Your Questions
Your Questions
Q: Dr. Eppley, I have few more question since our last conversation related to custom silicone implant for back of the head augmentation.
It’s not urgent so please reply when you have some free time.
1. When the silicone implant is placed on the back of the head is there some bone erosion or bone resorption due to applied pressure to implant like in chin implants?
2. Edge of silicone implant is going to be very thin, but is there going to be any capsule formation and hardness around implant? Can it be felt with fingers?
3. How the the implant is going to be sterilized? I know that implant is sterilized by manufacturer, but is it sterilized in some way one more time before insertion?
4. Are silicone implants safer or unsafer than HDR and PEEK implants (or there is no difference) and is there some difference in how the body is reacting to theme?
5. If its need to be removed, does the scalp shrink normally?
6. The use of silicone implant for back of head augmentation is approved by FDA (Food and Drug Administration)?
7. Which company you are using for implant manufacturing (you already told me but i forget)?
A: In answer to your questions about a custom occipital skull implant:
- Bone erosion or implant settling is not a phenomenon I have seen in skull implants.
- All implants in the body get a surrounding capsule or layer of scar tissue. This is normal and is not the source of a palpable implant edge. The only method to reduce that risk is a feather edge to the implant which is done in the implant design.
- The manufacturer sends the implant already sterilized.
- All FDA-approved skull implant materials are similarly safe. One material is not ‘safer’; than another one.
- All soft tissues contract when they are ‘devolumized’ when an implant is removed. Whether it will completely return to normal depends on the size of the implant and how long it has been in place.
- All custom made silicone skull implants are FDA-approved.
- Implantech
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wondering if a vermillion or lip advancement can change the actual shape of the lips? I have a flat/undefined cupid’s bow that I’d like to augment along with the rest of the lips, but Juvederm only flattens thie cupid’s bow even more. Plus I am tired of spending money and to getting the results that I want. Every injector says that can make a better Cupid’s bow but it never happens. Thank you.
A: The main advantage of a vermilion or lip advancement is that it affects the whole lip, from corner to corner, and one can change the shape of the Cupid’s bow. Injectable fillers, like all volumizers, can only take the lip shape and push it out, it can not make a cupid’s bow that is ill-defined and flat and make it more defined or pronounced.
The decision you have to make is not whether a lip advancement will accomplish your upper lip reshaping goals…as it will. The question is whether the fine line scar that is the result of the lip advancement is a worthy trade-off. In most women with thin flat lips it is, but each patient has to make that decision for themselves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry correction. I just had lower jaw surgery for an underbite. I had the bottom jaw rotated to the left as my jaw was deviated a but, but even after the surgery was finished, I still had asymmetry. I want this issue fixed if possible. One side is strong, the other is not. I don’t know if you would reccoment making the strong side less so, or the weak side stronger. Also, I live in another state and could come down for the operation, but I don’t think I could bring anyone. After the operation, could a nurse drive me back to the hotel? How does that sort of thing work?
A: Thank you for your inquiry. In answer to your facial asymmetry correction questions:
1) Mandibular osteotomies rarely fix lower facial asymmetry.They may reduce it but their movements are controlled/limited by the occlusion. You should wait a full three months after this surgery to allow the bones to heal and all swelling and soft tissue contraction to occur to fully assess the final results. I would need to see pictures of your face and eventually a 3D CT scan to determine how to best treat your jaw/lower facial asymmetry.
2) How best to treat the asymmetry (make the weak side stronger or make the strong side weaker) is best determined by computer imaging of both potential outcomes.
3) It is very common for patient’s to come by themselves and you have correctly assumed that our nursing service takes the patient back to their hotel if no overnight stay is warranted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry surgery. I feel as though one side of my face sags down (the right). I have spoken to a facial surgeon in my city and he believes that it is natural asymmetry in my face but I believe it is because of my accident which I was in when I was five. He said that any surgery would be invasive and might not even change that much. Just looking for a second opinion and any options that might be open to me .Thanks.
