Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a skull implant for my child. What is the youngest age you would fit a pediatric skull implant to a child? Can it be done under local anesthesia?My son is three years old.. He has plagiocephaly of 6mm and 92% brachycephaly. Would he be suitable for a skull implant? Would he need more surgery as he got older? How many children have you fitted with head implants? Many thanks for your time.
A: I have done onlay cranioplasty surgeries in children as young as 4 years of age using hydroxyapatite bone cements. I have yet to use a silicone skull implant in someone that young although there is no specific medical reason not to do so. It is just a request I have never had. An onlay skull implant would grow with the child as the bone underneath it expands outward. There may or may not be some settling of the implant into the bone a e] millimeters as the skull grows but this is a passive process not an active inflammatory or ‘erosive’ biologic event. If his occipital deficiency is 6mms I would preferentially consider preferentially consider bone cement but I am not opposed to an implant. Either way these are not procedures done under local anesthesia in children. Please send me a picture which shows his occipital plagiocephaly deformity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 35 year old man interested in a cranioplasty procedure. I haven’t been able to find a plastic qualified surgeon who is capable of performing cranioplasty in my or neighboring countries. There is a clinic in Korea. However their method is not predictable since reshaping given by surgeon at the time of operation by using bone cement requires a bigger incision. I have to undergo skull reshaping surgery due to a flat back of my head as well as the top head which is also flat head on top. In addition forehead recontouring and hair line lowering needs to be done. These procedures must be done in same session because of scalp efficiency concerns. In my case I guess scalp tissue expansion is gonna be first stage prior to skull augmentation in order to achieve maximum silicone implant thickness and to allow the hairline to come forward. I have copies of 3D CT scan in my hand so would please let me know which steps will be taken from now on? Kind regards.
A: You are correct in that those cranioplasty or skull augmentation areas and hairline lowering procedures would require a first stage scalp expansion procedure. I would need to see some pictures of your head as well as eventually a CD of your 3D CT scan. Given that you desire a combined hairline lowering and skull augmentation, the custom designed skull implant would need to be placed through the frontal hairline incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I practice plastic surgery in Chicago. I attended a cadaver course on facial implants last year in Las Vegas where you gave a superb number of lectures on a variety of facial implant procedures. I have a question regarding temporal implants and which tissue plane to place it in, I can not remember exactly what you said. From what I remember, it was placed under the superficial layer of the deep temporal fascia (on the temporalis muscle). Is that correct? Also, what would be the reason to not place it on the fascia? Thank you for your time.
A: Temporal implants should always be placed in the subfascial tissue location. (under the deep temporal fascia and on top of the temporalis muscle. Temporal implants should NEVER be placed above the fascia. Placing temporal implants in this area is what has caused them to be described as a bad procedure due to complications. When temporal implants are placed above the fascia the outline of the implant will be seen when the swelling goes down…not to mention the potential risk of injury to the frontal branch of the facial nerve in placing it in this more superficial tissue plane.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been interested in upper lip advancement (vermilion advancement) for a few years. My lips are full but very narrow toward the outer third. is there a maximum measurement of lip advancement that can be done in this area?
A: A vermilion lip advancement can be done to any part of the lip or its entirety. The only limits to vermilion advancement are aesthetic…you do not want the sides of the lips obviously fuller than the central part. Vermilion advancements of the outer third of the lips are not rare in my experience as many people have adequate central upper lip fullness but it tapers quickly down the sides into the mouth corners. This vermilion arrangement creates a mismatch between the vermilion fullness across the upper lip. Advancing only the sides of the vermilion upward is a simple and permanent solution to this aesthetic lip shape imbalance problem. It is done in the office under local anesthesia. There is usually minimal swelling and no bruising with a very quick recovery. The change in the vermilion shape is instantaneous and permanent. The only trade-off is the small fine line scar at the vermilion-cutaneous junction which certainly needs to be carefully considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a tracheostomy hole that is refusing to close. It have been over a year, and no ENT doctor or surgeon wants totry becaus they are afraid it will fail an dlave a larger hol.e. There is significant very har scar tissue or cartilidge on each sideto fhte helo, and nobody around here can figure a way to graft it back together and then suture the soft tisssue (which is very tight. the hole is less than the diameter than a dime, its just the tissue is tight and the soft tissue is so tight. Do you think you can help? And how?
A: You have a well-epithelized tracheostomy scar/hole that is not going to heal or close over at this point. That is evident by the time that has passed after the tracheostomy tube removal but by the epithelium that now lines it. It may have gotten a smidge smaller due to surrounding wound contracture but this is now a healed permanent opening. Your surgeons are correct in that any attempts at trying to free up the surrounding tissues will not only not work but injuring the tissues runs the real risk of making it even bigger. (although the real risk is just one of wasting time and creating the need for more tissue healing since it has no chance of being successful)
Understanding how to successfully fix your tracheostomy hole (way beyond just a depressed scar) starts with understanding the true nature of the problem….there is a lack of tissue. The hole needs more tissue and the surrounding tissues are both scarred and are tissues of poor quality. They can not be relied upon to be the sole donor tissue for the closure. New tissues must be brought in to create one of the needed three layers. This is likely going to require a pedicled muscle flap from sternocleidomastoid muscle of the neck. (partial pedicled muscle flap) to serve as the vascularized interpositional tissue layer. This would be placed between the internal lining (created by turning in the current skin lining of the hole and either a small skin graft or local skin flap rotated over it.
