Options for Infraorbital-Malar Implants

Q: Dr. Eppley, I’m interested in getting augmentation for my upper midface: infraorbital rims and the area lateral to it (upper part of the zygoma?). I don’t want pre-formed implants if the cheek is involved, because I believe that everybody’s anatomy is different. Especially the cheek area where shape is highly variable. I would be open to pre-formed implants solely for the infraorbitals if the other options aren’t suitable. 

Your blog mentions that there are several ‘custom’ options. 1) Fully customised implant from 3D CT Scan. 2) Implant based off of another patient’s design. 3) Intraoperative hand carving of an implant. 

Ideally I would get a fully customised implant, but I just don’t have the money for it. So I was wondering the prices of your other two options? Would I be correct in saying that the hand carved implant is about the same cost as a standard pre-formed implant? 

Regarding the hand-carved implant, I wanted to ask how reliable it is in terms of creating an aesthetic effect? For instance, if I wanted to project my infraorbital rim, and also have the implant taper around onto the zygomatic arch, would this be possible or would this be asking too much? I have seen hand-carved results that extend out to the very top of the zygoma area (beneath the outside corner of the eye), and they look good. But I’m not sure how much further these hand-carved implants can be taken. If it’s not possible, I would settle for a basic hand carved design involving the infraorbital rim and the top part of the zygoma. 

It is frustrating that the fully custom design is much more expensive, as it would really be the best choice. I have bilateral asymmetry involving the width of my zygomatic arches. It makes my face look narrow on one side. But this is a secondary issue to the infraorbital deficiency, and perhaps I could get the full custom implant some years down the line. I don’t know whether to wait and save up for the full implant, but I’m just not clear on whether it would be significantly better than a semi-custom version. I would appreciate any advice you may have on this matter. For what it’s worth I have thin skin and a lean face. 

Thanks, and great blog by the way! Best resource for plastic surgery on the internet. I wouldn’t have found you without it. 

A: In answer to your questions:

1) I would generally advise doing custom implants for the complex anatomy of the infraorbital-malar areas.

2) In some uncommon cases, I may use what we call ‘special design implants’ which are custom designs from other patients that I think can be modified to work for the patient who can not afford the ideal custom implant. These cost about halfway between regular and custom implants.

3) There are no standard implant styles for the infraorbital areas so that is not an option.

Dr. Barry Eppley

Indianapolis, Indiana

Occipital Skull Reduction Surgery

Q: Dr. Eppley, I first wanted to thank you for the detail that you’ve provided in each of your case studies. They are extremely informative. 

I had a few questions regarding the Occipital Skull Reduction case study (https://exploreplasticsurgery.com/case-study-occipital-skull-reduction-2/) 

I am in a very similar situation as the subject of the case study, except that the sides (more like, upper corners) protrude as well, and my overall head size is probably larger. 

I am currently in my early 30s. I have very slight thinning on the crown, but my hairline has receded a decent amount. I plan on getting a hair transplant (FUE not a strip, so there will be no strip scar) for the hair line within the next year, perhaps prior to undergoing skull reduction surgery. 

I believe I may have communicated with several years ago. At the time, you were very straightforward that there would be a very noticeable scar resulting from a reduction surgery, and compared it to a strip surgery / hair transplant scar. Is that still the case? I read a case study you posted on March 25, 2018 (https://exploreplasticsurgery.com/making-pleasing-scalp-scars-aesthetic-skull-reshaping-surgery/) regarding scars, and it seemed very promising. Have there been new developments, or are the scars still expected to be very noticeable? 

For instance, how noticeable is the subject’s scar in the Occipital Skull Reduction case study? I would wear my hair around the same length. 

Also, if I were to just flatten the top without doing anything to the back or sides, were would the incision need to be? 

Lastly, what would pricing be for a similar operation as the one in the case study? Thank you in advance.

A: Good to hear from you again. In answer  to your occipital skull reduction questions:

1) Any type of skull shaping surgery should be done before hair transplantation procedures.

