Your Questions
Your Questions
Q: Dr. Eppley, I have some questions about facial implants. I want to improve the narrowness of my face. You have posted many articles on face widening, but it seems there are so many options. I am hesitant to simply stuff my face with implants to solve this problem. Particularly, I feel my temple area and zygomatic arch should go more laterally than they do, which may contribute to the narrowness. Would fat injections be a viable option here? Does the fat just reabsorb like many people say? I looked into submalar implants, but, again, I would hate to go down that road unless I had do. It also worries me that they are placed through the mouth when I’ve had issues with the chin already. Are they at least screwed in? Because my chin implant is not.
A: The options for facial widening are only facial implants, fat injections and injectable fillers. While fat injections can be done to create a facial widening effect, and there is certainly no harm in doing so, one has to be prepared to accept the unpredictability of both its survival and persistence.
Even compared to fat, temporal facial implants are so simple and effective that I would not even consider fat in that area as a first option.
Any cheek facial implants placed through the mouth are always secured into place with small microscrews so they will never be dislocated from their optimal placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin, cheek and jaw augmentation. Like others, I am looking for exceptionally square, strong and masculine jawline to bring my facial aesthetics to the next level. I already have a fairly low body fat percentage (around 7-8%) but have always had slight TMJ on my right side and for as long as I can remember wanted to really strengthen my face.
Would I be a good candidate for a jaw, cheek, chin augmentation, and/or rhinoplasty to strengthen and balance my face? Or should I address the slight TMJ issue first? Which procedure or combination of the aforementioned would lead to the highly coveted male model facial look? I’ve attached a photo with the front and both sides of my face as well as a goal photo for reference.
A: I have done some imaging looking at rhinoplasty, cheek, and total jaw augmentation for your review. You have a good face for these type of changes because your face is already skeletonized, just disproportionate. The jawline change will require a custom wrap around jawline implant. Whether this would achieve the male model look that you desire is open to one’s interpretation
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about faclal implants. Can cheek implants be done with local or non general anesthesia? Also I have a short face and need to add lateral width and height but I worry about the big wrap around jaw implants involving the masseter muscle. So can we do a custom chin implant with wide wings extending laterally and vertically as far back posteriorly as possible but not hitting the masseter muscle. I realize there would be a major step off somewhere further down the jaw and the rest all the way around the ramus I would fill in with fat or radiesse. Also could that be done without general anesthesia too?
A: In regards to facial implants, certainly cheek and an extended chin implant can be done under IV sedation or MAC. (monitored anesthesia care) The use of local anesthesia for most facial implants alone would likely be inadequate and that would be doubly true if both cheek and chin implants are done at the same time. Be aware that the use of local or IV sedation does not save any money as the intraoperative time to do facial implants takes twice as long as when done under general anesthesia. So your motivation for the selection of anesthesia for these facial implant surgeries should not be one of saving money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orthognathic surgery even though my bite (Class 1) normal. Thus any orthognactic surgery would be cosmetic and not functionally beneficial. It just appears to me that my face and the bones in it did not grow in an optimal aesthetic direction. It seems that my face is too long and has dropped to a gaunt look with a flat midface. Could this be due to a downwards grown maxilla or other bones? Can it be fixed with a maxillary impaction?
A: Your malocclusion is modest and within the confines of a general Class I occlusion. The point being is that it is not the source of your aesthetic facial concerns. The difference between your child face and your adult one is the relatively standard change between the 2/3s dominance of the upper face in childhood to the completion of facial growth in early adulthood with a reversal in that proportionate relationship. Whether your face is too long is a personal assessment and not a function of actual facial structure disproportions.
Changing your facial proportions is done by decreasing the vertical length and improving the midface projection width. This is usually best done by a vertical wedge reduction genioplasty (chin) and malar-submalar implant augmentation. Doing a maxillary impaction would bury your upper teeth under your upper lip and would also require a concurrent mandibular osteotomy to keep your bite relationship from changing unfavorably.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know if there is a difference in the appearance between silicone cheek and jaw implants and medpor cheek and jaw implants. From pictures and my own knowledge I think it is clear that the Medpor looks and feels more like real bone. But I don’t know if this has an effect on the appearance outside the face. Does Medpor give a more chiselled appearance? I am concerned maybe silicone will give a softer, less angular look (even if customized to be angular). Is this true? I know the silicone is made in to harder material, but I have felt it and it is quite easy to cut (with scalpel). I also notice it can be bendy, and be twisted etc. I don’t think Medpor can bend like elastic, can it? I want a very sharp angle jaw and also cheek implants (sharper than angelina jolie even). Thanks in advance.
A: What creates an outer facial appearance is the shape of the implant that lies underneath. What composition facial implants are made of makes no difference at all. So that is a misconception. Do not get caught up in what the material feels or does outside the body. When any material is overlaid on bone it will feel as form and inflexible as bone.
