Facial Reshaping Surgery

Q: Dr. Eppley, We had previously discussed a facial reshaping surgery consisting of verical jaw angle implants, infraorbital-malar implants and a glabellar implant. Last week I had a second consult with another plastic surgeon that also specializes in facial implants as well. He offered very similar plan to you with only minor differences. I do have a few questions/confirmations i wanted to bring up after looking over the surgery plan:

1. The jaw implants for me would have both vertical and horizontal dimension?

2. Are the vertical and horizontal dimensions given in mm’s?  if so, what are the ranges of each dimension?  what size would you use for me?

3. The semi custom infraorbital-malar implants will be 5mm?

4. The other surgeon recommended a subperiosteal midface lift with the infraorbital-malar implants. Would you also do the subperiosteal midface lift?  

5. How many screws to secure jaw implants?  infraorbital-malar implants?  the glabellar implant?

Thanks for your time and answers.

A: In answer to your facial reshaping surgery questions:

1) Every standard jaw angle implant style offers both vertical and width augmentation changes. What makes the two basic styles different (vertical vs widening ) is the ratio of the vertical and width dimensions. Widening jaw angle implants provide more width than vertical length. Vertical jaw angle implants offer more vertical length than width.

2) Every facial implant, regardless of style and size, has very specific millimeter measurements which are provided by the manufacturer on their website complete with drawings and measurements. The best jaw angle implant style for you would be vertical jaw angle implants of the ‘large’ size. (11mm vertical, 5mms width)

3) The semi-custom infraorbital-malar implant will be 5mms at its thickest portion.

4) Every infraorbital-malar implant that is placed through a lower eyelid incisional approach is closed with a ‘subperiosteal midface lift’. Some surgeons chose to specifically call it as part of the procedure and even charge a separate fee for it. But, by definition, making the pocket for the implants requires raising a subperiosteal midface pocket to insert the implant. When the tissues are closed over the implant by sutures to the bone this is what constitutes the subperiosteal midface lift. It is an integral part of the procedure, some surgeons just chose to call it a separate procedure.

5) Jaw angle and glabellar implants generally only require one screw. The infraorbital-cheek implant may also only need one or possibly two. The judgment about the total number of screws is made at the time of surgery based on the stability and fit of the implants to the bone. Probably the correct  number of screws will be 8 not 6.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant Recovery

Q: Dr. Eppley, I am interested in knowing more about the custom jawline implant recovery process. I was looking at some of the before and after photos of custom wrap around chin and jaw implants on your website/RealSelf, they look amazing. Part of me says, I should do the whole jaw and be done with it. 

I would highly appreciate if you would explain to me one more time a detailed recovery timeline, progression of healing process such as what to expect in first few days to first few weeks and months,  along with most common complications and possible worst complications.

A: I will sum up the custom jawline implant recovery process, which is largely related to facial swelling, by this phrase…‘There will be more swelling that you can imagine and it will take longer to go away that you ever want’. If you embrace this concept then you will be well prepared for the surgery. To put specifics to it, 50% of the swelling goes down by 10 days, 66% to 75% by three weeks and 90% to 95% by 6 weeks after surgery. I do not judge, nor do I ever do any revisions, until the final result is truly seen three months after the surgery when all swelling, tissue shrinkage and psychological adaptation to the new look has occurred. Most patients will feel comfortable going out in public somewhere between 10 to 14 days after surgery.

The most common complication after a custom jawline implant is the inability of some patients to tolerate the necessary recovery process. They can feel it is ‘too big’ and want to rush to an early revision. (downsizing or removal) While this does not happen to all patients it probably occurs in about 25% of them and can pose a stressful recovery process for both surgeon and patient.

Dr. Barry Eppley

Indianapolis, Indiana

Male Brow Bone Reduction

Q: Dr. Eppley,  I am a  male interested in brow bone reduction. i have actually seen five surgeons….I vaguely talked to a plastic surgeon about it while I was getting basal cell removed from my nose. You mentioned the incision and that great thought needs to be put into it being done in a male.  After talking to surgeons I am a little confused about the scar.  One surgeon suggested either one of two things, a cut around the whole top of my head or multiple smaller incisions called endoscopy. He told me the same thing that we need to really think about it but he was referring more to male pattern baldness which is unknown.  Then I went back years later and he told me he wouldn’t work on me.  Another surgeon said he’d make an incision so thin that I could be bald and it wouldn’t be noticeable. Another surgeon said the same thing but I believe he said he’d just make two incisions at the top of my forehead and kinda do an endoscopy type thing and pull up my brow…burr it down and remove calcium deposits.  He said the way they were going to do it was that my forehead would appear smaller because my hairline would come down which sounded good to me. I think when I was a baby and since my head is large…I know there was a problem with me crowning when I was born…I think since my head was soft like all babies are it affected the way my hair grows to…..my hair grows down not straight up…..so I can’t grow it very long at all…matter of fact I generally have it shaved on the sides at a 1 or 2 guard….I  am afraid that you would see the scar.  I am also aware that there are hair grafts and I am wondering if that could be useful in my case.  Make no mistake the biggest problem is my brow…..its just two low, kinda grows downwards, and just looks extremely heavy.  I only get one life and I really need this done. I don’t want to make a mistake and fix something, but look unnatural or have a scar I have to worry about.  I’m not looking for a miracle…..before I turned 16 my brow wasn’t developed like it is now but my head was still wide…..i just want a more normal, natural, attractive, and vibrant appearance.

