Skull Augmentation

Q: Dr. Eppley, I am interested in skull augmentation surgery with an implant. I don’t know if I may need a scalp expansion first or not. I think a little less skull augmentationresult will be OK for me. How is a scalp expansion done by the way? 

Would you tell me about how the procedure is done? Where will the incision be and how big will it be? Are there any possibility that I will get loose hair where the scar is made? Are there any possible complications with his surgery? How will the recovery be?

Thank you again.

A: A scalp expansion is done by the placement of a scalp tissue expander under the scalp. It is then slowly inflated over 6 weeks in preparation for the second stage placement of the skull augmentation implant.

A scalp incision of about 9 cms is made across the top of the head near the crown area to make the pocket and place the implant. The incision nor the underlying implant will affect hair growth. There will be a resultant fine line scar but it heals very well and usually is barely detectable.

Like any other implants the body there is always the risk of infection, but the good blood supply of the scalp and skull bone makes it a very low risk. Having done hundreds of skull implants. I have yet to see an infection. (this does not make it impossible however)

Recovery is usually much quicker than one would think since it is just an implant in top of the head. There are no after surgery restrictions. Most of the swelling is gone in 10 to 4 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Cheekbone Reduction Complication Treatments

Q: Dr. Eppley, I saw you on Real Self answer questions regarding to cheekbone reduction complication treatments. 

I had my cheekbone reduced and very unhappy with the results. If i was to attempt to reposition the cheekbones to the original anatomical position would that require a coronal incision across the scalp? Or is there a less invasive method? If i choose to bypss all that and choose cheek implants, would that help with midface sag or do i still need a coronal incision to lift the muscles back up? or would a SMAS  facelift suffice? Thank you.

A: Thank you for your inquiry. Reversal of cheekbone reduction osteotomies are done the same way the original operation was performed…which I assume intraorally for the anterior cheek osteotomy and a small preauricular skin incision for the posterior arch osteotomy. (which is how I do them) I would need to see x-rays, however, to see how yours were done. But most certainly you would never do a coronal approach to reverse it from above. (While effective it would not be worth the tradeoff of that operation for it) 

Alternative approaches are to use an implant to create some soft tissue cheek lift. A facelift helps with any sag along the jawline but less so of the cheeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I am interested in multiple facial reshaping surgeries for my nose, cheeks and jawline. I have attached my pictures with morphs of what I want to achieve. I want to see off these type of results are possible.

A: Thank you for sending your picture and providing a detailed description of your facial reshaping goals. To summarize that list it includes the following: rhinoplasty, cheek and jaw angle implants and chin reshaping. The rhinoplasty is straightforward as you seek a more swooped or concave dorsal profile and a more refined and upturned tip. Your jaw angles need a little more definition as it is yet to be determined whether that is primarily a width or vertical lengthening cap implant but either way such implants would come from preformed standard styles and sizes. The cheek augmentation, as defined by the outcome you have drawn, does not come in any preformed style that fits that exact shape. But it is a design that goes back along the arch from the main body of the cheek and I have some special design styles that would work. You appear to want the chin vertically reduced but I not clear about the other shape change. (narrowing?)

Dr. Barry Eppley

Indianapolis, Indiana

Secondary Rhinoplasty for Upturned Nose

Q: Dr. Eppley, I would like to know how to get information about secondary rhinoplasty with Dr Eppley. I have seen some approaches to correct upturned noses, and I am interested in knowing the options Dr Eppley offers.

A: Thank you for sending your pictures, x-rays and a very detailed description of your surgical history particularly as it relates to your prior rhinoplasty. Your prior nasal concern, and the most difficult challenge to correct, is that of the over rotated nasal tip. There are two fundamental approaches to driving down the tip of the nose, 1) stack caritlage grafts on the infralobular side of the tip while reducing tip length (push the tip skin down using the existing nasal cartilage as the floor) or 2) place an interpositional graft between the septum and the nasal tip to push it down from behind it. Each approach has its merits but with either technique the key is having good cartilage with enough rigidity to create the effect. I will assume that your septal cartilage has been harvested for the original rhinoplasty as well as having one ear harvested as well. This limits your cartilage donor options to either rib cartilage or cadaveric cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

Skull Implant Revision

Q: Dr. Eppley, I’d like to get an injected skull implant revision, but I have a few concerns/questions.

1) You mentioned removing and replacing the implant as being the preferred method. What size scalp incision would that take? What material would you use to replace it?

2) You recommended not doing the burring only. Is it because of the potential unfavorable results or is it another reason? How long would that incision be?

I’m nervous to go under the knife again after the results of the last skull implant procedure. My main concern is the resulting scar length and width.


A: While I don’t recall what the material that was injected (t would be very helpful to see the operative note from that procedure), I assume it was bone cement or PMMA. The ability to give it a better contour by contouring what is already there is nil. That is why it is better to remove and replace it by:

1) 3 cms scalp incision over it. Such scalp scars heal really well with minimal width. The aesthetic result of such scalp scars is all about how they made and then closed with protection of the hair follcicles.

2) Probably replace with new bone cement because it can be better contoured under direct vision. But this would depend on the size of the defect of which is not known to me yet.

Dr. Barry Eppley

Indianapolis, Indiana

Head Augmentation

Q: Dr. Eppley, I am interested ins time head augmentation. I have a generally small head and wonder if it is possible to add some volume to the skull to make it a bit higher and wider. Have you performed this kind of surgery before? How is it done? Are there any possible complications or dangers with this surgery?

A: Thank you for sending your pictures and the morphed head shape images. What they show is a crown and side of the head augmentation effect. A custom skull implant can certainly be designed to achieve that type of head shape change. This is not the question. The only question is whether your scalp will stretch enough in a single procedure to accommodate such an implant. The amount of augmentation you seek is right on the edge of whether your scalp will allow for the implant to be placed and a competent scalp closure achieved over it. Generally thin Caucasian females have the least amount of scalp flexibility due to its thinness. In other words do you need a first stage scalp expansion or not? If you can accept a little less of a result then you would not.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Implant Bone Erosion

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

Facial Fat Atrophy Prevention

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

Skull Reshaping

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

Vertical Facial Lengthening

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