Quite frankly Medpor is not a very good facial implant material that turns into a major problem if you ever have to revise it. And the potential revision of any type of facial implant should not be underestimated. Removing or revising a Medpor implant is very traumatic and destructive to the tissues. I take them out frequently from other surgeon’s work and I shake my head every time wondering why this material is ever put in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about facial implants. Do tear trough, cheek implants, and orbital rim implants become visible as the skin ages? If I need to get them removed will it leave obvious scars? If I get the facial implants but later decide to get a cheekbone reduction would it affect the implants? Thank you!
A: This is a good question about facial implants and is not the first time I have heard it. I have not seen increased visibility of midface implants with aging but that does not mean it does not exist. It would depend on the patient’s face and whether they suffer significant fat loss in the face as they age. It would also depend on how much fat one has in their face and the number and size of midface implants placed.
The removal of implants does not usually any more scars than those that were used to place them. If you get cheek implants and then elect later to have cheekbone reduction, the implants may or may be in the way based on how far back the tail of the cheek implant goes. Usually the implant would be in the way but it could easily be displaced so that the cheekbone osteotomies could be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal and jaw angle implants. But when I get really old would it look like this if I have implants in my face? See the attached picture of breast implants where one is able to see all the edges of the implants. This is a scary picture.
A: It is important to separate what can happen with facial implants vs that of breast implants with aging. The show of breast implants can become more obvious when one loses weight or has very little subcutaneous fat cover from aging. Breast implants are ultimately only covered by the thickness of the breast tissue and if they are partially under the muscle. (which the lady’s implants in the pictures are not) Facial implants are placed next to the bone with a soft tissue cover that is not as influenced by fat loss. (more muscle cover) Thus, facial implants will never get as skeletonized or develop implant edge show as breast implants can. Facial implants are bone implants while breast implants are soft tissue implants. That is a fundamental anatomic difference. Because facial implants add support to the overlying soft tissues they often are a positive additive feature rather than a detraction from aging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat augmentation around my facial implants. My biggest concern is how much fat will survive as the plastic surgeon I saw mentioned that the presence of the implants will make it less likely the injected fat cells will be able to develop their own blood supply and grow. This gives me pause as I’m not too keen on another procedure that might just be an expensive temporary natural filler. I would appreciate your thoughts on this and how to maximize the survival of any grafted fat. Are there any other options to reduce the noticeability of the implants and fill/round out the cheeks more?
A: Your plastic surgeon did reach out to me and I have discussed your case with him. Fat injections are the only treatment that can be used as the ‘missing’ piece of your face is now not what is on the bone but is where the bone/implants aren’t. It is true that the final take of injected fat is both variable and not completely predictable. But I know of no scientific evidence that supports the supposition that fat grafts take less well over or around facial implants. And where you need the fat is to fill in the areas around and between the implants which is only soft tissue anyway.
One technique that can be done to improve fat graft survival is the use of platelet-rich plasma. (PRP) By mixing PRP with the fat grafts, it optimally enhances fat cell survival through its growth factor effects. It may also have an inducing effect on the stem cells that naturally reside in fat. Given that it is an extract from your own blood, there is no reason not to use this natural fat ‘booster’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to make a few enquiries regarding facial implants.
My plan is to have bespoke implants fitted precisely over my current facial skeletal bone structure to adjust the appearance. I am interested in various different locations on the face, and I know fairly precisely the dimensions of the facial appearance I would like to have. I was wondering if you have an information pack for new patients for this procedure and some advice on getting started?
My second questions is in regards to the materials used for the implants. On your website, you mention two materials – silicone and Medpor. I was wondering if you ever work with, or would consider working with 3D printed titanium implants. the reason I am particularly interested in this material is the strength advantage it has over others.
A: The best way to get started is to send me some pictures of your face and a detailed list of what you want to achieve and where you envision the augmentations to be done. Using that information, custom implant designs can be done on a 3D CT scan which you would need to get. That CT scan can be done in your local community.
As for custom facial implant materials, only silicone is currently available for use as a custom facial implant material for 3D CT fabrication. While I am certainly not opposed to using any other material, such as titanium, you have to factor in other important considerations such as cost and access. Very stiff materials, such as titanium, require much larger incisions to place dependent on their size and location. This is an issue that patients never think about but can be a very limiting issue. In addition, there is no advantage to a stiff metallic material as an implant. Since bone is the backing for all implant materials, they all become firm and ‘bone-like- once in place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw surgery just over a year ago and it left me with some irregularities. This led me to get chin and paranasal implants a month ago. While they have provided some improvement and there is still some swelling, they still have not completely solved the appearance of nasolabial folds and pre-jowls.
I now suspect that this may be a soft-tissue problem. However, because I am only 25 years old such soft tissue deficiencies seem unusual. Anyway, I’ve googled facial fat grafting and this image really pinpoints the areas I would like to build up and bring forward (the direction of the arrows). My biggest questions are as follows:
1) Could my soft tissue issues have been caused by my previous underbite (thereby affecting soft tissue development) or the jaw surgery itself?