Anything short of a solid three layer closure for your established tracheostomy closure is doomed to fail.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to consult with you concerning forehead contouring. I am mostly interested in using an injectable filler to achieve a more vertical and convex shaped forehead.
A: Forehead contouring can be done by a variety of surgical and non-surgical methods. But their effects in achieving the desired forehead shape is not the same and those distinctions are very important to understand. The use of any form of injectable filler for forehead augmentation is not a good treatment method for forehead augmentation. Whether it is a temporary filler or fat material, the result will often be irregular and only temporary. While there is nothing wrong with injecting fat into the forehead any irregularities may or may not eventually resolve as the fat resorbs and heals. Using bone cements or an implant is far more reliable and produces a much better result. Getting the desired shape with a smooth contour requires a material that can consistently allow that to happen. And placing the material through a scalp incision is the best method from which to accomplish that goal. I would need to see pictures of your forehead to better answer what would type of forehead contouring procedure would work best for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 15 years old male teenager. I have a plagiocephaly flat head which wasn’t treated when I was a baby. I hate it so much especially in pictures as it makes my face looks lopsided. I can not go on with this face anymore as it is embarrassing. I don’t like going out because of it as I don’t like showing my flat side of my face. It is very horrible. There is not one single person that I know and that I have seen that has this type of plagiocephaly head. I need you guys to help please (:
A: While the effects of plagiocephaly are often most pronounced on the back of the head it often will have facial effects as well. Since plagiocephaly is really a twisting of the skull during development this can create numerous facial asymmetries as well. What is seen on the front of the face is often the mirror image of what is seen on the back of the head. This craniofacial condition is often more common that one would think. Because of your age under 18 years old) I can not communicate with you any further for treatment recommendations without parental consent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, how much would neck liposuction cost? Could you give me an idea of what my realistic expectations would be? If you performed neck liposuction on me on a Monday or Tuesday, would I be able to be back t work the following Monday?
A: The best way to think about results from ‘neck contouring’ is to look at the three surgical methods of doing it….1) liposuction alone, 2) submentoplasty (neck liposuction with muscle tightening) and 3) formal neck lift. These are increasingly progressive neck contouring methods that produce increasingly better results. On a scale of 1 to 10, a formal neck lift would be a 10 as it addresses all three issues that are causing the sagging neck. (extra fat and loose muscle and skin) Everything else need to be compared to that ‘gold standard’ which will create the best neck contour with a sharp neck angle and defined jaw line. Thus liposuction will produce a 4 to 5 on that scale as it depends on the skin tightening up a bit. (halfway between where you are now and what the ideal neck change is) A submentoplasty would produce a 6 or 7 on that scale, better than liposuction but not as good as a real neck lift.
While there may be some swelling from liposuction 5 to 6 days after the procedure I do not see a limiting reason as to why you could not be back to work again in less than a week. The swelling would probably not be worse than the way the neck looks now for the most part. (in terms of size)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking for a surgeon with experience in macrotia reduction and came across your website online. Both of my ears are large in height. I believe I need a helix creation and scapha reduction.. Attached are some pics. If you could give me an idea of how these procedures can be done and if you have any helix pictures you’ve done that would be great. Or any pics of people similar to my case that you have shortened. Do you think I need a helix created or is a scapha reduction enough to achieve results?
A: Macrotia reduction surgery is generally done by removing a portion of the scapha and then back cutting across the helix lower on the ear. Most of the scar is hidden inside the helical rim and the only portion ever seen is where it crosses the helix usually about in the middle of the ear. Your ears are a bit of a challenge for this procedure because you do not have a distinct helical rim (the inside of the rim is exposed) where such a scar line could be easily hidden. This is somewhat concerning for macrotia reduction surgery.
Creating a more prominent helical rim requires rib cartilage grafts to do so and I do not think that effort would be worth it unless you are very highly motivated to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek and orbital reconstruction on the left side of my face three weeks ago for an old cheekbone fracture. The left area of my face that you worked on is still about 40-50% swollen. I also am still numb in my left lip area and on occasion I feel tingling in my face.
My questions are is the numbness and tingling a normal part of the healing process and if so, how long can I expect that to continue? How long until the swelling goes down completely? Can I take anti inflammatory medicine and use ice packs on my face to help the swelling go down? Will the ice affect the fat injections? Lastly, will the asymmetry of the left side of my face eventually match the right side of my face because as of now, the left side of my face is making it appear that the right side of my face is the side that is flattened?
