NOTICE: Ask Dr. Garcia is intended for educational and discussion purposes only. It does not constitute a formal medical evaluation nor consultation. No doctor-patient relationship has been formalized by this communication. If you desire such, please feel free to call and schedule an appointment. Otherwise, please be advised that all information that has been given here should be cleared with your primary care physician before changing or instituting any therapy. Explanation of off-label use of substances may be discussed here in but does not reflect an endorsement nor promotion of such off-label use.

• Dear Dr. Can you cut a silicone implant with out the implant leaking? Is it dangerous or anything if i am going to use it. I am going to ask my surgeon if he can cut the sides of an extended chin implant, but wanted to ask you first. Best regards.

  Answer:  if you are referring to breast implants, no, it will leak. If you are talking about facial implants like cheek or chins, yes, they are solid and can be cut or carved. JG 1.23.12

• Dear Dr. Im having silicone implant screwed on my medpor implant. Can you tell me if i have to deal with any coming complications? Or any negativity what so ever? Are they a bad combination close together? Best regards.

  Answer:  well, that is an unusual case, and although you are having a screw placed, unless two are placed, it can rotate. JG 1.22.12

• I have one cheek with a Gor Tex implant. I would like to have it removed. Will tissue stick to the Gor Tex? Will I end up with a hole? Will this be an easy operation? Also I want to get silicone implants in my top lip. Is that the way to go instead of Botox?

  Answer:  there is some adherence but I have taken out Gortex implants before without a problem. The overlying tissues might have been stretched out some, all depends on the size implant and how long it was in place. I would not suggest silicone implants in the lips if you are trying to get rid of small wrinkles and I never use Botox around the mouth for fear of muscle weakness causing drooling and impaired speech. JG 1.18.12

• I just posted the question about removing the chin implant and want to add that I am seven months post-surgery.

  Answer:  It should still help to remove it. JG 1.19.12

• I have written to you before about a painful chin implant and a problem opening and closing my mouth. The pain has extended into my front neck muscles and it causes pain when I eat. A neurologist said it is atypical facial pain and that I can take pain meds or chance that removal of the chin inplant may help. The original plastic surgeon told me if I did this I`d have the pain from hell, and two others said it is possible it may help. The neurologist wouldn` say one way or the other. As it stands, I must wear or chin bra or the pain is so severe,I end up bent over. I have feeling in the chin area. Do you have any comments?

  Answer:  I see no reason why removing the implant would cause an increase in your pain. It would either not help at all, or it would feel better. I wish you the best. JG 1.10.12

• Hello Dr Garcia, I have asked a lot of questions about the granuloma in my lip caused by dermalive, I was considering the perma lip implant and you had said you would be worried that if the granuloma is removed the implant may not stay in place. Well the doctor said we could take natural tissue form the other side of my lip once the granuloma is removed and then put the implant over it. What do you think? Im really upset and just want to get on with my life. If you dont agree do you have any other suggestions. So far this seems like the best option but id like your opinion. Thank you so much.

  Answer:  placing a solid or semi solid implant over the tissues of the lips is easy to do, but if there is an uneven surface underneath the implant, it might not look or feel straight. You can certainly try it and if you do not like it, the implant can be removed later if it is not comfortable for you.JG 1.9.12

• Feliz ano nuevo Dr Garcia,I trust 2012 will be a great for year for you! I have a question to ask, is it safe to get fillers on top of cheek implants and is there a risk of infection with doing this? I have medium malar ePTFE coated silicon implants (also my PS told me that they are easier to remove that Medpor?) and was wondering in your professional opinion what you thought? Thank you so much!

  Answer:  Those implants are easier to remove, yest. I think it is safe to inject over the implants, and there is no difference in infection risk. All the best for the New Year. JG 1.3.12

• Some years ago a dermatologist inject my cheek and lower lid with kenalog to dissolve scar tissue but it eroded most of the tissues of my midface. I`ve been getting by with Restalyne under the eye and Sculptra in the mid-face, but it never looks right. It`s always variable and often looks swollen after injection and then deflated (with an ectropion) when it`s time for another round of injections. I`ve consulted with a few plastic surgeons, and a famous facial reconstructive surgeon is recommending a spacer graft with hard palate. He considered an orbital rim implant but said he`d have to free up my entire midface to place it and that would be too dangerous in light of my histroy. Another surgeon told me that he thinks that a hard palate graft is completely crazy. Is this really an unusual (and unusually risky/ crazy ) surgery? While my face never looks right, I can sometimes have about a week or two each year between the waxing and waning injections when I at least don`t get stares on the street or questions from strangers about what happened to my face. Will the spacer graft make me look more normal or is it likely to make me look permanently distorted in the way that I do after being injected? I`m embarrassed to say that this whole situation has caused me to be depressed for years, which I never, ever was before this injury, It`s really hard to make these decisions when I`m getting conflicting medical opinions, since my physical health and my emotional health are on the line as much as my appearance. I want to make the best choice possible. I very much appreciate any wisdom you can give me. What would you do if you were in my situation? Or what would you advise a close friend or family member to do? Thank you so much for your help.