2) Given my age, can fat grafting be done for these regions? If so, how much volume of fat is usually required?
3) Instead of fat grafting, are permanent fillers an option? Alternatively, are there any different implants that can be placed in these regions?
4) I have implants near these areas. Can fat grafting be done safely without infecting my implants?
Anyway, I also had some fat grafting done to my brow ridge and central forehead to make it look masculine. My surgeon did a decent job, but I’m noticing that insufficient fat was placed in the central forehead (the area between the two eyebrows and just above the nose), which means that my outer/lateral brow ridges are more augmented than the inner portion, causing it to look like I’m constantly frowning. I’m looking to add more fat to the central forehead, but I understand that a revision should only be done a few months later. Regarding this, I have a couple of questions:
5) It has only been 4 weeks since the fat grafting, can I use temporary fillers to augment the deficient areas in the meantime?
6) If so, will fillers affect how my fat graft survives at this stage?
A: I am going to assume that your jaw surgery was orthognathic surgery, possibly a mandibular advancement osteotomy. But that issue aside, let me address your specific facial fat grafting questions.
- The cause of your nasolabial folds and prejowls is impossible for me to comment on since I don’t know what you looked before your jaw surgery or your most recent facial implant surgery.
- While injectable fat grafting can be done for these areas, how retentive it will be is somewhat dependent on your body habitus. Thin young people usually have a poor rate of fat graft survival and retention. The fat graft volumes needed for the nasolabial folds are 3 to 5ccs per side. The prejowls usually require a similar amount of injectate.
- There are few permanent fillers available in the U.S. and, even if there were more, I would not use them. All of the so-called permanent fillers run the risk of lump and nodules. While more often these do not occur, but if they do they are problematic to treat. Other styles of facial implants may indeed be more effective than what you have such as a true maxillary implant. (combined medial and lateral maxillary coverage which is much ore comprehensive than a simple paranasal style which I find archaic and inadequate for many midfacial hypoplasia needs)
- Fat grafting is done above the level of the bone where the implants reside so they are not in danger of being accidentally injected.
- I would probably wait another month before placing synthetic fillers into the fat grafted areas. The fat grafts are still healing and there is an increased risk of causing an infection by introducing another material into these areas.
- At 8 weeks after fat grafting, injectable fillers will not have any adverse effects on the outcome of the fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you and I spoke previously about temple implants. cheek implants, and forehead fat grafting. You did some imaging for me as well, and I realize you understand my goals in reshaping my face better than anyone. With this said, I would be interested to see how the overall look of what we discussed previously would first look by using injectable fillers to achieve the results in widening my face and adding more volume.
A: The issue with fillers for augmentation of various facial areas is one of pure volume and the associated costs. When it comes to small areas like the lips (1cc) or even the cheeks (2ccs), voluminization by hyaluronic acid-based fillers is reasonably cost-effective even though the effects will not be permanent. Beyond these volumes one has to look to the use of a filler like Sculptra to achieve a broader or wide-based facial volume effect. While these longer-lasting particulated fillers can achieve better volume enhancement of the cheeks and temples, the need for multiple treatments to achieve their effects and an increased risk of reactions to the implanted ‘seeds’, it is usually better to venture into the realm of injectable fat grafting where there are no volume restrictions or risks of any injectate reactions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need help in figuring out the best way to enhance facial volume. I have hollowing under my eyes and would like a stronger jawline. I had cheek implants placed two years which have done great so am looking for similar impact on my other facial areas. But I’m not sure what the best way to accomplish this is using either facial implants, fat injections or injectable fillers.
A: When it comes to facial volume enhancement the surgical debate is always whether it should be done by fat injections or facial mplants. This is no different that the debate would have been about your previous cheek augmentation. There are advantages and disadvantages for either approach but that debate must be assessed more specifically for the facial area that one wants to enhance and whether it is composed of underlying bone, soft tissue or both.
The jawline is primarily supported by bone so any effective augmentation is almost always done by some form of implant placement. You would have to further define what jawline area to which you want changed to better answer what type of implant may best address it. This is identical to your cheeks which are usually most effectively done by implant because they are a bony supported area.
The under eye area is different than the jawline because it is a combined bone and soft tissue area. The lower end of the under eye area is the inferior orbital rim while most of the lower eyelid is soft tissue supported. This usually means that fat injections are needed as an implant only covers the very lower end of the under eye area and placing it requires a lower eyelid incision to do so. So fat injections, even though they are unpredictable, usually win out over any implant augmentation. Their ‘softness’ is kore appropriate for the under eye area than the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, from my research and various consultations, I believe Medpor facial implants is the way to go. I have heard that with silicone it will eat away the bone’s density as it has shown on my latest CT scan. (which was sent to you also) Over years will the bone keep deteriorating from the silicone? What is your opinion on both types? pros/cons?
