Your Questions
Your Questions
Q: Dr. Eppley, I am specifically looking for angle of the mandible implants (jaw angle implants) to increase the width of my jaw as well as increasing the vertical height to give it a more angled, defined look to my otherwise high, weak jawline. I am wanting to have a simultaneous chin implant to compliment the jaw implants.
While I can find endless information on chin implants, jaw angle implants seem rather non-existent and very few plastic surgeons perform them which has me a little apprehensive as to why this is. Would you be able to tell me more about this wrap around style implant and the advantages/disadvantages of having this over a simultaneous angle of the mandible/chin implant?
A: The history of chin and jaw angle implants are quite different even though they are located on the same bone. Chin implants are ‘end of the bone’ augmentations that are easy to predict the outcome, simple to place and have minimal morbidity and recovery because the overlying muscle and soft tissue cover and disruption is small. The first chin implant was developed in the 1960s and was and continues to be the most recognized and important bony facial profile enhancement technique. Chin implants have gone through many different designs and shape changes over the years to meet the differing needs of many different types of aesthetic chin problems.
Jaw angle implants, conversely, are very much the opposite of chin implants. They are ‘middle of the bone’ augmentations whose aesthetic reqiurements are harder to predict, require more skill and experience to place, and have more morbidity and recovery because the largest muscle on the face (masseter muscle) is being disrupted.The first jaw angle implant was introduced in 1995 without any design changes since then…with an original design (width only) that is inadequate for most patient’s jaw angle deficiencies. (vertically short)
With an increasing public demand for more complete jawline enhancement, there is a need for neeawareness offew surgeons however have ever performed them or had any training to do so. My experience with jaw angle implants and overall jawline enhancement in general is considerable as I have focused on changing how jaw angle implant surgery is done through new implant designs and the surgical techniques in placing them.
The fundamental difference between using a preformed 3-piece or a custom one-piece jawline enhancement is the connection between the chin and the jaw angle augmented areas. If one wants a perfectly straight line between the chin and jaw angle, then a custom jawline implant is the approach of choice. Custom implants are also needed when the dimensions of the jawline changes are desired exceeds the size or shape of what is available ‘off-the-shelf’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I exhibit a weak jawline and recessed chin. I have had several consultations with doctors in the Los Angeles area. The most logically sounding consultation seemed to be a custom jaw implant. I see that you do this procedure yet also use off the shelf products as well. My question is…is a custom implant truly superior and does the higher cost justify this type of implant? The doctor made a compelling argument for custom implants however the price was extremely high. Look forward to your reply.
A: The key decision between off the shelf and custom jawline implants is in what you are trying to achieve. Depending upon the nature and magnitude of the dimensions of the jawline changes desired, only a custom implant will work for some patients. In fact, in some of these patients they should not have the procedure at all unless they go a custom fabrication route, For others, a custom implant may have no significant aesthetic advantage and off the shelf implants will work just fine. You would have to supply me with the exact jawline changes you are seeking and some pictures to better answer your question about what will work for you.
When it comes to cost, it is important to realize that custom facial implants today are not significantly more expensive than preformed off the shelf implants. Why? While the material cost of the custom implant is higher than the material cost of preformed implants, they are capable of being surgically placed ini half the operative time. Thus the extra cost to design and fabricate a custom jawline implant is partially offset by the savings of a quicker operation. You also have to consider the risk of revisional surgery, where if it were necessary due to an aesthetic issue, any savings from using off the shelf implants would be completely wiped and exceeded.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle surgery and it was over-resected. I want to reconstruct my jaw angle (vertical height) and widen my front chin . I have a before and after x-rays of my mandible and I want to have it reconstructed as before. Also I want to get rid of my titanium screws. I enjoy boxing and i am really worried about this reconstructing surgery.
1) Can silicone be broken or bent or destroyed by punches?
2) Can silicone be moved or migrated by punches? Even if I get a 3D customized fit and screws attached? ( I’ve heard that it happens quite often)
You told me before that silicone would never move no matter how hard it is traumatized and I can enjoy every sport. However I’ve seen many cases of silicone implants moving. If your word is true please explain me how does that work.
A: While I don’t know where you are getting your information about jaw angle implants, I can only tell you what I know based on my experience answering questions and treating patients from all over the world in the past two decades with this type of facial implant surgery. I have yet to have an actual patient or an inquiry where someone has had jaw angle implant displacement from trauma. Perhaps this has happened to someone in the world, but I have yet to ever hear about it or treat anyone for it.
