Should I Have A Rhinoplasty Before or After Having Midface Implants?

Q: Dr. Eppley, I’m an Asian female looking to enhance my midface region, namely frontal cheekbone and paranasal area. I also plan on getting a rhinoplasty either before or after facial implants. I was wondering if getting a midface/paranasal implant would affect rhinoplasty – would lateral osteotomy and alarplasty be affected if I got the implants beforehand? If I got implants after rhinoplasty, would the paranasal implants alter rhinoplasty results? Would you recommend getting facial implants or rhinoplasty first?
Thanks!

A: It would make the most sense to have the rhinoplasty first since paranasal/midface implants may be either in the way of the osteotomies or become secondarily infected by the location of the osteotomy line.

Dr. Barry Eppley
Indianapolis, Indiana

Will Perioral Mound Liposuction Be Helpful In Further Reducing My Chubby Face After Buccal Lipectomies?

Q: Dr. Eppley, I’m fully aware that I won’t be able to achieve exactly what I have in mind, but either way, I’d be content with any sort of improvement overall. With buccal lipectomy, it definitely did decrease the “chubby” look to my face. But as you said, the results would have been even better had it been accompanied with perioral mound liposuction. So would it be too late to get it still? Is it usually only done with other procedures as the same time? Also, is it a safe procedure? I noticed that not many doctors tend to conduct this procedure? Or what other procedures can be done to reduce the fat in my cheek area? 

A: In answer to your perioral mound liposuction questions:

1) Perioral mound liposuction can be done secondarily and, is often do so, in patients who have had a prior buccal lipectomy.

2) Perioral mound is a perfectly safe and effective procedure that complements the buccal lipectomy.

3) There are np other facial defatting procedures other than buccal lipectomy and perioral mound lipectomy.

Dr. Barry Eppley
Indianapolis, Indiana

Can Liposuction Improve My Lower Leg Lipedema?

Q: Dr. Eppley, I have Lipedema and have had some surgeries with a lipedema doctor and they were very conservative. My biggest concern are the knees and the tops of my thighs, my public area and inter thighs. I have calf concerns but that can be later on down the road. 

A: Thank you for sending your pictures. The critical question becomes in the face of lipedema what happens with liposuction? Will it be effective or overwhelmed by chronic swelling? Will it aggravate the existing lipedema or make it worse? The prior lipedema surgeries may have been ‘conservative’ but may have been done for a good reason…to avoid aggravating the lipedema.

Forgetting the underlying lipedema for a minute, the treatment of your type of lower extremity lipodystrophy requires a very aggressive liposuction approach. With that comes one known and and one unknown risk. The known risk is that the cellulite appearance on the thighs will undoubtable get worse, not better. That is unavoidable. The unknown risk is will it aggravate the lipedema? Just because the conservative treatments did not, that is no guarantee that a more aggressive approach will not.

Dr. Barry Eppley
Indianapolis, Indiana

What Is The Best Implant Material For Jaw Implants?

Q: Dr. Eppley, Thank you so much for your reply. The custom implant  approach sounds good . My doctor says He will use Goretex implant and craft the  implants right there during my surgery.  I also want to know is it possible to use Goretex or Medpor  because he mentioned  these material are more natural than Silicone and it will grow into my bone? Silicone will look more unnatural later on when body starts to  form capsule? Now i would like to know how soon can i get surgery done after first consultation?and how long does it take to make a custom jawline implant, I hope  one trip can do it all. Thank you.

A: The concept that Goretex or Medpor is more natural than silicone to the body is a completely bogus statement with no basis in scientific fact. Nor are they more natural or create a better facial look. In the end what matters is the shape and dimensions of the implant, that is the key.

The limitations of trying to patch a bunch of different implants together during surgery by hand to create a good result and have the right dimensions of the implant that is needed and symmetric for both sides, speaks for itself.

Biologically all implants produce a capsule (layer of encapsulating scar) around them, Medpor and Goretex are not different. Capsule formation is a normal reaction to any synthetic material placed in the body, and short of actual bone, all compositions of implants form an equal amount of capsular formation. To say that one implant material forms more or less scar than the other one fails to have adequate knowledge about the implantation healing process.