2) The incision used for many occipital reduction procedures are far shorter in length and lower on the back of the head than the traditional strip harvest scars for hair transplantation. The length of the scar is related to how much skull reduction  needs to be done in terms of location and surface area treated. Without knowing this exact details int your case I can not comment on what your scalp incision would be in terms of length.

3) I will have my assistant Camille pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant Revision

Q: Dr. Eppley, I am ten days after my custom jawline implant and, while all has gone well and it looks good, I desire just a little more vertical chin lengthening. I think now would be the time to do it while I am still healing. My gut feeling before surgery was that it was not vertically long enough in the design and my feeling now is that it is just a bit short. What are your thoughts on an early custom jawline implant revision?

A: When considering an early custom jawline implant revision, let me pass along my thoughts based on an enormous experience with facial implants, particularly larger ones that are often done in young men:

1) it is critically important to wait for the true final aesthetic result to be seen and appreciated, which takes a full three months, before judging the final result from which one can make accurate and well thought decisions as to what to do next, if anything. Sitting in a hotel room alone in a different country thousands of miles from home at ten days after surgery does not really qualify as a reasoned perspective on which to make sound surgical judgments. Just because it may be convenient to consider improving an early perceived result does not make it a sound medical decision to do so. 

2) Every new surgical procedure around an implant involves additional infection risks, particularly when an intraoral incision is used. You are not even beyond the initial set of infection risks from the first surgery. (6 to 8 weeks) Having additional surgery within this time frame essentially doubles the infection risks from the first surgery.

3) I have seen patients in face and body implants who had a ‘90%’ result, and in the pursuit of a more perfect result, incurred complications that ended up with an outcome that was far less than had they just left the 90% result alone.

4) It is important to remember that when it comes to placing implants in the body, we are creating an  unnatural situation. Implants are not meant to be there and it is a marvel of the human body that they tolerate them as well as they do most of the time with a relatively low rate of complications. But every time you manipulate an implant, particularly one that seems to be doing well, you risk tipping the delicate balance between tolerance and intolerance. 

May this experienced perspective add some additional insight to your early surgical recovery,

Dr. Barry Eppley

Indianapolis, Indiana

Hip and Thigh Implants

Q: Dr. Eppley, I am interested in hip and thigh implants. I have the following questions:

  1. My one hip is a bit flat, would it be possible to have a small hip implant on one side as well and a larger hip implant on the side that needs more volume?
  2. Do you see any issues with putting a thigh implant on my thigh where I have a skin graft?  I touch the skin and seems it would stretch. I wanted to get your thoughts on that.
  3. After the procedure, when can I start:

          a.- Walking a bit (around the room)

          b.- Walking normally without pain

          c.- Doing exercises in the gym

          d.- Lift weight?

4. How many check-ups do I need after the procedure? I live out of town, I would like to start planning how long I should plan to be in Indianapolis.

5. Are implants going to be positioned under the muscle or over?

6. Can muscles still grow with exercise having an implant in there? Would this affect the shape of the area?

7. How long does it take to get custom implants?

8. Should I meet with you in person to take measurements and finalize everything before scheduling the procedure?

Thanks much!

A: In answer to your hip and thigh implants questions:

1) Since the hip implants are custom designed, they can be made to any reasonable dimension on either side of the hips even if they are different.

2) I do not envision any issue with placing a thigh implant around/under the skin graft site.

3) Your recovery would, of course, be a progressive one but you need to begin walking and moving around immediately. Back to unlimited exercise is going to take up to 6 weeks after surgery.

4) You should be able to go home within a few days after the procedure. Followups would be done in a virtual fashion.

5) In the hip area implants are placed one top of the TFL fascia. (above the muscle) In the thigh area, if possible, they are placed under the muscle.

6) Muscle hypertrophy through exercise is still possible even with an implant in place.

7) Most custom can be made, sterilized and shipped for surgery in about three weeks.

8) The method that I use to design custom hip and thigh implants is to mark the patient where their desired areas of augmentation are, make a paper template and then determine what their surface projection and contour would be. Sometimes a silicone moulage model is made. In many cases the patient can do the former paper template method and we can discuss vis Skype to work out the details. But certainly seeing you in person would be ideal but is not always completely necessary based on the complexity of the implant shapes needed.

