Your Questions
Your Questions
Q: Dr. Eppley, I’m a 24 year old male and, due to an untreated positional plagiocephaly in early infancy, the right posterior part of my skull is flattened showing the typical pattern of occipital postural plagiocephaly with an asymmetry of 6 mm between the two cranial vault diagonals. Since I got my hair shaved because of the incipient baldness, this flattening is more obvious.Thanks to the complete and invaluable information you provide on your website I think I have found a solution for my problem, a custom occipital skull implant, but I have doubts due to the particularities of my case.
The flattened area extends on the right side (viewed from the back), partially over the occipital and parietal bones, and slightly over the more posterior portion of the temporal bone. On the occipital zone, this causes a depression in the area surrounding the superior nuchal line where the occipitalis, trapezius, semispinalis capitis, splenius capitis and sternocleidomastoid muscles are attached. This is the area my question is about.
I understand that in cases of prominent nuchal ridge reduction these muscles of the superior nuchal line are detached for burring the nuchal ridge. I have also seen in the Web this kind of detachment in cases of anterior and lateral foramen magnum meningiomas surgeries where an extreme-lateral transcondylar and retrocondylar approaches respectively are performed, as well as in mastoidectomies.
My questions are:
1. The area corresponding to the attachment of the superior nuchal line muscles (the area delimited by the red line in the images) can also be augmented through a 3D custom-made silicone implant, or is there a maximum occipital inferior border to place the lower edge of the implant?
2. In which layer would the implant be placed? It will be directly placed on the skull bone and below the periosteum?
3. If the placement is subperiosteal and the nuchal ridge muscles are detached, how do the muscles are reattached to the skull if there is a piece of silicone underneath where they should be reattached? Does it have anything to do with the access being subperiosteal and lifting all the layers above the cranium like a flap?
4. Would detaching and reattaching the muscles cause muscle atrophy and, therefore, a reduction in its volume? If so, how can this unwanted effect can be camouflaged? Can detachment/reattachment affect the functionality of these muscles?
5. Can the implant be extended in one-single piece from the area of the upper nuchal line up towards the parietal bone?
6. Will the implant be fix to the bone with titanium screws?
7. Where will the incision be located in order to access the affected area?
8. The fact there is so little offer for cosmetic skull reshaping procedures around the world has something to do with the complexity of the procedure (technique, 3D custom implant supply,…), the lack of knowledge by the plastic surgeon about the existence of this procedure, the need for training as a craniofacial surgeon or maybe it is the little demand for this kind of cosmetic “job” (even when there is an increasing rate of people affected by plagiocephaly because of the “Back to sleep” campaign)?
Thank you very much in advance for your response.
A: Thank you for your inquiry and providing your specific skull shape concerns. Having done hundreds of skull implants of which the back of the head makes up half of them (of which those half are done for plagiocephaly), I can provide you the following answers to your occipital implant questions:
1) Augmentation of the occipital skull is NOT going to be done below the superior nuchal line. The contour below that line comes from the muscle not the bone and any detaching the muscle to have an implant extend below that line is counterproductive.
2) All skull implants are placed in the subperiosteal layer directly against the bone.
3) Once neck muscles are detached, they do not reattach nor can they be reattached regardless of whether there is an implant there or not.
4) Since the neck muscle can not be reattached and will cause some slight volume loss if so done, they should not be detached in any significant way. Hence why augmentation is not done below the superior nuchal line.
5) A custom skull implant can be designed to easily cover any contiguous skull area.
6) Most custom skull implants are secured with titanium microscrews.
7) A horizontal scalp incision, usually in the range of 7cm to 9 cms, is placed at the location of the nuchal judge in the hairline.
8) This does not appear to be a question but a statement for which I have no answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a small mouth and it makes me very uncomfortable especially when I talk I feel like people are always judging me. Anyway I heard that you can do a procedure know as lateral commissuroplasty or mouth widening. Now I am aware of the trade off of scars and am not worried about it. What I am worried about is if it will look normal. I have never seen any before and after pics and I’m quite skeptical about it. If you could provide me with some information about the procedure to make up my mind. So my questions are, 1.will it look normal or will you be able to tell that its not 2. How successful is these procedure. Thank you very much.