The apparent negligible incidence of silicone jaw angle implant displacement can be explained by an understanding of its biomaterial composition and the biology of encapsulation around it. The solid silicone elastomer of facial implants can not be fractured or broken, regardless of the imposing force, because it is not a brittle material. You can take a hammer to a facial implant and you simply cannot break into pieces. The bonds between the silicone molecules are flexible nor rigid. Thus when I say putting a silicone implant against a facial bone acts like a bumper, that is because of what it actually does and behaves like.
The long-term stability of any facial implant is ultimately determined by the body creating a layer of scar around it, a process known as encapsulation. This capsule (layer of scar) is what holds the implant in place and preventing future migration or displacement. The purpose of screw fixation of facial implants is to hold the smooth surfaced material securely in place until this enveloping scar tissue forms. For most patients, the screws beyond this point (6 weeks or so after surgery) have little value. But in the patient who may be exposed to some periodic facial trauma (e.g., boxing), the screws add extra insurance against any potential risk of implant displacement
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a minor case of asymmetry to my jawline .the right side of my mandible is angled higher and shorter in length to my left side. My right side is also weaker than my left side . if there is one thing I am pleased with about my right side it would be the shape. I like the shape of my right side better than the left. My question is is there any way my right side can be made the same length and just as prompt as my left side? And can my left side be made to shape my right side?
A: There is only one way to do what you want to do with precision for improving your jaw angle asymmetry….and I would submit that without this precision for your ‘minor case of jawline asymmetry’ it should not be done. Computer designing of the right jaw angle implant could be done using left side as the model from a 3D CT scan. Only a computer design process can match up the jaw angle sides. In short, you need a custom right jaw angle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have sent you a lot of pictures and will try to explain my questions! I definitely have some skull asymmetry. The back of my head is kind of flat and it looks really weird when I have s short haircut. I also feel that the space between my chin and neck is very small.
I also have facial asymmetry and one side is bigger than the other. One eye is than the other although I feel both sides of my face are not matched. My neck on the lower eye side also feels tight and I can’t move my head straight.
It’s a mess and doctors here say I was born like this but it has gotten worse over the years.
Thanks for reading this. Hope to here from you.
A: By your pictures and your description of symptoms and physical findings, you appear to have a relatively classic case of craniofacial scoliosis caused by occipital plagiocephaly as an infant. There are three potentially improvable craniofacial problems:
- The back of head flatness can be corrected fairly well through skull augmentation by either bone cements or a custom skull implant.
- You asymmetric eyes (orbital dystopia = one eye lower than the other) is improveable by orbital floor augmentation with or without eyelid elevation. Fortunately the eyebrow appears to be in a symmetric position.
- The tightness in your neck may be unsolveable. Unless there is a very distinct and palpable band (cord) along the sternocleidomastoid (SCM) muscle (i.e., band torticollis), the tightness may be a function of congenital shortness of the neck muscles. If there is a band, then it can be surgically released although this would be an unusual finding in an adult. One non-surgical option to consider is Botox injections into the tightest area of the SCM muscle.
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 am intersted in finding a physician that can do A Fleur De Lis tummy tuck with hernia repair after weight loss for “reconstructive repair” that will accept and submit to insurance. I know there are lots of patients getting this covered by insurance. It is how the surgeon submits it to insurance. Educated staff staff do know how to submit as medically necessary and not cosmetic. I was just wondering if your office was one that was able to do this procedure and have insurance cover it. Having a hernia, rashes, back pain, etc. is how it is covered, reconstructive, after weight loss is how it is worded. Thank you for your response. I don’t need to waste my time or the physician’s if they are not experienced in this area.
A: While I appreciate your perspective, from someone who does this for a living, it is not true that any one that wants it can just get it approved by insurance. And there are not lots of patients who are having this surgery being covered by insurance. The latest plastic surgery journals report that less than 20% of all bariatric patients ever have some type of a tummy tuck and even fewer are able to get it approved through their insurance.
There is not magical statements or way to juggle how its coded to make it medically necessary for insurance. There are very specific ICD9 codes for the diagnosis and CPT codes for the procedures. There are no guarantees that insurance will cover it no matter how it may be coded. It is not a function of ‘how it is worded’. Insurance does not care how it is worded. What they care about is does the patient meet their very specific criteria and have the medical documentation to support the procedures that are coded for. The criteria are well known and published and include two main issues:
1) An abdominal pannus that hangs over the groin and onto the upper thighs. (photos from three different angles)
2) A history of skin rashes under the pannus that has proven refractory to topical treatments over a 3 to 6 month period. (photo documentation of the existing rash and medical records that show it has been treated for at least 3 months)
Any insurance submission that does not include these two minimum criteria will be automatically denied.
