Your Questions
Your Questions
Q: Dr. Eppley, I have concerns about chin implant bone erosion. I have noticed the bone holding my lower teeth appear to be eroding somewhat from an overlying Gortex chin implant. Can you remove it and put something in the correct place that will not erode bone.
A: I would like to see the x-rays from which you have determined the occurrence of any bone erosion from an overlying chin implant. What sort of symptoms are you experiencing from it? Almost all chin implants will develop some natural passive settling into the bone which is often interpreted as ‘chin implant bone erosion’. That phenomenon becomes most apparent when the chin implants sits high, above the thicker basal bone of the chin and on the thinner alveolar bone closer to the tooth roots. But this is not a true progressive active inflammatory condition.
That being said it is clear that you also have does aesthetic concerns about the location of the chin implant and maybe even its outward aesthetic augmentation effects. The existing implant can be removed and a new chin implant placed lower over the basal bone. But all types of chin implant materials (silicone, Medpor, Goretex and Mersilene) can develop this passive bone remodeling effect. I have seen it radiographically as well as clinically during chin implant replacements and adjustments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need a question answered about facial fat atrophy prevention. I am 29 years old and have been using tretinoin cream (0.05%) every evening and sunscreen with SPF 30 (Mexoryl) every morning since the age of 20.
Therefore my skin has visually not aged since I was 20 years old and looks even better, firmer and tighter.I would also like to prevent the age-related loss of facial fatty tissue. As a sunscreen from inside, I also eat 2 tablespoons of tomato paste together with olive oil every day, because lycopene is a powerful antioxidant. Now I have read that lycopene also accumulates very strongly in the fatty tissue.
Could lycopene prevent or slow down the age-related loss of facial fatty tissue, because of its antioxidant effect? Could it also protect the connective tissue of the deeper tissue layers of the face? What do you think? Thanks in advance for your reply!
A: I think there is no scientific evidence that taking or consuming lycopene is a useful compound for facial fat atrophy prevention. Such an approach is a theoretical one but no clinical or animal trial has ever proven it. But there is n harm in its ingestion so I would continue to make it as it appears to make you feel more comfortable in doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My questions are concerning what skull reshaping procedures could be combined under a single operation. My skull deformity isn’t localized, the result of untreated craniosynostosis. I have the typical trigonocephalic skull, which is narrow in the front, and wide and tall in the back.
I believe that for an augmentation covering such a large area of the forehead, a preformed silastic implant is preferable.
1. Can a silastic implant be combined with burring of the forehead? How does that affect the printing of the implant, since you’re modifying the bony contours the implant is based on?
2. Can the posterior temporalis muscle be resected in the same operation?
3. Can the saggital ridge be burred down a couple millimeters in the same operation?
4. Would it make more sense to make a number of smaller incisions versus a large coronal incision when combining procedures?
The contours of my skull cause great psychological distress, so I have no particular concern for scarring.
Thank you.
A: Thank you for your inquiry. In answer to your questions:
1) Skull implants combined with skull bone reductions are common. The bone reductions are factored into the implant design process.
2) The posterior temporals muscle can be removed in the same operation as #1.
3) The sagittal ridge can be burred at the sam time as #1 and #2.
4) If the hair density and hairline permit, it is always ideal to use a coronal incision. But I regularly seek how to limit the scalp incision as much as possible in skull reshaping surgery. I can certainly envision for #1 to #3 above that a complete coronal incision would not be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in your custom jawline wraparound insert, largely for the sake of vertical facial lengthening but have a few questions. First, what is the maximum vertical height that can be added through these implants, would anything in the 15-18mm range be completely out of the question? What is the recovery time for this procedure, generally?
A: In theory a jawline implant that provides vertical lengthening (inferior border elongation) can be designed to any length. But the limiting factor is the ability for the soft tissue of the chin to stretch down and the masseter muscle in the back to similarly do so without disruption of the masseteric sling. As a general rule 10mms or so is what these tissues will usually tolerate for alloplastic vertical facial lengthening.
Recovery from a custom jawline implant is largely about swelling and it takes a good 2 to 3 weeks for a significant part of the swelling to go down to look more ‘normal’. Although a full resolution of the swelling and a completely normal appearance to occur will take a full six weeks after surgery. Tyoucally the complete resolution of the facial swelling takes much longer than most patients think.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was diagnosed Linear Scleroderma at the age of 7 years old. Due to this disease it has created a bald spot that I am able to cover with my hair on the top on my head. This bald spot is about two inches wide and five inches long. I also have a dent on the left side of my forehead. This is something that I have always wanted taken care of and just to look and feel normal. I am able to come to a face to face consultation or I can do a virtual one as well.