A: Whatever you have heard about silicone facial implants is both inaccurate and untrue. It does not cause any deterioration of the bone. That is an occasional passive phenomenon in the chin where the implant may settle into the bone from the pressure of the overlying muscles if the implants are placed too high on the chin bone. It is a simple passive phenomenon and not an active inflammatory process, It is never seen beyond the chin area in my experience.
I have used plenty of both silicone and Medpor facial implants in both primary and revision work. I could detail all of the advantages and disadvantages of each but, in short, if I never could place another Medpor implant I wouldn’t. (I still do when patients want but I have yet to see any advantages with its use and there are plenty of disadvantages) It costs more, has a higher rate of infection (as any textured surface implant does anywhere), is difficult to place, requires longer incisions to insert, is harder to modify, and poses a real problem when it comes to revisional surgery. (and remember even with custom implants the revision rate is not insignificant in the young male face patient) Whatever benefits they may be to some tissue ingrowth are overwhelmed by all of these disadvantages and screw fixation easily eliminates its only one advantage. (tissue ingrowth = implant stability) Over the years I have come to one conclusion about Medpor… it is an implant material that is really a poor choice for facial implants but it has been around so long and is an alternative to silicone that doctors keep trying to make it work.
But some patients are very emotional in their decision for Medpor although the logic of its use does not meet the scientific test for being any better than silicone. (and is a much worse handling material) But if that is what the patient wants, I will use it most of the time unless I feel it really compromises the ability to get the desired result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about facial implants. I had a square chin implant and paranasal plus midface rim implants placed one month ago. I’m happy with the augmentation they’ve provided, but they haven’t exactly addressed the areas I really wanted augmented. I’m aware that there’s still quite a bit of swelling, but the parts of my face that were initially deficient now look worse in relation to my augmented mid-face and chin. Here are my questions:
1) It has been 4 weeks since I had these implants placed. Given your experience, what % of swelling is there still remaining?
2) The paranasal implants have given me mid-face volume, but the area that I really want augmented is the areas under the nose and above the upper lips. I’m looking to make that region more convex to obtain a ‘step off’ between the upper mouth and the mid-face. I’ve done a bit of research, and I suspect I may need premaxillary implants.
3) I had this weird issue of there being some kind of ‘jowl lines’ from my lower lips to the sides of my chin. The chin implant does seem to have exacerbated it, and I don’t think implants are going to address the issue. I’m not sure what has caused it, but the region below my lower lips appears to be more convex relative to the areas to the side of it, which is what gives the appearance of jowl lines.
Anyway, do you think that fat grafting to the perioral and upper chin region will address it? Further, if I’m getting fat grafting done, should I consider getting fat grafts placed in the premaxillary region too? Could you kindly give me your professional advice on my options to augment these areas?
A: At just four weeks after facial implant surgery, you probably have about 75% of facial swelling reduction. But the remaining 25% of facial swelling and soft tissue adaptation to the new facial contours will take several months to resolve.
Facial implants are generally designed to provide augmentation of facial skeletal areas that are flat or convex in nature. They are not effective for concave facial areas that are not supported by bone. Thus, premaxillary augmentation is best done by an implant while the jowl areas above the jawline are better augmented by fat injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering facial implants to rejuvenate my young but old-looking face. I am 37 years old and underwent gastric bypass surgery two years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye. I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows .I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change…not me… I want a drastic change. I lost over 1090 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.
A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had custom chin and jaw angle implants placed four months ago and then I had them revised with new implants two months ago. While it is much improved and is almost what I want, I think I need another surgery. How soon should I have another jawline implant surgery again, I am ready right now?
A: While I am not your plastic surgeon, I do not agree with any patient changing their facial implants repeatedly over very short times. Making facial structural changes before 9 to 12 months short of some major aesthetic problem is often premature. You have been through two surgeries over a short postoperative period of time and now you want to change the look again…before you have ever truly seen the final result and before you have had time to psychologically adjust to your new look. Perhaps you have learned that, despite all the preoperative predictions and planning, that it really isn’t the look you want or maybe achieving that look isn’t even possible. I am not looking for an explanation nor do I want one from you as to the logic of the desire for another surgery, it is just this decision just seems very hasty sitting from my perspective.
The other equally important reason that I advise against prematurely jumping in and changing facial implants is that each surgery carries risk and the more surgery you have the greater likelihood that one of those risks will occur. Every surgery always involves some form of a trade-off and each new surgery creates the opportunity for a new problem to appear. The dreaded one, of course, is infection. Just because it has not occurred before, each new surgery involves a new spin of the wheel so to speak, and repeated surgeries increases that risk.
