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Q: Dr. Eppley, Can you design a custom hydroxyapatite forehead implant? I need a bio scaffold type implant.
A: That can not be done in a satisfactory aesthetic manner (will have a lot of visible edging since HA can not be made with 0.2mm feather edges) nor can it be surgically placed unless a full coronal ear to ear scalp incision is made.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Epple, Hi doctor , thank you for your work!! What happened to me was that in my younger years I experienced a traumatic event . Now as an adult I’m still living with past trauma from my past . I’m highly self conscious of my head , in the back right side , as a result of that incident . I will send the pics and was wondering if I can correct that because it’s really hurting my life. Also , I’m self conscious of my nose and was terrified and concerned that if I get work done on the back of my head , that my nose is going to get more deviated because of the nature of the procedure in the back of my head . Since I will be laying face down . Is that true ? And also am concerned of the final results and any visible scars . Please comment
A:When back of the head skull augmentations are done the patient is in the prone position. But to protect the nose from pressure the head is placed in a special padded donut head rest that keeps the nose from touching the operative table. This is classic periooperative pressure sore prevention.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in the largest custom butt implant that I can obtain with or without fat transfer. Is 1,000 ccs the largest available? Do you place tissue expanders in the buttocks as an option? Thank you.
A:Unless you have indwelling buttock implants you have correctly surmised that first stage tissue expanders would be first needed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am very interested in decreasing the overall width of my head. I have been reading about both the anterior and posterior temporal muscle reduction procedure and I think both would be a suitable procedure to decrease overall head width. Although I am concerned about thickness of my bone on my forehead which still adds a substantial about of thickness to my head size. Would it be possible to know if I would be a good candidate to have both anterior muscle reduction and forehead recontouring (forehead burrowing) by assessing pictures of my forehead?
A:Your question about head width reduction is a good one since the sides of the forehead and the temporal areas share a similar developmental origin, so often both are involved. The only way to answer that question is with computer imaging to show temporal width reduction without any change to the bony forehead so you can be the judge as to whether forehead reduction is needed as well. (see attached)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have what I consider a receded chin, and I don’t care about anyone else’s opinion on it to be blunt. I want a more forward appearing lower jaw, and would like to get reconstructive jaw surgery, but if sliding genioplasty can create the profile I’m looking, then I would be willing to a less invasive surgery. My main concern with just genioplasty is the labiomental groove. Mine already bothers me a lot, and I need it to be much, much flatter. I’m also interested in Rhinoplasty but my main concern is my chin. I’ve attached a few pictures or my profile, as well as two edited photos to give you an idea of what I’m looking for.
A: When you a short chin, deep labiomental fold and lower lip eversion this is all a reflection of an overall short lower. What really improves the depth of the labiomental fold and the lower lip eversion is having the whole lower jaw come forward. As the lower teeth move forward this pushes the labiomental fold and the lower lip forward. Thus you ideally need a BSSO mandibular advancement…but it will not create by itself the chi projection you are showing. It would need to be combined with a sliding genioplasty also moving the lower jaw forward will not create that degree of chin projection.
The alternative to total lower jaw advancement is a sliding genioplasty combined with grafting of the bony stepoff with fat injections to the labiomental fold. This will not produce as good as a result of the labiomental fold correction as the combined lower jaw advancement and sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The top back of my skull is depressed due to surgery as an infant. The depression is deep, wide and long so if plastic surgery was performed it would need to stretch skin or need a skin graft. I’m not sure of your capabilities but has your practice dealt with the issue described. Thanks.
A:What you are suggesting is the possibility of needing a first stage scalp expander procedure. (not a skin graft) That is a procedure I do regularly when more stretch of the scalp is needed for the amount of skull augmentation required.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in gynecomastia reduction surgery with nipple reduction at the same time. But did have one concern that another physician raised regarding a nipple reduction – specifically, the physician was very hesitant that such a procedure was worthwhile considering the risks (which he described as a 20% chance of necrosis of the nipple following such a procedure) – I would be curious to hear your assessment of this risk (or others) as pertains to a nipple reduction procedure before I make a decision.
A: I am not sure at all what is the origin of the statement by a surgeon of ‘there is a 20% risk of nipple necrosis when nipple reductions are performed with gynecomastia reduction’ for the following reasons:
1) Nipple reduction in a male almost always means nipple amputation, the complete removal of the projecting nipple, thus there is no nipple left to have any necrosis. I can only assume what this doctor is more likely referring to is ‘areolar necrosis’ or difficulty with the nipple reduction site healing. This has not been an issue that I have ever seen.