Dr. Barry Eppley

Indianapolis, Indiana

Silicone Custom Jawline Implant

Q: Dr. Eppley ,I might just take this moment to get a full understanding of the silicone custom jawline implant by asking some questions:

1. The common problem of bone erosion with silastic implants is eliminated if the silastic implant is customized and fixed with screws?
2. Custom made silastic implants are made to last a lifetime inside the patient? In other words, there is no need to replace them unless the patient desires to do so.
3. In my case the silastic implant would be inserted intraorally since the PEEK implant will be extracted this way?
4. You would let me be involved in the designing process from start to finish and will show drafts and answer emails if the patient tries to engage you in the design?
5. You are willing to design implants that do not just provide volume in the right places but also correct asymmetries between the facial halves?
6. Do you have any computer program that could reasonably project how a finished implant design (for both the cheekbones and the mandible) would make my face look before we manufacture the implant?
7. Your finished implant design can be scrutinized and revised, if necessary, until we are both satisfied that it would fulfill my aesthetic wishes?
8. Implants are made well in advance and would only be manufactured with my explicit consent?

Kind regards

A: In answer to your silicone custom jawline implant questions:

1) All implants on the jawline, regardless of their composition, create some degree of passive implant settling and even bony overgrowth particularly back at the jaw angle area. These are natural phenomenon when placing implants on bone that is most manifest on the mandible. The concept of ‘bone erosion from silicone implants’ is both misunderstood and erroneous.

2) All implants for the jawline (silicone, Medpor, PEEK etc) are permanent materials that do not undergo degradation of the material over time. From a material standpoint they are lifelong devices.

3) If your PEEK implants were inserted intraorally then silicone implants can be done as well.

4) to 7) I have a very specific protocol on how custom implants are designed with patient participation. I have attached a document which explains the details of this process that every custom implant patient is required to read and sign before the implant design process is ever started.

Dr. Barry Eppley
Indianapolis, Indiana

Buttock Implant Removal

Q: Dr. Eppley, I am still considering having the buttock implant removal. I really wish I had done it at the same time as the facial implant removal. 

1.  Have you removed many subfascial buttock implants?

2.  If so, are there many potential complications with this surgery? 

3.  Will I need drains?

4.  Is there much pain afterwards?

5.  Would I need to stay in Indiana long? It would be great if I could just stay 3 days or so. Or would I need to stay to have stitches removed?

In answer to your buttock implant removal questions:

1) I fortunately have rarely just removed buttock implants without some form of replacement. So I certainly have not done ‘many’ and never hope that I have to.

2) Like all implants removals anywhere on the face or body, there is going to be generalized tissue deflation/flattening effect. Your cheeks are a good example fo what happens when you remove the underling support from a projecting prominence.

3) A drain is not needed.

4) Any postoperative discomfort will be a fraction of what its as to place them. Your facial implants are a good example of what ti expect.

5) You should be able to go home in one to two days at worst. All sutures are under the skin and are dissolveable.

Dr. Barry Eppley
Indianapolis, IndianaButtock 

Lip Advancements

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

Custom Midface Implant

Q: Dr. Eppley, I have a custom midface implant procedure  and canthoplasty done by you last year. The recovery went well and there hasn’t been any sign of infection. Immediately after the surgery i was very happy with the result. After my face became swollen and recovered the look was different as the lower portion of my cheek had swollen. I thought it was swelling and that it would subside but almost a year later its still prominent.

Although I had the infraorbital implant placed there is a large shelf like gap between my eye and implant which appears sunken. Last time we spoke you said the best approach would be tat grafting and retraction of the eyelids to address the drooping and hollowness. 

I had fillers done to the undereyes which did help the hollowness up until the implant. The doctors said they could not place filler between the undereye implant and eyeball. Which leaves a large hollow gap.Besides from augmenting the implant is it possible to liposuction the lower cheek fat beside the philtrum? Whats the best solution the address the fullness?