A: Thank you for sending your pictures. You have a classic case of linear scleroderma that involves the first division of the trigeminal nerve. Thus its effects go from the eyebrow straight up in the scalp along the pathway of the nerve involving atrophy of bone and soft tissue.. I would treat your case with a two-stage approach that includes the following:
1st Stage = Placement of two scalp tissue expanders on each side of the wide scalp scar with fat injection grafting to the foreheads/brow.
2nd Stage (6 weeks later) – Removal of tissue expanders with excision of scalp scar and advancement of hair-bearing scalp flaps to cover it and placement of custom forehead-brow bone implant
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye asymmetry surgery. I was born with congenital torticollis. The torticollis was not caught early and resulted in me sleeping exclusively on my tummy with the left side of my head smushed against the mattress as a newborn/infant which resulted in the asymmetry in my face. My head/neck as a baby would not turn to the left due to the torticollis. I had a plastic surgery consult when I was 12 and we decided to correct the torticollis (by releasing my left side sternoclatomastoid muscle) but the other facial reconstruction freaked me out too much. At that time, it involved significant intracranial work and taking bone from my ribs and raising eyeball …in short it was overwhelming to a 12 year old so I told my parents I didn’t want to do it.
I now feel that with age my right side has become too bulky and my left side seems to be sinking in more which is causing the eye asymmetry to be more noticable. When I was younger, you didn’t notice as much, as the baby fat was more evenly distributed in my face.
When I saw your case study with the Hydroxyapatite cement, it gave me hope that there might be a less invasive fix to even out my eyes?
A: Thank you for sending your pictures and detailing your history. The treatment of eye asymmetry or vertical orbital dystopia (VOD) that has a 5mm or less discrepancy can be done through orbital floor/rim augmentation as well as some surrounding ancillary procedures of the eyelid, cheek and brow bone. (eye asymmetry surgery) A 3D CT scan is very useful in determining the vertical discrepancy and how much orbital floor augmentation would be needed and/or can be done. In many cases of VOD my preferred method is a custom designed implant that covers the orbital floor crosses over the infraorbital rim and onto the cheek…all orbitofacial skeletal areas that are deficient in all cases of VOD.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a transgender male to female who is investigating how best to further reduce the masculinity of my face. Overall, my face has a width problem with wide temporal muscles, laterally protruding cheekbones, and a wide chin. I spoke with you on the phone a few months ago about the temporal reduction which I still plan on doing with you later this year.
However, I am also concerned about my chin. I had a chin reduction with another surgeon, and he used a submental burring approach. This was effective in making my chin more rounded and less square, but it’s still a wide chin. And considering the fact that I am looking into doing temporal width reduction and cheekbone reduction one day with you, I realize that if this wide chin issue isn’t dealt with it will look even more disproportionate.
1) What do you think is the best way to deal with a wide chin? Would I be correct that a wedge osteotomy to remove a center wedge of bone and pushing the two sides together would create the narrowed chin shape that I desire?
2) Can temporal width reduction, cheekbone reduction, and a chin reduction procedure all be done together?
Thank you!
A: I am not sure why with a submental chin burring technique you did not get enough width reduction. That technique can create as much narrowing as an intraoral wedge reduction chin osteotomy. They are just two different ways to achieve the same result. I suspect your surgeon was simply not aggressive enough and may not have been comfortable doing so. A wide resection of the side of the chin can definitely make it more narrow and probably more so than an intramural midlne wedge osteotomy.
Temporal, cheek and chin reduction surgeries can all be done together and would make the most sense to do so given the overall objective of a total facial narrowing effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Pectus Excavatum implant surgery over twenty years decades and have had any problems with it and have been happy with the results. This past fall I got struck on my chest on the right edge of the implant. Quite quickly a bulge appeared but there was no skin break. I saw my doctor within a few days later and he drained the surface fluid. However fluid had formed under the implant. My doctor referred me to an interventional radiologist whom aspirated the fluid under the implant using ultrasound. The fluid returned. I have had 3 subsequent aspirations.I have had a CT scan. At this point what are my options. Can the implant be saved?