2) This ‘statistic’ is based on what I do not know since there has never been anything published in the plastic surgery literature in that regard or any other literature since the performance of male nipple reduction in gynecomastia reduction is so rarely done.
3) The relevancy of potential vascular compromise to the nipple-areolar complex is based on what type of gynecomastia reduction is being performed. If an open gynecomastia reduction is performed through an inferior areolar incision, where the nipple-areolar complex is left with a thin layer of tissue underneath it and it depends on vascular inflow from the surrounding dermis (where half has been cut off from the inferior areolar incision). then one would have reason to consider there may be the potential for vascular compromise from the healing nipple reduction site. But this issue becomes moot when the gynecomastia reduction is performed by liposuction without a direct areolar incision.
4) But when in doubt one can always delay the nipple reduction for a week or two after surgery since it can easily be done as an office procedure under local anesthesia. (where the chest is largely numb anyway for awhile)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering whether to get a chin implant or a sliding genioplasty for chin. I want my chin to be wider and square from the front view I want vertical and horizontal projection.
In terms of front view of face, can the sliding genioplasty provide as much chin widening as an implant can for that masculine look? And for the side profile, I am aware that the genioplasty provides more projection.
A: Thank for your inquiry and sending your picture. You have numerous misconceptions/misinformation about what are the dimensional effects of chin implant vs a sliding genioplasty. So let me provide you with some clarifications:
1) A sliding genioplasty can effectively create more horizontal and/or vertical increases in projection. It, however, does so at the expense of width. Depending upon the degree of horizontal advancement the chin will always get more narrow. It has NO ability to make the chin wider.
2) A standard chin implant can effectively create more horizontal projection and width but can only create very minimal vertical lengthening.
3) The amount of horizontal projection between a standard chin implant and a solidify genioplasty is equal out to 10mms. Beyond that only a sliding genioplasty can add greater horizontal projection.
4) A custom chin implant can create horizontal, vertical and transverse (width) increases. It is the only option that can create a 3D chin augmentation effect.
By your own description you are seeking every dimensional increase possible which can only ideally be met by #4, the custom chin implant.
There is also an amalgamated approach to achieving a 3D effect with the two basic chin augmentation methods, a sliding genioplasty for the horizontal and vertical increases combined with a chin implant overlay to create the width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thanks for doing the imaging on my potential shoulder width reduction procedure. From the picture it looks like so much change. But I have the following questions.
If the clavicle is cut, will there be any backbone issues as I have to always have the shoulders moving forward? Will it not create a structural stress on my back in the future? How will my shoulder blades adjust to this pulling forward? Will it impact my range of motion?
A: As I discussed with your husband at length on the virtual consultation and to answer these questions to you directly:
1) Clavicle shortening of 2.5cms per side does not cause any spine or shoulder joint dysfunction. To potentially create such dysfunction it has been shown that it takes greater than 30% reduction in clavicle length to do so. With an average female clavicle length of around 14cms and a reduction of 2.5cms, this is only an 18% change in clavicle bone length….enough to make a visible difference in shoulder width but not enough to cause shoulder joint dysfunction.
2) The clavicle shortening is 90% horizontal reduction and 10% forward movement. Thus their is a very minimal anterior rotation which does not cause a substantial pulling of the shoulders forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I have been looking to have chin surgery for a while now. My chin is my biggest insecurity. I never smile due to the way my chin pulls down when I smile. I also dislike the dimple in my chin and how wide my chin looks when I smile.
A: Thank you for your inquiry, sending your pictures and detailing your concerns. You have two specific soft tissue chin concerns, 1) hyperdynamic chin ptosis and 2) a vertical chin cleft. They may be anatomically related as a vertical chin cleft occurs due to a midline soft tissue deficiency. For improvement/correction a submental approaches needed as the size of the chin pad must b reduced and the chin cleft managed by a muscle repair in your case. Such soft tissue chin repairs, while not technically challenging to perform, are difficult to predict the outcomes since surgery is done in a static setting while your chin issues mainly appear with dynamic motion. (smiling)
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 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?
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
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
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
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
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
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
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
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
Q: Dr. Eppley, I am interested in hip and thigh implants. I have the following questions:
- 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?