A: Mouth widening surgery produces less visible scar formation than mouth narrowing surgery so it is a more favorable procedure in that regard. The procedure always makes the mouth wider, it is just a question of how much. The goal is to increase the width of the mouth by 5 to 7mms per side. It is really no different than an upper or lower lip vermilion advancement. It is just done on the normal corners of the mouth rather than the ‘north or south’ lip borders.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is the laser used for eyelid lift? (aka Laser Eyelid Lift) Is this a real procedure?
A: The simple answer to your question is largely no. The concept of a ‘Laser Eyelid Lift’ is one that is more of a marketing concept and not an improved or contemporary blepharoplasty technique. Using lasers in surgery always sounds like it would be better but the reality is often very different. Using lasers to cut skin causes a thermal injury and a much worse potential scar than if ‘cold steel scalpel’ is used. Beside the worse scar outcome it does not make the surgery faster, cause less bruising/swelling nor expedite the recovery in any way. Due to the thermal injury to the skin’s edges they are also associated with an increased risk of after surgery skin edge separation (wound dehiscence) due to a delayed wound healing response. While lasers have a valuable role to play in facial skin resurfacing, they are not a useful technique for any facial surgery in which they are applied to cut the skin. They can be used to cauterize bleeding points and even help cut out fat during a blepharoplasty procedure, but they do not offer any real advantages over the traditional use of needlepoint electrocautery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young Asian male whose brow bones are flat, and is seeking to get them stick out through brow bone implant surgery. Would there be any long and short term side effects through implants, considering the amount of delicate nerves that lies in close proximity?
A:The nerves to which you refer (supraorbital and supratrochlear nerves along the brow ridge) are neither sensitive nor are they motor nerves. They are sensory nerves from the first division of the trigeminal nerve that exit out the brow bones and head north to supply the feeling to the forehead and the front of the scalp. They are very hardy nerves that are manipulated quite frequently in many forehead/brow bone procedures. In placing any brow bone implant around these nerves the implant design must consider their location so they are not compressed as a result of the implant’s placement. But this is usually an avoidable problem. This becomes a very relevant issue in the implant’s design if one is trying to drop down the brow bone edge inferiorly or desires a lot of horizontal (forward) projection. But fir the typical forehead/brow bone implant, a notch is made in the design of the nerve foramina based on the patient’s 3D CT scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. I am a 26 year old female that is almost 3 years post op from a sliding genioplasty. I’m unhappy with the results and original surgeon has offered to reverse it, but I have numbness and my lip has never returned to its previous position on the left side. I desperately want my previous smile back, but am extremely concerned about causing more numbness/nerve damage with a revision.
A: While I have no information about your chin other than your description, I would not count on ‘getting your smile back’ just because the bone is returned to its original position. You might but there is an equal if not greater chance you will not. You undergo a reverse genioplasty because you want the original look of your chin back…which will be a very likely outcome of a bone repositioning procedure. The smile is a result of dynamic muscular actions whose effects can not be assured by what happens to the bone as the soft tissues have been permanently changed from their being stretched. There is also the risk of creating further sensory loss of the lip although I do not consider this a major reason for not doing the reversal. Once the damage is done it is not likely to be worsened.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the tracheal shave procedure. I am a young female with a trachea that protrudes out quite a bit especially while looking up. I’ve been self-conscious about it for almost my entire life, since puberty. I’ve consulted with another surgeon and she believes she can go in through a scar I already have under my chin. I was curious if you’d be able to to do the same? I’d really rather not have a visible scar on my neck. Thank you for your consideration!
A:There are two approaches to the tracheal shave procedure, a submental and direct incision techniques. While there are two incisions to approach it, the reduction results will not be the same. Having done it both ways, the submental approach will achieve about 50% of the reduction that the direct approach will. The direct approach uses a 2.5 cm long incision in a skin wrinkle line right above or over the tracheal prominence. The submental incision uses a 3.5 cm long incision under the chin. It comes down to how much tracheal reduction you will find acceptable as well as the location of the fine line scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. I want to understand the differences between the materials that are used for skull augmentation and the risks. Can these materials cause infection or can your body reject it? Also, will they have to be replaced with new ones after a certain period of time due to breaking down of the implant material?