If approved, insurance provides coverage for an amputation abdominal panniculectomy (infraumbilical panniculectomy), not a fleur-de-lis tummy tuck which is an extension of a panniculectomy. Any modification/extension of that basic procedure will be at the patient’s expense.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin and maybe jawline implants. Do you favour the intra-oral or extra-oral approach for chin implants? Also, do you use silastic or porous implants? I have attached some pictures so you can see how short my chin is.
A: The first question to decide before one considers how to augment the jawline is exactly what type and degree of changes does one seek. As you can see in the attached imaging, you could just do chin augmentation only (side view prediction) vs. total jawline augmentation of chin back to the jaw angles. (oblique view prediction) Your chin is so short because your entire lower jaw is underdeveloped so your jaw angles are rotated up and backward (high) as well. There is also a debate to be had about your chin as to whether that should be done with an implant or a sliding genioplasty. Therefore, options include:
Chin implant only
Chin and jaw angle implants (performed)
Total jawline implant (custom)
Sliding genioplasty alone
sliding genioplasty combined with preformed jaw angle implants
But when it comes to using jawline implants of any configuration, silicone implants are far superior to Medpor and a submental approach (vs intraoral) is easier with a quicker recovery. The small skin scar is inconsequential.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In elementary school I was diagnosed with Linear Morfia but I have also heard the doctors call it scleroderma as well. I am now in college and it effects the right side of my face. I notice it on my forehead, under my eye continuing down to my cheek and a little on my nose, on the corner of my lip, and also some places under my chin and on my neck. The places on my neck are barely noticable so I’m not sure if they are even fixable but all other places I think would be able to be improved. I’m not sure what procedures would be needed but I’ve heard a lot about fat grafting. I would love to hear from you on what you could possibly do for me to make me feel better about it. I am attaching a picture of the left side of my face to compare to the picture of the right side of my face. Thank you for your time.
A: Fat grafting is the best treatment that we currently know for the soft tissue atrophy that linear scleroderma causes. Since fat loss is a big part of the tissue thinning effect it creates, it is logical that fat replacement would be a key part of its treatment. Harvesting fat by liposuction and then processing it for concentration is how injectable fat grafting is done. Injectable fat grafting is very versatile so it can be placed almost anywhere on the face.I have done this many times for linear scleroderma and it is certainly the one treatment that can help. While historically any treatment for linear scleroderma was recommended to be done once the disease processhad burnt itself out, my feeling is that fat grafting should be done even if the atrophic process is ongoing. It may help abort further tissue atrophy. Sinjce fat grafting is harmless since one’s own tissues are used, there are no adverse effects with its use and it can be repeated as many times as is necessary for optimal soft tissue volume restoration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Since you are always up on the latest cutting edge techniques I was wondering if you were aware of Biotimes Renevia scaffolding gel injectable which was created to be a 3d scaffolding to be mixed with mesechemal stem cells from fat and then injected sdubcutaneously for lipatrophy defects. Biotime has granted Stem Center in Spain to do the clinical trials last year. I am thinking of going there to get injections for the post rhinoplasty defects I have to the soft tissue on my dorsum. The Renevia is composed of a special hyaloronic acid, collagen gel, polyethelyne glycol and stablizing agents. Do you have any opinions of this new technology?
A: While in theory this type of synthetic implant sounds promising, it is inportant to remember that this is a European clinical trial. A clinical trial means that there is no yet proven effectiveness for this product’s theoretical benefits…and it is not yet clear as to what clinical indication this product will be studied in. Just because it is going to be studied unfortunately does not mean it will work…this is why it is being studied.
Renevia is a type of hydrogel that resembles the network of molecules outside the human cell membrane, known as the extracellular matrix. Injected as a liquid and combined with some type of stem cells, the hydrogel forms a tissuelike scaffold that anchors the new cells onto existing ones, allowing for more effective tissue regeneration. This is the company’s statement and it all sounds very promising but has yet to be proven to work as such in a human subject for any specific clinical problem.
While the concept of stem cells delivered by any method is always very appealing, to date none of the clinical trials conducted on them have shown convincing and consistent benefits. This does not mean they never will but it is important to temper what they theoretically could do with what they may actually do. There is predicate story from nearly 25 years ago that may or may relate to stem cells and that is growth factors. Much euphoria, enthusiasm and research was put into turning their well known benefits into clinical products. To date few such useable medical products have ever made it to market.
We are a long way off from seeing what stem cells do during natural development into a clinical product that can have such amazing tissue regenerative properties in fully developed adult tissues. For now, you would be far better off to use conventional means of dealing with dorsal rhinoplasty defects such synthetic fillers, fat injections, crushed or injected cartilage. There are all more reliable and currently available soft tissue augmentation materials in the nose that have a well established track record of success.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a brain tumor surgery (meningioma) the size of a tennis ball taken out three years ago and I would like to know if bone cements for forehead augmentation/ reconstruction has any after affects. What consequence could the use of this material have on me. Where would the incision be done? How good could the outcome from forehead augmentation be?