A: Thank you for sending your pictures/. Your facial asymmetry is caused by a left-sided facial hypoplasia. (presuming the images are not switched) It is natural only from the standpoint that it developed this way but that does not make it normal or aesthetically acceptable to you. This could be improved by the combination of a left jaw angle implant combined with a right perioral liposuction to better balance the two sides of the face. The other option for the soft tissues is to fat graft the left side of the face in the perioral region based on how you want to balance out the soft tissue asymmetries. Yes surgery is invasive but that is the only way to improve your facial asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a testicular implant replacement with the silicone implant. I have read some of your case studies on your website about testicular implants, I think the one I have now is the saline implant. it is very firm and is attached too high. uncomfortable at times and the attachment point hurts sometimes. I had the implant installed due to removal of an undescended testicle. The first surgery I had in my early 20’s was an attempt to lower it but later I had to have it removed and a prosthetic installed. I am 62 years old now.
A: Thank you for the clarification on your testicular implant history. Everything you have described is classic in the use of saline testicular implants in some patients. (Hard, high riding and somewhat uncomfortable due to a suture fixation point)
While you may now be 62 years old, your age is irrevelant to have it replaced with a much softer implants that sits lower in the scrotum and hangs freely without an unnatural adhesive point of attachment. This is not a complicated surgery and one is really never too old to have it done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’m a 26 yearr old woman from South Korea. I want to do custom facial implants for two sides of my kaw. I had a bad surgery two years ago and they cut off my two sides of jaws way too much and also sliding my chin upward which made my face look unproportional. I want to augment my jaws line. Any suggestions?
Here’s my history of surgery… I had lower jaws surgery by Maxillofacial doctor in 2005 as I had protruded lower jaws. The doctor moved back my lower jaw about 5-6 mm so the result was very subtle. In 2013 I had two sides of my jaws cut off and my chin sliding in front. (V-line jaw surgery) My face looks unproportion. I have protruded chin than before my first
surgery and I don’t have jaws angle!
Now my desire is to have a proportion face and less protruded chin.
A: Thank you for sending all of your x-rays. You had the classic V-line jaw surgery where the jaw angles are removed and the chin is narrowed and advanced forward. To totally or partial reverse your prior surgery, you would need vertical lengthening jaw angle implants and a setback bony genioplasty. This is the classic ‘reversal V-line jaw surgery’ that I have done any times for those patients who find that their new face is now disproportionate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask a very brief question for your blog that is relevant to me, and I believe will help others.
Custom skull implants can cover the entire bony skull, forehead and brow, the scalp tissue permitting. Because of financial constraints I cannot afford multiple implants. However I want augmentation of the temporal area. With a two stage tissue expander is it possible to include the temporal region in this singular total skull implant? Also how far down the lateral orbital rim may the implant extend. I’m aware that the top part is contiguous with the brow and can usually be augmented at the same time. How much exactly of the lateral orbital rim could be covered with this custom skull implant (can it stretch down slightly below the lateral canthus)?
Thank you.
A: Thank you for your inquiry. As best as I can understand your question about custom skull implant coverage, it can be designed to any size or cover any area including that of the temporal region. There may be issues of implant placement, incision size etc that may affect that consideration, but it is not a design restriction. I have done large custom skull implants before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, we’ve been emailing for the last 3 years about my skull shape and various skull reshaping methods to improve it. I hope you’re doing well. Last we emailed, I was thinking about getting two parasagittal skull implants which would require a pair of of 2.5 cm incisions.
Is that still the best option today? I was wondering about a single central incision as I think that will be hidden a little better with my naturally thin hair. Do you have an idea of 1) whether that’s possible with 2 implants, and 2) roughly how short we could keep the incision? I recently saw a blog post of yours where you performed a sagittal reduction through a small central incision. This might be a good chance to do a little bit of reduction along with implants.
Finally, are there any long-term health risks with these implants?
A: The truly best option for your skull is to have a combination of a sagittal ridge reduction with custom parasagittal skull implants placed through a 4 to 5 cm incision. It really comes down to whether the sagittal ridge is addressed or not. If it isn’t then the two bilateral smaller incisions would be best. Because the one central incision is essentially going to be he addictive width of the paired incisional approach.
There are no long-term medical risks with these skull implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read from a few plastic surgeons that bone erosion can occur some time after a jaw/chin implant procedure. (jaw implant bone erosion) Would you mind elaborating on this for me? Will this effect the result in the future? How can I minimize bone erosion?
A: To put those comments into perspective the statement that jaw implant bone erosion occurs implies an active inflammatory bone destructive process…which does not occur. All facial implants, like all body implants including breast implants, create the biologic reaction of tissue adaptation around the implant. This is a normal process that the misinformed interpret erroneously as ‘bone erosion’. It is better turned ‘passive settling’ which means the implant is associated with a pattern or imprint on the bone which is the body’s way of relieving the pressure from an object that is naturally not meant to be there. This may be a millimeter or two of the implant settling into the bone. There may even be bone growth around the edges of the implant up onto the implant.This is a self-limited process and is most commonly associated with smaller facial implants, most commonly standard chin implants. This is not a biologic process that I have seen in much larger implants like wrap around jawline implants or skull implants…probably because the larger size of the implant distributes the pressure of tissue displacement over a broader surface area
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin augmentation. I have attached a few photos band a facial analysis report from another surgeon. My goal is to define my jaw, neck, and balance my chin for a chiseled appearance. I am also interested in eradicating the horizontal neck lines. I plan on losing 20lbs before booking a online consultation, but would love to hear your opinion.Thank you.
A:Thank you for sending your pictures. Your chin deficiency is completely of a vertical dimension, you have adequate horizontal projection. Your lower facial third is vertically short. Thus what you need is a vertical lengthening bony genioplasty combined with a submentoplasty neck procedure. Essentially drop the chin and bring up the neck angle. That is what your ‘chin augmentation should consist of and it has nothing to do with a chin implant unless you want to custom design a vertical lengthening chin implant but I advise against since it may not carry the soft tissue chin pad down with it whereas moving the chin bone down will. How much you would like to vertically lengthen your chin is a matter of aesthetic taste and the attached imaging is just one version of it.
Your facial analysis report is non-sensical to me as bimaxillary osteotomies are not an appropriate solution for your facial concerns nor do they address the neck component.
No surgical procedure exists that can improve horizontal neck lines, that is not an achievable goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in several face and body procedures. For the face I am interested in buccal fat removal and maybe chin augmentation. I really want a more defined Jaw so we would have to talk and see how you could achieve those results. For the body, I am interested in body shape adjustments through liposuction, anatomic waist reduction and maybe fat grafting or hip implants. I have already had liposuction of my waistline done with buttock augmentation with implants but not getting the desired body shape yet.
A: Thank you for sending all of your pictures and detailing your goals. In reviewing the face and the body pictures I can make the following comments:
1) Having been through liposuction and getting buttock implants, your options for further body contouring are now more limited. Not knowing how your liposuction was done, perhaps there may be room for further improvement in waistline reduction but it would not be dramatic. Even with further liposuction the amount of fat you have to harvest would be less than the first time so its use for far grafting would not be substantial. It could be used to add around your buttock implants which appear to be the subfascial location. At best this would add some filling around the buttock implants. Any fat harvested should be used for the buttock region and not wasted on the hips..
2) For larger hips your only option are hip implants. You don’t have enough fat to harvest to provide any hip augmentation effect. Whether the small incision to place them is worthy of the augmentation effect is to be determined.
3) Even with some further waistline reduction and hip augmentation, I don’t see you getting that close to your projected image goals. It would be better than where you are now but those pictures are not that realistic of a goal with your body type.
4) You face would benefit from some thinning/defatting including buccal lipectomies, perioral liposuction, and submental/jawline liposuction.
5) To achieve a better defined jawline with the facial thinning, the chin is going to have to come out further to help lengthen the jawline. Whether that is done with an implant or a sliding genioplasty can be debated
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Could possibly send me two pictures of the difference between a linear and non-linear jawline shape? That would be very helpful in the designing of my custom jawline implant as I am still not sure what the difference looks like on real people’s faces.
A: The concept of linearity in jawlines is based on the connection between the chin and the jaw angles. A linear jawline shape is when there is a smooth line between the chin and the jaw angle area when seen in the front or oblique views. This is what a custom jawline implant does well if so designed. A non-linear jawline shape is when there is a noticeable inward dip between the chin and the jaw angles when viewed from the front and the oblique views. This is what will most commonly occur when standard square chin and widening jaw angles are used or when a custom jawline implant has a very minimal connection between the chin and the jaw angles. I have attached some picture examples of the differences between these two jawline shapes. Many times models show a non-linear jawline shape because they are biting down which causes the masseter muscles to bulge outward but it still illustrates the concept. While these model pictures show these two jawline shapes this should not imply that you will have a jawline that looks exactly like theirs does no matter how the implant is designed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a buccal lipectomy three months and now my face is slim and less square. I would like to have jaw angle implants to have a wider and more square face again. I have attached some before and after pictures so you can see how my face has changed.
A: Thank for sending your pictures. A buccal lipectomy (bichetomy) should have no effect on slimming the face anywhere but under the cheek area. It does not extend anywhere close to the jaw angle region whose shape is determined by the jaw angle bone and the overlying masseter muscle. In fact the biggest aesthetic problem with buccal fat removal is that it usually has only a very modest effect, and one that is usually underwhelming to the patient, rather than too much of an effect
But that anatomic issue aside, all that matters is your perception and how you see your face now. I can certainly see the change in your facial shape in your pictures even though I don’t have a good explanation.
Jaw angle implants can be used to make the back part of the jaw wider and hopefully more square. The only question is what size (thickness) of implant to use. Sizes typically run in the 5 to 10mm range.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. I want to understand the differences between skull augmentation materials that are used and their risks. Can these materials cause infection, can your body reject it? Also, will they have to be replaced with new ones after a certain period of time?
A: In answer to your skull augmentation material questions:
1) The vast majority of skull augmentations I do are done with custom implants made of a solid silicone material. This materials offers computer designing implants that are both cost effective and can be inserted through smaller scalp incisions.
2) Any implanted material placed in the body runs the risk of infection. That risk for skull implants is very low due to the superb blood supply of the scalp and skull bone. I have yet to see an infection from a custom silicone skull implant.
3) Such materials do not develop rejection since silicone is one of the most biocompatible of all synthetic materials and as a long history of safe medical use.
4) Silicone skull implants are permanent. They do not degrade or break down and thus never need to be replaced. They should not be confused with silicone breast implants which are gel-filled devices and do require replacement in most patients.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been researching the jaw implant recovery process. However I can’t find much on the recovery from jaw angle implants, whereas there is a lot on what is it like after orthoganthic jaw surgery. Can I take it that the recovery process is the same. For example follow the advice on diet, ice packs, sleeping upright and similar pain levels? I am looking how to best prepare myself after surgery as I am travelling by myself.
A: While there are some similarities in the beginning (swelling) between jaw bone surgery and jaw implant surgery, I would say that jaw implant surgery is not as severe as orthognathic surgery as the actual functional disruption of jaw opening and the degree of trauma to the tissues is much less. Jaw implant surgery disrupts the masseteric muscle attachments while jaw bone surgery disrupts the bone and the muscle.
Pain would be less and ultimately you will recover much faster in jaw implant surgery. It is largely the swelling and the time it takes to go down to look acceptable (2 to 3 weeks) that can be psychologically stressful. Most patients will be on a soft diet for a few weeks and ice is good for the first 24 hours or so after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very intrigued by the mesh implant insert in breast lift surgery that both yourself and another surgeon in the area are using. I am primarily hoping for a more perky shape, added fullness, areola revision, and “bra free” aesthetic look. I developed fairly large breasts at a young age that were large for my frame and after two kids and minor weight loss, I am hoping to have a more youthful chest.
I do not want to dramatically go up in size but I am realistic in regards to a small implant being necessary for upper pole volume and maintaining the long term results I am hoping to achieve. I have done a consultation with a surgeon and while I liked him and felt comfortable, the total cost for a breast lift with implant was far higher than any other surgeon in the area that I’ve observed.
This is a decision that I have researched adequately and feel strongly that I don’t necessarily want a “budget” procedure performed, but I was quoted almost $14,000.00 which seems very excessive to me. Please forgive me if I am incorrect.
What are your thoughts?
A: Thank you for the details on your breast reshaping goals. When the implantation of mesh is used in breast lift surgery the cost of the mesh alone will approximate $4,000 to $5,000. That adds considerably to the overall operative cost. Mesh is a nice addition to a breast lift but, like icing on a cake, it is not absolutely essential. While it may have some modest benefits and is very theoretically appealing, you have to put a value on its addition to the procedure. For some breast patients it is essential to the result, particularly in revisional breast reshaping surgery. But in a primary breast lift/implant case for most patients it remains a luxury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son is 18 years old and very uncomfortable with the openness of his lips while at rest. (lip incompetence) It is affecting his day to day life and I’m desperately trying to find a solution for him. We have seen two oral surgeons who would not recommend jaw surgery, but would do it we decided that was the only route. We don’t want to take that route! He has a short upper lip and a long upper jaw. In addition, he is on his third round of orthodontics. He needs some hope and frankly so do I. We will travel to see you if you think it is worthwhile.