A: You are recovering exactly as how I would have expected after cheekbone reconstruction (with cheek implant and fat injections). At three weeks after surgery only about 50% of the swelling will be gone. It will take a full three months to see the final result for all swelling to go away. Also I would expect some lip numbness to be present at this point but that will eventually go away with more time. Anti-inflammatory medication and ice packs will not make it go away any faster. This is a process of time for complete healing. I do not judge the result until three to four months after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few questions about rhinoplasty grafting. A few surgeons that prefer implants have told me that they do not prefer diced cartilage wrapped in fascia because the cartilage tends to flatten and the borders are irregular. Other surgeons have said that it lasts a lifetime if placed correctly. What has been your experience and what do you prefer as a natural substance? Also, does skin thickness have anything to do with implant extrusion? My skin is thin but my implant was placed properly and very well because there is no deformity and the skin is smooth. Also, what is alum from a cadaver? I have heard that this is something relatively new.
A: It is impossible to beat your own cartilage as the best natural and permanent nasal augmentation material in rhinoplasty grafting.. How to best shape the cartilage for the desired result depends on the source of the cartilage, the amount that can be obtained/needed and the surgeon’s ability to work with the material. It is not as simple as just using cartilage any way one wants. If one can harvest a nice straight piece of rib cartilage then that would make the perfect dorsal augmentation method to carve and shape. But many pieces if harvested cartilage are not straight and be diced and wrapped to ensure a straight result. It has not been my experience that diced cartilage grafts flatten out and create irregular borders. I will not use any type of cadaveric material for nasal grafting so I can not comment on its use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering Jaw angle implants and have a few questions for you. I previously had upper jaw surgery, orbital rim and chin implants done. I feel that my jaw needs augmentation to fit in with the rest of my face, I am struggling to find a surgeon with great knowledge in jaw angle implants and am considering traveling abroad for surgery. If I were to fly to you for surgery how long would I have to stay in the USA before returning home? Also with Jaw implants I hear talking can be a struggle after surgery, how long realistically can I expect this to last? In so far as jaw angle implants type I cannot decide whether I would benefit best from lateral only or both lateral and vertical lengthening? Also the degree of augmentation (small/medium/large). I have attached photos, please can you advise. I am also interested in having the plates from my jaw surgery removed, would this be possible alongside jaw implant surgery?
A: Most patients who come from afar for jaw angle implants surgery return home within a few days after surgery. While patients will experience some difficulty with chewing in the first few weeks after surgery I am not aware that patients have any signficant talking problems. You did not really provide enough pictures to make a full analysis of your face as the all important front view is missing. But as best as I can tell from the pictures provided, medium size lateral width only jaw implants would be my initial impression for your facial needs. While plates and screws from prior surgery can be removed during jaw angle implant surgery I would need to see x-rays of their locations to properly find them. As long as not too much bone has overgrown then they can be removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had custom jawline implant (chin and jaw angle implants) made and placed and I have included my before surgery and after surgery pictures. I am very happy with the chin portion. I also like the jaw portion, but feel like it left me with a sort of puffy look versus the more v shaped jaw i was looking for. I know it isn’t possible to look like Brad Pitt or a male celebrity, but I at least wanted to try and emulate the general characteristics. Just going off of what the implants did, I figured going a few mm more in width and couple mm in posterior drop would be beneficial, but of course I defer to you. I have attached some pictures of the general look I am going for, and would appreciate any comments on what you think would look good for me. Also, in seeing my pictures, do you think I would benefit from the temporal augmentation with implants? Or is it something you don’t think would add much? I have always appreciated your expert and honest advice.
A: Your jaw angle implants did not get close to your desired result because they did not go back far enough and had no vertical drop. Thus they may you look ‘puffy’ but did not add any angularity to the jaw angles and don’t really match the chin that well. Also the inplant design appears to be connected on the left side but not on the right for some reason. Without dropping the entire jawline from chin on back to the angles you will not improve your posterior jaw shape. In essence you need a connected wraparound cusyom jawline implant that is better designed for your objectives.
If you increase your jawline than I would agree that the width of your temporal and lateral forehead region is comparatively too narrow. Extended anterior temporal implants would provide a good balance with a new posterior jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 49 year old male and in good shape but yet I have a really bad sagging neck. Attached are photos of my neck from the front and both sides. I’ve always had a sagging neck and had liposuction done 24 years ago so the fat under the neck is not great but the muscle and skin sag. I’d like a sharper jaw line. I consulted with a surgeon here who stated that to achieve a sharp jaw line, I’d need a full facelift and that a neck lift alone would only achieve a partial result. This doctor stated that I should get a facelift and I don’t want a full facelift – I just want the neck tightened up. Thanks for your time.
A: Thank you for sending your pictures. The dilemma that you have is a common one for many men. They want to improve their neck and jawline but don’t want the facelift operation to do so. They believe that a ‘necklift’ will solve their concerns. What the plastic surgeon told you was correct…partially. You can only redrape the neck and jowl skin up over the existing jawline through a lower facelift procedure. The concept of a full necklift is really the same as a lower facelift….they are one and the same. There are other neck tightening procedures but they achieve their effects by making changes below the jawline.Thus they tighten but never really truly lift the neck…achieving only the partial result that your plastic surgeon correctly informed you of.
