Q: Dr. Eppley, I had a PMMA forehead implant placed a few years back, but I’m looking for more augmentation still. I would like to go with the custom silicone implant route, but I have a couple of questions. Is it possible to remove the PMMA implant and design the silicone implant from scratch? I’ve heard some surgeons say that bone cement is impossible to remove, much like Medpor. Can the incisions used for the previous implant be used again for the new silicone implant? I would like to avoid additional scarring if possible.
A: Thank you for your inquiry. In answer tho your questions, a PMMA forehead implant can be removed quote easily. So the surgeons who have said it is difficult or impossible to remove must have no experience with it. A silicone custom forehead implant is designed off of a 3D CT scan. During the deign process the PMMA implant is digitally removed so only the bone is seen. Thus it is no problem to design a forehead implant with an existing PMMA implant in place. I will use the ghost image of the PMMA implant to design the new implant since it serves as a useful reference for how much more augmentation can be achieved. The identical scalp incision used to place the PMMA implant would be used for the new custom forehead implant so no new scarring would be created.
Dr. Barry Eppley
Q: Dr. Eppley, I had a forehead implant placed three weeks ago, but it seems a little too big. At this point, roughly how much swelling is left from the procedure? I’m just a little concerned as it has been quite a while after the surgery.Thank you for taking the time to read this and it is much appreciated.
A: I am afraid you have my at an informational disadvantage. I did not do your forehead implant surgery, I have no knowledge of what you looked like before your surgery, nor any idea as to the size and dimensions of your forehead implant. This is really a question for your surgeon who implanted it. You had the confidence for him/her to do the surgery, you should have the confidence in what they are telling you now about your postoperative concerns.
But as a general rule, 50% of the swelling is gone by 10 days after surgery, 75% by three weeks after surgery and 95% by six weeks after surgery. This it is still a bit too early to know what the final outcome will be. There is certainly still some swelling that remains so your recovery is still not yet complete.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a combination of procedures including:
1. Brow bone implant augmentation using a custom made brow bone implant and possibly forehead augmentation as well. As you can see from the attached pictures this area of my face lacks definition. i would like a more masculine look. I had upper eyelid surgery done some six years ago. Unfortunately that was a botched operation, the surgeon operating on me sliced off too much of my left eyelid which has left the eye about half way to a third open when I close my eyes. The left eye is wider than the right when open. I was wondering, since the brow augmentation is performed around this area, would this type of surgery cause my eyes,particularly the left one to open further, thereby leaving the eye completely open when shut or when i am asleep? I guess implanting around this area is bound to pull the upper eyelid area upwards and pressure on the tissue surrounding that area.. I would not consider going ahead with brow bone implant augmentation if this is the case. Your opinion on this is greatly appreciated
2. Lip reduction to lower and upper lips. Just minor reduction to counter drooping which I notice and is probably due to me getting on in age. When at rest I can see the pink of my inner lips showing.
3. Alar base reduction in combination with Weir incisions to reduce nasal side walls and inner nostrils as well. When I smile my nostril flare excessively which bothers me, so I refrain from smiling as much as I can.
4. Finally I would like to raise/heighten my dorsal bridge as well as trim the bony area along the bridge to give definition. In addition I would like the bulbous nasal tip defatted if this is something you can do. Again, I just a subtle change as I do not want it looking to pointy.
5. I have had previous rhinoplasty with a premaxillary implant inserted below nasal base and I want to remove this.
Are these procedures you can do? Can you perform these procedures at the same time? Have you any experience performing all the procedures i have mentioned above on ethnic people like me?
A: Thank you for your inquiry and sending all of your pictures. In answer to your procedural questions:
- When it comes to a brow bone implant it is critically important that the decision for total forehead augmentation be considered using computer imaging. That has to be factored into the implant design. With the slope of your forehead I suspect brow bone augmentation only may only make the forehead look more inclined backward. As for the effect on the eyes, I have not really seen much effect on the eyelid position. If anyway I would think it would push the eyelids down lower and not pulled upward.
- Lip reduction almost produces less of a lip reduction effect than most patients want. So a more subtle lip reduction effect is the more likely one to be achieved as opposed to too much of a reduction.
- Reduction of nostril width changes the outer location of the nostril but has no effect on the inner nostril along the midline columella.
- The height of the nasal bridge can be raised and this can be done by either an implant or a rib graft. Since you may already being having a brow bone-forehead implant, I suspect the implant option would be more appealing. Reducing a bulbous tip in thick-skinned men always produces more of a subtle change and never a dramatic or a pointy one.
- The premaxillary implant can be easily removed.
All of these procedures can be done at the same time (custom forehead implant, rhinoplasty, lip reduction and premaxillary implant removal) The only thing ‘ethnic’ about your procedures is that of the nose and I have done many such ethnic rhinoplasties.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in forehead augmentation. I have very large brow ridges, and a sloping forehead with a prominent central bump in front of the coronal suture. I suffered a blow to the saggital region as a younger boy, and I have always believed that I suffer from premature suture closure. The saggital region is pointed, and my skull height is reduced. I read your procedure articles about plastic inserts in the forehead region to round the forehead and perhaps make it appear higher and more vertical, as well as similar inserts to widen and heighten the overall head shape. I am 68 years old, and have combed my hair over my forehead since I was a young man because I am embarrassed about my appearance. At my current age, and with thinner, receding hairline, this is becoming impossible. Can you help me?
A: Thank you for sending your pictures. I can clearly see your forehead concerns with a large flat area above your brow bones which slopes backward up into the skull. There is a relatively straightforward solution to our forehead deformity by building up the bone over the area of the depressed forehead region which is fairly well delineated. (forehead augmentation) This could be done using either a custom made silicone forehead implant from a 3D CT scan or using bone cement (PMMA) to do the forehead augmentation.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a forehead implant. What would the duration of the stay after surgery need to be? How long is it going to take to make the forehead implant? Also what is the maximum you can fill the forehead outward just for reference? How large are the implants able to go? Mine won’t be a very large one I don’t believe, but I’ll send you a picture as requested. Its more the upper part of the forehead I’d like to add volume to and maybe the brow area also if you can do that. But it is mainly the upper forehead so I have more even side profile and not a slanted forehead.
A: With a 3D computer designed forehead implant the dimensions of it can be just about whatever one wants. Given your descriptive requirements there does not appear to be a limit to the thickness of the implant particularly at the upper part of the forehead which usually never needs more than 7 to 8mms of thickness. The implant fabrication process takes about three weeks from design to having the sterile implant arrive for surgery.
You would likely not need to be here after surgery for more than a few days so ou feel comfortable traveling home after your forehead implant surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I had a silicone forehead implant placed through a scalp incision after an injury which left an indented forehead. I still have a high hairline so I want to do hair grafts or transplant. My question is can they still put hair transplants over silicone implant or will the hair not stay and grow? The implant goes from my brow bone all the way to middle of scalp.
A: The location of any skull implant, like a forehead implant, is way down at the bone level. This is numerous tissue layers away from where the hair follicles are located which are just under the skin. Thus any forehead or skull implant will not have any negative impact on hair transplants anymore than the overlying existing hair that is there now. You can freely have hair transplants done along the frontal hairline without fear that they will not take and subsequently grow. I have had numerous patients have this done, including women, with very successful hair transplant results.
Dr. Barry Eppley