I say all of this because a patient’s decision to undergo any revision should be based on the severity of the problem versus the degree of risk involved. There does come a time when the balance between those two should give one pause for reflection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you have written in regards to facial implants that the translation of bone augmentation to an exterior soft tissue facial change is not a 1:1 ratio. Does this mean that a 3mm malar implant may not necessarily provide 3mm of augmentation? If so, do implants tend to give more or less augmentation than their specified dimensions? Additionally, what is the reason for it not being a 1:1 ratio?
A: The reason that augmentation of bone (a hard substance) does not translate exactly to the exterior surface of the overlying soft tissue is the compressibility factor between the two different types of tissues. If the enveloping soft tissue was as hard as bone then augmenting the bone would create an exact 1:1 ratio translation. But the soft tissue of the face has varying thickness and is soft, thus pushing on it from below is somewhat ‘blunted’. Thus the ratio of bone surface change to external soft tissue change would be less than an exact 1:1 relationship. This would be influenced by the thickness of the overlying soft tissues. The thicker it is, the less is the 1:1 relationship, the thinner it is (less fat) the closer it is a to a 1:1 relationship. This phenomenon is well established in orthodontics and orthognathic surgery where these hard:soft tissue relationships have been studied by cephalometric analysis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been diagnosed with a mild midface deficiency. I would like to have this corrected to end up with the most aesthetic appearance possible. I have been reading about facial implants and the work you have done with them. I would like to achieve a reduction of the depressions on either side of the nose, reduction of the heavy creases going down to the corners of my mouth and better projections of my face to make it look less wide and flat. In addition I am also interested in lip implants. I already have some lip implants placed. They were the type that look like spaghetti and the size was 4mm top and bottom. I would like to add to these to make my lips bigger. Specifically I would like to show more of the pink lipstick area rather than just make them stick out more. I would also like to bring the implants out to the edges of my mouth to make the lips and mouth appear wider.
A: When it comes to facial implants, there are a lot of facial changes that they can make…and there some changes that they can not. For a mild midface deficiency, consideration can be given to paranasal implants to bring out the base of the nose and anterior submalar implants to provide some upper midface projection. The lower nasolabial folds as they approach the corners of the mouth will not be affected by any bone-based implant. This area is best treated by fat injections.
In regards to the lips, you either have more recent Permalip silicone implants or older style Advanta lip implants. Either way it is not a good idea to double stack lip implants as there will be a great tendencey to have them roll or twist on one another. You may exchange them for the largest 5mm implants but, for the sake of a 1mm increase, that is not likely to make much of a difference. Furthermore, some of the lip changes you desire can not be achieved by lip implants. No implant will increase the vertical height of the vermilion (pink lipstick area) nor will they make the corners of the lip appear fuller or wider, they are too thin in this area. To make these kind of lip changes, you will need to consider a vermilion or lip advancement procedure which directly changes the location of the vermilion…which is what is needed to make the type of lip changes you desire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering facial implants to rejuvenate my youthful face. I am 27 years old and underwent gastric bypass surgery 4 years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye..I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows..I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change..not me I want a drastic change. I lost over 160 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.
A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Medpor infraorbital rim and paranasal implants placed last year. The recovery was uneventful, but I’m hoping for further augmentation that’s more suitable for my face. This is why I’m contemplating getting a custom made implant for the entire mid-face region. However, my biggest concern is with removing these implants. I understand that Medpor removal comes with its risks. Assuming that I’m willing to undertake these risks, can I just check if it will at all be possible to remove the infraorbital rim and paranasal implants? If so, what kind of soft tissue damage can I expect? Would any tissue resuspension be necessary, especially if I were to replace them with the custom made implants in the same surgery? Thanks!
A: Having done a lot of Medpor facial implant removals, I have yet to see an implant that could not be successfully removed. There really is no risk with their removal other than the swelling which naturally occurs afterwards which usually isn’t worse than the original implantation surgery. I don’t think there is any risk of soft tissue sagging with their removal particularly if replacement implants are being simultaneously inserted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been looking into getting facial implants, specifically chin, cheek and jaw angle implants, now for quite some time. During my time researching these procedures I have come across many reputable sources of information, like yourself, and millions of internet experts professing to know the ‘truth’ of some sort of another regarding facial implants. Nowhere amongst all this are clear and unambiguous answers to some of the most basic questions. Hopefully you can provide these for me. My questions are as follows:
1. If a chin, cheek or jaw angle implant is placed, the surgical wound heals, all is well and the patient loves the result several months after the operation, what is the likelihood that the implant will become infected years or decades later.
2. In your experience, if an implant is placed uneventfully can the patient then go on to live for decades having ‘forgotten’ about the implant, so to speak? I don’t want to have to come back to any implants later in life, I want to have my first cosmetic surgery and then forget about it forever.
3. Is the removal of an integrated Medpor jaw angle implant as difficult as it is said to be? Also, is there a silicone jaw angle implant that can provide the so called drop down effect?
4. There is a lot of confusion regarding cheek implants for men who want their cheekbones to flare out laterally. Do you think it is a deficiency in zones 1 and 2 of the malar-zygomatico complex that needs to be corrected in order to achieve the male model look? If so, are custom cheek implants capable of achieving this in the right individuals
5. Individual implants will not make a person look radically different. Is this something that can happen, for good or ill, when several implants are placed at once?
A: In regards to your questions about facial implants ( cheek, chin and jaw angle implants), my answers are as follows:
1) The risk of implant infection is greatest in the perioperative period (first month or two after surgery) usually as a result of implant contamination during placement. Delayed facial implant infections are very rare. not impossible, but it would require contamination into the implant capsule like from a dental local anesthetic injection. Delayed infection risks are so rare that they are almost case reports for the literature.
2) If one has uncomplicated healing and is pleased with the size and symmetry of the facial implant result, having them will quickly become a ‘natural’ part of one’s anatomy and they will be forgotten as being a synthetic extension of one’s face.
3) Medpor implants,including those of the jaw angle, can be removed and I have removed many of them. They are much more difficult to remove than silicone implants but that is an issue of relativity. Silicone facial implants are so easy to remove that anything that is more adherent seems difficult.
New styles of vertical lengthening silicone jaw angle implants are now available. I designed them to provide a better implant material to that of Medpor. They are much easier to insert and replace/modify if necessary.
4) The concept of getting cheek implants to achieve any type of facial look is more ambiguous and harder to achieve that most would think. The cheek area is a complex four-dimensional structure and the interpretation of what is a pleasing shape is as variable as the anatomy of each person’s cheek bones. It frequently is not as simple as just pulling an implant off the shelf, regardless of its style and size, and the desired look is achieved. Even using custom designed implants is not a guarantee that the desired look can be achieved as the ability to translate a design to what it makes the outside of the face look like is not a mathematical one. Many men seek the so called ‘male model’ look which often but not always means a high angular skeletonized cheek look. You would have to define what cheek look you are after by using model pictures as examples. While all of them are models, many of their cheek shapes are quite different.
5) The more facial implants that are placed, if they are not properly sized, the more different one can look.
The one caveat I would add to all of this is a basic fact based on my very extensive experience with male (almost always young) facial skeletal augmentation surgery…such patients have a remarkably high revisional surgery rate which approximates 50% or greater in the first six months after surgery. These revisions are almost never because the implants have any medical problems but because many young men are impatient of the healing process and often are uncertain if they like the aesthetic outcomes of their procedures even if it is exactly what they thought they wanted. Thus, when you think about getting facial implants this revisional surgery issue is what you need to consider, not all the other concerns that you have mentioned which are fairly irrelevant compared to this consideration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting facial implants and am gathering information about getting plastic surgery. My intention is to improve my facial features with facial implants and cosmetic plastic surgery. I would like to get your professional impression and advice to enhance my look.
The areas that I would like to improve are:
– Jawline. I think I have an elongated face. So, I am looking for a more square and strong jaw.
– Cheeks and Eye Hollows. I am starting to notice some eye hollows. I think I do not have a strong features in this area, they are somehow “flat”. At this time, it is not bad, but I believe with time they will get more pronounced.
– Upper Eyelids. I notice that I have extra skin on my eyes lids, especially on my left eye.
– Any suggestions to make the face more aesthetically balanced and harmonious with the rest of the face.
Concerns:
– I am concerned about the scars and the surgery around the eyes. I do not mind internal scars but external incisions concern me.
– What is the material used for the facial implants? I read about Silicone, Medpor and Gore-Tex. I would like to know your impressions about these materials, and their pros and cons, and why you use ones over the others.
– Asymmetry, implant shifting and/or misplacement (due to position, scarring, etc.)
– Final look. I would like to look natural and not “done”.
– Revisions. What is your policy in case of revisions?
– Complications during and/or after surgery. What is your policy in case of complications during the surgery and/or after the surgery? nerve damage?, secondary effects?, responsibility, cost, etc.
– Bone erosion with implants over time. What is going to happen with the implants when I get older. I am 30 years old at this time. What is going to happen with the implants and the bones when I am 85-90 years old? the implant, the screw, the bone. Is there any research done about this?
Ideal:
– I can imagine you have heard this before, but I would like to get the “model” look. Strong, symmetrical, pleasing features. I attached some photos of some ideal looks, by all means I don’t want to look exactly like a specific “celebrity” or “model”, it is just an idea of the look I am looking for.
Questions:
– Could you provide me with your professional impressions about the surgery/ies that I will be benefiting from, their related costs and results?
– Do you provide any imaging about the possible results. I attached photos of my face in different angles.
– What are the difference between conventional and custom designed implants? what are their costs?
– How long will I have to stay in Indianapolis after the surgery?
– When would I be able to return to my normal life work, exercise, being in public, etc?
– How much discomfort should I be expecting in the surgery?