A: Thank you for your inquiry. Your son has vertical maxillary excess which is the source of his excessive tooth show, apparent short upper lip and long, unrotated lower jaw and lip incompetence. I see no recourse but for him to undergo a maxillary impaction procedure (LeFort I shortening) probably combined with an osteotomy of his mandible (to get his bite to fit again) and a sliding genioplasty advancement. It is a big decision but the only one that will work for him in the long run.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would really value your opinion on the following; I am a 46 year old female. Over the last 15 months I have undergone orthodontic treatment to reduce my considerable over jet by bringing my lower incisors forward. Orthognathic surgery was not offered to me after assessment. I am very happy with the result. I have recently visited a maxillofacial surgeon with regard to surgery for my retrognathia. He suggests an advancement sliding genioplasty but with no vertical lengthening as my lower third is not deficient. My question to you is do you think this procedure would deepen my labiomental fold, resulting in an unharmonious appearance? I could send a lateral x ray photo if that helps. Many thanks for your time.
A: The answer to your question is very straightforward…yes it would. Every sliding genioplasty by definition will deepen the labiomental fold as the moveable chin point comes forward and the labiomental sulcus point stays fixed where it is. So the question is not really whether a sliding genioplasty will depend a labiodental fold but by how much and whether it will be aesthetically disadvantageous. That would depend on how deep the fold is now and how far forward the chin would be advanced. X-rays don’t help answer the question, actual pictures of your face would.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you do the 3D imaging there for the glabellar implants? Also being from out of state can it all be completed in one day. Thanks for your time.
A: There are three methods for doing glabellar implant augmentation depending upon the exact nature of your glabellar forehead deficiency and the time needed in preparation for surgery.. Using 3D imaging you are referring to a true custom glabellar implant made for you from a 3D CT scan of you. You get the scan where you live and then it is sent to me. It is then designed online and manufactured and shipped for surgery. That is a process that takes about a month to do. The implant is then implanted through a small scalp incision. There are also special design glabellar implants which means I take a custom design already used for another patient and use that same implant design, if appropriate, for your glabellar contour issue. This does not require a 3D CT scam to be obtained and can be ready in the days. Lastly, an intraoperatively fabricated implant made from a ePTFE block can be made during surgery. (hand carved implant) This also does not require a 3D CT scan.
The extent and complexity of the glabellar contour deformity would determine which type of ‘custom’ implant approach would be used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am a transgender woman who is curious about procedures to narrow the width of my overall face. My face height (from hairline to bottom of the chin) is long, which by measurement seems to be around the female average, but my head looks wide due to the disproportionate width. The primary culprits seem to be the lateral projection of my zygomatic arches as well as a wider than average skull (lateral projection above the ears).
My understanding of male vs. female cheekbones is that male cheekbones tend to have more lateral projection, while female cheekbones tend to have more anterior projection. Would lateral cheek bone reduction combined with implants to give more anterior projection be a good solution to feminize this part of the face? And could this be combined with a reduction of the temporal muscles above the ears to achieve the effect of a less-wide head?
A: While I have not seen pictures of your face, your overall supposition seems aesthetically accurate. Posterior temporal reduction, posterior zygomatic arch reduction and anterior zygomatic (cheek) augmentation all seem like the correction combination to achieve a more feminine facial shape.
I wiould need to see some pictures of your face to provide a more qualified opinion in that regard.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an atrophic abdominal scar, similar to a C-Section. It was due to surgery at an early age (I am male). There are two potential solutions to it. One is subcision to release the scar from being tethered to the underlying muscle fascia. The other is autologous stem cell injection at the scar site, something which I am not sure has been done before on this particular issue although I have seen nearly miraculous results on other injuries such as major burns.
With my scar, the surface of the scar is not bad, it is just tethered down. This creates a deformed appearance resulting in a major impact on quality of life. If it was level with the rest of my stomach then it would be hardly noticeable. However, stem cells could theoretically remove the scar permanently.
Please let me know if you can help.
