Your Questions
Your Questions
Q: Dr. Eppley, I am interested in orbital rim and brow bone implants. I have a sunken eye area and eyes that seem to bulge out with droopy eyelids and bags under the eyes. What combination of procedures would produce the best results based on my overall appearance? I’ve also attached a picture of an actor whom I want similar features to.
A: While orbital and brow bone implants may be what is ultimately needed, that is not the first place to start. I would have fat injections done first to both the brows and the entire infraorbital area first. This would be initially done for three reasons; 1) To try and rid some of the hyperpigmentation of the lower eyelids. This is going to be a chronic skin color disorder which is both common with your ethnicity and may be unimproveable. 2) To improve the quality of the tissues particularly that of the lower eyelids if eventual implant surgery is desired and 3) it is possible that enough fat may be retained that implants may not be needed.
While orbital rim and brow bone implants can help make more deep set eyes when done together, they do require scalp and lower eyelid incisions to place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like information about brow bone augmentation with calcium hydroxyapatite and customized implants from 3D CT scans. I had a rhinoplasty where the surgeon used transverse and medial osteotomies of the nasal pyramid, and nasal dorsum. I realized that the eyebrows lost support after surgery. The augmentation surgery in the region of the supra-orbital rim or brow ridges with customized implants are made of what material?
A: Brow bone augmentation can be done by different materials which can also control the surgical approach to place them. (incisional access) The traditional and still most commonly performed technique for brow bone augmentation is through an open scalp incision using either PMMA or hydroxyapatite bone cements. When just the brow bone is being done, hydroxyapatite cement is the material of choice. But when the brow bone is being combined with total forehead augmentation, PMMA bone cement is used due to being a more lower cost material per amount of volume. Performed or custom implants can also obviously be placed through such a wide open exposure. Custom brow bone implants made from a 3D CT scan are always made of a silicone material, primarily due to ease of adaptation to the underlying brow bone and cost. Newer techniques of placing custom or preformed silicone brow bone implants are being developed to avoid the larger scalp incision. (endoscopic frontal and upper eyelid incision)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will getting the hair transplants have any adverse effect on brow ridge implants? My surgeon has informed me that he’ll be using sheets of intermediate hardness silicone to build up the brow ridges while carving them to smoothen them out by hand. He will also only use sutures to secure them rather than using screws. Is this something that you do too, and should I insist on him using screws? For reference, the incision will be made via the upper eyelids.
A: My method doing brow bone implants (rather than cement) is quite different. Symmetry of the implants shapes and ideal location on the bone is a challenging issue when more limited access approaches are being done. I prefer to use either preformed brow bone inplants (made out of silicone and using designs from other patients) or have custom ones made off of the patient’s 3-D CT scan. Then I place them through en endoscopic approach and secure them into place with a percuatneous 1.5mm screw technique.
There are no adverse effects of hair transplants on the underlying brow ridge implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read about you on some forums and was recommended to contact you regarding this issue. Anyway, based on your website, you seem to be one of the few surgeons who perform brow ridge implant and eyebrow hair transplants. Basically, I’ll be getting my brow ridge implants done next week, but I also have an appointment set up for my eyebrow hair transplants a month later. However, the surgeon doing the brow ridge implants has asked me to wait 6 months between procedures, whereas the hair transplant surgeon has advised me that it shouldn’t be too big of an issue to space them 3-4 weeks apart. Based on your experience, do you think it will be fine for me to get the brow ridge implants done, recover for 3-4 weeks and let majority of the swelling subside, then get the eyebrow transplants? Or, should I wait 6 months? I understand that it’ll take 6 months for swelling to subside fully, but will the small amount of residual swelling at 3-4 weeks post-op present a major risk to the eyebrow hair grafts? I sincerely thank you for taking the time to answer this as you are doing me a huge favor.
A: I see no biologic reason as to why eyebrow hair transplants can not be done a month or so after brow ridge augmentation. The blood supply to the eyebrow tissue is unaffected by the underlying implants, regardless of whether the overlying tissues have fully resolved their swelling and achieved final tissue adaption. In addition, the access incision for the brow bone implants is far away from the eyebrows and has no deleterious effect on their blood supply, even if a revision may be needed and done on them later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will the silicone implants have to be custom made, or will you be able to carve them during the procedure? Out of curiousity, but why don’t more surgeons perform brow ridge augmentation with silicone implants? Being able to bypass a large scalp incision seems like a huge plus. Also, with silicone brow ridge implants, will it look unnatural if I smile or animate my face, especially since there doesn’t seem to be much soft tissue coverage in the region. I’m also assuming that the implants will be screwed in, will there be any substantial risks to this? Will recovery also take a long time?
A: The reason that any form of brow bone implants has not been historically done is for two reasons. First, there are no preformed brow bone implants that are available and, even if there were, there would likely be some fit problems. Secondly, only more recently has computer technology made it possible to take a 3D CT scan of the patient and make on the computer screeen exclusively the exact design and size that meets the patient’s aesthetic desires and will have a perfect fit to the underlying bone during surgery like a crown on a prepared tooth.
With the brow bone implant secured to the bone there will be no animation deformities, just like when open brow bone augmentation is done. The biggest risks to the procedure are asesthetic, does it look natural (not overdone) and is there good symmetry. (here is the value of computer-designed implants) Recovery is aesthetic, meaning how long for swelling and any bruising to go away. That will depend on the approach used to placed the implants, endoscopically (7 to 10 days) and through the upper eyelids. (3 weeks)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve read your articles on brow bone augmentation and was wondering if silicone implants could be used instead of hydroxyapatite or PMMA? Apart from the scalp incision, could the silicone implants be placed through any other incision (upper eyelid)?
A: Performed silicone brow bone implants could be placed either through an upper eyelid incisional approach or through an endoscopic technique through two small scalp incision. Because they would be made of a flexible silicone material, they can be inserted in two separate pieces and ‘assembled’ once inside. If this brow bone augmentation technique is done, it is best to make the preformed silicone implants beforehand using a 3D CT scan of the patient.
Dr. Barry Eppley
Indianapolis, Indiana