A: I have done some computer imaging on your face for the various facial implants for the following procedures:
1) Square chin augmentation
2) Vertical lengthening as a well as width expansion jaw angle implants
3) Cheek implants
4) Fat injections to the lower eye hollows/tear troughs
In answer to your questions:
CONCERNS
– there would be no external incision with fat injections
– implants would be silicone, best because of better shapes and easily reversible or modifieable
– all implants would be screwed into place
– natural comes from not using too big of implants, particularly when multiple implants are being used.
– we have a complete page of the revision policy which you would get to read before surgery.
– bone erosion is a non-issue. The implants will look the same decades from now as they will one year after surgery.
IDEAL
– you are correct in assuming that every male who wants this kind of surgery wants the ‘male model’ look. Those who have a chance to come close to that look have to have thinner faces and some decent underlying facial bone structure…you are the uncommon one that actually fulfills these criteria.
QUESTIONS
– I have attached some imaging predictions for your review. I will have my assistant pass along the costs to you in a day or two.
– you should be fine with standard implants. Custom implants are always ideal but at the additional costs of $7500 they had better provide a real difference…which in your case they do not.
– 2 to 3 days, all based on how you feel.
– that is based on how you feel and look, somewhere between 10 and 21 days after surgery.
– jaw angle implants provide the most discomfort, the other procedures are much less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions regarding facial implants. I did not see this addressed on your blog so thought I would ask. My question is regarding the known/ suspected long term effects of having facial implants if any. While I understand that for instance solid silicone implants such as the jaw/ chin implants I’m interested in will last a lifetime; however, what does the aging process hold for those that have such implants? Does placing an implant under the largest muscle (of the jaw) have drawbacks as I age. ( only in my 30’s now) Will jowls/ sagging skin etc show up faster since the muscle is now stretched over this new ( larger jaw)? How will chewing be effected if at all due to this as I age. Or will aging and its various processes just march on as if I never had anything done and just as if I was born with this new wider jaw and more pronounced chin? Thanks again for your time.
A: Facial implants, of any location, have no negative impact of facial aging and may actually have the reverse effect. As implants add volume by addition to the bone, they may prevent some tissue sag, or delay it, that will inevitably occur with aging. Jaw angle implants have no negative effect on chewing other than the initial discomfort and stiffness in mouth opening right after surgery that persists for a few weeks.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’ve attached a photo of my side profiles and front. The main issue I have is with my eyes, which effects my self esteem the most. They also protrude quite a bit and I was hoping orbital decompression could be done whilst aligning them? I know it’s a very complicated invasive procedure.
The others issues are my jaw, hairline and eyebrows. I clench my jaw (whilst sleeping) predominantly on the left side resulting in having to get a root canals to subside pain in those teeth. So it’s more function than anything.
If it’s possible to get the alignment sorted out, I would possibly at a later stage want augmentation done on my jaw and cheekbones to balance my face out. What would your opinion be on that? Thanks again, your time is very much appreciated.
A: Thank you for your inquiry. You are making an incorrect eye diagnosis. You do not have true orbital proptosis or bulging eyes. You have pseudoproptosis…meaning the eyes appear bulging because the orbital bones around them (infraorbital rim and cheek bones) are deficient. Thus the eyes appear bulging when in fact the eyeball has a normal position. Thus orbital decompression surgery is an incorrect and inappropriate treatment for you. The correct treatment is to build up the underlyling bones which are deficient through onlay facial implant augmentation.
In regards to other issues, Botox injections are the ideal treatment for painful masseteric muscle clenching, which can work spectacularly well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to achieve a more masculine jaw line. My face is oval and I want a more square cut lower face. I had a chin implant back in 1990 with a rhinoplasty. Would like to know what my options are and also would this implants just be inserted or are they secured with screws. How many days do I have to stay inIndianapolis before flying back to home. Thanks so much for your fast response.
A: Thank you for sending your pictures. I did some preliminary imaging based on what I perceive as your desire for a more masculine jawline. This was done using a combination of chin and jaw angle implants, the most common approach to make a circumferential change to the jawline. One interesting issue with you is that you already have a chin implant and the change to get you to the imaging result is significant. This raises the question of whether an off-the-shelf (stock) chin implant can really achieve that goal of which I have doubt. This leaves the possibility of either making a custom chin implant or doing a combined sliding genioplasty with a small square chin implant placed in front of it for the square width effect.
All facial implants are always secured by screws for stability of position on the desired bone position long-term.
No matter how it is done, you would be returning home 48 hours after surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, In your experience what’s the least expected facial implant material to get infected? Also can maxillofacial bone cements or pastes be able to be used for the chiseled look? Also there’s a procedure where you cut the cheekbone and advanced the bone then added plates and screws can that give masculine cheeks/zygomatic arch look?