A: I assume you had a frontal craniotomy/bone flap done to remove your meningioma and this has results in some contour deformities of your forehead. This is common as the frontal bone settles and heals with irregularities around the burr holes and the plates and screws used to fix them into place. These forehead defects/irregularities could quite easily be smoothed over/augmented by any of the different bone cements. The best bone cement to use would be that of a hydroxyapatite composition. There are no adverse consequences of this material on your bone or the overlying scalp. You would some or all of the same incision for your forehead recontouring that was used for the neurosurgical tumor procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32-year old woman and I have been searching for a solution to my protruding mouth (or perioral mounds)…I have had this all my life, and recently got some filler in my chin to balance out my bottom lip protrusion and also have Invisalign to correct my teeth. However, none of these treatments will get rid of the fat around the corners of my mouth and under my bottom lip. I saw a great case study on your web site and I’m wondering if I might be a candidate for the corner of the mouth lift and perioral mound liposuction. My big concern is that surgery could affect the muscles, leaving irreversible damage. Also, I wanted to comment on the results in the case study were very appealing to me because it appeared that the mouth lift and liposuction actually gave the patient an illusion of dimples, which I think is very attractive.
A: Small cannula liposuction can be done very successfully on the sides of the mouth, known as the perioral mounds. But it can not or should not be done below the lower lip as, not only will not be effective, but may cause injury to the depressor muscles of the lower lip. (as you have correctly surmised)
Tweaking up the corners of the mouth with perioral mound liposuction can certainly create the appearance of dimples as the mound area goes from convex to concave with enough fat removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw resection surgery.But it was overresected. So I am thinking of my jawline reconstruction. In theory would it be possible to have a strong and tough jaw by having my mandible reconstructed with 3D printed customized titanium alloy additive? Usually I heard that silicone or PMMA is often used to make a jaw line but they are not as strong as titanium and don’t have osteointegration properties. I love sports like boxing and I want to know if I can enjoy the sport with my reconstructed titanium mandible.
A: You can have your jaw angles reconstructed by using a 3D method to fabricate titanium implants rather than silicone. However the cost to do so may be prohibitive as the costs of the implants alone will come close to $10,000 and that does not include the surgical fees to place them. While this can be done, I don’t see the advantage of a metal reconstruction over the option of custom silicone jaw angle implants. They offer similar protection, would be easier to place, cost far less to manufacture, provide protection to the bone by acting as a ‘bumper’ and can be securely fixed to the bone so that they would have no problem withstanding any sports activity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting cheek implants next week but I became worried because my surgeon says he does not use any screws to secure the implants to the bone…just uses a pocket and wait for the scar tissue to hold implant in plance. Should I find another surgeon?
A: Just because your surgeon does not use screw fixation for cheek implants, that does not mean it will not be a successful surgery and outcome. Surgeons do use different techniques in facial implant placement and, as long as it works successfully in their experience, then that technique is adequate. I would say that those surgeons who secure their cheek implants with screw fixation is far fewer than those who don’t. The most common type of cheek implant fixation is pocket positioning that may be combined with sutures or even an external cotton bolster into which the sutures around the implant is passed. (this is generally removed in one to two days after surgery)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long face shape but small forehead. (like Sarah Jessica Parker). I really hate my face shape and would like to make it shorter. My nose is long and I was wondering if it were possible to shorten my nose, raise my mouth and then make my chin a lot smaller so that my face is a lot shorter but still in proportion. I also have a bump on my nose that I would want straightened.
I’m not sure if such thing is possible but if you could let me know if there is anything that could be done. I have attached a picture of what kind of thing I would like done. The picture on the left is what I look like now and the one on the right is kind of how I would like to look like after. The third picture is of the bump on my nose and whether this would be able to be corrected as well. Thanks!
A: Based on your pictures and goals, I would say that two of the three facial changes you would like are achievable with fade shortening surgery. A rhinoplasty can be done to eliminate the bump on your nose and provide some further refinement. A vertical reduction genioplasty can be done and the bone removed behind it back to about the mid-body of the mandible through an intraoral approach. It can achieve the amount of vertical reduction you are showing on our imaged picture but it is the most that can be done. probably about an 8mm reduction in anterior chin/mandibular height. Lastly, it is not possible to surgically raise your mouth (lips).
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you tell me what the cost of jaw surgery would be to shorten and recontour the face? I attached photos which show my face length.
