Will I Need Head Massages After A Custom Skull Implant?

Q: Dr. Eppley, I hope this finds you well! I learned that my 3D CT scan copy is received and we will be able to move on to implant design process very soon, which is exciting.

At the same time, I was meaning to find out the following, if you may share your input, that would be great.

1. The following link from your blog shows that this case achieved a 15mm-20mm of augmentation, without a 1st stage augmentation involved. Is this amount of augmentation achievable in my surgery?

 https://exploreplasticsurgery.com/case-study-flat-back-of-the-head-correction-by-augmentation-cranioplasty/

pastedGraphic.png Case Study: Flat Back of the Head Correction by Augmentation Cranioplasty – Explore Plastic Surgery – Explore Plastic Surgery – Dr. Barry Eppley – Plastic Surgeon

Background: The shape of the skull is affected by numerous factors including genetics, in utero skull pressures, post delivery head positioning and growth of the brain. In general, the skull has an oblong shape that is slightly wider in the back than the front. While there is no uniform aesthetic standard for a pleasing skull Read More…

exploreplasticsurgery.com

2. During the design process, how can we figure out what is the maximal augmentation level that is right below unduly tense (too tight) level while it is at a largest viable stretched amount?

3. For augmentation of the areas on which the head is in contact with a pillow while sleeping, e.g. the back of the head, the sides of the head, what are the chances for the implant be moved or loosened, caused by the weight from my head and neck pressuring on the implant approximately 8 hours a night over many years?

If this is a real concern, can we address to this risk during the design stage?

If implant loosening does occur at some point in the future, due to the weight from the head and neck during sleep, how will we handle it?

4. I highly regard your input in the design process of the implant. I replied Dawn’s email on what surgery outcome I would pursue. Please don’t hesitate to share your advice.

5. After surgery, I may choose to have a shaved head style some point in the future. When there is no any hair bearing for camouflage, will the skull shape still look natural and smooth, especially at the edge area where the implant ends and connects to my original skull area?

What makes a smooth and natural transition at the edge of implant possible?

6. Will the implant cause infection many years after the surgery is done?

7.  Is an augmentation implant supposed to last all a life-time long?

If not, in what circumstances does the implant require what form of maintenance in the future?

8. After surgery, will it be ok to receive head massage? E.g. finger pressuring on scalp, which is provided by a regular message therapy store.

9. Will I need an additional revisional surgery? If one is needed, how long after the surgery will this happen?

Thanks for your attention Dr. Eppley : )

A: In answer to his custom skull implant questions:

1) No. That was done with a full open coronal incision which allows for some added expansion due to the mobilization of tissues.

2) There is no exact science as to how to know when the implant is too big or the tissues would be too tight to allow it to be placed and the incision safely closed. My design estimates are based on my experience of placing such implants.

3) Zero. While an understandable question it is never been a postoperative concern., I have never seen a custom skull implant move after surgery.

4) I still need to know what skull areas we are going to cover…back only, front only or both?

5) Due to the feather edging in the design there is a smooth transition from implant to bone.

6) No. Infection risks are in the perioperative period. (up two three months after surgery) Once last this time period the infection risk is negligible.

7)  Custom skull implants are made of a solid silicone material which will never degrade or breakdown…thus no need for future replacement due to material failure.

8) Head massages are not needed or advised after surgery.

9) Revisional skull implant surgery would only be needed if you determine you want a bigger implant or a different  design later. This is not done until six months after the initial surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Should I Wait Until The Injectable Filler Has Dissolved In My Chin Before Getting A Sliding Genioplasty?

Q: Dr. Eppley, do I need to wait until the Radiesse filler in my chin is fully dissolved before getting a sliding genioplasty in order to minimize risks?

A: You do not have to wait until the Radiesse completely dissolves which could take a year or longer. In addition there is no reversal agent for the type of filler Radiesse is. There are no adverse consequences of having an injectable filler in the chin to performing a sliding genioplasty. Most, if not all, of the injectable filler is mainly in the soft tissue with a minimal amount on the bone. Whatever is on the bone will simply be removed as part of the surgery. I have seen lots of different fillers on the chin in performing this surgery and it has never been a problem during or after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

At What Age Can A Child Undergo Skull Augmentation for Skull Asymmetry?

Q: Dr. Eppley, My daughter is 2.5 years old and I have been worried about her head shape since she was 10 weeks old. I brought it up at every wellness check but was dismissed by her pediatrician saying it was fine. Now it’s too late and I live with guilt and regret daily. I was reading on your site about the skull augmentation implants on toddlers. How invasive of a procedure is this and what are the risks? How many cases have you done on toddlers and what is the success rate? I have attached some photos of her head.

A: Skull augmentation is not an appropriate procedure for infants. The skull needs to grow a lot more and the earliest I could consider it is 4 or 5 years of age….but likely even later than that age.

Dr. Barry Eppley
Indianapolis, Indiana

Can A Failed Surgery to Correct Inverted Nipples Ten Years Ago Be Successfully Done Today?

Q: Dr. Eppley, I had a surgery to correct my inverted nipples ten years ago and it did not work. It just left me with scarring. I read some reviews on your success with the surgery and wanted to get more information about how I go about scheduling a surgery living out of state.

A: I have found the best method for inverted nipple correction is to do a release and simultaneous placement of an interpositional graft. (e.g., stacked Alloderm wafers, dermal-fat graft) Whether that would be effective now for scarred down inverted nipples of long duration after a prior effort can not be predicted before surgery. It could only really be known by doing it. A prior procedure and scarring makes it more difficult than it would otherwise be. One test that could be help is whether you can manually make the nipple come out by gently squeeing on it. If so that is a very positive sign whether you have had prior surgery or not. I suspect, however, that yours does not even your prior surgery. That does not mean, however, that subsequent surgery may not be more successful.

Dr. Barry Eppley

Indianapolis, Indiana

Can the Mersilene Mesh Implant Be Safely Removed from My Nose?

Q: Dr. Eppley, I need your consultation. I’m a female and I had three previous rhinoplasties. In the last nose job in 2012, my nose was implanted with double grafts of mersilene mesh on dorsom. I have a lot of side effects because of the mesh implant. The mersilene mesh shows through the skin and makes it red as well as difficulty breathing at night; the mesh is attaching my immune system causing me a lot of diseases osteopenia, high Rheumatoid factor, unable to digest food, pain, cramps, etc. Besides, I hate the look cause it looks bigger with hump and deformities and does not make me breath well while sleeping and I hate everything about the change of my nose and would like to undo everything, remove all those implants. What is the complications and risks of nose mesh removal specifically after 7 years and is it possible to revise the nose at the same time removing the mesh implant? Can you perform such complicated surgery? Please advise 

Looking forward to hear from you.

A: While mersilene mesh allows tissue ingrowth and is harder to remove than some implanted materials, it is not impossible to remove and it can be done so. Because the mersilene mesh removal will result in some soft tissue loss and tissue thinning, it is important to realizer that the tissues over the dorsum will not return to what they were before they were implanted. Thus you should probably consider having a thin allogeneic dermal graft (0.5mm thickness) placed in its replacement to compensate for the thinning of the overlying skin.

Dr. Barry Eppley

Indianapolis, Indiana

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