the basis of the question but the fundamental principles to understand are the following: to get a significant aesthetic result you could not be conservative in designing the implant. As a general rule significant problems require significant effort. Conservative approaches work best when you don’t have much of a problem.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had Bellafill injections under my eyes and on my cheeks . As I am aging, it’s becoming more noticeable. Like to have a consultation to see what could be done. Not expecting a miracle, but hoping that I can soften the effects somewhat if possible. Thank you
A: Bellafill is a permanent injectable filler that creates its effect by the implantation of small acrylic or plastic beads. Scar tissue forms around them and that becomes the basis of their sustained effect. Removal of such an injectable filler requires an excisional approach, meaning it has to be cut out. Depending upon where it is on the face it could be reasonable to do or not reasonable to do. Meaning if it’s in an area that allows favorable incisional locations where are the filler can be accessed then it may be reasonable to do. For example if it is in reasonable proximity to that of a lower blepharoplasty incision then it could be potentially reduced or remove.
On closer inspection of your picture it looks like most of the filler is that the lower lid cheat junction which would make it either impossible to safely access for would likely caused lower lid retraction problems even if it was able to be removed. In short the risk benefit ratio in my opinion is not a favorable on.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Basically, I did an endonasal lip lift 4 months ago that, despite giving me a really good upper lip, changed my nasal sill’s shape (it cut the nasal sill’s skin in between the transition from nose and philtrum). I spoke about it to my surgeon, but he said he does not know how to fix it. Then I went to a couple other surgeons, they mentioned about cartilages or retail (however retail would give me a huge scar on my nasolabial folds, which I dont want), but they did not want to operate me, because it would be their first time at a case like that maybe cartilages or even fillers could help me? I don’t know, I really want Dr. Eppley’s opinion
A:What you are referring to is loss of the nasal sill from this type of lip lift. That is unrepairable problem Once it has been obliterated it cannot be restored. This is the expected trade-off for not having the scar line along the base of the nose. One can have a debate about which problem is more significant, a scar line along the base of the nose with the standard technique or loss of the nasal sill with the endonasal technique, but that is in a relevant issue now. The endonasal lip lift has its merits but you have to select patients for it very carefully. Those patients that had a prominent nasal sill preoperatively, like you, are going to be more aware of the loss of the sill than in those in which it is less prominent.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I attached before and after photos for a procedure called FaceTite with microliposuction of the perioral mounds. I’m wearing very little makeup in these photos, and overall I’ve been bothered by my perioral mounds since I was a young adult. I’ve had them since I was even a child/teenager.
I’ve consulted three different plastic surgeons, the last of whom was able to offer me that procedure. I do notice that it made a difference, but I was told that any further improvements could only be done via a deep plane facelift. I haven’t met a surgeon yet who has been able to offer targeted perioral mound debulking because of anatomic constraints. If Dr. Eppley could take a look and consult with me I’d appreciate it. I’m turning 33 in October, and since the surgeon that did my FaceTite procedure is open to a deep plane facelift, I’m strongly considering getting one within the next couple years.
A:I have never been impressed with the results for any Face Tite procedure and I don’t really know what exactly is done with ‘microliposuction’ of the perioral mounds. In other words what size cannula was used, how aggressive and how much surface area was done in the procedure etc. I simply don’t know how thorough the liposuction was done. Microliposuction could mean an aggressive and extensive area was done using a miniature cannula to do so. It could also mean a very limited amount of area which traded hence the term micro.
When it comes to perioral mounds there really are no anatomic constraints. Anatomic constraints in the face typically means where are the branches of the facial nerve. But in the perioral mounds in the lateral facial area on a line between the mouth corner to the ear and down to the jawline there are no facial nerve branches in this area. While this is basic facial anatomy it seems to escape many plastic surgeons as they frequently tour anatomic constraints as to why it cannot be treated or or not treated much beyond the area right at the corners of the mouth.
That being said the real question is whether you would benefit by a more thorough treatment of your area of facial concern. It is hard for me to say, not knowing exactly what was done previously, as to whether further liposuction efforts have merit. I can only make the comment in reverse in relation to considering a deep plane facelift at your age. That is a bit like using a shotgun to remove an annoying fly in your house. The solution seems to be far greater been the problem. In that regard it may be worth trying something far less in magnitude before committing to that type of effort.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello! I had a consult with Dr. Eppley a while back about testicular implants which had been done in Beverly Hills. I was not satisfied with them because they were too hard. Upon Dr. Eppley’s advice, I had them removed. Now I find that I would like to have implants again but I need confirmation that the implants that Dr. Eppley uses are softer and more lifelike than the previous ones.