A: Thank you for you detailed description of your history and recent event in regards to your pectus excavatum implant. At the least your issue requires an open procedure to clean up the pocket, resterilize the implant and place a drain. While this is not a guarantee that the implant can be salvaged, this would be the best approach to try and do so. Because the implant has done so well over many years I would be optimistic that it can eb salvaged from this traumatic event.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a deep vertical groove in the area between my eyebrows. I have tried Botox injections but it didn’t do a thing. I even tried injectable fillers but it also didn’t improve it. What do you think about a glabellar implant to help push it out and make it smoother? I have attached some pictures which show how deep the groove is between my eyes.
A: Thank you for sending your pictures. What you have is a very deep glabellar furrow on the left side as well as other less deep wrinkles lines on the right side. When a glabellar furrow gets this deep it will not respond to any neuromodulating agent (Botox) or injectable filler. It must be treated like a depressed scar, which in many ways it is without the traumatic injury history. In these deep glabellar furrows, which occur more frequently in men, I treat them directly by furrow excision, glabellar implant augmentation down at the bone level, muscle release and excision and geometric skin closure. This comprehensive approach to deep glabellar furrows is the most effective strategy that I have found to be effective. It is the only way to change a deep V-shaped skin and soft tissue groove betwee the eyes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want like to have a sliding genioplasty to bring the chin forward to balance my facial profile. I also thought of another option to have a solid hydroxyapatite chin implant (not paste) with hydroxyapatite screws, is this possible? I have some questions.
-How long does a sliding genioplasty take to perform?
-How much projection can be achieved with a genioplasty?
-I understand that it is not necessary, but I want to remove the metal plates some time down the line and have any irregularities smoothed out if there are any.
-Can bone removed from my ridge reduction and used for a bone graft to place where there would otherwise be a step to add better form to the new chin?
A: In answer to your sliding genioplasty questions:
1) It takes one hour to perform a sliding genioplasty.
2) How much horizontal projection can be achieved depends on the thickness of the chin bone. But, on average, 10mm to 12mms can be obtained if not more in a male.
3) You can have the metal plate and screws removed 6 months after the surgery when the bone is well healed.
4) Bone grafts from the tibia can be used to fill in the step of your sliding genoplasty if desired. This would be a good use of ‘recycling’ of the removed bone from the tibia.
5) Making a chin implant out of hydroxyapatite is not possible as no U.S. manufacturer will do so. But even if it were possible, such a chin implant would be fairly brittle and hard to place due to its stiffness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get a chin reduction, I have lots of soft tissue and bone that sticks forwards when I smile. However when I don’t smile my side profile looks slightly weak due to the way the soft tissue sits. I also have a small overbite.
My face structure becomes very witch like when I smile. I am hoping to achieve a more symmetrical v-line chin, I quite like the shape of my chin from the front but I would like to remove the part that sticks forwards.
I have a very petite face and don’t really want to loose much vertical length, it’s more the way it sticks forwards from the side that bothers me.
My face is also asymmetrical, I have TMJ in the left side of my jaw, this side of my face is more rounder & wider than the left side of my face.
I have attached lots of photos to give you a good idea of how my chin looks from different angles. Would a simple chin reduction be able to fix my problem? I would like to avoid implants and adjust the bone and soft tissue if possible. However I worry that reducing the bone would result in a weak side profile when not smiling as it only sticks forwards when I smile.
I feel like my chin ruins my whole face and I would be much prettier if I could fix it.
A: Thank you for your inquiry, detailing your objectives and sending your pictures. With a hyperdynamic chin protrusion but a weaker or more normal chin shape at rest, that makes can reduction more aesthetically precarious. Chin reduction surgery reduces soft tissue, bone or both but the most effective chin reductions remove both bone and soft tissue. But no matter what tissues are removed it will have different effects from smiling to non-smiling. If the reduction improves how it looks when smiling there is the risk it may adversely affect how it looks when not smiling. (as you have astutely mentioned) Thus it is not likely possible that any chin reduction procedure will produce the desired chin shape from any angle regardless of whether one is smiling or not. That is not a completely realistic and achievable aesthetic goal.
In hyperdynamic chin protrusions like yours some horizontal bone and width reshaping (not vertical length reduction) with a submental soft tissue excision/tuck is the likely effective approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just had some concerns regarding the silicone skull implants. The first concern I have read about are possible issues with erosion of the skull over time by the implant.The second is something about water collection within the implant over time.What are some adverse side effects that may be possible due to the use of silicone skull implants?
