Q: Dr. Eppley, I have a question about buccal lipectomies to which I could not find the answer online. Since you are expert on buccal lipectomy and other facial procedures I know you would know. Can the removed fat pads ever grow back once buccal lipectomies are done. I know fat can grow back or go to other areas after liposuction fat removal so I am wondering if it is the same for buccal lipectomy facial fat removal?

A: The buccal fat pads are a unique collection of fat whose role is not a metabolic one. Once the main body of the fad pad is removed it is permanent and will not return with weight gain. The small volume of the buccal fat pads (3 to 6ccs) is not significant enough to result in a visible fat redistribution effect. (fat homeostasis)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I like how I look from the front mostly (except for my bent nose), and from the left angle. But absolutely hate how I look from the right angle. Part of this is due to bad nose asymmetry. However, a large part of it also seems to be due to how my face is from the right structurally. I was wondering if I could get an infraorbital implant or something like that to maybe fix this issue? I had cheek implants along with other facial surgeries last year. And I actually like the results the cheek implants give from the front and left side and would really not like to remove them or change them if possible (but i’d definitely be fine adding to the under eye area or adding on the implants if that would fix the issue). Would it be possible to have this bad asymmetry/ugliness from the right fixed without altering my current cheek implants too much? Help would really be appreciated as fixing this issue is extremely important to me especially given how my cheek implants (although helpful overall) did not change this particular problem at all. I would also like to buy a lip lift along with whatever can fix this issue, depending on the price of the main treatment. Attached please find my photos. 

A: Thank you for your inquiry and sending your pictures. Between your description of concerns and your pictures it appears that  the issue is a right infraorbital deficiency. Short of a custom imply approach, the use of standard infraorbital implants may suffice. If placed through a lower eyelid transconjunctival incision the right cheek implant can be completely avoided. This can certainly be combined with a subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a Occipital Crown Deficiency in my skull that’s why I feel really bad about this. Is there any chances to reshape it without risks. So i will look normal as others.

A: I would need to see some pictures of your occipital crown deficiency to determine whether a custom skull implant would be the correct solution. By description alone certainly sounds like it would. While no surgery is not without risks, skull reshaping surgery in general and custom skull implants in particular have the lowest risk of almost any plastic surgery that I know.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wish to achieve a more square head shape around my temporal lines and get my sagittal ridge reduced. Can this by done with sagittal ridge reduction as well as a silicone skull implant?

A: Thank you for your inquiry and sending your picture. The pertinent question is whether your sagittal crest is present because the parasagittal area to the sides is too low (not square) or whether you need a combined square-shaped custom skull implant with a sagittal crest reduction. You may just need a modification of the attached custom skull implant design to achieve your desired effect. It will take some computer imaging to help make this determination to compare how these two types of skull reshaping changes would look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have bigger testicles to fill out my scrotum. What are My options here?

A: Thank you for your inquiry and sending your picture. The scrotal skin/sac has very elastic skin and for some men there is a great disparity between the size of the paired testicles and the scrotal soft tissue containment. To fill the capacity of the scrotum there are two testicular enlargement approaches….a side by side custom testicular implant placement which can hide the editing testicles or custom wrap around testicle implants which envelope the existing testicles. Each approach has its advantages and disadvantages and the exiting size of the testicles also plays a factor in the choice between the two scrotal-filling approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a 6mm genioplasty but i dont like how it brought out the imperfections in my jawline. My side profile looks good and overall an improvement, but my chin is naturally weirdly shaped and my mandibles are inward so my jawline is not smooth. I want to look into maybe moving the genioplasty back 3mm and getting a custom jaw implant to make my chin more symmetric and smooth, as well as my mandible and full jawline.

A: What you have is a very common sequelae from sliding genioplasty which is a natural result of the geometric shape change at the front of the lower jaw. As the chin is brought forward the wider U-shape of the chin can develop a more pinched shape at the back end of the osteotomy lines. While his usually does not occur at just a 6mm bone advancement it can if the osteotomy lines are significantly angulated. 

There are two approaches to smoothing out the existing inferior border indentations at the back end of the sliding genioplasty osteotomy lines. While certainly the sliding genioplasty can be reversed that would throw away any of the good aesthetic improvements you have obtained from the initial surgery. The alternative approach is to fill in the bony indentation which can be done by a variety of materials from standard ePTFE sheets to small custom interior border implants. (lateral chin implants)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get an implant of the style provided by the picture that I have attached. (Medpor lateral and infraorbital rim implant) I have two questions about this kind of implant: 

1) Is it possible to maneuver this implant to sit higher up on the face? You’ve made comments before about elevating the infraorbital rim with implants, is it possible to just shift an implant like this upwards; and then screw it in place, in the same fashion as is done with a custom implant? 

2) Is it possible to actually fine-tune the shape of an implant like this by shaving certain parts in order to give more fullness in a particular area? 

Thanks

A: I believe the framework of your question is whether to avoid making a true custom infraorbital implant can this preformed Medpor implant be used instead. The answer is yes with the following caveats:

1) There will be irregularities at certain points as no matter how it is carved it is impossible to adapt it perfectly to your own bony anatomy. This is not a very easy material to hand carve as it is very rigid plastic. The thin tissues of the eyelid is very aesthetically unforgiving for an irrgularities..