This dilemma leaves you with two options. First an isolated submentoplasty can be done from under the chin which will tighten up the neck angle but will have no effect on making the jawline sharper or more prominent. (neck angle change) The other approach to augment the jawline with the submentoplasty. This would be particularly beneficial in your case as your jawline/chin is somewhat vertically deficienct. Improving the prominence of the lower jaw through a wraparound jawline implant with a submentoplasty will make the entire jawline stronger, will pick up loose skin in the neck and create a sharper neck angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope this email finds you well. I have always been self conscious of my small head and weak Jaw. I recently had custom jaw and chin implants placed 7 months ago. I am happy with the results, especially with the chin, but would like to go with something bigger at the jaw with more support at the side between the jaw and chin. I assume I would need an inferior drop to the jaw, where my prior implants had none. I wanted to know how feasible this is to do from a safety standpoint and how the recovery would be compared to the original?
Regarding my forehead, it narrows inward and is concave compared to my zygomatic arch. I saw that you perform temporal implants with amazing results. I just wanted to know if these implants will feel natural once they are placed?
Finally, what kind of costs am I looking at for these procedures? I would want custom implants again for the chin/jaw but I don’t know what you would recommend for the temporal area. I would of course defer to you for both decisions. Finally, how much would these procedures cost in total if done together versus done staged?
A: Thank you for your inquiry. I would need to see pictures of you to give specific answers but I can provide the following general comments.
Since you have indwelling jaw angle implants in place that do not appear to provide any vertical elongation, new jaw angles can be placed. It helps that you have existing pocket so, in theory, the swelling and recovery would be less. (I assume your custom implants are made of silicone. Releasing the implant pocket and dropping the jaw angles down further is not a safety concern.
Based on your description of your temporal deficiency, it sounds like it goes all the way up to the forehead. Thus what you need would be what I call extended and Zone 1 and 2 temporal implants. All such temporal implants are placed on top of the muscle but under the fascia. Patients do not report any problems with such temporal implants feeling unnatural.
As for cost I am a but unclear as to how your current chin and jaw implants were made when you say custom. I assume this was done off of a 3D CT scan. If so that same scan can be used again. I will have my assistant Camille pass along the cost of the procedures if done together during the same surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am interested in forehead contouring. I have a hard lump at the centre of my forehead for the past eight years now. it is not really big but it is noticeable. Please i need a surgery for this because I have been experiencing a hard time with my life with this forehead lump. I have attached some pictures from different angles so you can see my forehead lump.
A: Thank you for sending your forehead pictures. I can clearly see your central forehead lump. There are two ways to do your forehead contouring to get rid of this central lump. First the forehead lump could merely be burred down to the contour of the surrounding forehead. The other approach would be to build up the area around around the lump so the entire central forehead area is smooth. (fill in the two grooves on each side of the lump) Which way is best depends on how one prefers the shape of their forehead to be. The other consideration is the surgical access to do either one. Both could be done through a small incision at the edge of the frontal hairline. (irregular pretrichial incision) to blend in at the edge of the hairline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe I have an underdeveloped jaw. In 2008 I had a chin implant which I feel was not correct and seems to sit on my face. Also there is a dip where my chin ends. My jaw is very undefined and seems to blend into my neck. Last year I wanted to get it fixed again. And the surgeon was adamant the chin implant was sufficient but he said I really needed a face lift. I have deep lines from my nose to chin which I hate. Within only a few days after surgery including liposuction to the neck the lines reappeared along with the fat along the neck and jaw. I approached the surgeon and sadly he said what’s the problem you look Younger. Although that was not actually what I was looking for. I have already spent a lot of money and looked and felt no better. I have also had huge issues with my teeth when my wisdom teeth grew impacted causing infections and damage to the other teeth. I am currently having all of these teeth removed at my local dentist. I do have an overbite but was never referred to an orthodontist, my dentist simply removed about 6 teeth when I was a child. I would love to hear your opinion and find out whether you feel there are options available to help balance my face. I am 36 years old and this has really affected my confidence. Many thanks!
A: Thank you for your inquiry. I am sorry to hear that your plastic surgery experiences were not more favorable. In looking at your pictures and your age, the real facial rejuvenative effect would have come from total jawline augmentation not a facelift. Your lower jaw is very short with still significant chin retrusion and high jaw angles. Even with the chin implant in place, whose size is unknown to me, you are still 8 to 10mms short. I think you would be better served by a sliding genioplasty with vertical lengthening jaw angle implants or a total wrap around jawline implant. The key for real facial improvement would be lower jaw augmentation to bring your lower face into better balance and proportion with the rest of your face. You are not a candidate for orthognathic (maxillary or mandibular osteotomies) due to lack of adequate teeth and the need for significant orthodontic preparation even if you had adequate teeth for the procedure. Plus as an adult it is a long orthodontic preparation process before surgery that can create other dental problems. (e.g.,periodontal recession). This you can not really have your lower jaw ‘corrected’ .Therefore you need to do a camouflage approach to the lower jaw deformity by moving the chin bone forward (sliding genioplasty) and augmenting the deficient jaw angles. (jaw angle implants) This keeps your existing teeth where they are and cosmetically makes the lower jaw more advanced and aesthetically balanced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a tummy tuck revision. I had a tummy tuck a year and am not happy with the results as you can see in my attached pictures. I hope they will help you see my concerns. My stomach is not flat. My muscles were not tightened and there is still excess skin. One concern is if the belly button can be reattached to the abdominal wall where it should be. And then to have stomach muscles tightened. I had a c-section 25 yrs ago and muscles were never tightened? Thank you.
A: From your pictures, there appears to be a midline rectus muscle separation and the belly button looks like it became detached at the base or scarred off the abdominal wall. Hard to tell about any loose skin but the tummy tuck incision is very long and low so I would assume that some significant abdominal skin was initially removed. There is no question you can have a tummy tuck revision with your rectus muscles tightened from your tummy tuck scar (it is a long way from way down there but it can be done) And the umbilicus can be reattached back down to the abdominal wall. That is by far the easier part which will make it deeper or more indented
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, About 2 years ago I had a chin implant put in during a rhinoplasty revision in Miami. It looks great BUT the lisp NEVER went away. It resolved to about 90% and continues to have good days and bad. The chin implant is a medium size. I’ve spoken to a neurologist as well and he does not feel this could have anything to do with mental nerve irritation as there is no area of numbness. At this point I’m quite frustrated and got a CT hoping to see some gross abnormality or slipping of the implant. The CT shows only a slight periosteal reaction (not-osteo per the radiologist) on the right and a .5cm asymmetry of implant riding posteriorly on the right. Could this be the cause of this? I do notice a corresponding limitation to my ability to retract my lower lip on right. Searching the internet, you seem to have the most facial implant experience so I wanted to get your opinion as general consensus thus far (including a speech pathologist) seems to think replacing it with an implant that projects less would be the answer.
A: This is not a postop problem with chin implants that I have personally seen before. I would not feel that the size of the chin implant nor its position is the problem. There are lots of chin implant patients with gross asymmetry of their implants and they don’t have any speech issues. Conversely there are patients with huge chin implants that don’t have a lisp either. It sounds like there is a mild weakness of the marginal mandibular branch of the facial nerve, which affects the retraction of the lower lip, which can be a source of a lisp. That is a lower lip problem that I have seen before. Recovery of a marginal mandibular nerve weakness, which is a monofasicular nerve, will have reach its potential by two years after surgery. Thus I would have no confidence that any manipulation of your indwelling chin implant would offer any improvement in your current speech issue. You can, of course, prove or disprove that conjecture by replacing the current implant that you have. But the chance of improvement to me would be very unlikely.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin and jaw reduction ten days ago. It went well except that I have had worsening swelling each day after surgery. Today, when I woke up with even larger swelling on the left, I went to the ER to check it out and the ER doc after examining me was concerned I had a hematoma or an infection and ordered a CT scan with contrast. When the doc came back to my room he said the CT showed a large abscess on the left and a smaller one on the right and said I needed to get them drained. Then he consulted another plastic surgeon in the ER who looked at the CT and then called my plastic surgeon to consult him. After consulting each other it was determined these were pockets of liquid that can be a complication of surgery and would eventually be reabsorbed so no need for drainage. One determining factor was my WBC was normal however I just finished up my antibiotics yesterday. Also the ER doc sent me home on another week of antibiotics so I am wondering if he isn’t still somewhat concerned about possibility of an infection. So nothing is going to be done about the liquid pockets and the large one on the left is particularly bothersome and really has me concerned not only about the possiblity of infection as well as it is delaying my progress with recovery (worsened the swelling, discomfort, etc).
I know that you do a lot of jaw reduction surgery and would so appreciate to get your opinion re: these pockets. Should at least the large one be drained to reduce chance of infection and speed up my recovery?
A: Since you are within the first few weeks after surgery, these fluid pockets are either blood, serous fluid or a combination of blood. Bone when it is cut can ooze after surgery since it is hard tissue that does not have the capability of soft tissue contraction around the oozing exposed blood ‘channels’ and relies on compression of the overlying soft tissue on the bone (external wrap), an indwelling drain to pull off the fluid or just naturally stopping on its own. (which it may do if the bone removed is fairly superficial) Probably every facial bone reduction procedure gets a little bit of fluid which just naturally resorbs on its own within the first month after surgery.
Large (and it can be debated as to what constitutes large) pockets of fluid do have an increased risk of infection (good bacterial culture medium), can be uncomfortable when big enough and can prolong the recovery of one’s appearance and the final result because of increased resorption time. Draining them by needle aspiration or opening the incision and suctioning the fluid out can provide a prompt resolution to these concerns.
I can not tell you what you should do since you are not my patient for this surgery and that is between you and your surgeon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions and concerns about skull implants and would really appreciate it if they can be answered in detail. I am very serious about this operation and would like to find out more about it.