- 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.
- 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
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
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?
A:
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
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
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
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
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
Q: Dr. Eppley, Everything is going exactly as you described with my chin implant recovery and I love it. It’s been about 6 weeks since surgery and the numbness in my lip is almost entirely gone. The left side of the implant felt good right away. The right side of the implant took longer to settle in. Now both sides feel symmetrical and completely natural!
The only question I have is about the scar itself. How long does it take for the stitches to dissolve? I can still feel some stitches and there are some puss-filled bumps/abscesses along the scar. One spot in particular has been a little red/swollen and I’ve had to drain it a couple times. Please advise if I should do anything for this.
I haven’t shaved my beard yet since I’ve been waiting for the scar to heal. When I do, I will send you some pictures of my new chin.
Thank you again, Dr. Eppley.
A: Thank you for the followup and the good report. Such small suture abscesses are very common in the submental area of men after any chin procedure with beard hair. They are not due to the external dissolveable sutures (which go away in a few weeks but due to the internal dissolveable sutures which take much longer to go away. (months) Because of the hair follicles, these are the sutures that can create some stitch abscesses that you have developed. The one recurring stitch abscess is because the dissolveable suture is still there and infected and needs to come out for a complete resolution. The one method that can help solve it is to squeeze it like a pimple and see of you can force it out when it is at its most inflamed. That often will allow the knot of the suture to come out and then it will be a resolved issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implants but have some questions. I am 4′ 10″ tall and weight about 115 pounds and I’m currently a 34D. I don’t really want to go any bigger but I want implants to fill in the loose skin I have after having 3 children. (BTW you did tongue reconstruction surgery on my 19 year old son when he was 7 months old) Is there a way to get implants without making my breast much bigger? I feel like at my size if I go too big it just won’t look good at all.
A: While I would ideally have to see pictures of your breasts to provide an informed answer, adding implants to breasts that have loose skin and some sag to fill them out will, by definition, make them bigger. That postoperative outcome would be unavoidable…like filling up a deflated balloon so to speak. I suspect you are trying to fill out loose sagging breasts which is likely not a good strategy. Breast implants can not fill out a sagging breast nor can it lift them. Rather it will make the breasts look worse by pushing the sagging breast mound even lower. Sagging breasts usually need to be lifted first before any consideration of volume additions should be considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I have a question regarding shoulder widening surgery. Have you ever performed a clavicle osteotomy or know of anyone having this done? Would widening of the clavicle in turn move the scapula? I know its extreme but do you think this is safe and effective? I’ve been researching on surgeries to broaden shoulders and I’m very interested in the clavicle osteotomy but there is hardly any information on it. You are the only expert in this field that has at least talked about this procedure. Please could you shed light on this operation.Thank you.
A: There is very little information in regards to clavicular osteotomy because it would be considered an ‘extreme’ surgery in the quest for wider shoulders. There are other more conventional forms of shoulder widening that would be considered equally effective including deltoid (shoulder) implants and fat injections.
Clavicular osteotomies would be considered only for the most of motivated of men for the following:
1) Only one shoulder is done at a time with a 3 to 6 month spacing between the two sides.
2) Recovery would be considered similar to that of a fractured clavicle.
3) It requires plate and screw fixation with an interpositional allogeneic bone graft.
4) There will be a resultant scar over the clavicular osteotomy site.
5) Clavicular gap widening would be 2 to 2.5 cms maximum.
For all of these reasons it takes a very highly motivated person to consider this approach to shoulder widening surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ear reconstruction. I got bit by a dog a year ago and lost the lower third of my ear. I have attached pictures for your review.
A: Thank you for your inquiry and sending your pictures. Your traumatic injury represents a classic case of reconstruction of the lower third of the ear…the hardest area of the ear to remake. To do so requires a two-step procedure with the first stage being to raise a skin flap from behind the ear and attach it to the visible edge of the missing ear section. After 8 weeks the attached skin has gotten a good blood supply of its own and it can be released from its base, rolled to make both a back side as well as front side of the missing area and closed over a cartilage graft or implant to support the lower helical rim and where the earlobe would be. This keeps moist of the scar to do within the shadow of the ear rim.
Both stages of this ear reconstruction could be performed as an outpatient procedure and each takes about an hour to complete under IV sedation or even local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana