Your Questions
Your Questions
Q: Dr. Eppley, I started taking Accutane exactly 2 weeks ago – the dose is quite low, at 20mg once daily. I now have a problem / query. I realized I should have had surgery before starting on Accutane. I had an infected jaw implant removed in August 2017 and now, in my eyes, have terrible asymmetry as the jaw implant on the other side is still in place. I cannot wait 12 months to have this corrected (I say 12 months as the plan was to be on Accutane for 6 months followed by 6 months being Accutane-free.) My cheek implants are also contributing to asymmetry (they are visibly misplaced).
My question is – how soon can I have surgery (custom wraparound jawline implant at least) seeing that I’ve been on 20mg Accutane daily for the last 2 weeks?
A: It has long been believed that wound healing may be compromised in patients taking systemic isotretinoin. The cellular basis of this potential adverse effect is that his drug affects the synthesis of collagen which is essential for normal wound healing. Despite this contention, animal studies have failed to show adverse effects in wound healing at doses of 4 mg/kg per day. Case reports and cohort studies looking at facial skin laser resurfacing, facial chemical peels, laser hair removal, rhinoplasty, tooth extraction and ENT procedures have failed to show any demonstrable or consistent increase in wound healing problems.
Does this mean that the purported adverse effects on wound healing by isotretinoin are a myth? It is fair to say that most of the clinical studies reported have very low numbers of patients which makes it difficult to really know if those findings are valid. Equally relevant, none of these clinical studies have involved the use of implants which have natural higher risks of complications and is always the ultimate test of wound healing.
Given that most of aesthetic facial surgery procedures are elective and there remains some doubt that isotretinoin has no adverse effects on wound healing, one should not have surgery while actively on the drug. If you stop the medication now, having been on it for just two weeks, the risks a wound healing problem from having facial implant surgery a month or two from now should be very low.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year old male from Europe looking for a surgeon who has experience with facial implants, in particular with cheek implants. I had Medpor cheek implants placed one year ago but I am not happy with how the result turned out. They are placed too low on my face and the size of the implants is way too small for the result that I was looking for. I wanted to have bigger implants placed more on the “outside” of the face to make my narrow face wider and give it more of a feminine and oval shape. Since I think that the standard range of silicone/medpor implants will not fit my expectations regarding the size of the implant, I was looking for custom cheek implants with a very big/important projection.
As I said before, I am not from the US – could you maybe explain to me how it works for international patients to have surgery with you. Do I need to come for a pre-operative consultation or would a consultation via Skype be sufficient? and plus, since I am looking for custom made implants, would it be OK for you to have a 3D scan of my face and discuss the options via Skype and email?
Thank you very much in advance for your assistance.
A:Thank you for your inquiry and your detailing your history. By your description it sounds like what you are looking for are what I call ‘malar-arch’ cheek implants that extend much further back along the zygomatic arch. This produces a much more dramatic sweeping effect to the cheek augmentation result. These type of cheek implants are best made in a custom fashion from a 3D CT scan. All subsequent discussions and preoperative planning can be done in a virtual fashion (Skype and email)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in elbow lift surgery. In reading online one of the surgeons on there said: “Realize that a scar on the elbow does not heal very well. The scars tend to go wide as the area bends so much and separates the scar.” Is this true even if I take say a month and don’t bend my arm all the way? Another wrote: “I have found a combination of Sculptra and radiofrequency treatments like Venus legacy and Thermage help increase the tightening in this area. Fractional laser like Fraxel added, can help increase collagen as well.”
What’s your experience been with those modalities?
A:The key to a successful elbow lift is ultimately how the scar does as one does not want to tradeoff one aesthetic problem for another. The key to a limited width elbow scar from a lift is the zone of excision, where it is placed and how much is removed. This is determining by preoperative markings with the elbow in BOTH extended and 90 degree flexed positions. If the surgeon only takes into consideration the amount of tissue removed in the extended position, it will be too much and a wide scar will result. It is first marked in the extended arm position and then checked and reduced in the flexed position so not too much skin is removed and tension is placed on the wound closure. This is a basic plastic surgery concept but often overlooked. The name of the game is maximal skin removal with the best scar result. In aesthetic surgery the scar result takes precedence over the maximum skin removed.
For excess skin around the knees, and any joint for that matter, non-surgical modalities will be only of benefit to the provider of them. While most of these non-surgical treatments are largely harmless, only surgical excision can really get rid of loose skin just above the elbow
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you could answer a few questions regarding the custom wrap around type jaw implants I came across on your blog. I had a BSSO, Lefort 1 and sliding genioplasty about 8 years ago. Following that, I had custom medpor jaw implants placed to correct some significant notching that had developed around my jaw angles and along the genioplasty site. These implants added no length and very little width, only enough to make my jaw symmetrical. My bite is now perfect, and from a functional standpoint the surgery was a success. However, I have been extremely unhappy with the aesthetic results. First, my jaw remains very steep and narrow, giving the lower portion of my face an elongated, weak shape with an odd shaped protruding mouth that looks as if I have to strain to keep it closed. Also, my chin has a bit more horizontal projection after the genioplasty, but still looks relatively long and weak, especially when viewed from the front.
I am interested in the wrap around type implants because it seems to me that my lower jaw is deficient in all three dimensions. Also, I am not looking for anything too drastic, I would just like a more balanced, masculine lower face shape. I would like to know if I am a candidate for this surgery, given my previous procedure. Second, I noticed that you typically use silicone implants. My current implants are Medpor, and I really like how they feel completely natural, as if it’s my own bone. I don’t know if this has anything to do with the tissue ingrowth seen with the Medpor material, but I was wondering if there are any major differences in sensation when using silicone.
A: By your very own description you are the exact patient who is only going to get a much improved jawline result by a custom implant approach. Your history of prior jaw surgeries does not preclude you from having a jawline implant but the scar tissue and implant removals do make it more challenging than the patient who has never had any prior surgery. But in my practice your history is common and about half of custom jawline patients have a prior history of bone or implant surgeries.
The perception that Medpor implants feel ‘more like bone’ than silicone is a myth. There is no biomaterial or biomechanical basis for it. With bone as the implant backing, all currently used implant materials will feel the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I get hip implants if I have PMMA injections already in my hips? is it best to have it removed or just some of it removed beforehand? Because my hip area is already tight and some days I am in pain. These hip implants were not heard of when I got the PMMA injections. It still was not enough to make a difference that I don’t still get told I look like a man from the waist down and I still barely fit into trousers so it didn’t exactly make me curvy for how much was injected. I am meant to be petite, and that is fine, but I still wanted better proportion. I’m 5’m 2” and 103 lb. I do have a doctor that will try fat grafting although I’m thin. He said he could also remove some or most of the PMMA. But I had big indentations without the PMMA so that might leave me looking worse, especially with really not enough fat to maybe fill it back up, let alone to get bigger than I am now. The only thing that could still be worthwhile about that is he would be trying to slim my waist more and that would help my waist to hip ratio, but won’t change fact I have big shoulders so I would still look manly without bigger hips and only a smaller waist.
A: If you have PMMA material in the area of potential hip implants and the tissues are tight and it has some pain associated with it, you would not be a candidate for hip implants. There would be a substantially increased risk of infection. It is never wise to put implants in any tissue bed that is not in a near pristine condition, does have foreign material in it and has inadequate subcutaneous fat thickness. If your hip areas are pretreated with fat injections and the tissues become softer, you may then become a potential candidate for hip implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was curious about a bony genioplasty as a cure for lip incompetence. Have you had success with that in the past? It seems like a genioplasty is the only way to fix this. I have a quite large chin. Unlike many people with lip incompetence I am more in a need of vertical chin shortening if possible.
Also I’ve read a lot of your articles and you’ve mentioned doing septoplasty and turbinate reduction. I do have sinus issues and have been told my septum is slightly deviated and my turbinates are enlarged and my nasal passages are quote narrow. I don’t know if you could expand the nasal passageway, but that would definitely benefit my breathing. Do you still perform these ENT procedures. I would prefer to knock everything out at once.
A: A sliding genioplasty may have some benefit in the improvement of lip incompetence in the horizontally deficiency chin. But whether it would be of any benefit in the vertically long chin is far less certain. At the least it would not be a detriment to it in the intramural vertical reduction wedge genioplasty.
For nasal airway function, inferior turbinate reduction offers a greater cross-sectional area improvement than septal correction in most patients. But any septal deviation would be corrected at the same time, even minor, due to anatomic proximity.
Any form of nose surgery is commonly combined with any method of chin reshaping.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i would like to know if a 11mm advancement genioplasty could be reverse to 3-4 mm. I’ve had the procedure done about 3 month ago and I don’t like the result. I feel my chin is still swollen but I hate the fact that now my upper lip look thinner and my chin longer et my face more masculine. Will the soft tissue go back to normal after reversal? What are the risk? And how many time you have perform this type of procedure and what was the outcome ? Thank you!
A: A sliding genioplasty can be successfully reversed from 11 to 4mms. Th risks of the surgery are identical to what they were at the time of the original procedure, it is just the same operation with different direction of bone movement. It is probably best that you don’t take the chin all the back to its original position as the the recoil of the soft tissues is less assured. It is important to realize that not all of the soft tissues are going to return to exactly what they were before the original genioplasty procedure.
Of the many reversal sliding genioplastigs I have done (from 6 weeks after to surgery to 14 years after the original surgery), patients were happy to have less chin projection even if some of their soft tissues issues were not completely cured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am confused about the differences between standard and custom facial implants. A custom approach would seem to be better since their shape would be more assured to achieve the desired facial shape change. Since facial implants are not adjustable during surgery one would want to have the best implant shape possible going into surgery.
A: Let me provide with some further clarifications as misconceptions about standard and custom facial implants are understandable common.
1) All facial implants are made of malleable material which is always adjustable whether it be shape (reduction) or adaptation to the bone. (shape and/or implant fixation) Such adjustments are commonly done even on many custom facial implant cases. The only feature of any facial implant that is not alterable is that volume can not be added to it.
2) Custom implants are made from the patient’s 3D CT scan. But what those size and shape dimensions of the implants should be for any patient’s aesthetic desires is an artistic guess for which the surgeon and patient have no assured way of knowing the actual outcome. The computer can certainly not tell us, it only creates what it is told to do. Whether the ‘input’ is the desired patient’s ‘output’ is not always 100% predictable.
3) As a result of #2, over 50% of patients that receive custom facial implants go on to have revisional surgery or have new custom implants made to get closer to their desired aesthetic facial result.
4) Patients that have indwelling facial implants, like you, have an advantage in custom facial implant design because they have a known external aesthetic effect from their previous surgical efforts. That does help in knowing how to improve their existing facial implant shapes and sizes. But this does not make such a patient immune or eliminate the risks of undesired aesthetic outcomes or implant asymmetry in bilateral unconnected implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, after a lot of consideration I am now actually considering to do a full facial reshaping surgery. However after you see my pictures you might tell me if it is possible or if there are any limitations. I have attached a picture of the face profiles that I like. I put a picture of my actual face and a picture of my desired result. I will explain what I wish and you tell me if it’s possible or there are limitations. The whole idea of this is to bring the eyes as front as possible.
1)Brow Bone Reduction to move back the brows as much as possible. My desired result would be where my eyebrows are in line with the eye lashes.
2) Rhinoplasty to reduce the nose as small as possible with a nice curvy shape and the top entering in line with the eye lashes.
3) Brow contouring since I will have a lot of excess skin there so I think I will be needing a brow lift.
4) I would consider reducing my forehead by 1cm or 2cm.
5) Upper lip lift (the space between the nose and the upper lip needs to be less.
6) Chin reduction . a shorter and narrower tip,also resulting in a horizontal jaw.
7) A little facelift that would cover the old scars I have from my past facelift ten years ago.
I have studied this very carefully as to see that they are possible. I am guessing the major surgery is the brow bone reduction.
A: Thank you for your sending all of your pictures and detailing your facial reshaping surgerygoals. In answer to your questions:
1) BROW BONE REDUCTION – you are demonstrating a maximal brow bone reduction result which wold require an osteoblastic bone flap setback technique to achieve.
2) RHINOPLASTY – The limitations of your skin thickness will prevent making your nose from becomingas small as you have imaged.
3) BROWLIFT – Your imaged results clearly show the need for a browlift with the brow bone reduction.
4) FOREHEAD REDUCTION – I assume you mean by this a frontal hairline advancement to reduce the amount of vertical forehead skin show. Whether your hairline could support this type of procedure can not be determined based on the side view pictures shown. If it did a 1 cm reduction is realistic but not a 2 cm reduction.
5) SUBNASAL LIP LIFT – That is a straightforward lip procedure of which your long upper lip can benefit.
6) CHIN RESHAPING – This type of chin change can be done by an intraoral t-shaped bony genioplasty technique or submental inferior border shave chin reshaping method
7) FACELIFT SCARS – That is the type of preauricular facelift scar I have never seen before. It can not be relocated back into the preauricular skin crease as you have illustrated. Besides not having the skin laxity to do so, even if it were possible your sideburn hair area would become aesthetically distorted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came across your Paranasal implants examples on this website,
http://exploreplasticsurgery.com/category/paranasal-implants/
To make sure that we are on the same page, below is a picture of my lateral facial profile. I am unhappy with the fact that I have a slightly prominent mouth. I am also unhappy that the angle between the bottom of my nose and my lip is an acute angle, which is around 55 to 60 degrees. And I want to let you know that I have had a nose surgery to heighten my nose already.
I have read on your website as well as other Paranasal Implant cases done in other countries. I wonder if a Paranasal implant can be done on me in your opinion to make my nose look a bit taller, and to make my mouth less prominent, and to get a larger degree between the bottom of my nose and my lip.
I look forward to seeing your email. Thank you.
A: What you are referring to is not a paranasal implant per se as that will only augment the side of the nose underneath the nostrils. To change the nasolabial angle and add more projection above the mouth, the central premaxillary region needs to be augmented. Whether that needs to be combined into a premaxillary-paranasal implant design for a more overall nasal/midface effect depends on your aesthetic goals. With either midface implant style, however, the nose is not going to become ‘taller’ as a result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions in regards to brow bone augmentation.
1. In most of your work in this area of face, a more pronounced upper brow bone area can be noticed from the profile view, which actually is the main purpose of the procedure. However, I feel that the lower part of the brow bone (where the upper eyelids and the brows meet) isn’t affected much except in this case where bone cement was used.
Does this bigger augmentation amount (compared to other patients’ results) in the upper brow area have to do with the material used or with the soft tissue anatomy of the patient?
2. I’d pursue brow bone augmentation to mostly augment the part of the brow bone I talked about before. Is this the right operation for me? If yes, are injectable fillers a good yet temporary alternative to achieve similar augmentation degree to your result that I previously linked?
A: In answer to your brow bone augmentation questions:
- Actually the differences between using a custom implant or bone cement are exactly opposite of your supposition. It is far more predictable and effective for lower brow bone augmentation to use a custom implant if it is designed to do so. It is very hard to get bone cements that low due to the working properties of the material.
- Injectable fillers are always a reasonable test for any form of brow bone augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in hip implant augmentation and have some questions for you.
1. Knowing that I do not have enough fat for the Brazilian style fat injections, what are the relevant considerations when selecting either synthetic injections or the silicone implants? (Everything I have read suggests that the synthetic injections are likely to be more dangerous, provide less certain results, are of limited life, and more expensive, but would like to have a first hand professional assessment.)
2. Going on the assumption that you recommend the silicone hip implants, is the 2″ addition to each hip achievable?
3. Would a silicone implant move with the body and look reasonably natural in all positions and further how would such an implant feel?
4. Are your silicone hip implants customized for your client and how specifically are they crafted?
5. How secure are these implants after insertion, are they held by a muscle like a butt implant?
6. Do you have pictures showing the before and after of this specific procedure without accompanying injections?
7. What would the normal life of such an implant be?
8. From your website the procedure is listed at around $5500-6500, does this still seem reasonable in light of the details provided and are there any other fees that she should be aware of?
9. Given that a Silicone butt implant is already in place would there be any issues with adding a hip implant or in customizing the shape to work with the butt implant?
10. As noted, the butt implant took place Sept 29, 2017. How long would it be advisable to wait before undergoing a hip implant surgery?
11. What will recovery look like generally? Specifically, she will be coming via a 4 hr flight, how long must she plan to stay in Indiana after the surgery before being able to fly back. (Additionally, how many follow up visits will be required, particularly if after the flight is allowed?)
12. On some sites this surgery is connected with the need to wear some sort of structured garment during the healing phase, is such a shaping garment required for your procedure, and if so how long must it be worn.
13. How long is it generally recommended before returning to work following the procedure?
14. Probably aligned to the flight question, but how long before she will be able to drive?
15. How long before more restrictive clothing like jeans may be worn?
16. Reviews and other information about your practice seem very positive, but just as a point of clarification, where your site lists “board certified in the specialties of Plastic and Reconstructive Surgery” does this mean board certified by the American Board of Cosmetic Surgery?
17. Will you personally be performing the procedure?
A: In answer to your hip implant questions:
1 The concept of using synthetic materials and injecting it into body areas for augmentation is a fundamentally dangerous one. While it may be successful for some people without complications, some patients will suffer foreign-body reactions which will be both difficult to treat and will end up in various amounts of tissue destruction. In essence such injections are not truly reversible. Conversely hip implants are completely reversible without ill effects on one’s health for either medical or aesthetic reasons.
2 The amount of hip augmentation achievable by implants depends on numerous factors include the thickness of the soft tissues and their ability to safely stretch and accommodate the implants. Probably 2” or a 5 cm thick implant is too much particularly in a thin person.
3 Hip implants are ultrasoft and very flexible so they do not interfere with movement and feel about as natural as an implant can feel. (no implant can ever feel perfectly natural since it is an implant not natural fat tissue)
4 All hip implants are custom made based on measurements taken on the patient for surface area coverage. (aka implant footplate)
5 All implants, regardless of body location, are held in place by the initial tissue pocket made and the scar capsule that ensues.
6 Patient pictures are confidential and are only released by the permission of the patient.
7 All implants last a lifetime as they are made of a non-biodegradable material.
8 The cost of the procedure will be forwarded to you by my assistant.
9 With a buttock implant in place, it is importantly that the two implant pockets do not connect. If the buttock implants is intramuscular this is not a concern. But if the buttock implant is subfascial, the design of the hip implants must take its location into consideration.
10 Three months should separate the placement of buttock and hip implant surgeries.
11 Most patients can fly home in 3 to 5 days after surgery but such travel is really based on how the patient’s comfort. There are no specific followup visits scheduled unless there are urgent issues. All followups are done on a virtual basis.
12 A compressive garment is helpful in the first few weeks after surgery to help the implant pocket heal around the implant.
13 Depending on how physical one’s work is, one should able to return in two to three weeks after the procedure.
14 Driving after hip implants surgery is based on one’s comfort.
15 Jeans can be worn as soon as one is comfortable in doing so.
16 My board certification is by the American Board of Plastic Surgery. The American Board of Cosmetic Surgery is not a board certification recognized by the American Medical Association.
17 I am the only one available to perform the surgery under my name.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, When is it ok to go to the dentist for a deep cleaning and root planning after my custom jawline implant ? And should I tell them about the jawline implant?
A: Dental treatments in the patient with certain types of facial implants (cheek, paranasal and chin and jawline implants) pose issues that make telling your dentist that such implants exist. If screw fixation was used with the implants these will be visible in some dental x-rays. (e.g., panorex) The need to perform local anesthetic injections into the tissues overlying the implants is the most significant consideration.
A deep dental cleaning should not be done for three months after the facial implant procedure. If they are going to perform any local anesthetic injections, whether it is for cleaning or other dental treatments, they need to the aware that an implant exists along the jawline. Inadvertent needle penetration into the implant’s capsule has a high risk of causing an infection. The needs can track bacteria from the mouth into the implant’s surface. Fortunately local anesthetic injections can still be successfully done with some modifications (avoiding deep injections down to the bone) when a complete jawline implant exists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am not quite ready for a facelift but would like to restore the fullness to my face/cheeks through cheek implants. Here are my pictures. I am interested in your thoughts about cheek implants for me. Thank you in advance.
A: You are an excellent candidate for midfacial volume restoration or augmentation through a combined malar-submalar shell style cheek implantas. You are spot on in terms of what would have the greatest anti-aging effect on your face. Such as implant is really like a ‘deep plane facelift’ for the midface. By elevating the cheek tissues off of the masseteric fascia they are allowed to float upward and are supported by the ‘spacer concept’ of the cheek implants.
Like all facial implants proper selection of cheek implant style and size is essential. Particularly relevant is the surface area that they cover in the midface, The aging face with sagging cheeks requires that the implant pocket extend down over the origin of the masseter muscle on the cheekbone.
I would agree that you are not only not ready nor would a traditional facelift produce the type of facial rejuvenation change that would most benefit you in the midface.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, It’s a pleasure to meet you. Do you mind if I ask you some question about custom forehead implant surgery? I have read many times about your surgeries on the site.
I have done a bone cement surgery on my forehead and my eyebrow. (custom forehead implant) Can I get more bone cement added onto the current implant? Because I don’t want to remove the current implant. I am happy with the shape, just want to add more. If not, can you take the implant out and reshape it? Or do you have to make a totally new one?
I have got the surgery based on my exact skull model with the 3D printer. So the implant is really well shaped based on my forehead and brow bone. So I just want to add little bit more bone cement on the current implant.
Like one the first photo, there are some gaps between my real bone and the implant . I want to fill those gaps if its technically possible. (Glabella, brow bone) If I need to remove the current one and get a new one , is it possible to make the implant model like the second photo?
Also i found that photo model on your site. Is it possible to add extra bone cement on the part that I circled with purple color?
Thank you so much !
A: The answer to your fundamental question is that it is not possible to just additional cement to your existing forehead implant to create a result that will be perfectly smooth and even in the areas you have highlighted. Although you did not state what exact material your implant is I would wager that it is PMMA, an acrylic bone cement which is commonly used in Asia but not the U.S. for custom forehead and brow implants. I have removed and replaced many such forehead implants as their design is often identical to yours and the patient’s desires for an improved implant shape is also identical to yours as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In regards to my pectoral implant revision, I googled PowerFlex 1pectoral implants and it took me to the Implantech web site. I took a look at all their pectoral implant styles. The shape is what I am looking for although the projection is 3.9 cm. It is tempting although I think this would be too large. I noticed on the Implantech site there is a PowerFlex Pec Implant (Novack style 2) that may work for me. It states that this implant is “coming soon”. The shape looks excellent although I am not sure if this would be large enough. The dimensions are 15.2 x 12.4 x 2.2 cm and the volume is 345 cc’s. Do you think this would fit well for me? Not sure what my chest dimensions came to that you took on my last visit. The pectoral implants I have now are 2.8 cm in projection although I would not mind going a little smaller to the 2.2 cm. This time I think the definition and shape are more important than the volume. Also, on the Implantech site they show the original Novack implant that is 15.3 x 12.6 x 2.3 cm and the volume is 300 cc’s. This is a little confusing since the Novack original which is a little larger then Novack style 2 implant although the volume is 300 cc’s (original) and 345 cc’s (style 2). Can you double check the dimensions for the PowerFlex Pec Implant (Novack style 2) with Implantech?
A: In looking over all the pectoral implants from various manufactures I think the conclusion is the right shaped one is a little too big and those with the right volume don’t quite have the right shape.
The ones you have in now are too big in terms of surface area coverage and could also stand some more projection particularly in the inner and upper poles of the implant.
Given that you have a reasonable acceptable result, albeit with its own issues, the only reason to have pectoral implant replacement surgery is to make a really substantial improvement. To do so it would be best to get the best shape, projection and volume of the implant based on the measurements and numbers that we know would be better….aka just make custom implants for your pectoral implant revision..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wanting to know if there is anything you could recommend to remove what I have heard are called forehead horns.(forehead horn removal) They are wide and stick out of the left and right side of my forehead. They get bright when light shines on them and I feel more insecure as I grow older and they grow. My idea is that I have a large forehead so smoothing out the bone (forehead horn reduction) and bringing my hairline forward so the hair closer to the top of my head moves towards my front face. (forehead reduction)
Thank you please help!
A: Thank you for sending all of your pictures. What you have are classic forehead horns. The incision location of a hairline advancement procedure would be the only way to access them for forehead horn removal. While a combined hairline advancement and forehead horn reduction is a logical set of procedures to put together, the incision location must be carefully considered in a young male as the long-term stability of the frontal hairline may or may not be assured. In essence you don’t want to trade off one aesthetic problem for another….horns vs scar in a male with closely cropped hair.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had off the shelf Medpor chin and mandibular angle implants in for the last decade and desire a greater degree of augmentation and resolution of underlying asymmetries that could only be achieved with custom implants.
My two questions are; 1) can 3D CT modeling be done with the current implants in place, and 2) will removal and replacement of current Medpor implants really carry a large risk of disfigurement?
Thank you in advance for your reply.
A: In answer to your Medpor facial implant removal and replacement questions:
1) Your indwelling chin and jaw angle implants are not a problem for designing new custom implants as they are digitally removed to do so in the designing process. Having existing jaw implants in place does help in designing new implants as having a known effect guides what an improved effect should look like.
2) Having removed and replaced many Medpor facial implants I am not certain where the concept of causing facial disfigurement emanates. Certainly their removal poses greater difficulties than if they were silicone implants, but their removal does not cause facial disfigurement/deformity that I have seen. Their removal often causes greater temporary swelling due to the more extensive tissue dissection needed from the adherence of the soft tissues to the implant surface.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just underwent breast implant revision with new and larger implants. I just wanted to follow up with you on my revision. No pain to complain about. No pain meds needed just the antibiotic. I was a bit worried about the shape of the right implant as it still looked a bit odd in shape. However they are gradually taking on a very nice shape. The projection is perfect. I am very pleased with your work. Thank you!
I have two questions:
1) Will these implants drop and fluff during the next 6 months or will they hold the current shape. I really like the shape and strong projection. There does not seem to be much swelling.
2) There seems to be a lot of “gurgling” going on. I assume this will absorb into my body over the upcoming weeks.
Dr Eppley, thank you again for your outstanding work and patience with me.
A: Thank you for your early breast implant revision followup. I did debate with myself in surgery as to whether to go with the 350HP or the 400HP. The latter gives more projection but would also make the breast mounds overall bigger…so I went with our previously discussed 350s.
In answer to your questions:
1) Now that the lower poles of the breasts have been released there will be a lowering of the implant (dropping) as they heal as the scar impediment to do so has been removed. This generally takes about 6 to 8 weeks to finalize.
2) The gurgling you hear is some irrigation fluid used to wash out the pockets before placing the implants as well as an ‘air space’ existing between the implant and the overlying soft tissues. The fluid will be absorbed and the tissues will shrink back down over the implants in the next few weeks of further healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m thinking about having a custom jaw implant or a custom wrap around jawline implant. I’m a male who has a round short chin with a smooth jaw. I want my lower third of the face to be longer and wider. Not so much of a horizontal projection on chin but a significant vertical height and definitely a square,defined chin. So I roughly measured the projections I want myself. They are:
Chin width 4cm – 4.5cm not mm
Chin vertical projection 8mm – 10mm
Chin horizontal projection 3mm
Mandibular vertical projection 1mm – 2mm
Mandibular horizontal projection 5mm
Do you think this dimensions are realistic or achievable? And thank you for your consideration!
A: In answer to your questions about your proposed jawline implant dimensions I would make the following comments:
Chin horizontal projection – 5mms (yes)
Chin vertical increase – 5 to 10mms (5mms is more realistic)
Chin width increase – I not sure whether you mean in addition to your natural chin width or that this is the amount you want added. The former is very possible, the latter is too extreme as the side tissue can not be stretched that much. (Maybe 1 cm per side)
In the chin area of the jawline the soft tissue chin pad is much more restrictive in allowing it to be expanded than in the back part of the jaw. This is particularly relevant in vertically dropping of the chin. If you want a 10mm increase with the other chin changes, I would also consider doing an opening vertical bony genioplasty of 10mms (this carries the soft tissue chin pad down better) and placing custom extended jaw angle-lateral chin implants to accomplish most of the other changes.
What I would also say about the chin width is that most patients, understandably, can’t appreciate the impact of measurements that they take on the outside of their face for what an implant size should be. That often over estimates the impact of such skeletal augmentations on the face. In my experience, if patients were left alone to devise the implants based on measurements they believe would work, all such implants would be too big. One of my tasks in custom facial implant designing is to help avoid that aesthetic problem or other more significant problems that can come from very large implant dimensions.
Jaw angle width increase – 5mms (yes)
Jaw angle vertical increase – 2mms (yes)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in enlarging the current size of my testicles. (testicular enlargement implants) Do you perform soft testicular implants that go around the testicle to enlarge them up to 3 inches in size?
A: In regards to testicular implants, you are referring to a testicular enlargement procedure that uses an implant that wraps around one’s existing testicle to expand its size. This is different than a testicular implant procedure where a missing testicle is replaced. Testicular enlargement is done using a specially designed bivalved silicone implant that opens up like a clamshell to envelope one’s existing testicles and is closed down around it. This increases the size of the testicles by adding an implant layer around it. An opening for the vas deferens and the neurovascular pedicle remains at the top of the enveloping implant to keep these important structures intact and not to be pinched or compromised as the clamshell implant is closed around it.
Whether a testicle can be increased in size up to three inches depends on numerous factors including the current size of your testicles. I am not sure you may grasp the size of a 3 inch or 7.5 cm testicle but this would be quite large. Even in the XL testicle implants I have done the largest size has been 7 cms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe my upper third of my head is excessively wide so I’m considering temporal muscle reduction surgery. ]But my jaw is also small relative to the rest of my face so my question is. Is itt possible to combine jaw implants with temporal muscle reduction surgery, or could the extra mass cause functional issues? Thanks.
A: Jaw implants and temporal muscle reduction can be performed during the same surgery. Besides each being performed at two separate anatomic sites, their muscular effects are on different masticatory muscles. (temporal vs masseter muscles) As a result their temporary muscle effects are not functionally additive to create any long-term jaw dysfunction.
The combination of temporal muscle reduction and jaw angle implants will bring the upper and lower thirds of the face into better proportions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ankle fat grafting. I would like to know if fat augmenting will be good for my leg and ankles. I have very thin legs and ankles and I’m unable to wear heels because it hurts. I am also ashamed of not being able to wear skirts and dresses which I love to wear and can’t.
A: Fat grafting to the lower extremities, particularly the ankles, has a low rate of fat retention for most patients. As a general rule injectable fat grafting works best in areas that already have some fat. (good recipient site The thinner the natural subcutaneous fat layer is the less fat grafting takes. This may be partially overcome by a large amount of fat grafting if one has adequate donor sites to harvest. While injectable fat grafting may not have a high predictable take in the ankles, it is the only treatment option that exists for making them bigger.
Ankle fat grafting should be undertaken with the knowledge that it may likely require more than one treatment session. Thus the importance of having enough donor sites to undergo more than one fat harvest and grafting surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have noticed that you have some bone cement skull reshaping before and after pictures and in some Real DSelf posts of the past. I have noticed you suggesting bone cement to fix flat heads.
1) Has your opinion on bone cement changed over time due to the subpar results from it? Or maybe you’ve refined your skills with implants?
2) Why is bone cement subpar? Wouldn’t it be easier to use them on easy/non-severe cases?
3) Would you still use bone cements if a patient wants it? I’m guessing a lot of patients may not feel favorable with implants…
A: In answer to your questions:
- The development of 3D imaging and implant printing in the past five years has revolutionized how skull and facial implants are done. For skull augmentation, custom implants have made bone cements for most skull reshaping procedures an almost historical procedure.
- The application of bone cements is harder than implants in most skull cases because of the limited incisions used in this type of aesthetic surgery. If you have an incision from ear to ear across the top of your head then the application and correct shaping of a bone cement material becomes ‘easy’. Most patients in an aesthetic operation, however, do not want a full coronal scalp incision.
- Bone cements are a synthetic implant material. There is nothing natural about them. The only difference from that of a preformed implant is that they come in liquids and powders that are mixed and harden after application. But they are still a foreign implant material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle augmentation. I understand it is not a good idea to extend the jaw angle implant back closer to the ear. I have few question for you. Hope that’s okay?
You mentioned standard jaw angle augmentation implants may be suffice. I assume custom made is other option? What is the difference/advantage between off the shelf implants vs custom made?
If custom made, what is the time frame to have them made as I’ll be entering US on 90 day waver visa?
I’m told jaw angle augmentation surgery can be much more complicated then chin and cheek implants ( because main nerve of the face close that area) and not many surgeons do this procedure for that reason. Not sure what I’m asking you here but maybe you can fill me in on your knowledge and experience in doing jaw angle augmentation implant surgery and if it is in f act the main nerve that is in danger? Thank you!
A: In answer to your questions:
1) Custom made jaw angle implants are better if one has significant asymmetry, unusual or altered jaw angle bony anatomy or the patient’s aesthetic needs exceed what standard made implants can do. Custom made facial implants are done from the patient’s 3D CT scan and take about 30 days to design, manufacture and be shipped for surgery.
2) Jaw angle implants are the hardest of all facial implants to perform, and have the greatest risk of complications (infection and implant asymmetry), but it has nothing to do with the facial nerve or any other nerve. It is because the access and visibility to place them from inside the mouth is limited, the precision of placement over the jaw angle bone is critical, most surgeon’s have no experience in understanding jaw angle aesthetics and proper implant selection, there is the risk of masseter muscle disinsertion with improper dissection technique, and the risk of intraoral incisional breakdown, implant exposure and infection is high without meticulous wound closure. In other words the comparative simplicity of a chin implant should never be confused with the challenges of its more posterior cousin the jaw angle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple of questions regarding the custom midface implant that we have previously discussed. Firstly I would want the implant to cover the whole midface including the infraorbital area and extend to the sides of my eyes. However I have previous history of hypertrophic scarring and I am not sure whether just a intraoral incision would suffice or whether an external scar by the eyes would be required. It is the under eye area of my face which I am mainly concerned about.
Secondly I have very minor nasolabial lines and I was wondering whether the custom midface implant could treat these and stop them becoming worse in the future as I age?
Many thanks as always.
A: Such a midface implant design would be placed from incisions inside the mouth only. Getting the implant up and around the infraorbital nerve is always the challenge, and is what accounts for some temporary numbness after the surgery, but can be done through the technique of an infraorbital split implant method. Augmenting the paranasal region can only help the nasolabial lines but any improvement should be considered a bonus and not a expected outcome.
Dr. Barry Eppley
Indianapolis, In
Q: Dr. Eppley, I am interested in secondary rib graft rhinoplasty. I had silicone rhinoplasty done seven years ago. (they used silicone for the bridge and septal cartilage for the tip).Although I am very happy with it aesthetically, I also started getting autoimmune problems shortly afterwards and now have full-blown Lupus. While the link between silicone and Lupus isn’t firmly stablished, I don’t want to take any chances and would like to swap out the silicone for rib. Is there any way I could do this via closed rhinoplasty?
A: You are correct in that there is no established connection between solid silicone implants and autoimmune diseases currently. But I can certainly understand what you would want to replace your silicone nasal implant. While I have no idea of your implant’s size and shape, it can be replaced with a rib graft.
Some general comments about rib graft rhinoplasty in your case would include the following. It may be possible to use a closed approach for the replacement as the implant has an established capsule/pocket. Whether the rib graft should be inserted as a solid piece or in a diced fashion would depend the shape of the harvested rib and its ability to be inserted through a closed approach. It would be important to realize that any form of a rib graft may not have the completely smooth and perfect shape as that of a preformed nasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been reading a lot of your posts online. It seems like you have a lot of knowledge when it comes to facial implants. I am interested in jaw implant revision.
I had silicone chin and jaw angle implants sic weeks ago and I went too small. I want bigger all around. My surgeon says to wait another two months to see if I like it and if I don’t like it he’ll do a revision… I don’t know if I want to wait that long if I don’t absolutely have to.
My questions to you are the following:
1. How long do you think I need to wait before I can get them replaced with bigger dimensions
2. Is there any physical reason why I can’t replace them now ? Like do I need to wait for scarring / healing or anything like that?
3. What will the recovery be like since it’s a revision and the tissues and muscles have already been distributed and will go through all of that again. Will the healing/swelling be more or less than the first time?
4. He used screw fixation. Is that going to be a problem to unscrew and then re screw?
Thank you for your time
A: In answer to your jaw implant revision questions:
1)Three months is the require time to wait for performing almost any facial implant revision. The tissues must be allowed to heal fully and the patient needs adequate to fully appreciate the results.
2) Your incisions are not zippers, they can not be opened and closed in close intervals and expect them to heal normally. Adverse incisional healing over an implant can result in loss of the implant.
3) Many facial implant replacements, particularly if the implants are bigger, have a recovery that is just like the first time and even more so.
4) Implants can easily unscrewed and removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wanting to know if there is anything you could recommend to remove what I have read as forehead horns. They are wide and stick out of the left and right side of my forehead. They get bright when light shines on them and I feel more insecure as I grow older and it grows. My idea is that i have a large forehead so smoothing out the bone (forehead bossing reduction) and a reduction of my hairline so the hair closes to the top of my head moves towards my front face.
Thank You, Please help!
A: The forehead horns that you have are classic in my experience and are all known aesthetic deformities of the forehead. The forehead horn reduction is a procedure that I do regularly. The challenge in doing this procedure in a male is the location of the incision needed to do it. As you have already mentioned you are considering a frontal hairline advancement. Such a procedure provides ideal access for a forehead horn reduction procedure. The only question now in a young male is what is the long-term stability of your frontal hairline? That would be the key question in moving forward with either procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had large deltoid implants placed over a year. After the swelling went down, they’ve given me a rather deformed appearance. I can send you pictures. Is there anything that can be done to give me a less deformed appearance? Someone recommended a fat graft would be the least risky alternative but he also stressed that the results from a fat graft might not last. I hope you can help. Thank you.
A: Thank you for your inquiry. I would need to see some pictures of your shoulders to best answer what may be able to be done. But my suspicion is that the implants are short in surface area with a projection that makes them stick out like ‘bumps’ on your shoulders rather than blending in and having a more confluent look to the surrounding shoulder contours. Your options would be to either replace them with custom implants that are better designed and softer or remove them and then secondarily do fat grafting. Fat grafting would only be an option if one has enough fat to harvest to perform the procedure and with the understanding that the survival of fat grafts is very unpredictable.
Dr. Barry Eppley
Indianapolis, Indiana