A: In answer to your skull reshaping questions:
1) The vast majority of skull augmentations I do are done with custom implants made of a solid silicone material. This is a material that does not degrade or breakdown unless exposed to very high heat. (375 degrees F or higher)
2) Any implanted material placed in the body runs the risk of infection. That risk for skull implants is very low due to the superb blood supply of the scalp and skull bone. I have yet to see an infection from a custom silicone skull implant.
3) Such skull implant materials do not develop rejection since silicone is one of the most biocompatible of all synthetic materials.
4) Silicone skull implants are permanent. They do not degrade or break down and thus never need to be replaced other than for aesthetic concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have typical flat back of head. I am interested in custom skull implant augmentation.What is full cost of augmentation. How many days would I need to stay there? Is it local anesthesia? I can’t seem to find anyone in this area that does this..if you know please tell me as I am concerned about follow up and tweaking.
A: Thank you for your inquiry. In answer to your flat back of the head questions:
1) Assuming this is a one-stage custom skull implant procedure, I will have my assistant pass along the cost of the surgery to you tomorrow. How much augmentation one can achieve is based on one’s natural scalp flexibility to stretch to accommodate the implant. I would need of see side view pictures of your head and do some imaging to determine what type of augmentation change you seek.
2) Most patients return home within one to two days after surgery.
3) It is general anesthesia as no skull augmentation procedure can be done under local anesthesia if the implant has any size to it.
4) I can not speak for who else in the world does this procedure as that I am unaware of anyone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to get an idea of what my options would be should I need a custom facial implant revision should it end up being too big or too wide. How many months after surgery could the implant be reduced in size?
A: When revising any facial implant it is first important to determine what its final size and shape will be. Thus it takes about 8 to 12 weeks to have all swelling go down, tissue contraction to occur and the patient to psychologically accommodate to the change. This is a process you undoubtably know well from your prior experiences. The other reason for the ‘3 Month Revision Rule’ is the quality of the tissues. Entering too early after surgery in intraoral incisions whose wound edges have not full recovered and returned to normal tissue quality runs a big risk of them not healing when traumatized too soon. As a result the incision may break donw, exposing the implant for which an attempt at secondary wound closure will not work for the same reason it came apart in the first place. It is important to remember that intraoral incisions are not like zippers, they can not be just opened and closed repeatedly in close time intervals and go on to normal healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am trying to decide between having a facelift or getting laser resurfacing. I am using Retin A religiously and have seen improvement . Have been using it for a little over a month. I am supposed to have CO2 laser next month but I am not sure if I want to do that or have a face lift. I cant afford both so will have to decide which I want more. I know the laser will do nothing for the turkey neck or jowls but I also know the facelift won’t help my wrinkles. I guess what I am asking is what do you think I should do.
A: In discussion of the debate between laser resurfacing and a facelift, the question is what did you want to achieve. What each one can accomplish is going to be dramatically different. A lower facelift with improve the neck and jowls/jawline as well as help with some of the wrinkles around the jowls and at the side of the mouth. It will provide no improvements in the cheek or around the eye area. Conversely laser resurfacing can be done all over the face (but not the neck) and its improvements is to fine wrinkles and skin texture with very limited skin tightening properties.
The overall facial rejuvenation effect is far greater with a lower facelift as you may have suspected. I would think one would choose full face laser resurfacing instead of a facelift for surely economic considerations where the skin’s appearance can be improved even though the jowls and the neck sag will not be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal hollowing correction surgery. I have attached some pictures of my temporal areas. My temporal hollowing tarted after I had filler injected into my cheeks four months ago. I had one syringe of Voluma in each check, the “apple” area of the cheek only, but injected quite deep (near the bone). On the left side of my face, some of the filler formed a lump which was sitting on nerves and causing pain and numbness in my face and severe pain shooting up into my head. My temples began to disappear as did my upper eyelids. The temple on the left side is worse since that is where the pain was more severe. I went for several treatments to dissolve the filler. The pain is not as bad now, but I still have pain and this is one of my concerns. Because I am still experiencing pain in my head (including temple area), I don’t know if I should wait or try fillers first or fat transfer. I don’t want to make the situation any worse.
I would appreciate your feedback.