A: Good hearing from you and thanks you for the long-term followup. As per the attached pictures one can see that the implant did exactly what it was designed to do. It added forward projection and fullness to the infraorbital-midface based on the areas of its design. Like all facial implants and surgery in general, it is never going to be perfect and it can not completely augment all areas of your non-skeletal deficiencies. What you are seeing now and asking about are those areas of imperfections that such an implant either creates or could not adequately treat.

In answer to your custom midface implant questions:

1) The fullness you see in the lower cheeks is the result of the implant pushing out the soft tissues. While this is an area that can be treated by microliposuction it is not very effective. It would make more sense to treat the basis of the aesthetic problem….remove the section of the implant beneath it and let the tissue fall back.

2) The gap between your eye and the implant is because the implant can only go so high particularly given that it was designed to be placed from an intraoral approach. (see attached picture with arrows) The issue is that the entire infraorbital rim needs to be elevated from the tear trough area out to the lateral orbital rim. Even if so done there will always be some sort of visible transition zone as your soft tissue anatomy is made for the underlying shape/volume of the bone. Fat injections is an option but its success would be based on how well the fat survives… which would be dubious in a young man with a high metabolism and a low percentage of body fat. Adding more implant through either ePTFE sheets or an implant ‘extension’ is another option of which lower eyelid approach would be needed. The other approach is to smooth out the implant over the lateral infraorbital rim/cheek so the transition is smoother/less obvious.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I had jaw surgery to correct my overbite and gummy smile which got fixed. I still however feel I have a long face and want to shorten it a bit even more. I feel as if my nose and chin are vertically too long and I would love to shorten and make them smaller. I would also like to add filler to my lips and cheeks to give me more width volume. I feel as if my chin reduction would be hard to do because I don’t need a lot and it would have to be precise to get a good result and not look odd or throw off any facial balance. My nose also is a bit droopy at base and long. I would like to shorten my nose from the bottom without it looking “piggy” and then add some upper lip filler to keep my philtrum still looking short and in balance. Do you think my picture results are realistic and do you think my genioplasty result could turn out the way I want it. You are probably the best at genioplasty as many doctors can’t seem to have nice feminine results when I see their after pics. What procedures would I need to get the “what I want” result in my pictures. What procedures would you recommend to give my face a more compact feminine look.

A: Thank you for your inquiry and sending your imaged pictures. What you are showing is a vertical reduction of the chin extending back into the jawline but not back all the way to the jaw angles. That could be done by two types of jawline reduction techniques, (intraoral vs submental) each with their own distinct advantages or disadvantages. While the submental approach is the ‘easiest’ method to do, needing just a little reduction (to quote you…although that looks at least 5mms reduction to me, maybe even 7mms) would suggest that the intraoral osteotomy method may be acceptable because it is scarless. Certainly the combination of chin reduction, rhinoplasty, and filler injection to the lips and cheeks can also be done at the same time for a comprehensive facial reshaping approach.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I am interested in facial reshaping surgery. I really don’t like my face and want to change pretty much everything like jaw/chin, browbone/forehead and nose. But the things I don’t like most is the chin/jawline, the nose and brow bone. I would like to have a bigger jaw and the chin and bottom lip to be pushed forward a bit. The small hump on my nose removed and to have a bit wider nose. And the brow bone I would like to be more prominent and cover my eyes more, something similar to what you did on a guy in one of the photos in the photo gallery on your website. And the forehead to be more square and straight. Do you think its to much, what would you change? How big are the risks of the end results looking weird? Is there a way to predict what i would look like without having to meet you personally and do a 3D facial scan?

A: Thank you for your inquiry and sending your facial reshaping pictures. Many of the changes you have indicated can be done (forehead/brow bone, nose, and jawline) but a few of those changes can not be accomplished. (lower lip coming forward which only happens with an advancement of the entire lower jaw since that is tooth-driven and the nasal widening with hump removal)

I have done some imaging looking at the following:

Forehead-Brow Bone Augmentation

Infraorbital-Cheek Augmentation (it wasn’t on your list)

Hump Reduction Rhinoplasty

Chin-Jawline Augmentation

The key about ‘not ending up looking weird or unnatural’ is based on the degree of facial changes being done. This becomes particularly relevant when multiple facial structures are being augmented.

Dr. Barry Eppley
Indianapolis, Indiana