  Answer:  Your scenario is hard to evaluate for what is needed. If you cand send me some photos to drgarcia@lvcosmeticsurgery.com I might be able to give you more info. JG 1.3.12

• Hello, again. I am considering removing a multiple stitch chin implant that was done in conjunction with a deep necklift. Can it be done and ,if so,how long is the recovery?

  Answer:  can be done and I think you should be back to full activity in 3-4 weeks, got to take it easy the first two weeks to avoid bleeding. JG 12.28.11

• Sorry I meant ENT.

  Answer:  Plastic surgeon would be best. JG 12.26.11

• Happy New Year! I am the same person who had the chin implant and a neck lift. When I move my mouth, the muscles in the neck are being pulled. I now feel that I have rubber bands around my mouth and in my neck after seven months Who can treat people like me with SERIOUS problems ..a plastic surgeon,an EMT or a neurologist. Again, my PS has shown no interest in talking about it.

  Answer:  I think it best to see a plastic surgeon, but you sound like you need to find a new one. All the best. JG 12.26.11

• I forgot to ask if wearing a chin bra will make my condition worse. Merry Christmas and Happy New Year!

  Answer:  no, it will not hurt. JG 12.23.11

• Will wearing a chin bra make my condtion worse and whatis is the best medication for my condition pain-wise? I should have included these questions in my prior post. Thank you again! I have a close friend in Las Vegas, I`d love to . come out ot get a personal consultation. Merry Christmas and Happy New year.

  Answer:  will not make it worse, and as to pain medicine, I ask the patients not to take any pain medications that can cause blood thinning for two weeks after surgery, then usually Advil or Motrin is what we try to use. Please feel free to come to the office for a consultation if you are in town. JG 12.23.11

• I had a facelift, a necklift, a chin implant and fat grafting to my cheeks and mouth areas. I now have bumps and swelling on my inner cheeks and gums. I have trouble moving my mouth below the implant. This has gone for seven months. I must wear a chin bra to get some relief from pain and discomfort. My PS says he doesn`t have any idea why. Can you help? Margo

  Answer:  well, the muscles of the chin need to be lifted off the bone to place the chin implant and their ability to reattach to the bones will influence their function. Also, injecting fat into the mouth area, if the muscles that help the function in that area are bruised or scarred from the fat injections, they could be the problem. Besides massage for the fat injections there is not much to do. If it were due to the chin implant, if it is bad enough you could consider removing the chin implant and reattaching the muscles to see if the function improves. Sorry to hear about the problems. I wish you the best. JG 12.23.11

• No, my chin is not long, its just not square. I apologize for the misunderstanding. Its normal sized, but round. What type of chin-implant would you suggest? I`ve seen this implant called Terino square chin - style I. Could that be something? or do you suggest other?

  Answer:  It will help but the center part will also be bigger, there is no implant that will square it without making the central part more prominent too. JG 12.18.11

• Dear Dr. I have a round longer chin. I basically want a square chin. What type of chin-implant would you suggest to make it look like a square masculine chin? I don`t want the chin to be longer, but wider and square and more projection. Thank you on advance for your time.

  Answer:  I think if the chin is already long, an implant will likely not work. You might need to have the jaw bone surgicaly reduced and shaped, sorry. JG 12.17.11

• How long does it take for the scar tissue capsule to form around a silicone premaxillary implant? Upon removal is it possible it would leave some augmentation( even if its only in for a short period), and if so can it be flattened with 5fu?

  Answer:  there will be some minor amount after 6 weeks, and it will continue to grow for another 4-5 months. The degree of improvement it would leave is relatively small though, due to the thin tissue over it. It can be flattened with 5FU, yes.JG 11.7.11

• Hi Again, I`m the one who had the implants submalar and premaxillary in for 3.5 weeks and removed 5 weeks ago...the swelling is starting to subside and I have very noticeable sagging n/f and marionette lines my cheeks seem to have dropped, I feel like this may be permanent and might require a mid face lift..I was told it was a reversible procedure..what do you think?

  Answer:  I think it will take at least 6 months for things to settle in, I would not make any decisions until then, I think a lot of it is reversible. JG 11.1.11

• Hi dr Garcia I have been posting on here with my concerns since I had my cheek implants placed and then removed and I appreciate all your answers and you Babying me through it. My most recent concern of many is that my incision scars above my gums are creating lumps in the left side when I animate. What can I do to make them go away?