A: The concept of facial shortening by double jaw surgery is based on whether you have vertical maxillary excess and a gummy smile. If one does not, then shortening the lower facial bones is going to bury your teeth under your upper lip which has a very negative aesthetic outcome. The pictures you sent do not show you smiling but I suspect you do not have true vertical maxillary excess as, even with non-smiling, one would have an open mouth posture or show evidence of mentalis muscle strain when the lips are together. Without true vertical maxillary excess, one has to look at a variety of other compensatory facial procedures like vertical chin reduction, subnasal lip lifts and rhinoplasty (that shorten the facial look) and potentially procedures that increase facial projection. (e.g., cheek augmentation) To determine the potential impact of any of these procedures on your face I would need to see some better pictures for computer imaging. (front and side views that are non-smiling)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping, specifically a reduction of a sagittal ridge. Not sure what to expect, I got a high top ridge at the back of my head (covered by hair, so a photo does not really show it) – rising maybe 2.5 cm above the rest of the skull top, which looks strange. Would you have reduction experience for that kind of surgery? Can one expect a great change in appearance. (assuming only 5-7mm can be reduced)? Thanks for your advise. 🙂
A: With very high sagittal ridges in which bony reduction alone can not make it confluent with the parasagittal skullbone, one can consider a combined sagittal reduction with augmentation of the areas right next to it. However, the first question to answer is really how much bone can be reduced. In very high ridges the bone may be quite thick and more than the typical 5 to 7mms could be reduced. This would require a CT scan to determine the sagittal ridge thickness and what type of reduction change to expect. It is also possible that in many sagittal ridge reductions I have seen that the bone is much thicker than normal and more may be possible to be reduced. This will be seen in a CT scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask you a quick question regarding jaw implants revision. I am a 29 year old male and have had silicone jaw and chin implants placed previously. I am very happy with them, however, as time has gone on I feel like the jaw implants could be slightly larger in width(1-2 mm each side at most). I am perfectly happy with the chin implant. I know you had said this desire for further augmentation is a common occurrence among young men and clearly you were right. I guess my question is a two part question. The first question is if fillers can address the slight augmentation desired, and if so which filler should be used? Any risks associated with this since there is a pocket and an implant already there? The second question is that were you to suggest surgery, would it be a very difficult procedure to remove just the jaw implants and replace them after nearly 3 years? I would of course like to do this as minimally invasive as possible.
Thank you so much for sharing your knowledge and providing this valuable advice.
A: Whle you certainly can have fillers done, I dount they will be very satisfying in the long run. Since you have jaw angle implants in place, it would be important to make sure that the injections avoid violating the implant capsule under the muscle. I don’t think the type of injectable filler used matters , they all will work. The injection technique is more important that want is placed.
For a permanent increase in jaw angle width, you can either replace the implants you have or use a wafer or wedge technique to augment what is in place alreasy. It is much easier that the first jaw angle implant surgery as you have an established pocket to do either. The simplest, and probably the most the most effective to do what you want accomplsih is the wafer method. This is where a wafer of implant material is put behind the existing implants to create the increased thickness. This does not necessitate the need to remove the implants, merely lift them away from the bone to slide the wagfer of extra material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 21 years old and I have average sized cheekbones. I’ve always dreamed of having very prominent and chiseled cheekbones, such as those of Mads Mikkelsen (even though I’m a girl) that have more projection on the outer corners of the zygomatic bone as opposed to the classic apples in the area below the eyes. I would like to augment a good part of the bone, yet pay much more attention to the area adjacent to the zygomatic arch. Many people would recommend me to aim at a natural and light outcome, but I want a very noticeable difference. I’m also a bit confused about the procedures. So far I’ve read a fair few articles regarding PMMA bone cement as well as Kryptonite and something about Medpor, still I have no clues whatsoever which one would suit my needs best. I would like something that is permanent, that endures time, that is at least as strong as the bone itself and that doesn’t get loose. As to the volume to be added, would it at all possible to have a 7mm or over projection.
A: When it comes to cheek augmentation, it is very important in any patient that the correct zone (s) of the cheek or zygomatic bone is augmented or highlighted. You have described exactly where you want the maximal augmentation to be done (posterior malar) as opposed to anteriior submalar which, as you have corrected stated, is the usual highlight augmentation zone for a female. That is is very helpful as then the correct cheek implant style can be chosen.
When it comes to cheek implant augmentatation material, no form of bone cement would be appropriate. What is used are preformed implants made of either silicone or Medpor material. Both are permanent materials that will never degrade or change shape and when fixed to the bone will be just as strong as the bone underneath it. Their ability to stay in place is more about how the pocket is made and how they are secured than it is about the material. There are advanatges and disadvantages to either solid silicone elastomer ot medpor, but my preference is for silicone as there are many more styles and size options and it is far easier to revise should that ever need to be done.