2) Because of its rigidity, a larger lower eyelid incision is needed to place them than with other materials.

3) Should a revision be needed be aware of the traumatic nature of its removal due to the tissue adhesion.

4) Given the high risk of irregularities around the eye area I would be very cautious about trying to ask any preformed implant to do too much. This is what custom designed implants do better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley – I have a few questions about custom jawline implants and  custom infraorbital-malar implants:

1. After the implants have been secure, I understand that swelling will occur for a few days and maybe weeks after the procedure. How many weeks after the surgery do you suggest that one must wait before they engage in heavy weightlifting? I don’t want the implants to have any shifting.

2. How many days after the surgery should you wait before you can head back into the office?

3. In the event that something occurs like infection or implant shift, what would be the best course of action?

Thanks in advance,

A: In answer to your custom facial implant surgery questions:

1) One can engage in any strenuous physical activity after surgery when one feels capable. The residual swelling and implant positions can not be harmed by these activities. So it is really up to the patient’s comfort in returning to any non-contact strenuous physical activity.

2) I think your question is when will you be seen in followup after surgery. That will depend on when you plan on returning home but I see patients ever few days while they are still here locally. But if you are referring to returning to work that is going to depend on the amount of facial selling you have and when you would feel comfortable having it be seen.

3) Oral antibiotics is always the first course of action in an infection and that will usually last up to 30 days after they are started. Thereafter one goes off them and we see what happens. Should the infection return the implant will have to be removed. This potential issue is a lot more relevant in custom jawline implants than orbital implants where I have never yet seen an infection in all my years of practice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After giving careful thought to the imaging and other considerations, I would like to further seek your expertise. I’m seriously considering scheduling a procedure soon, but need to make sure I ask your advice on some things, first.

Accordingly, at your earliest convenience, would you, please, advise on the following:

1) With the custom wraparound jawline implant, I have concerns about the likelihood of desired change from the front view. I have been advised that when one lowers the jaw angle, the masseter muscles (that predominantly contribute to the appearance of the jaw from the front view) sometimes fail to stretch with the implant, accordingly. Moreover, it is argued, the masseter muscle often still sits where it originally inserted, and the jawline implant extends below the muscle; yet, the implant isn’t really visible, so one attains this kind of rounded look at the angle of the jaw from the front view.

Would you please advise on the likelihood of either of these outcomes, with regard to my surgery, specifically?

2) Considering that the imaging projections present a “worst case scenario,” as you say, what elements of the surgery could turn out “better” than the imaging? Does the imaging show what I would look like with the liposuction or without?

Thanks.

A:In answer to your custom jawline implant questions:

 1) There is always a risk of masseteric muscle dehiscence in any surgery that involves the jaw angles whether it be standard jaw angle implants or a custom jawline implant. An important element in the surgery is to lift the masseteric muscle sling off of the bone so that it stays over the implant after it is placed. But this sling attachment is thin and tenuous and the risk of a tear and muscle retraction always exist. The risk is higher in jaw angle implants that lengthen the jaw angles as opposed to those that just widen them.There is no absolute predicting who will or will not get it. Most of the time it does not occur but the risk is always present.

2) The purpose of the imaging is to show the least amount of change which should serve as the stimulus for surgery. (not the best case scenario) No one can say whether it will or what parts may turn out better.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I wanted to follow up on my previous question regarding skull width reduction. You said that the bone above the temporal muscles can’t be narrowed very much. I’m curious to know how much it can be thinned. I assume it varies depending on the width of the bone, but is there a percentage rule of thumb? 

Also, you seemed to say that the removal of the muscle is an all or nothing procedure, meaning the muscles have to be entirely removed and can’t be partially removed for only minimal thinning. Here’s the dilemma I have: because the bone on top of my temporal muscles is just as wide if not wider than the area below with the muscles, I’m concerned that removing all the muscles (say it’s 7-9mm) but thinning the bone by say 3mm (if that can be done) will cause it to have a curved appearance. Meaning it would curve in right above my ears and then curve out on the top by the bone. Obviously that would not be an ideal outcome. 

So I’m worried if my concerns are justified, and if so, if there’s anything I can do to make the thinning of bone and muscles proportionate. 

Here are my thoughts: 

1) to get Botox to thin the muscles, and if it produces a noticeable effect, to just thin the bone equal to the reduction Botox caused to the muscles. Essentially this way no muscles would be removed. 

2) to thin the bone everywhere by an equal amount and not remove any muscles. Essentially to thin the bone behind the muscles and on top of the muscles. 

The purpose is to make the thinning equal everywhere. 

Thanks for the help,

A: In answer to your skull width reduction questions:

1) The temporal bone can only be thinned 1 to 2mms. But regardless of what can be reduced the only way to do so is an incision along the side of the head. It can’t be done from an incision behind the ear.

2) While you can do Botox to the temporal muscles, it is such a large surface area of muscle and the dose injected is likely to be very inadequate that this will not replicate a surgical effect for either bone or muscle reduction.

3) If you want to thin the bone you have to lift the muscle off the bone. To do so which will cause it to undergo some atrophy even if no muscle is removed.

4) While I can understand what you are trying to achieve the concept of ‘even reduction everywhere’ is not as simple or straightforward as it may seem.

Dr. Barry Eppley

Indianapolis, Indiana