  Answer:  Massage and after 6 weeks, if very hard, you caan have your surgeon use some 5FU. Hang in there. JG 10.23.111

• Thanks for your response regarding my nerves (lip twitch) and muscles in my face (after gortex cheek implant removal).Dr, do you think it could possibly be “Synkinesis” that has caused this whereby my nerves have happened to become mis-wired while regenerating and resulting in this lip twitch with closure of my eye. If so, will this be permanent, would botox help with the lip twitching when my right eye closes as it seems to come from the nasolabial region. Do you think I have not healed properly or as you mentioned it could just be nerve stretching and scarring as result of the removal? Would botox maybe help? It is only slight but does distress me a little. I am seeing my PS in 2 weeks time. Muchisimas gracias, agradezco su ayuda, usted es una estrella!

  Answer:  Synkinesis is a very low probability, more likely is the tethering and scarring that will get better. Botox can help with the twitching, yes. I think the nerves are stretched and irritated but were not cut, so in time, it will get much better. Nerves are more easily cut during the placement rather than the removal. Give it time and all the best. Y es un placer ayudarle. JG 10.17.11

• Hola Dr Garcia! You answered a question of mine a few months back telling me to hang in there regarding my face after having goretex implants removed with regards to the muscles etc. It has now been 3 months and my face has slowly improved, but now I can’t see much more improvement, I am still unable to lift my upper right lip and pull my lip up on the right, at the moment I can only do this by a couple millimeters. I feel as if my healing has now halted and the muscle is stuck. I think it is the Zygomatic muscle responsible for this, however, I have noticed this past month that when I blink my r.side lip automatically twitches/ lifts up in conjunction when I blink just for a second almost as if the blinking action is causing my lip to pull upwards. Is this nerve damage or are muscles still in the process of healing? I am worried and hope to get my lovely smile back and should I be worried about my twitching of my lip - what do you think? Thank you ever so much for your patience and kindness in replying!

  Answer:  I think it is related to nerve stretching and scarring, but the fact there is twitching and some movement tells me the nerve is not cut. Progress will likely be slow form here on out, massage should help the muscles move better in time though. Its tough waiting but more intervention is not safe or warranted at this time. All the best. JG 10.16.11

• Hi Dr.Garcia, I had cheek implants about 8 months ago. They were sewn in and not screwed in. Within the first few weeks I noticed a slight indentation below my right eye and that the right implant appeared very slightly lower than the left. I had a bad infection on the left side - however it did resolve within a month (antibiotics etc). Now that it has been 8 months I have noticed that the right implant is not as pronounced as the left. No one else has noticed it, in fact I have to point it out to them. Should I have the implant repositioned? I am honestly afraid to redo the surgery because it cost me several weeks off work originally. The surgeon believes the difference is so subtle that it should not be redone. Is it possible that it shifted - even after 8 months? Thanks

  Answer:  It might be best to leave it alone if other people do not notice it as the difference form right to left is likely more due to the scar tissue that developed on the left side from the infection and not from the right implant moving. After 6 weeks it is hard for them to move. Removing scar tissue on the left is risky and moving the implant on the right up could make it more visible yet not achieve the symmetry you desire. JG 10.14.11

• I`m considering orbital rim implants to support my lower lids following severe ectropion from an aggressive bleph. I had a canthopexy and two canthoplasties and still have the problem. What are the pros and cons of the ORI from your perspective? Some surgeons say they will help by supporting the lower lids; others say they will make the ectropion worse by exerting a downward pull on the lids. Which is correct in your view? Thank you for your help.

  Answer:  well, the problem is that it might give some structural support but at the same time as they will enlarge the area, they will pull on the skin and may potentially make the ectropion worse, although not in all cases. As your case is from an aggressive blepharoplasty, I would doubt you will get any benefit and the negatives outweigh the positives, in my opinion. JG 10.13.11

• Hi Dr. Garcia, recently I asked you about using a fibrin glue sealant to help prevent sagging after cheek implant removal and you noted that it would not provide any significant support. Aside from not being very effective, could the fibrin negatively effect the outcome by making the scar tissue capsule more visible and noticeable on my cheeks if I were to use it? I`m asking b/c I`ve read that the substance of fibrin plays a critical role in scar tissue formation. Thanks again!