A: What you previously head is a form of a wraparound implant which in your previous case was a clamshell type approach. That is not the style of wraparound implant that I use in which it is not partial but a complete wraparound in which the natural testicle fits completely inside the implant. While this is a completely logical approach it is not a complication free implant. Just like the clamshell style you had previously, in which you did not experience any complications other than how it feels, there is always the risk of disengagement of the implant from the testicle after surgery. That is a problem for which I have not yet come up with a method for attachment with a 100% assurance that the complication, detachment of the implant from the testicle, could not occur. Ideally that risk is lowered when the design of the hollow chamber inside the wraparound implant completely matches the patients natural testicles size, which always differs between the two sides, and is optimally determined buy a preoperative ultrasound so a true custom design implant is made.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Unfortunately it is not easy to show in pictures how my knees look. Therefore I sent the video. The upper part of the knees is actually fat and skin. Hope this helps ?
A:Thank you for sending the additional pictures. What you are not factoring into the consideration of any knee lift with and supra patellar tissue excision is what happens when the knee is bent at 90°. Lifts that cross a mobile joint such as elbows and knees must consider what happens to the stretch on the scar line when the joint is bent at 90° or greater is this will ultimately determine how well the resultant scar will appear. Take this same amount of pinched up tissue in the extended position and then bend your knees at 90° or greater and see what happens. You will find out quickly that the pinched up tissue becomes stretched out and under much greater tension. This is what will happen to the scar line in that situation and the result will be that you will likely have a scar problem that you will dislike much worse than the original problem that it was intended to solve. The best knee lift candidates are those that have several olds of skin in the suprapatellar area in the extended position which reduces to one fold when the knees is bent at 90°. Excision in the situation results in a much more favorable scar trade-off.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I’m attaching photos of what I’m looking for.
I don’t like the projection of the chin which in my opinion is too much (profile), I would prefer it to be wider and a little more squared like in the photos (not excessively)(frontal/ 3/4).
Also I would like a consistent cheek augmentation.
My main concern is to reduce the triangular and elongated (fox-like) shape of my current face by improving frontal and 3/4 views.
A:If I interpret your request/goals accurately you would like a chin that has less projection but is also wider and more square. Those type of chin dimensional changes are very hard to achieve as reduction involves bone removal well within squareness generally requires implant augmentation. So to some degree these desired dimensional changes are conflicting. The only possible autologous option to try to achieve these changes is a setback genioplasty with a midline expansion/bone graft. The other option is a chin projection shave and adding implants onto the side. But in either case you need to be aware of that anytime chin projection is reduced it can cause other issues such as redundant tissues in the submental area (fullness) as well as fasciculations of the mentalis muscle of the soft tissue chin pad.
As for the cheek augmentation I am not certain what consistent means. I would need some more specific clarification as to the cheek augmentation goals.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My eye are very close and my inner eye corner are very big and down turned my eye is over all very round and short and high on my face and very up turned and very unsymmetrical they are very close
A:Thank you for your inquiry and sending your picture. You have numerous eye shape concerns some of which are improvable while others are either more challenging or unable to be significantly changed. The most improvable in my opinion is the round shape of your eyes to do a low ;id position. Lateral canthoplasties with spacer grafts would help raise up the lower lids the outer aspect of your lower lid and decrease your sclerosed show. The large inner lack lacrimal lake area that is downturned can be shortened a bit and not be so downturn. As for the eye position high up on the face that is not improvable issue.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I previously had two small implants at the base of my nose to increase the fullness (decrease flattened facial appearance) Although the doctor was on the right track, I think larger implants are needed. (he has since retired)
A:With confirmation from her previous surgery at paranasal implant augmentation what is the correct concept then the question becomes what was the size and material of the paranasal implants that was implanted. That would be helpful in determining what new size would be beneficial and also whether this is achievable by using existing paranasal implant sizes or whether a custom implant design is needed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I underwent a buccal fat pad removal surgery, during which approximately 5.0 ml of tissue was removed from each side. Unfortunately, I have since developed very significant adverse effects, including severe cheek hollowing, noticeable facial sagging, and what appears to be a collapse of the facial support structure. This has also led to concerning issues around my orbital area, such as a sensation of eyelid dragging downwards, potentially due to the loss of support. I learned that BFP is a structured, triangular fat compartment that provides essential upward and outward support to the midface. I am now desperately seeking a method to restore this foundational support as much as possible. I have consulted other surgeons, however, I was advised that standard particulate fat injection may not be a sufficient solution because it would be injected into the superficial or middle layers and cannot restore the deep structural support that the BFP provided. It would add soft volume but not stop the sagging, and may migrate downward over time. In my research for a lasting solution, I was profoundly impressed to learn about your advice in reserve BFP removal using en bloc fat grafting.This gives me much hope. Therefore, I would be incredibly grateful to know if you believe a revision procedure might be possible in my case. I am wondering is it possible to graft pedicled en bloc fat to the original compartment where BFP was in, potentially secured with material like fibrin net, to restore support? I seek your expertise with much respect and am available to consult. Thank you so much.