1) Let’s say I will get this operation during this month, how long will it be approximately before the incision will become unnoticeable? Also, Will I need to be wearing a hat for a certain amount of time until everything clears out to conceal it or no?
2) In what place will the incision be made and is 9 cm going to be the maximum for the incision?
3) Just out of curiously, will the implant be detectable when doing an x-ray or any type of scan at any doctor’s office or will it read as a single part of the skull?
4) Would you say this is a fairly easy operation?
5) Are there going to be any chances of infection/ nerve damage or any complications in the future or during the procedure?
6) Also, once the implant is inserted is it somehow attached or no? Or is it just inserted and the opening is closed?
Do you have any photos of how the incision/scar looks like right after it is closed?
7) Is it true that the thinner the custom implant is or the less material there is, the smaller the incision that needs to be made? Also, is it the patient’s choice or no?
8) Based on your experience, how likely is it that people around you will notice drastic changes of the shape of the head after the operation? Is it significantly noticeable or not noticeable at all?
9) It says on your website that the implants can be sectioned into 2 pieces and reassembled once inserted. Will this have an impact on the length of the incision or no?
10) After the surgery has already been done when can I see the incision disappear?
11) In the previous email you mentioned that it is better to do hair transplant using FUE in my crown area around 6 months after the surgery. Is there a particular reason why there is a need to wait for so long? If I decide to do the FUE before the surgery if it fine, how long must I wait before I can do this operation? Is there a specific time? Can I do it the next day?
12) Does the amount of silicone used affect the price in any way?
13) Is there going to be a significant difference in how it feels after the silicone is placed or no?
14) I am a casual smoker and I smoke very little. I would say I smoke around 1 pack per every two months or so. Also, I don’t smoke every day. Will this have any effect on the post op results such as healing time, etc?
Thank you and regards
A: In answer to your questions about skull implants:
- Provided one has hair for coverage the scalp incision would be fairly undetectable in short period of time. If one has a shaved head the incision will take several months before it fades considerably. The wearing of a hat or head wear is a personal choice, not one that I advocate either for or against.
- The incision placement would be based on what type of skull implant is used and its size. Without knowing these specifics I can not give a more specific answer. In general, however, most skull implant incisions are placed posterior more towards the crown of the skull area.
- Silicone skull implants are not detectable in plain x-rays. Their outline will be seen in CT or MRIs however.
- Placing skull implants can be a straightforward operation for those plastic surgeins who are very experienced in placing them.
- While infection is always a risk with any type of implant place in the body, it is not a problem I have yet seen in skull implants. Any other potential long-term concerns are related to the overall size of the implant but, in general, there is no risk of permanent nerve damage.
- I generally do place very small screws to secure the implant and use perfusion holes throughout the implant so tissue can grow through it between the overlying scalp and the underlyng bone. Thus making dosens of tissue connections through the implant.
- There is no question that the size and thickness of the skull implant affect how long the incision need to be to place it.
- I don’t think skull/head shapes are physical features that draw as much scrutiny as other facial features.
- While in some cases I do section very larges skull implants or are forced to based in their size or shape, it is not a preferred method as the integrity of the fit to the bone is most assured by placing them in the manner that they were fabricated.
- Incisions/scars do not disappear or go away completely. Their redness and visibility certainly improve with time and is a process of 3 to 6 months for maximal scar appearance improvement.
- When you induce changes to the scalp you do not want to put too close together traumatic (surgical) events. This stresses the blood flow to the scalp. This may cause hair shedding or, at worse, a devascularizing event where scalp loss may even occur. (I have not seen it but even the robust blood supply to the scalp is not immune to adverse vascular events) Therefore in elective scalp/skull surgery caution is prudent about the spacing of repeated surgeries.
- The cost of skull implants is not influenced by volume but by their method of manufacture.
- A silicone material placed on bone will feel like bone.
- You would be well advised to avoid any smoking for at least 3 weeks before and 3 weeks after surgery. Nicotine is a potent vasconstricting agent and carbon monoxide competes for space on the hemoglobin molecule with oxygen. Good blood vessel perfusion and oxygen levels provide for the best tissue healing possible and lowers the risk of infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had jaw angle implants and the implants used were a medium sized lateral jaw angle implants. I can tell the implant does what it is supposed to do and looks good, but I’m afraid the Doctor placed the implant forward of where it should be. I can send you photos. The problem is that this is the 2nd time I’ve done this procedure with this Doctor. Last year we used a posterior angle implant and the result was quite bad. I thought it was because we used the wrong style of implant and should have gone with the lateral implant. However, I now realize that it was because that implant was also not placed correctly. I can’t imagine that a Doctor would intentionally misplace an implant, or that the doctor wouldn’t know where to correctly place the implant. Either way I am not comfortable seeing this Doctor anymore. I found your website and see that you are an expert on jaw augmentation. I am able to travel to Indiana. Are you able to fix my situation by simply going in and creating a new pocket for the implant to correctly place it, or would you have to use a new implant?