  Answer:  really no significant negatives, it might make it less swollen right after the surgery, which is good, but unpredictable. JG 10.13.11

• Hi Dr Garcia, Im the one who had the cheek implants and premaxillary implant put in and removed 3.5 weeks later. I am almost 2 weeks post op removal and am still swollen (not badly) around the cheeks and nose and lower face. I have two concerns. 1) It looks like my face is sagging, I have jowls and smile lines that were not present before, Im wondering if this could be caused from the swelling making my tissues heavy and causing them to droop, and if this will resolve once the swelling does, normally I have very little fat on my face and no smile lines. 2) My nose is very swollen with wide upturned nostrils and is not back to my prep nose-hopefully this is due to the swelling aswell?

  Answer:  All normal, the implants were not in that long, so as the swelling goes down, the skin will shrink and reattach. Things will continue to get better, but slowly. JG 10.11.11

• I have been told that removing cheek implants or any implant for that matter can cause the skin to sag, not from the swelling, but from the muscle being lifted off the bone and not reattaching in the same position after removal. Do you agree with this? I had mid face implants in for 3.5 weeks.

  Answer:  I would agree with that statement, that is why some sort of reaatachment should be done if possible. If there is an infection, one may just be able to remove them and then suspend them later. JG 10.6.11

• Thank you for the rapid response about the fibrin glue sealant Dr. Garcia! I really appreciate it. Just a quick follow-up: The other option I was considering to prevent sagging following the cheek implant removal was fixing the inner lining of the implant capsule to the outer lining of the capsule that formed on the bone with several sutures at the zygomaticomaxillary junction. Do you think this would be effective? My surgeon has two reservations about this approach: (1)He is not convinced that this would help b/c whenever he has removed implants in the past there was no capsular layer on the bone itself to which the implant capsule could be sutured. - Has that been your experience as well? (2)He is concerned that this option could result in a dimpling of the tissues directly above the capsule. Do you think this would help and if not is there anything else that could be done intraorally at the time of removal to minimize any potential sagging? Thanks again...Have a great weekend

  Answer:  I think suture are fine too, but the most reliable is for a small screw to be placed into the bone and then suture the capsule to the screw, that creates suspension and also closes the pocket of the capsule. JG 10.6.11

• Hi Dr. Garcia, I am having my silicone malar implants removed (afer 9 years, now 32) soon and one option that I read about to help minimize sagging was a fibrin tissue adhesive which would be applied within the pocket to help keep the tissues suspended as they heal. Do you think that would help? I was concerned that it might keep the tissues which are attached to the implant capsule from naturally moving with the rest of the tissues. Would that be a problem? Thank you

  Answer:  Do not think it will do much, good or bad. JG 10.6.11

• Hi Dr Garcia, I`ve been looking through your older posts from some people that had there cheek implants removed. I had mine removed large malars in submalar area and small premaxillary implant in on sep 2nd out on sep28th. My healing is ok it`s only been 5 days, my cheeks have come down a little, I can smile and move my upper lip although movements feel tight around the incisions and swelling.My nose is causing me the greatest concern since it is still wide and snout like, not as bad as it was but not even close to pre op, is this only swelling or could scar tissue have already formed in 3 weeks? Is it possible there will be mounds left where the implants were, or sagging even in this short time? I read of one girl who still had swelling 5 months after removal...when can I truly expect to go back to my pre op look, this has been one of the worst times in my life, thankyou for your answers and support.

  Answer:  well, there is tissue aggravation , but not true scar tissue. I think that the area where the premaxillary implant will settle down quite a bit, but because those muscles move so much while talking or chewing, it will take longer than other areas where there is not as much motion. I think having swelling still there 5 months after the removal is quite unusual. Give it some time for your case, it has been a short time and I think there will be lots of changes in the next few weeks. JG 10.3.11

• Hola Dr Garcia, espero que estes bien! You have been a treasure with your advice re cheek implants - I have had a few issues regarding cheek implant size and infection. I have a few questions for you: 1) What do you think of goretex as an implant for cheeks, are they prone to infections even several years after implantation, what type would you use, what do you think of silastic instead as I don`t want to worry about infections in the future. 2) Will having a medium size instead of a large extended malar implant equate to less swelling as I had large previously and my swelling took an exceptionally long time do dissipate, my ps reckons that it could have been due to too much strain on my tissues and bruising (however I dont recall having bruising on my cheeks post op?). 3) Normally how long should swelling take to go down? Could it be that I swell more than average, is there anything I can do to prevent this pre-post op? Thanking you so much, your wisdom and kindness is so appreciated from the bottom of my heart! Sorry for all the questions but I really value and trust your opinion!!