A: As most buccal fat pads are in the 3cc range it would be fair to say that at 5.2ccs a substantial fat pad removal was done. I have done several buccal liecptomy reversals where a solid or dermal-fat graft is placed back into the contracted and empty buccal space. To get it back in place (back as far as possible) a threaded suture technique is used to pull it in. The fate of all fat grafts is unpredictable but dermal-fat grafts usually fare better than injected fat.
One element of the success of the procedure is how well the graft can be placed into the original buccal space. That is partially influenced by the time between the removal and the attempted graft implantation.
Dr.Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I am curious if the resorbable lag screws that can be used in a sliding genioplasty go unnoticed in dental x-rays and x-rays in general? If so, how long does it take for the complete healing and for the lags screws to be reabsorbed? Will it be 100% undetectable? Thanks!
A: Resorbable lag screws have a limited role in sliding genioplastics to more moderate sized advancements that follow the osteotomy line. But when used their resorption time is 9 to 12 months. At this point the residual screw hole will still be seen in an x-ray but that will go on to fully fill in with bone by 18 to 24 months after surgery. The resorbable screws are never seen in an x-ray, but it is the holes in the bone that will be radiographically visible for some time.
Dr.Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in jaw implant augmentation where a small external skin incision is placed either right at the back of the jaw angle or around the base of the earlobe.
A:A completely transcutaneous approach to jaw augmentation can be done provided at the amount of angle augmentation is not excessive. Such an incision is placed at the back end of the jaw angle. Coming from higher up at of the earlobe is not a good directional approach to placement of a bony implant.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, as you can see there is an obvious difference between the right side od the frontal bone and the left side. On my right side you can see concavity and lower brow bone . So im asking is there some sort of implant that can be inserted safely so i can get similar results like the left side and fill up the augumentation ?
A:Thank you for your inquiry and sending your pictures. Your brow bone asymmetry is a direct result of the right vertical orbital dystopia. As the right eyeball has developed lower than that of the left everything around the eyeball follows it down. Thus your right brow bone is lower and has less forward projection than that of the opposite left side. Such brow bone asymmetry can be improved at least in the filling in the concavity above the lower right brow bone. Whiel that some shape improvement I don’t think we could say that it will look exactly similar to that of the left side because the two brow bones alright completely different horizontal levels.
Assuming filling in the right front upper brow bone cavity is seen to provide effective improvement then the next question is what type of implant is needed to do so. In an ideal world we would make such an implant of of your 3-D CT scan to have the best possible implant design. Given that its size it Is likely to be small an alternative approach is to hand carved and implant based on visual estimates of the size needed. The reason to choose the latter approach is an economic one. Either way the brow bone implant would be placed through an endoscopic approach with a single microscrew fixation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a quick question about jawline implants and thick soft tissue. If someone has thicker coverage (skin, subcutaneous fat, and masseter muscle), does reducing some of those layers improve implant definition?
Specifically:
Would masseter Botox (to slim the muscle by ~25–30%) before or after surgery help the implant show better?
If someone gets very lean and/or does submental/jawline lipo, does that significantly improve the contour, or is skin thickness still the main limiting factor?
Lastly, does skin oiliness relate to thickness, or are they unrelated?
I’m just trying to understand if these combined approaches can offset soft tissue bulk, or if thick skin always prevents a sharp result.
Thank you for your time and expertise.
A:The external appearance of a jawline implant is a reflection of numerous factors including the thickness of the overlying soft tissue. The implant design, implant size and the thickness of the overlying soft tissues are the three main variables. Implant size can overcome thicker tissues but obviously you don’t want to have patrol augmentation diamonds up being too big. As a result for most reasonably sized gel implants many patients combine soft tissue reductions of fat in the cheek and neck area to help.
When you use the term developing a sharp result by that definition usually only patients with thin overlying soft tissues can never developed that outcome. No matter what is done to the patient with thicker overlying soft tissues a true sharp result is never going to be achieved.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