A: Thank you for your inquiry and I am sorry to hear of your lack of ideal results on your jaw angle implant surgeries. I do not believe your doctor intentionally misplaced the implants but jaw angle implants are the hardest facial implant to get positioned properly and in a symmetrical fashion. Releasing the tendinous muscular attachments can be difficult and is the key to proper jaw angle implant placement in most cases. Even with proper pocket development and implant placement if they are not secured with screws malposition is highly possible. Since there is so little different between Implantech’s posterior and lateral jaw angle implant styles, you are undoubtably correct in that implant positioning is the issue not the implant style. (as you have discovered after the second surgery)
If the jaw angle implants are providing the proper width increase in the jaw angles and are malpositioned anteriorly then repositioning and screw fixation would be the corrective approach. I obviously have no way of knowing where your jaw angle implants are and would prefer not to presume or guess where they may be. It would be ideal if we knew exactly where they were on the bone and this would best be determined by a 3D CT scan. That would provide unequivocal knowledge as to where they are and how far off from the ideal position on the jaw angles they may or may not be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I briefly exchanged messages with you a couple of years back as I was quite distressed with certain aspects of my appearance, namely the extreme narrowness of my skull and length of my face. I tend to have a narrower skull/face than most, male or female. I have a very dolichocephalic skull, with all the usual signs; long midface, excessive occiput, narrow bitemporal area etc. I had a mild skull deformity and borderline long-face syndrome that caused vertical facial growth and heavy asymmetry of the face. I have subsequently had surgery with jaw angle implants and a genioplasty. I am very happy with the results as it has gone some way to adding width to my face and restoring an element of balance. However, I have been very impressed with your extensive information on the possibility of forehead/anterior temple widening. Or basically, overall widening of the face and skull. I think that could apply to my situation where I want to add masculinity and width to my face/head. I have attached some before and after pictures for you to hopefully take a look at. I have tried to find pictures that show similar camera angles in the before and afters.
The questions that I have are:
– Can you see potential for my forehead and temple area to be widened?
– I have always had a small mouth, but since having the jaw implants it has perhaps become a bit more apparent. Can anything be done to widen the lips?
– I believe that the surgery I have had has helped to balance my midface somewhat, but still think it is perhaps a bit too long. Can anything be done to shorten/balance the midface?
Thank you for taking the time to read this. As a potential foreign patient, naturally I have many questions to ask before hopefully flying over! Have a good day!
A: As I suspected back then shortening the chin and adding facial width by jaw angle implants will go a long way to make your face less long and a bit wider. Adding extended temporal implants that go all the way up to the side of the forehead as well as posterior temporal implants will add further benefit to this overall effect.
While you can widen the lips at the corners of the mouth, there would be small scars to do so.
There is nothing you can do to shorten the midface. That is a fixed structure that can not be changed without burying the upper teeth under the upper lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard that chin implants cause bone resorption. If this is true do they cause resorption under silicone nasal implants too? My nasal implant only extends to the dorsum. Also, how does one know if nasal implants cause scar tissue in the nose bridge? Thanks.
A: Silicone nasal implants do not cause bone or cartilage resorption of the underlying nasal structures. Chin implants settle into the chin bone because of the pressure and contraction of the overlying mentalis muscle. This is not active inflammatory resorption but simple passive settling of the implant a millimeter or two into the bone for a pressure release. It is a self-limiting problem whose concerns about it are way overblown. A nasal implant is placed under the skin and is not exposed to the same pressure phenomenon. In nasal implants the potential is not for bone or cartilage resorption but thinning of the skin over if they are big enough.
All implants placed in the body form scar tissue around them or become encapsulated. This is normal and occurs no matter where or what type of implant is placed, including nasal implants. This is a normal bodily response to an alloplastic (synthetic) material)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a silicone chin implant placed on June 12th and it has been discovered that the right wing was malpositioned, it protruded through my gum line. I have the revision done on June 18th, and there is no improvement whatsoever, the right wing is still siting very high above the jaw bone. What would be the best chin implant revision option?
A: I am sorry to hear of your unfortunate chin implant experience. It usually does not proceed down this complicated postoperative course. To have have had your type of chin implant complications would suggest two things. First the chin implant was placed through an intraoral incision. This is the most way chin implant wings get too high. Second, the implant was not secured to the bone with screw fixation. (which is ideally needed in intraorallly placed chin implants) Thus migration of the one wing of the implant into the mouth.(vestibule) The chin implant revision solution is to remove the implant, close the intraoral wound and immediately replace the chin implant through a submental skin incision and then rigidly secure it to the bone with a screw. With some form of fixation efforts at repositioning a chin implant in a slippery encapsulated pocket are prone to failure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my facial problem is that I am very skinny. I have no volume in my face with flat cheekbones. The doctors say my maxilla is also very small and is retrusive by 6mms.has a reduction of 8mm. Even though my body is not skinny, I have talked with surgeons because I want more volume as my face is very flat/skinny. They placed implants in my maxilla on both side of the nose. Even tough my profile is good, my face still looks skinny and I cannot smile because the implants change my smile completely.