  Answer:  I normally use silastic silicone implants as there is a greater variety of shapes and size, but the infection rates short and long term are essentially the same. The size of the pocket required to place the implant influences the amount of swelling, but the difference between a large and a medium is very small and likely would not be visible externally as a difference. Most of the swelling on cheek implants the first go around is about 50-75% in 6 weeks and then the rest over the next few months, it would take longer on a second surgery. Besides ice afterwards and avoiding blood thinners, there is not much more you can do pre or post. All the best. JG 9.9.11

• I am 72 hours post op large terino shell submalar augmentation and small premaxillary implant I know it is early but my surgeon is offering me little comfort to my concerns I can`t move my upper lip although I can feel it and I am very swollen like a pumpkin..can I expect 50% of the swelling to be improved within 3 weeks? And is it likely I can`t smile or move my face due to swelling rather than nerve damage? I realize I need to be patient it is just very scary.

  Answer:  I think the swelling will be down at least that and the tissues should start moving better, remember that the implants are placed underneath the muscles, so that makes the muscles not work well for a bit, but it will get better. I do not think it is time to worry about nerve damage, that is rare. All the best. JG 9.6.11

• I am a 48 year old female who had a chin implant and lipo done on 8/18. I was happy with my results until a couple of days ago when I noticed a dime size indention in my chin. When I felt around the indention I could feel something like the pointed end of the implant. It comes to a point at the bottom of my chin right by the indention so I don`t know if the indention is from the implant not fitting right or from too much lipo is this area. The pointed end sticks out at the bottom of my chin and feels exactly what I believe the implant would feel like and it is definitely noticeable. The other side of my chin is perfect and I can`t feel the implant at all. I realize that I still have swelling and that I am less than 2 weeks out of surgery but I am starting to get worried. My next follow-up with my ps is not for another 3 weeks. Is this something that I should be concerned about or maybe something that will get better or should I contact my ps and let him know now in case it is something that needs to be corrected now. I hope I don`t have to go back and have surgery again to fix anything :(

  Answer:  I would call them and see if they want to see you sooner, I do think it might get better as things settle in, hang in there. All the best. JG 8.30.11

• Hi Dr Garcia, you very kindly advised me with regards to my cheek implants and their removal. You were absolutely right, I had a slight amount of skin sag to the left side of my face where I had prolonged swelling for several months due to infection etc. The right side looks as it did before as in nice and taut however there is now a slight fold near my nasolabial region on my left side which I feels on the one side ages me when you compare to the other side. What would you suggest as the best course of action for me? I am soon to be getting fillers for the interim period but was wondering when I get my cheek implants replaced in approx 6 months time will this help to lift the area that got sretched and help lift the slight fold or would I need a minimal lift of the cheek tissues so it looks similar to the right side? Thank you, so much!!

  Answer:  Fillers like Sculptra for now and I do think the new implant will lift and tighten things, hang in there. JG 8.21.11

• Dear Dr. García, thank you so much for your response, I really appreciate your help. I have decided to go with your advice and have both implants removed. I just wanted to ask what should I expect after the removal, will there be a lot of swelling (how long for) and will the tissues lapse or sag? As I mentioned in my earlier post, I am 34 but look a lot younger than my year, therefore I was wondering if the elasticity in my cheeks might prevent sagging as fortunately I have good skin. Having had an infection, does this mean I will be more susceptible to them in the future and would this be cause for concern when considering a re-insertion? Best wishes, Carla.

  Answer:  I think the swelling will not be bad, and it should be significantly decreased within a couple of weeks. The tissue might sag due to the fact you have had swelling for so long, but in most cases it is very small. an infection once does not mean it will happen again, but good tight closure of the incisions is key to avoid bacteria going inside. I wish you the best. JG 6.30.11