A: Thank you for sending your pictures and detailing your recent history. While I have done many cases of severe temporal hollowing correction before, your recent of history of acute temporal hollowing (due to fat atrophy) is not one that I have ever seen or heard of before. The exact mechanism behind such an acute and unprecedented temporal change can be hypothesized but the actual mechanism will probably never be known. (possible vascular compromise of the buccal fat pad??)
While I think temporal implants are the most effective treatment for your severe temporal hollowing, I don’t think you should do anything until your pain symptoms have completely resolved and the degree of temporal hollowing has stabilized.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How long does the recover take for the Sagittal Crest Skull Reduction procedure? My husband and I would be flying in. He has been self conscious of this for a long time and has been looking in to it but I would like to know more about the procedure myself.
- How long would we need to be out there?
- How long is his recovery?
- By shaving down the bone will it increase the possibility of brain trauma later on if he were to have a head injury due to the bone being thinner?
- What are the negative side effects?
- How long have you been practicing the Sagittal Crest Skull reduction procedure?
A: I will provide some general answers to your questions with the understanding that I have no idea what your husband’s skull shape is or the extent of the sagittal crest issue. More specific answers that apply to your husband’s case would require seeing some pictures of his head for my assessment.
1) You would be able to return home the day after the procedure.
2) Recovery is merely about some swelling on the top of his head which will take a few weeks too largely subside. There are no other physical restrictions after surgery.
3) The crest bone that is removed does not weaken his skull or make it more susceptible to injury or ‘brain trauma’ later.
4) The only potential risks (side effects) of the surgery are of an aesthetic nature…how much or well can it be reduced with good smoothness.
5) I have done many adult sagittal crest reduction procedures over the past ten years. It is one of the most common aesthetic skull reshaping surgeries that I do in men.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Could you give me a bit more information on the infraorbital implants approach to undereye concerns? I’ve researched online and many sources state fillers/fat grafting as the best solution due to the high risk of asymmetry and unnatural appearance through implants. I’ve also heard that implants do not age well. Would these infraorbital implants also improve the appearance of my cheekbones (which are also relatively weak I think)? Thank you for your prompt and direct response.
A: In answer to your infraorbital implants questions:
1)None of the statements that you have read about infraorbital implants are accurate. They undoubtably come from providers who have either never performed infraorbital rim implants and only provide fillers/fat. The concept to grasp is that there are no true preformed infraorbital rim implants, only tear trough implants. Tear trough implants are not the same as infraorbital rim implants and are what surgeons may be only familiar. True infraorbital rim implants are custom made for each patient off of their 3D CT scan. Thus they fit the bone perfectly, have smooth transition into the surrounding bone, can be extended to augment the cheek as well (infraorbital-malar style) and actually elevate the level of the infraorbital rim. (standard tear trough implants only sit in front of the infraorbital rim and thus only augment it in the horizontal dimension…they do not cover the infraorbital rimin a smoother anatomic fashion and do not provide any height to the rim level)
2) In the treatment of infraorbital rim deficiency, the three treatments are synthetic injectable fillers, injected fat and implants. Each has their own advantages and disadvantages. But none of them are perfect nor is one method best for all patients. Each case must be considered separately and the magnitude of the defect considered in the treatment selection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few more question since our last conversation related to custom silicone implant for back of the head augmentation.
It’s not urgent so please reply when you have some free time.
1. When the silicone implant is placed on the back of the head is there some bone erosion or bone resorption due to applied pressure to implant like in chin implants?
2. Edge of silicone implant is going to be very thin, but is there going to be any capsule formation and hardness around implant? Can it be felt with fingers?
3. How the the implant is going to be sterilized? I know that implant is sterilized by manufacturer, but is it sterilized in some way one more time before insertion?
4. Are silicone implants safer or unsafer than HDR and PEEK implants (or there is no difference) and is there some difference in how the body is reacting to theme?
5. If its need to be removed, does the scalp shrink normally?
6. The use of silicone implant for back of head augmentation is approved by FDA (Food and Drug Administration)?
7. Which company you are using for implant manufacturing (you already told me but i forget)?
A: In answer to your questions about a custom occipital skull implant:
- Bone erosion or implant settling is not a phenomenon I have seen in skull implants.