Thank you so much.

A: Let me help clarify the thought process for you about the approach and the scar that would need to be used to adequately perform your male brow bone reductiono surgery. First the procedure. The only approach to brow reduction that is going to work for you is not just simple shaving, that simply will not be enough and will not create enough of a difference. So throw out any suggestions about an endoscopic or limited incisional approach through your scalp. Your brow bone reduction needs to be an osteoplastic brow bone setback technique. Nothing short of this going to work. Second the incision. A osteoplastic brow bone setback technique needs wide open surgical exposure to perform adequately. Your incisional choices are either a full coronal scalp incision from above (almost ear to ear) or a mid-forehead incision through the deepest horizontal skin wrinkle that you have. The surgeon who told that a full coronal scalp incision could heal so well that it would be invisible if you are bald…is flat out wrong. That is complete fantasy and misinformation. While they can heal well and look good with hair, the scars often get widest in the temporal area and would never be well hidden with thinning hair or if one is bald. Given your concerns about the scalp scar I do not consider this a good option for you. This leaves with the mid-forehead incision which I consider to be the safest aesthetic choice. You already have horizontal forehead wrinkles so a scar that would look like one of them is a wider choice.

Dr. Barry Eppley

Indianapolis, Indiana

Nasal Depressor Septi Muscle Release

Q: Dr. Eppley, I have just read your comment about “Nasal Depressor Septi Muscle Release for Nasal Tip Animation Deformity”, I was wondering if separating the depressor septi muscle would not only stop a nasal tip droop when smile but also stop the tip from being pulled downwards while talking?

A: Nasal depressor septi muscle release, in theory, should also help somewhat with nasal tip deformity from talking as well. Although a more qualified answer would require seeing videos of your face while you are smiling as well a talking to look at the nasal tip movement that occurs.

It is also important to realize that there are two other muscles that also attach to the base of the nose, the nasal alas dilator and the superior quadratus, which can also create muscle movements that affect the base of the nose and how the tip may move.

The appropriate approach to your nasal tip concerns should be Botox injections. First treat the depressor septi muscle alone and see what happens with smiling and talking. If this is not completely effective than the lateral nostril bases should be injected to see if this produces a more complete elimination of nasal tip movement.

However

Dr. Barry Eppley

Indianapolis, Indiana

Cheekbone Reduction

Q: Dr. Eppley, I had cheekbone reduction surgery three years ago and I was left with these gaps/non unions. Of course, the gaps need to be closed and the bones repositioned and plates need to be used to hold the bones together. I have heard that I need to do this ASAP because the bones become dead. Right now I cannot afford surgery and I am saving money for a reconstructive surgery in the next year or so. How would you fix the problem and is it true that the bones become dead?  How urgent it is?  My face is sagging too.

A: It is certainly not true that the zygoma/zygomatic arch would become ‘dead’ if it is not reattached to bone segments urgently after the cheekbone reduction  surgery. The bone does not become dead per se, it remains alive but it will lose some bone mass/volume since it is no longer performing a supportive function.

But the for the sake of argument let us make the assumption that the bone did die if it is not reattached. At three years after the surgery this would have already happened and fixing it now would be an irrelevant issue. Therefore I don’t see the urgency to undergo ‘urgent’ zygomatic reconstruction at this point.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Reduction

Q: Dr. Eppley, I have jawline reduction surgery scheduled for next month. Could you answer a couple questions about the surgery? Can you have a look at the CT once more. The root of the last tooth on left mandible seems to be pretty close to the outer border of mandible. 

1)How many millimeters would it be safe to reduce on that point? Considering the nerves and risk of fracture in the future?

2)So the cortex parts of the bone seem to be the thickest. Will the bone adapt (create more cortex bone after part of it is shaved off? (afraid of fractures…)

A: In answer to your jawline reduction questions:

1) The bone that is removed in your type of jawline reduction  is from the inferior border of the jaw not the lateral border.

2) 4 to 5mms would be safe from a nerve protection standpoint. None of this bone removal places the bone at risk for future fracture. Not enough bone is being removed for that to be an issue.

3) The bone will not grow a new or thicker cortex. As stated in #2 above, this is not a surgery that places the bone at risk for fracture.