• Dear Doctor Garcia Firstly, I would like to thank you for your kindness in helping others and taking your time to answer and help so many people. I had cheek implants (Goretex) approx over a year and a half ago. (I am 34) Initially, I had a tremendous amount of swelling which made my surgeon think that perhaps the implants were too large as I have quite a narrow and petite face, (fairly flat in the cheekbone dept). The swelling took a long time to dissipate, several months infact. Unfortunately, just as the swelling was going down about 6 months ago and starting to look good, I got canker sores on my left side which happened to rupture in my mouth (I believe this was caused by using Listerine mouth wash, which I have now stopped using!) which consequently meant that gradually over 3 months and then more swelling to my left side and without realising my implant had come through as the rupture got bigger near the incision line near to my gums, consequently I had a surgical debridement to repair the wound and a resuturing. My ps told me that I was very lucky that I didn`t get an infection as I was left with an open wound for several months without knowing . Anyway, I thought that this would be it and that after the wound was healed I would then be left with the final outcome of my cheek augmentation, however I managed to get an infection in this wound which then caused a lot of pain and swelling. I wondered why the wound itself seemed to take ages to heal, well over 3 months and for my skin to grow back again. At the time of the debridement my surgeon and cut away part of the implant from underneath to allow the skin to heal. My surgeon now says that I need to get the implant removed asap, next Tuesday to be precise. He says that he thinks it’s best to remove the left side implant and leave the right one in. It means that I will have to wait a minimum of 3 months to wait and see how everything heals. My main concern is how will I look with only 1 implant left in place. I naturally have flat cheekbones and feel that with one large extended gortex implant it may look peculiar? My surgeon says that it wont look too odd as the swelling will slowly go down and hopefully in three months I can look to have it replaced. I asked if it would be possible to have some sort of filler in the meantime to balance out the proportions after the removal? He says that I would need to wait at least 2 weeks after the op to ensure that there is no sign of infection before injecting filler in my cheek. So for now I am on antibiotics and awaiting another surgery. In your professional opinion what do you think I should do ? Thanking you in advance for your time and advice. The right side looks perfect and I am very happy with how it finally looks but I am also worried that as with the initial surgery I will swell a lot and it will take a very long time to go down especially as it will be only on the one. My doc says that the 2nd time round should be no way like how it was 18 months ago and the swelling should go down much quicker with a speedier recovery. Apologies for the long message and thank you again for your time!

  Answer:  it is common for wounds not to heal when there is a prosthetic synthetic material in the wound that essentially holds on to the bacteria via something called biofilm, and it does not allow the infection to be eliminated until the implant is removed. It can be replaced once healed and after waiting at least 6 months. I would likely remove them both though, as you have had such a a tough time, in order to look as even as you can. I would wait at least 4-6 weeks for any filler too.I am sorry to hear about the issues and wish you the best. JG 6.30.11

• Thank you so much for taking the time to answer my question about the malar implants. I am so grateful for your information and the hope you`ve offered me. Is this something that you could help me with -- i.e., possibly reattaching the muscle and/or repairing the nerve? If not, whom do you recommend? I know you have a (wise) policy of not referring posters on this blog to your colleagues, but I don`t have the money or disposable time to fly all over the country for consultations, especially if they will only yield the same kind of response I have received at the facial nerve center where I am currently seen -- i.e., there`s nothing that can be done and it`s not even worth ordering any studies to confirm that opinion. Thank you again, Dr. Garcia. And God bless you.

  Answer:  I think you should go see someone who does this all the time, I might suggest seeking out a university based plastic surgeon that performs facial reanimation after strokes/paralysis, http://uwmedicine.washington.edu/Patient-Care/Our-Services/Medical-Services/Reconstructive-Surgery/Pages/ArticleView.aspx?subId=128 All the best. JG 5.23.11

• Dear Dr. Garcia, I fear I`m stuck with an irreparable dilemma, but I`m writing to see if you can offer me some hope. Two years ago, I had malpositioned malar implants replaced by a plastic surgeon who specializes in implant revisions. Immediately after surgery, I was unable to elevate or extend my right upper lip, which he attributed to post-op edema and temporary nerve trauma. After six months with no improvement, he posited that it was likely scar tissue and that the outcome was my fault for seeking a secondary surgery. After a year with no improvement, I went to a facial nerve center at an academic medical center. To my surprise, they didn`t do an EMG. They told me that undertaking that study would be pointless because 1) it`s impossible to damage the facial nerve in implant surgery because the dissection is done on the bone and 2) even if the nerve had been damaged, too much time had passed for it to be repaired; it should have been done in the first 6 months -- when my surgeon was insisting it would improve on its own. The nerve center enrolled me in their physical therapy program. Months of massage and exercises have done absolutely nothing. At my last PT appointment, they did biofeedback and could finally confirm with the electrodes that I was able to produce only the smallest amount of electrical activity on my right side, compared with a normal amount on the left. Here`s what I think: either the buccal branch of the nerve was damaged and hasn`t regenerated or, more likely, the levator anguli oris was transected. (Do either of these scenarios seem likely to you?) If the latter is the case, can that muscle be sutured together again and regenerate? if the former is the case, is there any possibility of repairing the nerve? Do you think I will ever smile or speak normally again, or am I stuck with this for the rest of my life? My overwhelming depression over this situation is augmented immeasurably by my shame in the fact that I brought this on myself by seeking out a repair (even if it was with a world-renowned surgeon and professor who urged me to pursue the surgery because the first implants were appalling in his view and mine). And now, I wear my shame on my face every day. It feels like some kind of cosmic punishment for what was originally a minor vanity. Instead of looking better, I`m functionally and aesthetically disfigured for the rest of my life, unable to speak clearly or to register normal emotion on my face. I`m so embarrassed -- on every level. Thank you very, very much for your compassionate help and time, Dr. Garcia. I hope my story and your reply may help your other readers even if it only helps them to know that they are not alone in their suffering. A particularly difficult aspect of suffering from adverse outcomes in plastic surgery is that we don`t even feel entitled to think of ourselves as suffering because, unlike those with real disorders or diseases which they themselves have not caused, we elected to bring these things on ourselves, even if we never intended them to happen or would never have pursued them if we knew where we would end up. And of course we can`t hide the evidence of our foolishness and vanity. It`s written on our faces. Forever. God bless you, Dr. Garcia, for caring for patients you will never meet or see in the way you do. You help our souls as much as our bodies.