- All implants in the body get a surrounding capsule or layer of scar tissue. This is normal and is not the source of a palpable implant edge. The only method to reduce that risk is a feather edge to the implant which is done in the implant design.
- The manufacturer sends the implant already sterilized.
- All FDA-approved skull implant materials are similarly safe. One material is not ‘safer’; than another one.
- All soft tissues contract when they are ‘devolumized’ when an implant is removed. Whether it will completely return to normal depends on the size of the implant and how long it has been in place.
- All custom made silicone skull implants are FDA-approved.
- Implantech
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wondering if a vermillion or lip advancement can change the actual shape of the lips? I have a flat/undefined cupid’s bow that I’d like to augment along with the rest of the lips, but Juvederm only flattens thie cupid’s bow even more. Plus I am tired of spending money and to getting the results that I want. Every injector says that can make a better Cupid’s bow but it never happens. Thank you.
A: The main advantage of a vermilion or lip advancement is that it affects the whole lip, from corner to corner, and one can change the shape of the Cupid’s bow. Injectable fillers, like all volumizers, can only take the lip shape and push it out, it can not make a cupid’s bow that is ill-defined and flat and make it more defined or pronounced.
The decision you have to make is not whether a lip advancement will accomplish your upper lip reshaping goals…as it will. The question is whether the fine line scar that is the result of the lip advancement is a worthy trade-off. In most women with thin flat lips it is, but each patient has to make that decision for themselves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry correction. I just had lower jaw surgery for an underbite. I had the bottom jaw rotated to the left as my jaw was deviated a but, but even after the surgery was finished, I still had asymmetry. I want this issue fixed if possible. One side is strong, the other is not. I don’t know if you would reccoment making the strong side less so, or the weak side stronger. Also, I live in another state and could come down for the operation, but I don’t think I could bring anyone. After the operation, could a nurse drive me back to the hotel? How does that sort of thing work?
A: Thank you for your inquiry. In answer to your facial asymmetry correction questions:
1) Mandibular osteotomies rarely fix lower facial asymmetry.They may reduce it but their movements are controlled/limited by the occlusion. You should wait a full three months after this surgery to allow the bones to heal and all swelling and soft tissue contraction to occur to fully assess the final results. I would need to see pictures of your face and eventually a 3D CT scan to determine how to best treat your jaw/lower facial asymmetry.
2) How best to treat the asymmetry (make the weak side stronger or make the strong side weaker) is best determined by computer imaging of both potential outcomes.
3) It is very common for patient’s to come by themselves and you have correctly assumed that our nursing service takes the patient back to their hotel if no overnight stay is warranted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry surgery. I feel as though one side of my face sags down (the right). I have spoken to a facial surgeon in my city and he believes that it is natural asymmetry in my face but I believe it is because of my accident which I was in when I was five. He said that any surgery would be invasive and might not even change that much. Just looking for a second opinion and any options that might be open to me .Thanks.
A: Thank you for sending your pictures/. Your facial asymmetry is caused by a left-sided facial hypoplasia. (presuming the images are not switched) It is natural only from the standpoint that it developed this way but that does not make it normal or aesthetically acceptable to you. This could be improved by the combination of a left jaw angle implant combined with a right perioral liposuction to better balance the two sides of the face. The other option for the soft tissues is to fat graft the left side of the face in the perioral region based on how you want to balance out the soft tissue asymmetries. Yes surgery is invasive but that is the only way to improve your facial asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a testicular implant replacement with the silicone implant. I have read some of your case studies on your website about testicular implants, I think the one I have now is the saline implant. it is very firm and is attached too high. uncomfortable at times and the attachment point hurts sometimes. I had the implant installed due to removal of an undescended testicle. The first surgery I had in my early 20’s was an attempt to lower it but later I had to have it removed and a prosthetic installed. I am 62 years old now.
A: Thank you for the clarification on your testicular implant history. Everything you have described is classic in the use of saline testicular implants in some patients. (Hard, high riding and somewhat uncomfortable due to a suture fixation point)
While you may now be 62 years old, your age is irrevelant to have it replaced with a much softer implants that sits lower in the scrotum and hangs freely without an unnatural adhesive point of attachment. This is not a complicated surgery and one is really never too old to have it done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’m a 26 yearr old woman from South Korea. I want to do custom facial implants for two sides of my kaw. I had a bad surgery two years ago and they cut off my two sides of jaws way too much and also sliding my chin upward which made my face look unproportional. I want to augment my jaws line. Any suggestions?