A: In answer to your silicone skull implant questions:
1) Bone erosion is not an issue with skull implants. I have never seen it nor is the general concept of bone erosion around any craniofacial implant accurate. Such a phenomenon, outside of an infected implant, does not really exist. There can be passive setting of the implant into the bone by a millimeter to two common in high tension situations like chin implants, but that is a passive and self-limiting natural biologic process.The broad surface area of a skull implant does not even allow that to occur.
2) I have never heard of ‘water collection’ around any craniofacial implant. There can be small serous fluid collections right after surgery but they are limited and self-absorbing and are common in any surgical implant site.
3) I have never seen any adverse effects with any skull implant material. The issues are always the same regardless of the material…how well did the shape of the implant achieve the desired aesthetic effects.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you also use Allofill? And if so, what experiences did you make with it?After two cheekbone augmentations with Medpor implants (after the first augmentation with Medopr Malar Shape implants, another Medpor implant was placed over the lateral part of the cheekbones, which was carved from a Medpor block), one can now see a transition between the first and the lateral cheekbone implants. Is Allofill suitable for correcting this transition of the cheekbones? Is the result really permanent and does the replenished amount correspond to the new tissue growth?
A: In treating facial implant edging or transition areas, I would not recommend Allofill injections for it. There is little clinical evidence yet that its effects are permanent. While there is no harm in dong so, its effects do not offer proven persistence beyond other types of synthetic fillers or fat injections. Other options include an overlay of ePTFE sheeting which would be better and more assured of a long-term solution mask the transition areas. Your case illustrates the potential pitfalls of having two implants right next to or over each other. Some palpable and even visible implant transitions areas can frequently result.
Dr. Barry Eppley
Indianapolis, Indian
Q: Dr. Eppley, I am very interested in the tear drop breast augmentation procedure. I am currently a small B and would like a small change to maybe a full C. I really want a natural look and a small implant so that my breasts still look natural and do not stick off my chest or look high up, so i am interested in the teardrop shape implant.
I also am interested in a chin reduction since mine is very long and prominent and protrudes significantly when I smile. I would like it to be shorter and narrower/ pointier. Another thing is that my face is rather narrow and long and I desire a rounder face and more full look, what procedures could help with this? I want my cheeks to be wider in diameter if that makes sense? thanks!
A: While you have mentioned tear drop implants for a natural look in breast augmentation, be aware that the same effect can likely be achieved using low profile round implants which often create the same look. In the upright position tear drop and low profile round implants have been shown to look the same. I mention only because the cost of tear drop breast augmentation is higher.
Otherwise a submental approach to your chin reduction is the best method to address both bone and soft tissue excesses.
The one procedure that is most effective at helping widen a face are cheeks implants. But not just any cheek implant will create that effect. It takes a special design cheek implant that specifically focuses on adding width back along the zygomatic arch.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i had a few quick questions about Medpor chin implant removal in advance so that I can speak with you with a clearer understanding of surgical possibilities next week.
1) If an implant is placed via an intra-oral incision, can it still be accessed via a sub-mental one?
2) Instead of removing a Medpor implant and replacing it with a different shape or size, can it be edited / cut down whilst still attached to the chin?
3) In my case my lip function is perfect. However the position of the lip is not correct; it feels like my lip is being pulled downwards by the weight of my mentalis muscle which (i believe) was not reattached successfully. Can the reattachment be made without further risk to the muscle-lip function?
Of course our conference call should give you a better visual idea of my situation and whether or not i have correctly identified the problems i am noticing.
I look forward to your thoughts.
A: In answer to your Medpor chin implant removal questions:
1) A chin implant that was placed intraorally can be subsequently accessed from a submental incision.
2) It is almost never a good idea to modify a chin implant in place as the amount and type of modification is very restrictive…and thus limits what can be effectively done.
3) I doubt very highly that the mentalis muscle was not reattached properly as there is only one way to do it…it is either done or it isn’t. It is important to remember that a chin implant displaces the muscle in an unnatural way forward. Your anatomy was not made to have an implant behind it. When this natural anatomy is changed and the muscle is dragged up over an implant, particularly one that gets a lot of soft tissue adherence, the risk is that it may feel stuck or being pulled down. That is why it feels the way it does, it has nothing to do with the muscle per se and messing with the muscle is going to create more problems not less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I talked to my surgeon and he explained some of the difficulties that may come of infraorbital implant removal. You see I had it done together with a SOOF lift and lower eyelid retraction surgery and so removing the implant might compromise the support of the lower eyelid area. I wanted to ask some tentative questions in case I go ahead with removal:
-How would you handle the risk of undoing the lower eyelid surgery I’ve had done and prevent any adverse effects that might require further surgery in the future?