  Answer:  well, firstly, you have no responsibility for the problem for seeking a second surgery, if the surgeon thought it too risky, they should have advised you of such. As to the levator anguli oris being transected or pulled off of its insertion, that is a possibility, but in time when the muscle scars in, there might be some motion, I have seen it in a couple of cases. If there is some degree of return but not to full activity, the muscle could possibly be tightened if it can be found. As to a nerve repair, if they could isolate the nerve that was transected, a cable nerve graft could be done like they do for paralyzed people and allow the nerve to regrow into the muscle, assuming the muscle is still viable. I would not give up the ship yet. I am sorry for all of the trials you have endured, but keep pushing, maybe seeking out another nerve specialist. I wish you the best. JG 5.22.11

• Hi, Dr. Garcia. I notice that you frequently post here that you like to use Sculptra to build up the zygomatic arch. Several years ago, I had small cheek implants placed and have been using Sculptra to build up the zygoma and temples. I wish I had known when I had the cheek implants placed that I could have (and should have) had extended implants that covered the zygomatic arch (and, in fact, temple implants too), since those areas are quite deficient in me. I was presented only with one option: small malar shells. The surgeon who placed the implants now doesn`t want to remove them and replace them with differently shaped ones and with temple implants, though he is a craniofacial specialist and routinely places these. I don`t understand why, except that he obviously stands to make more money with repeated Sculptra injections than with a single surgery. Unfortunately, I`m working class and don`t have money to spare at all. I need to minimize my expenses, so I`d like to correct this problem surgically and decrease the need for soft tissue augmentation. Can you tell me if there`s a common reason from a surgical standpoint not to correct this particular deficiency (zygoma and temples) with implants rather than Sculptra? I`m frustrated and broke! Thanks so much for your help and honesty, Dr. Garcia. I wish I lived near you. I`d love to be your patient.

  Answer:  I see no reason to not correct a problem that has been identified, in experienced hands those implants should do well. As a craniofacial surgeon he is likely able to do that for you. He may just not want to undertake it for purely cosmetic reasons and your only remaining solution is to seek out another surgeon in your area that feels comfortable with it. All the best. JG 4.22.11

• Dear Dr. Two questions here. I think i misunderstood something : Does a plastic surgeoun perform whatever an oral maxillofacial surgeoun does? or just some plastic surgeouns? And then i mean performing Jaw/chin implants of silicone screwed to the bone. Question 2 : I would like both Malar and Submalar silicone implants(cheekbone/cheekimplants) placed in my face in a few years. But, i already have small Malar implants of silicone placed on my cheekbones attached with screws which i don`t want to remove. Can a plastic surgeoun place new silicone cheekimplants both malar and submalar over them and attach them with screws? Thank you very much on advance. Sincerely

  Answer:  not all plastic surgeons perform that surgery and not all oral surgeons do either. I am not aware of surgeons leaving the old implants in place and placing a new one on top due to problems of shifting and breaking of the old implant and not allowing the new implant to lay in a proper manner. JG 4.17.11

• Hello Doctor, I have a question, I bumped my chin pretty hard a few hours ago and i have a chin implant. Now my lower lip and the skin below my lips going toward my chin wont stop quivering. Im scared the implant moved and now its pressing on some nerves or something. it doesnt feel or look like it moved....do you think this will go away??

  Answer:  I think the implant is fine, more likely is that the muscles or nerves were bruised and that will get better with time, might be a couple of days but it will slowly get better through that time. JG 4.17.11

• Dear Dr. I have heard that jaw implants and sidechin implants are a good option if u need definition in stead of a very larger jaw. I was planning to get artecoll, but i decided to instead have radiesse for now as a temporealy solution. Do you perform facial implant surgery a lot? I have already a chin implant and one left jaw implant. It looks nice, but what bothers me is that i still lack some small symmetry and defintion. Its important to look my best due to my job (being photographed). I wondered if its ok if i could get a consultation and if you could perform both ful fil lip implant and the smallest jaw implants/side chin implants? I will come all the way from Europe so i would hope it was possible to have the procedure as fast as possible when i arrive?I think silicone implants tighed with a screw is the best option instead of a permanent filler in a long term thinking way. About how much are the costs for both of the surgeries? How and when should i book a consultation and surgery day? Thank you very much.