Here’s my history of surgery… I had lower jaws surgery by Maxillofacial doctor in 2005 as I had protruded lower jaws. The doctor moved back my lower jaw about 5-6 mm so the result was very subtle. In 2013 I had two sides of my jaws cut off and my chin sliding in front. (V-line jaw surgery) My face looks unproportion. I have protruded chin than before my first
surgery and I don’t have jaws angle!
Now my desire is to have a proportion face and less protruded chin.
A: Thank you for sending all of your x-rays. You had the classic V-line jaw surgery where the jaw angles are removed and the chin is narrowed and advanced forward. To totally or partial reverse your prior surgery, you would need vertical lengthening jaw angle implants and a setback bony genioplasty. This is the classic ‘reversal V-line jaw surgery’ that I have done any times for those patients who find that their new face is now disproportionate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask a very brief question for your blog that is relevant to me, and I believe will help others.
Custom skull implants can cover the entire bony skull, forehead and brow, the scalp tissue permitting. Because of financial constraints I cannot afford multiple implants. However I want augmentation of the temporal area. With a two stage tissue expander is it possible to include the temporal region in this singular total skull implant? Also how far down the lateral orbital rim may the implant extend. I’m aware that the top part is contiguous with the brow and can usually be augmented at the same time. How much exactly of the lateral orbital rim could be covered with this custom skull implant (can it stretch down slightly below the lateral canthus)?
Thank you.
A: Thank you for your inquiry. As best as I can understand your question about custom skull implant coverage, it can be designed to any size or cover any area including that of the temporal region. There may be issues of implant placement, incision size etc that may affect that consideration, but it is not a design restriction. I have done large custom skull implants before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, we’ve been emailing for the last 3 years about my skull shape and various skull reshaping methods to improve it. I hope you’re doing well. Last we emailed, I was thinking about getting two parasagittal skull implants which would require a pair of of 2.5 cm incisions.
Is that still the best option today? I was wondering about a single central incision as I think that will be hidden a little better with my naturally thin hair. Do you have an idea of 1) whether that’s possible with 2 implants, and 2) roughly how short we could keep the incision? I recently saw a blog post of yours where you performed a sagittal reduction through a small central incision. This might be a good chance to do a little bit of reduction along with implants.
Finally, are there any long-term health risks with these implants?
A: The truly best option for your skull is to have a combination of a sagittal ridge reduction with custom parasagittal skull implants placed through a 4 to 5 cm incision. It really comes down to whether the sagittal ridge is addressed or not. If it isn’t then the two bilateral smaller incisions would be best. Because the one central incision is essentially going to be he addictive width of the paired incisional approach.
There are no long-term medical risks with these skull implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read from a few plastic surgeons that bone erosion can occur some time after a jaw/chin implant procedure. (jaw implant bone erosion) Would you mind elaborating on this for me? Will this effect the result in the future? How can I minimize bone erosion?
A: To put those comments into perspective the statement that jaw implant bone erosion occurs implies an active inflammatory bone destructive process…which does not occur. All facial implants, like all body implants including breast implants, create the biologic reaction of tissue adaptation around the implant. This is a normal process that the misinformed interpret erroneously as ‘bone erosion’. It is better turned ‘passive settling’ which means the implant is associated with a pattern or imprint on the bone which is the body’s way of relieving the pressure from an object that is naturally not meant to be there. This may be a millimeter or two of the implant settling into the bone. There may even be bone growth around the edges of the implant up onto the implant.This is a self-limited process and is most commonly associated with smaller facial implants, most commonly standard chin implants. This is not a biologic process that I have seen in much larger implants like wrap around jawline implants or skull implants…probably because the larger size of the implant distributes the pressure of tissue displacement over a broader surface area
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin augmentation. I have attached a few photos band a facial analysis report from another surgeon. My goal is to define my jaw, neck, and balance my chin for a chiseled appearance. I am also interested in eradicating the horizontal neck lines. I plan on losing 20lbs before booking a online consultation, but would love to hear your opinion.Thank you.