-Is my surgical case very uncommon or something you have experienced before?
-If I am unlikely to return completely to my previous look, what type of change is reasonable to expect, or perhaps that’s impossible to say?
At one month after surgery there is still some swelling but I believe I am correct that the sharp edges I see below my eyes are indeed the implant as it’s quite palpable. Just to be sure though I’ve attached two recent pictures and two of my face before surgery if you have the time perhaps you could take a quick look and tell me if there is any hope at all that this issue will resolve itself?
You correctly assumed the incision method and the size of the implants should be relatively small but they appear quite prominent, maybe because of the thin skin in the area. I forgot to mention that these are “extended infra-orbital implants” so they are longer than is usual which I now think was a mistake.
A: Thank you for sending your pictures. The basic concept is that you are going to have to undo everything that was done to do infraorbital implant removal. In addition there is little guarantee that you will return to your preoperative eyelid shape state.
These two concepts should give you great pause at this early point after surgery in having a reversal/removal procedure. Any implant edges that you feel now with time will not likely become less. They over time indeed may become more prominent. But no one can predict how you will feel about it months from now…which is the time one should allow for full healing to occur.
The ‘mistake’ that is often made in infraorbital implants is using preformed implants. The tissues are too thin and the implants are standard shapes, a set up for implant edge capability and potential visibility. This is what I almost always use custom implants or ePTFE sheeting which allows for very feathered implant edges and a better blending into the surrounding bone margins.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We spoke several months ago about my slipped rib and the possibility of having rib removal surgery for it. I’ve tried to manage things conservatively but my pain has not improved. In weighing the risks-benefits of an eleventh and twelfth rib resection, one of my concerns is the risk of a flank hernia. As you know, there is very little data on this in the medical literature. Most of what I’ve been able to dig up is in the context of rib resection to facilitate kidney removal. I would imagine that based on your extensive experience resecting ribs, you probably have more data than anyone on the potential risk of a flank hernia. In short, with the obvious disclaimer that you’re not giving me any formal medical advice, I would appreciate hearing your thoughts on the risk of a potential flank hernia from a resection of the eleventh and twelfth ribs. Thanks again for all your help. I really appreciate the time you’ve taken to answer my questions.
A: The simple answer to your rib resection question is that I have never seen such a complication or would I ever anticipate one. With preservation of the medial periosteal layer I can not imagine this occurring. This is quite different than opening up the peritoneal space for kidney removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came to your office back in August of last year. I had a temporal artery ligation on the right side of my head. The procedure went very well and is still holding up fine. I am planning to come back in the spring or summer of this year to have the left side done. My question for you is that I have some early stage pre-cancer spots on my head. This is from the result of being bald and exposed to the sun for most of my life. My Dermatologist has prescribed 5% Fluorouracil Cream to spread on my head twice a day for two weeks. This should help or take care of that problem. I just want to make sure that this cream will not affect the ligations when the outer skin peels off to replace the new skin. Thank You in advance for answering my question and I look forward to visiting your office again. Thanks.
A: Thanks for the followup and glad to hear that a good result has been obtained and is being maintained. 5FU is a strong chemical peeling agent that is commonly used in the treatment of superficial skin cancers. Its use will not interfere with the performance results obtained from a temporal artery ligation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it has been a while since I last spoke with you and I have been thinking more about the paranasal implants. In the photo morphs you sent me, we had adjusted the degree of projection to be a little bit less than the first morph sent a while back. In the current photo morph how much thickness of the implant would you estimate using? (<5 mm). The first picture is the morph of my face, the second an example of paranasal augmentation with cartilage I found in a paper, and the third is a patient review from a Korean plastic surgery site.
I have seen quite a few results from Korea on this procedure, but I feel that there is too much augmentation in these procedures, leading to an unnatural upper lip appearance. Before going for implants can an adequate saline injection or temporary filler give me a good simulation of how the implants might behave on my face?
If not, do you happen to know of any other publications or available data/photos on paranasal implant results?
Thank you for your time and advice.
A: When it comes to any form of facial augmentation, it is not an exact science. There is no way currently to know precisely what effect any degree of augmentation could create or how a patient will feel about the degree of change they have experienced. The only thing I know for sure about paranasal augmentation is that anything less than 3mms would be too small and anything bigger than 7 or 8mm would probably be considered too much. But how to pick an amount augmentation within this range is anyone’s guess.