As for size of the cheek implant, 7mms would be a very strong change and may or may not be too much. Such thickness numbers may seem small but when it comes to putting an implant on your face, it can easily end up being much larger than one would have initually predicted. When it comes to facial implants, a slightly too small change is always better than one that is too big…as that will always lead to revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m breast feeding now. How long should I wait after I stop before I come in for a breast augmentation consultation? How soon can I have breast augmentation after breast feeding?
A:You should wait for breast augmentation surgery until your breasts have returned to their natural size after breastfeeding. By so doing you can gauge properly the implant size you need and the type of breast lift if necessary. But one can come in even while breastfeeding to get an initial evaluation and some general information about the combined breast lift and breast augmentation procedure. That will answer most of your questions and help you prepare for the surgery when your breasts are ready. Then you just have to stop in for a quick implant sizing appointment right before the anticipated surgery date. While there is no hurry to get the ball rolling so to speak, you certainly can if you desire.
It is also important to note that many women who have breast augmentation after breast feeding may note that they have some milk production after the surgery. This is due to the pressure of the implants on the milk glands that can cause additional discharge from the swelling of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I guess my wish list is quite long, but I don’t want to look like a different person. I’d like to reduce or remove the hump and slightly shorten its length. Also, on front view it seems slightly crooked and very wide, especially when I smile. If you could magically decrease my excessive snoring, my husband would probably appreciate that too! I’ve spent a lot of time thinking about this and looking at pictures online. I think a lot of doctors go too far for my personal taste. One common thing I see online is when humps are removed and the nose ends up actually dipping down in the middle where the hump once was. I don’t care for that. I also think some take off too much length and drastically change the side profile. I am looking for something more subtle.
A:Thank you for sending your pictures in consideration of rhinoplasty surgery. The type of nose changes you are after is a straight nasal dorsum and decreased nasal tip length with minimal tip rotation upward. Trying to not make your nostrils flare when you smile is precarious as decreasing the action of those muscles to do that can also affect the way your upper lip moves when you smile…which would not be a good tradeoff. The best you can do in that regard is to minimize the amount that the nasal tip pulls down when you smile. As for breathing improvement that would depend on what the inside of your nose looks like and whether you have any significant airway impingement by septal deviation and/or inferior turbinate hypertrophy.
The best way to avoid having radical nose changes from rhinoplasty is to not over resect or remove too much cartilage or bone tissue. Knowing your nasal change desires as being a subtle change helps your surgeon know how aggressive or conservative to be when performing rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction surgery. I have always had a high forehead and I have been embarrassed about it most of my life. I do my bangs everyday cause its all I can do to cover it and I get stares constantly everywhere. I wanna be like a normal person so I can get up out of bed and run out the door without having to do my hair. I don’t even get the mail unless I do my hair. I don’t even wanna go out and play with my kids unless my hair is done. I don’t get in the pool with them because I don’t want to get my hair wet around people. I want to know if I would be a good candidate for a one step procedure because I don’t want my head inflated with a balloon. Thanks so much!! (sorry my pics are horrible but I can’t do anything with my hair cutting wise or color)
A: Based on the picture you have sent, I can see your concerns about a high and broad forehead. While the picture may be somewhat distorted because of the fisheye lens effect from a cell phone camera, there is no question that you have a high hairline and what appears to be frontal bone bossing. I would need to see a side view that is not so close-up to have a better appreciation for the hairline position and how much true frontal bossing you really have.
You would definitely need a combined frontal bone reduction and frontal hairline (scalp) advancement. The key to whether a single stage procedure would offer enough benefit to make the effort worthwhile depends on how much your scalp can be advanced. That would be a function of how much natural flexibility it has (looseness) and how much it can be mobilized. There is also the question of how much hairline advancement do you need to make a difference and what is the location of your temporal hairline. (which is the most resistant to any significant forward movement. More pictures would help make those issues somewhat more clear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom facial implants to correct asymmetry and deficiencies from previous corrective jaw surgery. My case is completed in that I have significant nerve damage on the left side and an existing Medpor jaw implant on the same side that doesn’t address the problem.
A: Your description of your mandible/chin concerns is complicated but that is what makes it only treatable by a custom implant approach. Using a 3D CT scan, the shape of the lower jaw can be clearly seen with all of its asymmetries and deficiencies as well as a clear view of the indwelling Medpor implant. An implant can then be designed, most likely as a single piece that wraps around the jawline, after the computer removes the Medpor implant. Surgeries like yours are challenging due to scar tissue and the never easy removal of Medpor but can be very successfully improved with the aid of a custom facial implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 20 year old male and am interested in forehead augmentation. I have a protruding occipital bone and a slightly sloped forehead. I would like to get my occipital bone reduced, and then have the bone transferred to my forehead to make it more vertical. I reckon my own bone would be a better and safer material for forehead augmentation than a foreign substance like methylmethacrylate. Is this possible? I have heard wonderful things about your expertise, and I am willing to fly all the way to the United States from Australia to get the procedure done.