A: Thank you for your inquiry. Let me provide some clarification on the concept of stem cell injections. Such a procedure in the purest sense of the term does not exist in the U.S. unless done under FDA-approved clinical trials for very specific study indications. Many people throw the term around like they are doing stem injections when they are not. It is strictly forbidden to harvest any cells from patients, modify them in any form and put them back into a patient. What is being done widely are fat injections which are erroneously touted, for marketing purposes, as ‘stem cell injections’ or even ‘stem cell enriched fat injections’. Fat coincidentally contains a lot of stem cells so all fat injections do have a high number of coincidental stem cells as part of it. How many are transferred with the fat, how many survive and what they do after transfer are all completely unknown. But to label fat injections as a true stem cell injections is misleading.
That being said fat injections can be done for scar releases in cases of contracted scars like yours. Their success, like all fat injections, depends on adequate scar release and a percent of the actual fat injectate surviving…whether that is due to some influence of its stem cell component can be debated.
Whether such an injection technique would be appropriate for your abdominal scar would require an assessment of pictures of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty to fix a retruded columella. I know a graft is needed to push out the base of the columella. One doctor told me that he would use septa cartilage. Isn’t the anterior nasal spine made of real bone, so wouldn’t you need something tougher than soft septal cartilage to do that? Would my nose lose structure/functionally feel weird if a piece of septum were missing? I’ve heard that some doctors use ears and ribs, what are your thoughts on that?
Also, do you feel that my nose tip need to be projected more forward and down, if the base will be lowered?
My other concern is about my nostrils. I think the outer corners droop down too much, hence I was asking about alar reduction (although that appearance could be exacerbated by the retruded columella).
A: In answer to your questions:
1) The anterior nasal spine is bone but you would never harvest a bone graft to place there nor would a bone graft persist. Cartilage is the correct choice, it is just a question of the quantity needed and the best donor site. Without question rib cartilage is best both in quantity and structural stiffness…if the patient does not mind a small chest scar to harvest it.
2) As the columella is rotated downward you are correct in that the tip projection will look less. As long as one has enough cartilage to graft, then the tip projection and rotation should adjusted accordingly. Like #1 the rib graft re-emerges and is essential if this nasal change is done. A rib graft rhinoplasty is the procedure you appear to be needing.
3) I think that the alar appearance is exacerbated by the retruded columella. Since any change to the alar rims requires an incision, I would not commit to the need for that change until one sees it in perspective of the columellar correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin reduction surgery. Unfortunately it seems that there are not that many Doctors in the US who do chin reduction. I even consulted two hospitals in Korea but I think I’ll skip. I don’t need anything major. Maybe just shorten and chisel it like 5 mm? Also I am 42 years old so I will need a facelift after? 🙁should we do the external approach to avoid the loose skin? I feel like there’s already too much tissue on my chin right now.
A: Thank you for sending all of your pictures and detailing your chin objectives. As you may know there are two methods to chin reduction, intraoral osteotomies and extra oral submental osteotomies. Because there are two methods it is not a surprise that there are some differences between them.
The intraoral approach uses bone cuts (osteotomies) where the a T-shaped pattern is done with both vertical and width bone reduction. It is then put back together with a small plate and screws. The soft tissues remain intact on the bottom and back side of the bone segments so there is not any resultant skin sag. (if there is too much soft tissue initially this won’t change) Its advantages are that it is scarless as everything is done from the inside. Its disadvantage is that the amount of bone reduction is usually a little more limited to protect the mental nerves and tooth roots since the actual vertical and transverse bone removal is done in the middle of the chin bone. There will be some temporary lower lip numbness as the mental nerve gets stretched with retractors to protect it during the bone cuts.
The submental approach uses a skin incision under the chin where the bone is shaved from the bottom up. The chin can be vertically reduced as well as the side bone cut down for reshaping. Because the bone removal is done from the ‘bottom up’ more bone reduction can be safely down particularly in regards to the mental nerve as well as the more direct linear access to the bone removal. There usually is little to no temporary lip numbness from this bottom up approach. Also any soft tissue redundancies can be addressed as most submental chin reductions get some form of a submentoplasty as a result. Its disadvantage is the fine line scar under the chin. This is why it is not popular in Asian countries where their skin types are more prone to adverse scarrring.