Dr. Barry Eppley
Indianapolis, Indiana

Will The Muscular Tightness Two Weeks After A Sliding Genioplasty Resolve With More Healing Time?

Q: Dr. Eppley, I’m 2 weeks post my surgery so I wanted to quickly touch base with you.  First things first, I’m so happy with my results! The projection is perfect, surprisingly my lip position has changed too it doesn’t look receded anymore. I also have no loss of sensation- yay! I’m so grateful to you, THANK YOU! Attaching a few pictures for your review.

My only concerns are:

1) I have some muscular/soft tissue asymmetry. My right side drops lower than my left when I smile or open my mouth. Not sure if that’s due to residual swelling or muscular tightness. Although I don’t think there is any swelling left. Is there anything I can do about it?

2) I started working out 10 days after the surgery and have noticed there is generally more swelling and slight pain the next day. Should I continue going to the gym or take a break?

Thanks again,

A: Thank you for the follow up. I would say that your sliding genioplasty went absolutely perfectly. It could not have gone any better. I actually used an 8mm plate and bent it to make for a 4mm vertical lengthening. I thought it replicated your jaw thrusting maneuver fairly closely. Not having any loss of sensation, temporary as it might have been, is always a bonus.

In answer to your questions:

1) It is common and expected that the mentalis muscle function will temporarily work a bit abnormally as its entire attachment to its bony origin was separated and was reconstructed back together. (that has to be done on all sliding genioplasties) The muscle recovery will take the longest time to normal function and that could be up to 3 months after the procedure.

2) I would not hesitate to get back to working out. That may cause some mild increase in swelling, which is expected, but is not of any concern.

Despite how well the first few weeks of surgery have gone, it is important to realize that a complete recovery, and the many nuances of it, takes a full three to four months. So you have a long way to go yet!

Dr. Barry Eppley
Indianapolis, Indiana

Can My Chin Irregularities Be Fixed and My Chin Made Smaller as Well?

Q: Dr. Eppley, I’ve had jaw realignment surgery, along with a genioplasty (burring) followed by a revision genioplasty 2.5 years ago. The initial surgery was done because my jaw grew longer on one side. The initial jaw surgery/genioplasty did a great deal to correct the asymmetry, but I still had some nagging asymmetry especially when viewed from below, and I was also interested in a slight narrowing. Following the revision genioplasty (also burring) I have quite a bit of dimpling in the chin and it did nothing to narrow the chin. First, I’m curious for a professional opinion if my desired look was ever actually achievable or realistic (I’ve attached photos). Second, I’m wondering if there’s anything that can be done to improve the dimpling/ scar tissue to gain a better contour. I would like to avoid filler or anything that would make the chin longer/ wider.

A: Thank you for your inquiry.  If I understand your history correctly you have had two bony genioplasty surgeries both of which used a burring technique. It was the second chin surgery that has created the chin indentations/dimpling you have now. I am assuming that both burring efforts were done from an intraoral approach since I don’t see a submental scar.

In answer to your secondary chin reshaping questions:

1) Your initial desired chin shape results may have been possible but never with a primary burring technique done from an intraoral approach. That technique completely degloves the soft tissue of the chin, reduces bony support and then often creates chin irregularities due to the mismatch between the same volume soft tissue and the reduced bone size which it envelopes.

2) The better initial approach would have been either intraoral t-shaped osteotomies or a submental shaving technique with some soft tissue reduction. But that is irrelevant now.

3) The more relevant question is what can be done for any further improvement. This is a primary soft tissue problem which can only be done from a submental soft tissue excision/tuck up procedure. How much improvement could be obtained can not be predicted beforehand. When such irregularities occur in the soft tissue chin pad they can be very difficult if not impossible to eradicate.

4) I would agree with you that adding fillers into the indentations will make your chin bigger which is the antithesis of what you are trying to achieve.

Dr. Barry Eppley

Indianapolis, Indiana 

What Is The Maximum Size of Testicular Enlargement Implants And Do They Feel Natural?