A:Thank you for sending your pictures. Your chin deficiency is completely of a vertical dimension, you have adequate horizontal projection. Your lower facial third is vertically short. Thus what you need is a vertical lengthening bony genioplasty combined with a submentoplasty neck procedure. Essentially drop the chin and bring up the neck angle. That is what your ‘chin augmentation should consist of and it has nothing to do with a chin implant unless you want to custom design a vertical lengthening chin implant but I advise against since it may not carry the soft tissue chin pad down with it whereas moving the chin bone down will. How much you would like to vertically lengthen your chin is a matter of aesthetic taste and the attached imaging is just one version of it.
Your facial analysis report is non-sensical to me as bimaxillary osteotomies are not an appropriate solution for your facial concerns nor do they address the neck component.
No surgical procedure exists that can improve horizontal neck lines, that is not an achievable goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in several face and body procedures. For the face I am interested in buccal fat removal and maybe chin augmentation. I really want a more defined Jaw so we would have to talk and see how you could achieve those results. For the body, I am interested in body shape adjustments through liposuction, anatomic waist reduction and maybe fat grafting or hip implants. I have already had liposuction of my waistline done with buttock augmentation with implants but not getting the desired body shape yet.
A: Thank you for sending all of your pictures and detailing your goals. In reviewing the face and the body pictures I can make the following comments:
1) Having been through liposuction and getting buttock implants, your options for further body contouring are now more limited. Not knowing how your liposuction was done, perhaps there may be room for further improvement in waistline reduction but it would not be dramatic. Even with further liposuction the amount of fat you have to harvest would be less than the first time so its use for far grafting would not be substantial. It could be used to add around your buttock implants which appear to be the subfascial location. At best this would add some filling around the buttock implants. Any fat harvested should be used for the buttock region and not wasted on the hips..
2) For larger hips your only option are hip implants. You don’t have enough fat to harvest to provide any hip augmentation effect. Whether the small incision to place them is worthy of the augmentation effect is to be determined.
3) Even with some further waistline reduction and hip augmentation, I don’t see you getting that close to your projected image goals. It would be better than where you are now but those pictures are not that realistic of a goal with your body type.
4) You face would benefit from some thinning/defatting including buccal lipectomies, perioral liposuction, and submental/jawline liposuction.
5) To achieve a better defined jawline with the facial thinning, the chin is going to have to come out further to help lengthen the jawline. Whether that is done with an implant or a sliding genioplasty can be debated
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Could possibly send me two pictures of the difference between a linear and non-linear jawline shape? That would be very helpful in the designing of my custom jawline implant as I am still not sure what the difference looks like on real people’s faces.
A: The concept of linearity in jawlines is based on the connection between the chin and the jaw angles. A linear jawline shape is when there is a smooth line between the chin and the jaw angle area when seen in the front or oblique views. This is what a custom jawline implant does well if so designed. A non-linear jawline shape is when there is a noticeable inward dip between the chin and the jaw angles when viewed from the front and the oblique views. This is what will most commonly occur when standard square chin and widening jaw angles are used or when a custom jawline implant has a very minimal connection between the chin and the jaw angles. I have attached some picture examples of the differences between these two jawline shapes. Many times models show a non-linear jawline shape because they are biting down which causes the masseter muscles to bulge outward but it still illustrates the concept. While these model pictures show these two jawline shapes this should not imply that you will have a jawline that looks exactly like theirs does no matter how the implant is designed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a buccal lipectomy three months and now my face is slim and less square. I would like to have jaw angle implants to have a wider and more square face again. I have attached some before and after pictures so you can see how my face has changed.
A: Thank for sending your pictures. A buccal lipectomy (bichetomy) should have no effect on slimming the face anywhere but under the cheek area. It does not extend anywhere close to the jaw angle region whose shape is determined by the jaw angle bone and the overlying masseter muscle. In fact the biggest aesthetic problem with buccal fat removal is that it usually has only a very modest effect, and one that is usually underwhelming to the patient, rather than too much of an effect
But that anatomic issue aside, all that matters is your perception and how you see your face now. I can certainly see the change in your facial shape in your pictures even though I don’t have a good explanation.