Having done a lot of each chin reduction approach, you have to choose which technique is most appropriate for the patient’s anatomy and aesthetic chin reshaping goals. It is not really a question of one being better than the other, they are just different with each one having their own distinct advantage and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions in regard to temporal implants:
1. Are there standard implants for augmenting the whole temporal complex? or just the anterior portion?
2. What the procedure be should the implants become infected post operative or years later?
3. How many days would I need to stay in Indiana for recovery?
4. Could an endoscopic brow lift be preformed at the same time through the same incisions?
A: In answer to your temporal implant questions:
1) Standard temporal implants only exist for the anterior temporal region. There are special design or custom temporal implant options for the posterior temporal region.
2) I have never seen a temporal implant infection. But if it would ever occur, like all implants, it would occur within the first month or so after surgery. It would not occur years later. The standard treatment for implant infections is removal.
3) 1 to 2 days at most would be all the time you would need to be here before traveling home.
4) Endoscopic browlifts require more superior scalp incisions to perform not lateral temporal incisions. As a result an endoscopic browlift could be performed at the same time as the placement of temporal implants. In fact the same high temporal incision could be used to perform both of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m needing some information on the ultra-soft testicale implants you talk about in you blogs. I have had a semi-solid Promedom implant placed three weeks ago. Now I find it is a bit harder than my other natural one, so are the soft implants you mention softer and more natural feeling than the Promedom semi-solid elastomer ones? Are they silicon gel filled or just a much softer elastomer? Which company makes and supplies them and how could I purchase them here in my country?
A:I can not speak to how the Promedom testicle implant compares to the ultrasoft testicle implants that I use here in the U.S. since I have never felt that implant before. I also have no knowledge of its silicone composition or properties. But due to the lowest durometer silicone that is used in my custom testicle implants and I have yet to see a patient state that it is too firm, I would guess that it is a softer solid silicone material that what you have currently in place. The testicle implants that I use are exclusively provided to U.S. surgeons based on FDA requirements and guidelines. How to get them in your country is a question for the manufacturer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, let’s say a patient is interested in permanent lip augmentation. From research, Ive found the only permanent options are a lip lift, fat graft to the lips (but it’s controversial as many have reported it deflating too soon) and the silikon 1000 injections. My concern with the lip lift is the scarring, especially because I have olive-dark tone skin and have read that those with darker pigmentation are more prone to keloid scarring. If I were to treat my skin to become lighter, does that help with the issue of dark skin = keloid scarring? I’d really like a lip lift as it seems the only permanent option.
A: For the sake of clarification, there is also two other permanent lip augmentation methods, a lip or vermilion advancement and internal mucosal V-Y advancements. So there are a few other options of which the concerns about scarring exist with the one (lip advancement) but not with the other. (mucosal rollout)
I have done many lip lifts on dark-skinned patients and I have never seen any adverse scarring issues such as keloids. So this would not be a major concern based on my lip lift experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I am currently 6 months after my rhinoplasty and chin implant and I am unfortunately more than disappointed with the results. I went in with my nose being my main concern and my plastic surgeon was very adamant about giving me a chin implant, as a lot of surgeons suggest doing with rhinoplasties. Because I trusted him and his work, I agreed to it. I wanted to wait to do the implant at a later time, thinking it would be too much all at once, but he thought it would be best to get it all over with at one time. Well, I should have stuck with my gut, because I was right- the results are too much. I wanted a new nose, not a new face- and with the two, I just don’t feel like myself anymore. I realize I had a small chin and maybe the way my chin is now, might be aesthetically perfect to others, but it is not me and I wish I could have loved myself for what I was. I went to my 3 month post-op appointment to voice my concerns with my plastic surgeon, because not only am I not pleased with my implant, but I am going to need a revision rhinoplasty. He looked at me in disbelief, telling me he was disappointed in me and that anyone else would be thrilled with their results- that what I’m seeing is psychological. I can assure you, I am not feeling good about myself, but I know I am not seeing things. When telling him I didn’t like my implant, he told me getting it out would be the biggest regret I would ever make and that the procedure is extensive and complicated. Right now, I just want to get back to feeling and looking like me again. Being that I am so early in my recovery for my nose, having this implant removed is all I can do and I really would love your input. I have done a good amount of research and I am terrified that I’ve made a huge mistake. I keep reading about people getting their implants removed and their lips/chins being permanently numb, hard, or they can’t move their mouth properly.. or they have the sagging skin, dimpling, etc. A big dislike I am having with this implant is that it has changed the way I talk, amongst other things. I had such a petite face/chin before and although this may be a small implant, it was enough to change my look completely. And to me, not for the better. I have tried to look into doctors who specialize in implant removal and did not have a lot of luck- it seems like a lot of doctors are able to put them in, but are not as experienced in taking them out. I just really want this done the right way, or not at all. I don’t want to be stuck like this for the rest of my life, but I really can’t handle dealing with anymore bad results. You were one of less than a handful of doctors that popped up right away in searching the removal of chin implants- Can you please give me some insight?