Dr. Barry Eppley

Indianapolis, Indiana

Temporal Cranioplasty

Q: Dr. Eppley,  I had mid facelift and a temporal cranioplasty area several years ago. I was filled all up the side from each ear to the temple area and about 3 inches in depth. I did not like the result as it felt monstrous so I asked for it to be removed. My surgeon asked if I wanted it removed or burred down and I specified removed. However, it feels as if quite a bit of the implant material is still in there and, several years down the line apart from still feeling like Frankenstein, I have a widened hairless scar on each side. More recently my hair seems to be thinning on the sides of my head in the area above the implant only. I have just got to menopause so this is evidently in part hormonal but it is definitely only in a specific area. I am really worried I am going to lose my hair. Please can you tell me if you have come across this issue before. I really look forward to hearing from you.

A: It is not uncommon to have widened temporal scars but this does not really have anything to do with the temporal cranioplasty implant material. It is just the nature of putting a vertical incision in the temporal area for some patients. It is also be partially related to how the incision was handled both in its making as well as its closure. Even if there is any residual implant material there it is not a known source of hair loss and has never been in my cranioplasty experience.

If you have residual implant material and would like it removed and well as performed temporal scar revision, I can certainly do that at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Wrap Around Jawline Implant

Q: Dr. Eppley,  I have a horizontally short chin and not very well defined jawline. Having made some very rudimentary measurements I would say I would like my chin advanced horizontally forward about 12 – 15mm. Due to the distance a sliding genioplasty seems out as an option. As I would be quite happy to have a better jawline as well as more prominent chin a wrap around jaw implant sounds like a good option to research. 

I have a few questions:

1. How many wrap around Jaw implants has you done? 

2. How many of these led to complications? 

3. What is the mean full recovery time? 

4. What is the mean recovery time to reach the point where I would not look post op anymore eg should be happy going out in public. 

5. What would be a full ballpark cost for the procedure both with a standard and custom wrap around implant? I would like this to include everything eg implant, hospital fees, Mr Eppley’s procedure cost, anaesthetists cost, screws etc.

A: Thank you for your inquiry about a custom wrap around jawline implant. Bringing the chin out 15mms with any type of implant is a ‘stretch’. (no pun intended) The tightness of the chin soft tissues would safely permit a 10 to 12mms change more ideally. In answer to your questions:

  1. I have done over 50 custom wrap around jawline implants.
  2. In terms of medical complications, I have not yet seen an infection or permanet nerve injury. However, such implants do end getting revised at the rate of 10% to 20% due to postoperative aesthetic size or shape issues.
  3. Full recovery in most cases is 6 to 8 weeks.
  4. Most people look reasonable by two weeks after surgery
  5. My assistant will pass along the total cost of the surgery to you later this week.

Dr. Barry Eppley

Indianapolis, Indiana

Hip Implants

Q: Dr. Eppley, I am a plastic surgeon who has a patient that wants to do hip implants. I just want to confirm that you put them under vastus lateralis fascia, over muscle, like calf implants. Any tips as this is new to me? A Canadian plastic surgeon describes placing them under TFL muscle. This seems risky to me.

A: The options for placement of hip implants are limited and are really subcutaneous in location for most patients in my experience. If you look carefully where most people want them it is higher that the upper extent of the vastus lateralis. It is either over the trochanteric depression or even slightly behind and above it.  In theory the TFL is more anatomic to the hip augmentation region but placing them under it runs a real risk of chronic pain not to mention the limited augmentative effect that will result from the tight fascia over it. Using an incisional approach high and behind the augmentative site also avoids any risk of running into the lateral femoral cutaneous nerve.

While it is always nice to have an implant deeper in the tissues, the hip region doesn’t provide any good and safe options to employ that concept. The other important implant feature of the hip region is that it needs to be of composed of an ultrasoft silicone polymer. (solid but feels like an ultra cohesive breast implant) For this reason I have them all custom made to get  the dimensions needed and the right implant feel. It also makes them easier to insert with a small incision.

I hope this is helpful,

Dr. Barry Eppley
Indianapolis, Indiana

Brow Bone Reduction

Q: Dr. Eppley, I am interested in brow bone reduction surgery. My brow bones are way too low. The ends of my brow don’t curve back behind my eyes much, they are more horizontal. Also I don’t know if you would call it my mastoid process or what but the part of my skull where the ears connect to skull and downward and upwards from there is too wide and it makes my face look wide. Basically I’ve noticed that most peoples ears are back set behind their cheek bones while mine are actually out a little further which gives my face a very wide look and makes my neck look too big for my face. Also since my head is so wide in the back it almost appears that it is my hair …it’s deceiving. I don’t know what all can be done but I also have calcium deposits on my forehead one of which gives me a pretty bad looking knot.

A: From a forehead standpoint, your brow bones can be reduced and reshaped and the entire forehead can be smoothed out. That can be done very effectively. The only question is the surgical access to do so. This will require some form of incision either on the forehead, at the hairline or back in the hairline. Such a decision to do so must be weighed very carefully in a male.

From a mastoid standpoint, I do not think that its impact is creating the effects that you think. I think your entire skull base is wide and this is what is creating the excess width issues. While the prominence of the mastoid bones can be reduced it will not create the facial and neck narrowing effects that you seek.

Dr. Barry Eppley

Indianapolis, Indiana