Certainly injectable fillers are an accepted temporary approach for a paranasal implants augmentation trial. They do not have the same push as an implant and do not create the exact same look, but they are still reasonable to try. But I am not sure they really give a good ‘implant test’ response.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some concerns regarding my head shape. To be specific, I have some abnormalities that are isolated to the top of the back of my head. I have one quite big indentation, probably caused by something hitting me to the head when I was younger, which also has caused the skin surrounding the indentation area to be a little lumpy. I believe I have a head shape similar to the “Skull reshaping 10” pictures from your photo gallery. I believe the only way to fix it is by adding what you call bone cement in the indentation. My questions to you are:
– Do you think this indentation is fixable? And from the little I have explained above, do you think fixing the indentation also would fix the lumpyness around that area?
– How much time is needed for a procedure like this? Are we talking a week or more for recovery?
– What are the risks when adding bone cement to my existing bone structure?
– Will putting bone cement into my body be of any hindrance when it comes to physical activity etc?
I hope you can answer all my questions, and I do hope this is something that could work for me, as it has been something that I constantly worry about.
A: To best answer your skull reshaping questions about what can be done with your skull shape concerns, I would need to see some pictures of your head. By your description the best way to effectively treat it would be a custom skull implant made from a 3D CT scan. This procedures the best contour result while avoiding any edge contour issues of the implant-bone interface. This is a procedure in which you could return home in a few days after the procedure. Rather than being a hindrance to any physical activity, such an implant actually increases the protection of the skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Two questions about buttock implant removal:
1.Do you remove the capsule? I would like to try fat grafting in the future to try to achieve a more normal appearance. I understand if the capsule is not removed or if it does not close completely the injected fat can die if it is injected into an empty pocket. Would you agree? Or is it better to leave the pocket for some “padding”?
2. Can fat grafting lift up a sagging buttock after implant removal or do you need something more solid like an implant?
Thanks
A: In answer to your buttock implant removal questions:
1) It is not necessary to completely remove the capsule and in trying to do so can be source of postoperative hematoma and would mandate the use of drains. The capsule will naturally undergo a lot of resorption once the implant is removed since there is no purpose for it any longer. It is not true that if fat is injected into it, it will die. In fact some surgeon espouse the opposite….injecting fat into a capsular space enhances its survival. But this is is really an irrelevant discussion sine the you might be injecting fat will be long after most of the capsule is gone.
2) Fat grafting will not lift up a sagging buttock. It takes a strong push from a solid implant to have that effect unless one injects a tremendous amount of fat…which you don’t have to harvest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young female from Montana. I am interested in lip advancements. I just have a few questions about the lip advancement procedure. I have pretty full lips. I have lip implants in currently and I like them. However, I would like my lip size to be a lot bigger. I don’t like fillers at all and, after reviewing what is offered, I am most interested in the vermillion advancement. My questions are:
1) Would this option of lip enhancement be good for a young person who dislikes lip fillers?
2) Can I have a vermillion advancement with Permalip implants in?
3) How big would I be able to make my lips with the vermillion advancement? I would want a big difference.
4) Would I lose any current lip projection (volume forward/pout), after the advancement?
A: In answer to your lip advancement questions:
1) Short of injectable fillers and implants, a surgical lip advancement procedure is the only option for making one’s lips bigger.
2) A vermilion advancement can be done with lip implants in place.
3) As a general rule, lip advancements can increase the vermilion show of the lips by 4 to 5mms on the upper lip and 3 – 4mm on the lower lip. Lip advancement are very powerful procedures for increasing lip vermilion show and their perceived size.
4) Lip advancements will not decrease the forward projection of the lips.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to ask about the paranasal implants. I have been doing research on this type of facial implant for a while. I have some questions.
- One is what is the material for the implants?
- Will it affect my facial expressions?
- How long will the implants last?
- Will they move around?
Thank you for your help!
A: In answer to your questions about this type of midface implant I can provide the following answers:
1) Paranasal implants are composed of either a solid silicone or an ePTFE material. The silicone ones are preformed. The ePTFE ones are hand carved at the time of surgery to the desired dimensions. There are advantages to each type of material but both can work well.
2) The implants initially will make your smile feel a little stiff but usually resolves by 6 weeks or so after surgery. There should not be any long-term facial movement limitations as long as the implants are not too big.
3) The implants are permanent and their shape and structure can never change or degrade over time. The materials used are non-biodegradable and non-reactive.
4) Paranasal implants will not move or become displaced as they are secured in place by small micro screws.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Dr Eppley, five years ago I received illegal silicone buttock injections once and I believe it is catching up with me now that I’ve become pregnant. I lost a ton of weight in the beginning of my pregnancy from being sick and was in the bed for months. I started noticing 5-6 hard lump areas in my butt and thigh areas and when I visited my family doctor he couldn’t understand what it was. They did a tissue ultrasound and didn’t see anything so they just prescribed me an antibiotic and said since I hadn’t had a fever or any pain, it should be ok. My OB however said he had seen this in pregnant women before and said not to worry about the antibiotic, but it would eventually go away (I don’t think so, it’s been months). I didn’t tell them about the injections out of embarrassment but I just need to know if you think this maybe the issue, and I so if I could get a consultation from you and possibly some insight on what to do?
Thank you!
A: Such buttock bumps as you have desired are undoubtably tissues reactions from the prior silicone injections. Why they have chosen to develop during your pregnancy I can not say. Perhaps the change in your hormonal levels from the pregnancy has ‘stirred them up’ so to speak. During your pregnancy no treatment for them can be done. But in a non-pregnancy state and if they became more symptomatic (continues to get bigger or become red), the treatment for them would be liposuction with fat injections. Antibiotics are of no benefit unless the areas became red. It will be interesting to see if they lessen once you deliver and your hormonal levels drop back to normal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What bothers me most is my side facial profile. My nose looks big because my teeth were pushed back so far with braces as a kid. I realize it was the common practice decades ago to pull teeth instead of widening the arch and pulling my lower jaw forward. I know it’s possible for a maxillofacial/craniofacial surgeon to slide the upper jaw and lower jaws forward but since my bite is actually good, I have had a hard time finding a surgeon in Oklahoma to do it. They don’t want to mess up my teeth but I am willing to do braces or Invisalign if possible and get teeth implants if needed to replace the ones that were pulled out when I was a kid. Basically I’d like to make my jaw more defined and more pronounced mandible.
A: Since you have identified your major concerns, a perceived midface deficiency, I can make the following comments:
1) With a stable and orthodontically corrected bite, your only option is a bimaxillary advancement surgery. (both and lower jaws moving forward together since the bite must remain unchanged) While this can certainly be done (and your chin position would actually benefit by it as well), this does require the application of braces immediately before and for a short time after surgery to correct any potential minor changes in one’s bite.
2) I would agree that your fundamental facial issue is the overall upper and lower jaw horizontal deficiency. A bimaxillary advancement certainly addresses this fundamental problem. It is the harder road to take so to speak but may be worth it at your age if one is so motivated.
3) Be aware that a bimaxillary advancement will not make your look smaller as the entire base of the nose is carried forward along with the maxillary advancement. The only way the nose can look smaller is by not moving its base and changing everything around it. (see #4 below)
4) In fairness and to give you the complete picture, there is also completely alternative treatment strategy which includes paranasal-maxillary augmentation, reductive rhinoplasty and chin augmentation. This is a different way to achieve many of the same results without going through a major maxillofacial osteotomy procedure and its potential associated morbidity. This will also do what a bimaxillary advancement surgery can’t do…make your nose look smaller.
5) These two approaches to your facial concerns represent a diametric and completely opposite treatment strategy…correct the bony foundation or an augmentative camouflage approach. Neither one is right or wrong, each has their own distinct advantages and disadvantages. Understanding what they are is the key to making the best treatment choice for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking treatment for an apparent linear scleroderma. I am delighted to know there is something that can be done to restore or improve my facial appearance. Is it common for a discoloration of coupe de sabre that was a relatively small discoloration to enlarge and become indented with age? In fact, I was always told I had a birthmark on my forehead! I was shocked when I came across pictures of people with this condition and even more so to see the changes I was experiencing were similar to some of the milder pictures of those with the condition. This “thing” seems to have taken on a life of its own!
A: While I would have to see pictures of it, everything you are describing is consistent with craniofacial linear scleroderma. This craniofacial condition is largely an unknown entity as why it occurs. While usually developing later in children or teens, I have seen cases that did not emerge until adulthood.
While the traditional approach is to wait and have the soft tissue atrophy burn itself out, I prefer to to treat it with fat injections during the active phase in an effort to stop its progression as well as treat the soft tissue defects. This may require more than one session of injectable fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having male facial sculpting through buccal fat removal and cheek implants. However I’m a bit unsure about the jawline area as whether I should get just liposuction or submentoplasty or custom mandibular implants. I’m aiming for a more chiseled jawline and masculine look. I’ve attached a stock image of the look I’m looking to achieve.
I’ve had a consultation in Europe and the doctor recommended buccal fat removal, zygoma bone grafts for the cheeks and liposuction for the jaw. However I’m unsatisfied with this recommendation.
I’ve attached my images from side front and 45 degree angle, I wanted your opinion on what procedures you would recommend.
A: In looking at your face as well as what your male facial sculpting goals are, I can make the following comments:
1) Your ideal facial reshaping goals, in terms of a chiseled jawline like the picture you have shown, are not realistic. You can never take your face and make it look like that picture. You simply have a much different face that is thicker and fuller throughout the entire face. While improvements are possible with your face, that type of change is too much to expect no matter what procedures are done.
2) Maximal defatting is needed including buccal lipectomies, personal mound liposuction and neck liposuction.
3) Cheek implants that have a high angular design that go back along the zygomatic arch are needed. (bone grafts are not going to be effective)
4) While your beard makes it difficult to assess your jawline, it appears that your chin and jawline needs some vertical length and well as some width. Only a custom jawline implant can create that effect. Liposuction can never create a bony augmentation look and is a flawed approach to it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in waistline reduction by rib removal. Here are some selfies and staged shots of my waistline. In my professional pictures of course the illusion is altered with posing and editing to create more curve but Ive always worked at it. I was drawn to you and how you spoke on the Doctors show with the model Pixie. I’m an entertainer/model and still going strong into my forties. I’ve always been curious about whether Raquel Welsh had rib removal but never the less I am a student of improving what I can. My life’s ambition is to be one of the sexiest women in the world and to stand up for aging women to be considered still desirable and most importantly feel desirable.
A: Thank you for sending all of your pictures. Your current waistline is a fairly standard one from someone seeking surgical waistline reduction. Such a typical patient is in good shape and would have an acceptable waistline by most of society’s standards but such a patient seeks a higher goal than what weight loss, exercise, liposuction and even genetics can do. The last anatomic barrier to a smaller waistline is the free floating ribs, although I have developed the additional techniques of wedge LD muscle resection and more aggressive flank liposuction with it to ensure that all that can be done has been done to achieve the maximal waistline reduction effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have developed a buttock implant incision opening. I have been putting antibiotic ointment on my buttock incision and washing it with Hibacleanse but, a few times when I sat down, lots of fluid came out of the incision. (clear pinkish yelllowish no bad odor or anything) I have to use Maxipads to soak up (a few, two fully soiled) I just wanted to make sure its normal. Also is there another type of ointment you can prescribe that will be stronger in helping the incision heal and close? That would be great. Looking forward to hearing from you, I am pasting a photo in this email of the incision as well.
A: Thank you for your buttock implant followup. It is clear that such fluid output represents a seroma. (fluid buildup in the implant pocket) Having one central infragluteal incision makes it impossible to know whether this is coming from just one or both implant sides. While I would obviously prefer not to have such a fluid output, it is always better that such fluid comes out rather than stays in. I would agree that this seroma fluid does not represent an infection, just a typical serous fluid collection that often develops initially around implants.
As long as this fluid continues to come out, it does not matter what topical treatment you use as it is really irrelevant. The incision is not going to go on to fully heal until this fluid egress ceases. There is nothing you can do for making the fluid output cease, it is just something that has to run its course. Once the fluid output is less or nonexistent, the topical treatment of choice is going to be Silvadene. This will help the wound edges heal in as well as provide an antibiotic effect. This is far more powerful than the antibiotic ointment you are using now. That is something I would like to start as soon as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about my upcoming custom forehead implant surgery.
1. Is it possible the implant can shift?
2. Can you take me through the surgical procedure and describe how the implant(s) will be placed? What materials are being used? How big are the incisions?
3. Will I still feel sensation in my forehead and will it effect my ability to show facial expressions?
4. How long before the “final” results show and I look “normal” again?
A: In answer to your custom forehead implant questions:
1) The forehead implant can not shift for a variety of design and fixation reasons.
2) The bets way to understand the incision and how the implant is placed is go to my website, www.exploreplasticsurgery.com and search under Male Custom Forehead Implant and must look at the pictures I posted one this case from last week.
3) Initially your forehead and the front parti of your scalp will the numb but that feeling will return in the months after surgery. Initially the forehead movement will be stiff but its full range of movement/expressions will return quicker than that of the lost feeling.
4) It actually takes a good 6 to 8 weeks to see the final result but you will look non-surgical in public by about 2 weeks after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