A: In regards to forehead augmentation, your concept of transferring bone from the back of your head to the forehead seems logical but unfortunately will not work for many different reasons. There would not be enough bone, it would have the wrong shape and part or all of it would be resorted. The safer, easier and highly predictable option are a variety of synthetic materials that maintain their shape, can be precisely shaped, and will not ever change shape after surgery. Options include PMMA, HA or a custom silicone implant, each either own unique advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in mandibular plate and screw removal. I had a sagittal split mandibular advancement done in 2012 with the use of 4 hole titanium plates and screw on each side of the jaw. Because I am a fairly thin person, I can feel the plates on the side of the jaw and I think they are also making my jawline wider in this area. Bone may have grown on top of them (which I am told is common) or there is a lot of scar tissue around them. Either way they make my face feel fat and I think their removal would have a somewhat thinning effect on my jawline. I went back to my original surgeon and he told me they look fine (weren’t loose) and removing them would be difficult, if not impossible, and wouldn’t make ay difference in how my face would like. Do you agree with him? Could these plates and screws be removed?
A: Your surgeon has the advantage of seeing you and your x-rays so any answer I would give would be based on incomplete information. But what I can tell you is that I have removed many times titanium hardware on the lateral cortex of the mandible in the angle and body area form either orthognathic or trauma surgery. I have yet to see hardware that could not be removed although it is never as easy as ‘just untwisting the screws and removing the plates. Bone overgrowth is common and to be expected. Often a thin film of bone covers the hardware and fills the screw slots. Some screws occasionally may have had their heads stripped while being tightened. You just never know what you are going to get. Burring off the bone from the screws will often destroy the screwheads which can make it very difficult.
One technical aid I have used recently is the Sonopet system for bone cutting and removal. Using high energy sound waves can very effectively remove the bone layer on the plates and screws with less trauma to the metal screw heads. It can also precisely and carefully remove bone from around the plate to get under it.
Whether removing the hardware will make your face thinner is matter of how big the plates are and the bone coverage that they have. But up to 5mms of thickness can be reduced from where the hardware once was. This can help reduce some width along the jawline in that area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In 2010 I had vertical Medpor jaw angle implants implanted. I am not so pleased with the result so therefore I would like to remove them. Is this possible?
Also, I would like to replace them with lateral width jaw angle implants, this is what I wanted in the first place but there was a miscommunication between myself and my previous doctor. If possible, and I know that it differs from case to case, what is the average approx. cost for this procedure? I would be flying in from Eurpoe so I would like to do the consultation and surgery in one trip. I can send pics to help before the consultation. Thanks.
A: I have had the experience of removing numerous Medpor jaw angle implants and replacing them with silicone-based jaw angle implants of various dimensions. Medpor implants can certainly be removed successfully although it is somewhat tedious as the tissues can be very adherent to them. It often can be just as traumatic to the tissues as their initial placement…and sometimes more so. But it can be done without any damage to the bone. Once the implants are out, there is plenty of room (pocket space) for the new silicone lateral width implants. But because silicone is a smooth material and the tissue pocket will be much bigger than the implants, it would he critical to secure the new jaw angle implants in with screw fixation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been an admirer of your work for some time & consider your website an invaluable resource for patients seeking to inform themselves in regard to cosmetic procedures.
I am a young male in my late twenties. My question relates to cheek implants. Specifically, I am looking to address two issues and I am hoping you might offer me some insight & the benefit of your expertise to provide advice as to what might be suitable choices. I have some asymmetry, my right cheekbone is less pronounced and has less anterior projection than my left side. I prefer the left side. I have also lost some weight & this has contributed to a loss of mid-face volume and deepened nasolabial folds. I do however have fairly good malar projection laterally, especially on my left side.
Would you advise me to address these issues with submalar implants of differing sizes or perhaps a combination implant on one side or both? I wish to avoid feminising my face through excessive lower cheek volume, but I am very keen to mitigate the asymmetry and restore lost volume in the midface. I would like to achieve the classic “v†shape model look if at all possible, but addressing the two issues I described is my priority.
Thank you for your time and attention.