  Answer:  most implants on the jaw in that position are performed by oral maxillofacial surgeons. I do not perform mandibular implants that you desire,sorry. JG 3.14.11

• Dear Dr.Garcia.Can all plastic surgeouns tighten a silicone implant to the bone with a screw? If not, does that mean he is not a good surgeoun? I heard the newer facial implants of silicone can leak? But can u screw them to the facial bones anyway? Or is that not true that the facial implants can leak? Should one spesific ask for the firm silicone implants?

  Answer:  it is certainly within the normal training as we are all taught how to fix a facial bone fracture with screws. Some doctors that perform the surgery in their offices may not have the drills though, and the screws cost money too. I have not heard of any evidence that any new facial silicone implants can leak silicone.They come in different firmness values, but none leak. JG 3.11.11

• Hi again, just to clarify, did you yes ori/ tear troph implants will make eyes look smaller? Would only getting a very small one avoid this?

  Answer:  well, maybe a little recessed is more accurate, since they aperture of the eye opening will not change. The larger the implant, the greater the difference, yes. JG 3.4.11

• Do ori`s or tear troph implants have the potential to male eyes look smaller? I have always had eye hollows similar to Angelina Jolie they are starting to look more pronounced, I don`t want to change the way my eyes look, big round innocent, I can`t to restylane since I have reacted to it with lumps in my lips. Could collegan be used under the eyes as a try on how long would it last in that area?

  Answer:  any time you make something come forward, the tissues around it might look further recessed, yes. Collagen can be used but will last a few months at most. JG 3.4.11

• Dr Garcia what is your speciality? I am interested in facial implants do you do alot of this work? Could I get a rough estimate of your fees for tear troph, paranasal and submalar silastic implants all done in one surgery? I would like to email you some pics also.

  Answer:  about 60% or more of my practice is facial plastic surgery. The costs of the surgery depend greatly on the time needed, so seeing your pictures first can give me some more info. Please feel free to send them to drgarcia@lvcosmeticsurgery.com JG 3.2.11

• I have naturally high cheekbones but am thinking of getting submalar cheek implant to give more fullness to my face, is it possible to place the implants in away so i still have high cheekbones? Is there a special submalar implant used with high cheekbones or size or placement technique?

  Answer:  there are submalar implants that come in a few different sizes, all depends on what you need, there is no special one used in patients with high cheek bones to start with though. Placement is the same. JG 3.2.11

• I am planning on getting silastic cheek implants and premaxillary implant, I have reacted to restylane injections in my lips with scar tissue formation, I`m wondering if I should not have facial implants since my body reacted to restylane as a foriegn body substance, should I be concerned about the facial implants being rejected or disfiguring scar tissue forming around them?

  Answer:  I think that will be different, there is 100% chance of a capsule forming around the implant, nothing that can be done to stop that, but it will hold the implant in position when properly done. JG 3.1.11

• Dear Dr. Garcia My 27yo daughter had a chin implant and lipo 10 days ago. We live in different countries so I cannot help her with her problem from this distance. She is pleased with the neck lipo and the implant but there is an open area in her neck that the doctor said was from the pressure dressing being too tight for 24 hours. My daughter thinks it is healing. It actually terrifies me that it will leave a scar. The doctor told her it was a rare occurance. Daughter said it started as a blister type thing then opened up.She sent me several photos, I don`t know how to forward them on to you. The wound is in the exact shape of a fishy cracker with a tail and everything. Can I send the photos to you? and do you think something can be done to avoid a scar? thank you , Rose

  Answer:  at this point applying topical antibiotic and avoiding pressure is the best thing to do. If the wound is superficial, it will heal well with minimal to no scarring, if it is deeper, then there might be some scarring, after the skin has healed using some creams such as ScarGuard or Mederma topically will help. It would be difficult to determine the depth of the injury by a picture, but you are free to send them to me at drgarcia@lvcosmeticsurgery.com All the best. JG 1.17.11

• Hi Dr Gsrcia Just wondering if you are doing the perma-sil lip implants.My daughter had them done and she looks fantastic.

  Answer:  we have just recently started, they are not for everyone though as they give the lip volume only, it will not give as much shape control as fillers can, and will not help small lipstick lines. JG 1.10.11

• Dear dr Garcia, can antibiotics clear an infection to porex implants (malar) or do they always need to be removed? Thanks and happy new year!

  Answer:  I would certainly try the antibiotics first, it might work, best of luck. JG 12.31.10