And does the bone grow into to the cut cheeks to reattach in case if plates ever needed to be removed? Is there any sort of special maxillofacial bone cut to the jaw to just add width and some drop down? Thank you.
A: While I appreciate the nature of your all of your questions, each one of them represents the same issue…you are searching for non-implant procedures to do what facial implants do. And the answer to all of them is the same…they either do not exist or do not work very well at all. There is only one bone procedure that replicates what an implant does..the sliding genioplasty. Otherwise, every other osteotomy/bone moving method works very poorly…and I know because I have tried them all over the years.
There are many factors that go into how implants can get infected so it is not as simple as one material is necessarily better than the other. If handled well, they all should have th same rate of risk of infectivity. But if I had to pick one just based on the material alone, it would be silicone because of its smooth and non-porous surface. It is harder for bacteria to get a good hold on this type of surface as opposed to a rougher irregular one like Medpor.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had a few questions. Here's history on me I have had a sliding genioplasty in 2010 and a rhinoplasty in 2005 now I’m happy with the outcome but would like to get a more masculine chiseled look. But I would like to stay away from implants such as porex, silicone, goretex, etc. Can bone grafts be used or is there a way of augmenting without the use of implants? I think my jaw line will need some augmenting. Along with slight some in the chin for its narrowness/mild step offs. Maybe some in my supra orbital rims to give a stronger appearance. Thanks.
A: What you are asking for and how you are asking to do it can’t be done. There is no way to achieve those facial skeletal changes without the use of synthetic facial implants. While bone grafts can be done they are impractical for two reasons. First onlay bone grafts will completely resorb for the most part and what will stay, if anything,will be very irregular and unpredictable in shape. Secondly the amount of bone graft needed would be impossible to harvest unless large strips of outer cranial bone were taken from you skull. Thus the concept of bone grafts for significant facial skeletal augmentation is an unwise and ineffective approach to improving your jawline. A more effective autologous material would be cartilage grafts which don’t suffer much resorption when applied as an augmentation material. But I don’t think many patients want to have multiple ribs harvested from the subcostal margins for a cosmetic change. The reality is that what you don’t like (synthetic implants) is the best, easiest and actually safest way to achieve your jawline goals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some skull and face asymmetry from positional plagiocephaly. The main issue is that the right side of my forehead bulges, is it possible to reduce this bulging so my forehead doesnt have such a broad appearance when viewed from one side? Also the left side of my face is less prominent, maybe you could say “weaker” than the right. Would some sort of implant help with the asymmetry and make the left side as prominent as the right?
A: Plagiocephaly produces the exact face and skull asymmetry that you have described. Your right-sided forehead protrusion and smaller left face are common. Although I have not seen any pictures of you, your theory for improvement in facial symmetry would be the correct approach. Reduction of the right forehead bulging and augmentation of the left face, most likely that of the left cheek and jaw angle, could offer visible improvement. I would need to see some pictures of you, particularly a straight-on frontal view, to confirm if this approach would be helpful.
The left facial implants can be placed from inside the mouth so there are no scar trade-offs for those improvements. That can not be said for the forehead reduction in which the scalp scar trade-0ff must be considered very carefully, particularly in the a male patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, does the mandibular angle implant bond to the bone through time? Or is it just the screws that hold it in place for the rest of my life?
A: There is no synthetic facial implant materials that truly bond to the bone in the truest sense of the word. Bonding denotes an actual bone ingrowth and attachment to the underlying bone without the interface of scar, much like a dental implant where bone bonds directly to the metal. That does not happen with either silicone or Medpor materials.
What does ultimately stabilize and maintain a facial implant into a secure position is the development of a surrounding layer of scar known as a capsule. This takes several months to form a solid capsule around the implant. So the primary purpose of implant screw fixation is to maintain the desired position until a good capsule forms. Medpor material does develop a more robust capsule formation than silicone but early implant stability can only be completely assured by screw fixation as that still takes time to develop. Medpor material also has a much higher frictional resistance (which is also why it is much harder to insert and usually needs bigger incisions) so this may help a little with early implant stability. But that is not enough for me to rely exclusively on this material property. Silicone has little frictional resistance and pocket development alone does not provide assurance that implant migration/mobility will not happen after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male 35 years old and I am interested in having facial implants. What’s the process to get them? What is the period of time to get healed after the surgery? And how much will it cost?
A: Your questions as posed are both vague and impossible to answer. Facial implants is a broad topic and there are implant possibilities for just about every region of the face. The first place to start is to find what you are trying to achieve with your face and whether facial implants may be needed. I would write me back and tell what deficiences you feel you have in your face, what changes you would like to see, and also send me a few pictures of yourself. With that information, I can determine if facial implants, or other surgeries, may be helpful in you achieving your aesthetic facial goals.
I must first find out what you need before the secondary questions of healing, recovery and cost can be determined. For now, you have the cart in front of the horse so to speak.
Dr. Barry Eppley
Indianapolis, Indiana