A: In regards to your cheek asymmetry, the issue is whether you should just correct the right side to better match the left or do both sides with differing size and shaped cheek implants. The issue with either approach is how to best obtain symmetry. To do so you have to have a stable target so to speak. It is more predictable with standard preformed implants to just do the right side to try and match the left. But when it comes to implanting both cheeks that are already very different, it is pure guesswork with preformed implants. And such guesswork will undoubtably lead to improved cheek and midface volume but persistent asymmetry of some degree. If you are going to both cheeks, it is probably best to consider custom designed implants to get the best coverage and volume with the best shot at achieving much improved symmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. I had a 6-7 mm sliding advancement genio a little over four months ago (no vertical change, just a straightforward Sagittal advancement secured with a single titanium bone plate). From the beginning, I hated it. Even as the swelling has gone down I think it makes me look masculine, old, and like I have gained weight. I regret it so much and cry every day. I know I can’t go on like this but I am worried that reversing the procedure completely will give me jowls, which I never had to begin with. I understand you have some experience with reversing the procedure and I’m wondering if you think I will ever look like I used to. Thanks and please write back as soon as possible, I am becoming extremely depressed.
A: Sliding genioplasty reversal surgery can be successfully done. I have done two such procedures just in the last month. I do not have a picture of what you looked like before to see if you can return to your previous look. But that issue aside, if you put the chin back form whence it came I see no reason why you wouldn’t return to your preop appearance. You are obviously young with good skin elasticity so you should return without a high risk of jowling. The way to hedge that risk of howling in a setback genioplasty is to just go back 4 or 5mms and end up with an overall 1 – 2mm advancement change from the original. There is some reason you had the genioplasty and this may be a good compromise approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding capsule formation that I was hoping you could clarify. I have heard what I believe is misinformation that the material of Medpor facial implants produces a different aesthetic outcome than silicone facial implants in terms of chin/jaw implants . The reasoning this individual used was that silicone implants form a capsule and therefore the appearance of such an implant will always appear “off”, and that Medpor implants will not result in such a capsule.
Correct me if I’m wrong, but I believe that Medpor also forms a scar capsule (albeit a smaller one) and that while silicone forms a capsule, it is not one that has any significant or noticeable aesthetic impact. Capsular contracture can form aesthetic complications, but that is a actually rare complication not common to chin or jaw implants.
Is my understanding correct? If one were to make a custom silicone implant the exact same size and shape as a Medpor implant, wouldn’t the aesthetic outcome be identical?
I would appreciate any clarification you could provide on this topic.
A: All implants placed in the body produce a surrounding scar, whether it is a facial implant or a breast implant, regardless of the material. This is a natural protective reaction of the body. (self vs non-self) Thus both silicone and Medpor facial implants produce a surrounding scar (capsule) with the only difference being is that the capsule produced around a Medpor implant will be more adherent or stuck due to the irregular semiporous surface of the implant. The scar capsule will also be slightly thicker as a result.The internal surface of a silicone implant capsule will be very smooth (and thinner) since the implant surface is smooth. But beyond that, the biology and make-up of both implant material’s capsules are similar.
From the outside and its aesthetic results, identically shaped and sizes of Medpor and Silicone facial implants will look the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a consultation with a plastic surgeon last year who had all my personal information prior to the visit. Within two minutes they told me they don’t do any surgeries of any kind on cancer patients who had received radiation. I was upset, mad and disappointed because they knew all my history. Then I was charged $125.00 to be told that. Are plastic surgeons not doing surgeries on cancer patients? I do not need reconstructive work. I only had a lumpectomy but I would like smaller breasts and a lift. Any information would be greatly appreciated.
A: Reconstructive and cosmetic surgery can be done on the irradiated breast but it requires different considerations and surgical approaches. The irradiated breast, which may appear quite normal, is not. Its ability to heal is compromised by the negative effects of radiation on the blood vessels that supply the breast tissue, skin and nipple-areolar complex. A surgical procedure will likely unmask its limited healing ability resulting in incision separation, skin necrosis and partial or complete loss of the nipple.
In reconstruction of the irradiated breast, this well known compromised blood supply is managed by bringing in normal tissue that has a good blood supply through tissue flaps such as the LD, TRAM and DIEP. Such drastic’measures in cosmetic breast surgery, however, are obviously not warranted.
The choice in the irradiated breast patient that wants to undergo a cosmetic procedure like a breast lift is to either take the risk that no such complications will occur or to improve its healing capabilities. Improving the blood supply of the irradiated breast is done by initially doing first stage fat injection therapy. Through liposuction harvest, fat is concentrated and injected through the breasts implanting fat and stem cells. This approach has been well shown to obviate many of the negative effects on the tissues caused by radiation. Three months after the injection therapy, a breast lift/reduction can be more safely done. It may seem counterintuitive to initially make the breasts a little bigger by fat injections but this therapy completely changes the vascularity of the tissues which is essential to heal from any tissue injury.
Dr. Barry Eppley
Indianapolis, Indiana