A: Thank you for your inquiry. It is always disheartening to hear of unsatisfactory aesthetic outcomes from any form of plastic surgery whether it is my patient or another…so I do feel your psychological pain. I always do preoperative imaging on any facial reshaping change to be certain that the patient likes their predicted new face. That may or may not have been done in your case. But either way it is irrelevant now. You have done the definitive test, you have worn this chin augmentation result long enough to know whether you like it or not.
A silicone chin implant removal is very straightforward and far less ‘complicated’ than putting it in. While the implant is small and has not been in for very long, and the risk of any soft tissue sag is low, it may be beneficial to do a little soft tissue tightening internally when it is removed. But based on how you feel, just get it removed ASAP and get back to the lower facial shape that you know.
The picture being painted that a chin implant removal is complicated and will lead to other adverse issues is not accurate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know that facial fat is a very difficult thing to address.
If you are young and have exhausted both options of Buccal fat removal and facial liposuction and still have an unacceptably fat and heavy face, how feasible would it be to get a face lift to address the deeper and superficial layers of fat by dissection? I know In older patients who get face lifts often everything is opened up and can be fully accessed and at times fat is taken out. I know the issue with taking out fat in the face is that it can’t be accessed easily since a lot of it is intermingled in different soft tissue layers. Wouldn’t a full face lift allow a surgeon easy access to all of it to dissect, remove and split carefully?
Can this be done with a younger patient who desperately wants a leaner face even at the expense of face lift scars?
Also what’s your opinion on Kybella for facial fatness beyond by chin?
A: In answers to your questions about facial fat reduction:
1) Kybella will be useless for our facial reshaping concerns.
2) A lower tuckup facelift will offer improvement. You are correct in that regard. But it is not really the result of fat removal, it exerts its effect by tissue lifting/tightening along and above the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested to read your comments regarding augmenting the skull area: ‘Kryptonite Bone Cement, can be injected through a very small incision (10mms) and shaped until set from the outside. ‘m (injectable cranioplasty) Would this procedure be suitable for expanding the cranium, beginning from above the forehead, top of the cranium ending at the back of the top of the head, as this is where I would require augmentation, the highest area to be approx 3cm in height? Also, what would be the cost? I look forward to hearing from you at your earliest convenience.
A: In answer to your question, both Kryptonite bone cement material and the concept of an injectable cranioplasty using it have been abandoned. While there may one a role for injectable cranioplasty for very small cranial defects, it is a technique that will not work for larger skull augmentations due to irregularities and lack of contour control.
While I commonly do large skull augmentations, this is done today using custom designed skull implants from the patient’s 3D CT scan. This ensures control of the surface area coverage and shape of the skull augmentation in a precise manner. In larger skull augmentation, like the 3cm thickness to which you refer, this would require a first stage scalp expander to generate the soft tissue coverage required of such a large skull augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in rib removal. I was wondering how much of the 11th and 12th ribs you remove during the procedure? Also, what is the risk of post-thoracotomy pain from the procedure? And what do you do with the intercostal nerves that run below the ribs when you do this procedure? Thanks very much.
A: In answer to your rib removal questions, the ribs are removed back to the lateral or outer border of the erector spine muscles. More medial resection towards right spine has no aesthetic benefit. There is zero risk of pneumothorax in removing ribs #11 and #12. The pleura of the lung sits higher than at these rib levels in most patients. I have only see the pleura one time during surgery at the level of the 11th rib. The intercostal neurovascular bundle, located on the inferior side of the rib in a bony groove, is dissected out and preserved throughout the extent of the rib resection out to their cartilaginous tips. Intercostal nerve blocks with Exparel anesthetic are administered at the end of the procedure prior to wound closure to help with decrease the immediate postoperative pain during the first few days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