Jaw angle implants can be used to make the back part of the jaw wider and hopefully more square. The only question is what size (thickness) of implant to use. Sizes typically run in the 5 to 10mm range.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. I want to understand the differences between skull augmentation materials that are used and their risks. Can these materials cause infection, can your body reject it? Also, will they have to be replaced with new ones after a certain period of time?
A: In answer to your skull augmentation material questions:
1) The vast majority of skull augmentations I do are done with custom implants made of a solid silicone material. This materials offers computer designing implants that are both cost effective and can be inserted through smaller scalp incisions.
2) Any implanted material placed in the body runs the risk of infection. That risk for skull implants is very low due to the superb blood supply of the scalp and skull bone. I have yet to see an infection from a custom silicone skull implant.
3) Such materials do not develop rejection since silicone is one of the most biocompatible of all synthetic materials and as a long history of safe medical use.
4) Silicone skull implants are permanent. They do not degrade or break down and thus never need to be replaced. They should not be confused with silicone breast implants which are gel-filled devices and do require replacement in most patients.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been researching the jaw implant recovery process. However I can’t find much on the recovery from jaw angle implants, whereas there is a lot on what is it like after orthoganthic jaw surgery. Can I take it that the recovery process is the same. For example follow the advice on diet, ice packs, sleeping upright and similar pain levels? I am looking how to best prepare myself after surgery as I am travelling by myself.
A: While there are some similarities in the beginning (swelling) between jaw bone surgery and jaw implant surgery, I would say that jaw implant surgery is not as severe as orthognathic surgery as the actual functional disruption of jaw opening and the degree of trauma to the tissues is much less. Jaw implant surgery disrupts the masseteric muscle attachments while jaw bone surgery disrupts the bone and the muscle.
Pain would be less and ultimately you will recover much faster in jaw implant surgery. It is largely the swelling and the time it takes to go down to look acceptable (2 to 3 weeks) that can be psychologically stressful. Most patients will be on a soft diet for a few weeks and ice is good for the first 24 hours or so after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very intrigued by the mesh implant insert in breast lift surgery that both yourself and another surgeon in the area are using. I am primarily hoping for a more perky shape, added fullness, areola revision, and “bra free” aesthetic look. I developed fairly large breasts at a young age that were large for my frame and after two kids and minor weight loss, I am hoping to have a more youthful chest.
I do not want to dramatically go up in size but I am realistic in regards to a small implant being necessary for upper pole volume and maintaining the long term results I am hoping to achieve. I have done a consultation with a surgeon and while I liked him and felt comfortable, the total cost for a breast lift with implant was far higher than any other surgeon in the area that I’ve observed.
This is a decision that I have researched adequately and feel strongly that I don’t necessarily want a “budget” procedure performed, but I was quoted almost $14,000.00 which seems very excessive to me. Please forgive me if I am incorrect.
What are your thoughts?
A: Thank you for the details on your breast reshaping goals. When the implantation of mesh is used in breast lift surgery the cost of the mesh alone will approximate $4,000 to $5,000. That adds considerably to the overall operative cost. Mesh is a nice addition to a breast lift but, like icing on a cake, it is not absolutely essential. While it may have some modest benefits and is very theoretically appealing, you have to put a value on its addition to the procedure. For some breast patients it is essential to the result, particularly in revisional breast reshaping surgery. But in a primary breast lift/implant case for most patients it remains a luxury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son is 18 years old and very uncomfortable with the openness of his lips while at rest. (lip incompetence) It is affecting his day to day life and I’m desperately trying to find a solution for him. We have seen two oral surgeons who would not recommend jaw surgery, but would do it we decided that was the only route. We don’t want to take that route! He has a short upper lip and a long upper jaw. In addition, he is on his third round of orthodontics. He needs some hope and frankly so do I. We will travel to see you if you think it is worthwhile.
A: Thank you for your inquiry. Your son has vertical maxillary excess which is the source of his excessive tooth show, apparent short upper lip and long, unrotated lower jaw and lip incompetence. I see no recourse but for him to undergo a maxillary impaction procedure (LeFort I shortening) probably combined with an osteotomy of his mandible (to get his bite to fit again) and a sliding genioplasty advancement. It is a big decision but the only one that will work for him in the long run.
Dr. Barry Eppley
Indianapolis, Indiana