Q: Dr. Eppley, I have two healthy testicles. I’m interested in your envelope implant procedure. (testicular enlargement implants) What are the available sizes (max) and how much volume in milliliters? Are implants oval or ball shapes? How hard or soft is the material? My assumption is as it envelops the testicle that it is a very soft material would feel natural? Do you have pictures of envelope implants a couple of months after surgery? I’m looking forward to your answer. Kind regards

A: In answer to your testicular enlargement implants questions:

1) The maximum external size to date has been 6.5 cms as measured longitudinally along its oval axis.

2) They are made of the softest durometer of which silicone can be made and still be a solid. They are ultrasoft. That softness is enhanced since there is no inner core of material.

3) Since all of my patients are from afar I never see them back again…unless they have a problem which as not occurred to date.

Dr. Barry Eppley

Indianapolis, Indiana

Does Botox Work As Well As Surgery For Temporal Reduction?

Q: Dr. Eppley, Can I please also ask for your honest opinion about using Botox for temporal reduction? I read on your website that it’s another remedy, but I was wondering if you think I could expect similar results, and if I could get it at your office?

A: Like the use and effectiveness for reduction of the large masseter muscle, Botox injections will similarly create a  reduction in size of the temporal muscles as well. Like all Botox injections its effects will be temporary and how effective it will be is based on dose. (number of units injected) Generally it takes a 100 unit treatment session (50 units per side) to see any appreciable size reduction. Such an effect will last 3 to 4 months.

While Botox can reduce the size of the posterior temporal muscles, it is to not as effective surgery which removes 100% of the muscle and thus has a more profound effect.

The value of Botox injections in the temporal muscles is really a test to determine if one may like the effect. Given that its effects are temporary this not a long-term solution to the problem. But for the unsure patient as to the value of surgery, this is a harmless and completely reversible treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Will Temporal Reduction Cause Any Functional Jaw Problems?

Q: Dr. Eppley, I have a growing interest in temporal reduction surgery, as I have had life-long issues with my head shape/size during my life. 

My number one hesitation, however, is a failure to comprehend how “the posterior portion of the temporalis muscle is removed and the anterior portion shortened” without an effect on function. Did God/evolution put these muscles here for no reason? 

I am amazed at the work you have done on others and am in disbelief that this type of procedure even exists, which is something I’ve wished for many times in the past. 

If there is anything you can provide in redone to my concern, I would appreciate it.

A: I can not speak for what God intended. But it has been my extensive observation on doing a lot of these surgeries that removal of the entire posterior portion of the temporalis muscle causes not functional changes in jaw opening and closing. This undoubtably occurs because when looking at muscle volume, that section only makes up about 30% of the muscle’s total volume.

While the posterior portion of the temporalis muscle is removed I don’t ever remember writing about ‘shortening the anterior portion of the muscle….as that is not technically possible from an incision behind the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Get An Implant To Reconstruct My Face After Radiation Treatments?

Q: Dr. Eppley, My facial reconstruction situation may be very complicated, I am just exploring all options to see if this is even viable for me. Just to give some background to my situation, to begin I was diagnosed with a maxillary sinus sarcoma on the right side. I had surgery to remove it, right infrastructure maxillectomy.  I then had 30 treatments of radiation therapy, then 18 weeks of chemotherapy.  All is clear now and my Dr is discussing reconstruction.  The reconstructive surgery poses a lot of risks because of the irradiated tissue. If there were a way to do an implant rather than the microvascular tissue transplant surgery I would be interested to know how or if it could be done. 

A: Thank you for your inquiry and detailing your facial reconstruction issues. The key concept to fully grasp is that radiation really adversely affects the tissues when it comes to healing. Getting healthy new vascularized tissue into the defect site is the key to changing the vascular environment now damaged by the radiation. While a microvascular tissue transfer is far from appealing, this is the only type of baseline reconstruction you should have. You have to change the tissues both in volume and vascular quality first. An implant in this situation would be completely contraindicated. The risk of microvascular tissue transfer today are far lower and it is a much more reliable procedure than it was twenty years. Even then when I did such surgery the success rates in the face were every high. (survival of the transplanted tissue)

Dr. Barry Eppley

Indianapolis, Indiana