I want to remove these implants. I want to have my smile back and more volume in my face, but I’m afraid if I put new ones in, the result will be exactly the same. I want to talk with a new surgeon so I can get a more satisfactory facial profile result. I have attached numerous pictures of my face so you can see my deficient midface profile.
A: Thank you for sending all of your pictures. If I understand your surgical history correctly, you currently have in certain types of midface implants. (malar and paranasal implants – four total implants) You mentioned malar but I wanted to be certain that you also have in paranasal (side of the nose) implants. Paranasal implants would be the culprit of affecting your smile, not the malar implants. Overall facial volume enhancement could be improved by fat injections which would provide a more global effect. Although I would not want to see you remove your existing malar implants as they are undoubtably providing some facial volume effect. I would have to know more about your paranasal implants as the style and size in place may be the problem not just paranasal implants per se.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, There is one other question that just occurred to me to ask you regarding jaw angle implants. I have noticed that when I clench my molars (I.e., bite down), my jaw looks wider and better-proportioned, which I’m assuming is due to having well-developed masseter muscles. Having said that, if someone’s jaw looks significantly wider when they clench their teeth, do you take this into consideration when designing a custom wraparound implant for them? Should the implant add only minimal width so that the patient’s jaw (after having the implant placed) doesn’t look too wide when they clench their teeth?
A: This is a good question but the simple answer is no, the prominence of one’s masseter muscles are not taken into consideration when selecting or designng jaw angle implants. The amount of time one spends clenching their teeth together or biting done is miniscule compared to the relaxed facial position. It is sort of like selecting clothes or an outfit taking into consideration what does one look like when they are flexing their chest or biceps. (although clearly some people do take that into account) You care much more about what one looks like naturally and not in a muscular contraction state.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, It’s been over a year since I had my frontotemporal skull implant surgery with you and I’m quite satisfied with how things have turned out. I have noticed however some hollowing near the eye brow roughly at the bottom edge of the temporal implants. This is very minor and I assume something like a filler or minor far transfer could smooth it out. In your opinion would it be safe to use fillers or fat around the skull implant site and its capsule?
A: Thank you for the followup and I am glad to hear that our custom skull implants efforts have come a largely satisfactory outcome. With such a large implant, particularly that extends far onto the temporal areas, it is not surprising that there might be a slight irregularity along one of the edges. I think it would be perfectly safe to use either injectable fillers or fat injections around the implant edges. As long as the capsule of the implant is not penetrated there should be no chance of infection. In order to eliminate the risk of implant capsule penetration any injection material should be done using a blunt-tipped cannula rather than a sharply beveled needle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about the jaw angle implants that worries me, I consulted a few Maxillofacial surgeons in my country. Some of them said to me that implants under the masseters muscles (for aesthetic reasons, not deformity corrections) is a bad idea, one of them even called jaw implants malpractice. The main argument is that due do the fact the those are the strongest muscles in the body and are constantly active (and mine are even hypertrophied) and will apply constant pressure over the implants, sooner or later it will lead to complications, that the main of them is bone erosion which will lead to relapse at the the best or more severe bone loss at worse.
I’v also been told:
– The procedure is quite aggressive and the masseteric muscles never recover completely from it.
– The procedure will cause mouth closing/ opening problems and chewing problems.
– The scar tissue that will created from the procedure will add 5 mm~ of width to both sides of my face, which will lead to an unaesthetic result, even if the implants will designed for vertical length only.
– The implants will cause thinning of the masseters over time, which will cause further health complications (I don’t remember specifically).
I would appreciate your reply to those concerns. Is the procedure really that dangerous?
A: The simple answer to almost everyone of your jaw angle implants concerns is that none of them are true or are based in any biologic or clinical reality. While it is true that jaw angle implants are placed under the masseter muscles, this does not lead to chewing or muscular dysfunction, underlying bone erosion, or aesthetically undesireable scar tissue formation. The only negative masseter muscle issue that I have ever seen, and it is an aesthetic one is that the pterygomasseteric sling can be disrupted if one is not very careful in their placement. This can lead to bulging above the jaw angle when biting down as opposed to the bulge being over the jaw angle point normally. Other than this potential issue I have found having placed, modified and removed many jaw angle implants that they are as safe and effective as any other type of facial implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you answer a technical question about lip lifts? Is there a difference between a corner mouth lift (smile surgery) and corner lip lift? Do you perform these type of lip lift surgeries?
A: In answer to your questions, a corner of the mouth lift and a corner lip lift sound very similar but there is a subtle difference. A corner of the mouth lift evens a downturned mouth corner by removing a small strangle of skin just outside of the mouth corner. A corner of the lip lift creates more visible vermilion at the tail of the upper lip (and can be combined with a corner of the mouth lift) by removing a small strip of skin kist above the lateral vermilion lip edge. Some people only need a corner of the mouth lift while other people only need a corner lip lift. Then there are some people who need a combined corner of the mouth lift combined with a corner lip lip lift because their whole side of the lip is turned down. I have performed a lot of both of these and you have to pick the right procedure for the lip problem. Often times I see patients who had the wrong type of lip lift performed.
Dr. Barry Eppley
Indianapolis, Indiana
