Sliding Genioplasty

Q: Dr. Eppley, I had a sliding genioplasty two years ago and I’m not fully satisfied because I would like more projection. The surgeon is brilliant and he did everything very well but I just want a little more. Is it possible to repeat a sliding genioplasty and will the bone heal the same? 

Also 10 months after the operation when I visited the surgeon who performed the genioplasty he pressed quite hard on my chin with his thumbs to feel the bone. Could that have pushed it back or am I just paranoid? Is the bone, plate and screws strong enough for that kind of treatment after ten months? 

I visited him again 16 months after the operation and he did the same thing again. 

I also hit my chin a little when I pulled my cover up while sleeping yesterday. I’m constantly worried that it’s shifting or lose. Do I need to be? 🙁 

Sorry for such a long message. Thank you!

A: There is no reason that you can not have a secondary bony sliding genioplasty years later that would heal just as well as the first one. While there is no good reason to be pushing on the bone, there is no risk of causing it to move backward. The plate and screw fixation is more than adequate to resist any displacing forces early after surgery and the healing of bone s more than adequate to do so months to years later.

Dr. Barry Eppley

Indianapolis, Indiana


Q: Dr. Eppley, I have a small lipoma on my stomach that I’m interested in having removed without a scar. I found some of your posts relating to this issue and LipoDissolve (Kybella) seems like a viable alternative. Your post mentioned that it might take multiple injections, do these injections have to be within a certain amount of time? I work outside the US most of the year and only travel home to Indy a few times per year so I might have to spread the injections over a long period of time. 

A: The only non-surgical alternative to surgical excision of a lipoma is injection therapy. While one known as Lipodissolve, it is now known as Kybella injections. These are pure deocycholic acid injections which help break down the lipoma by disrupting the cell walls of the adipocyutes within the lipoma capsule. Over the years I have treated a fair number of lipomas with injections and it almost always takes ore than one injection treatment to get the maximal reduction. While I usually space these as close as 6 weeks apart, there is no harm in having much longer periods between the injection sessions. It does not adversely affect the injection’s effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant

Q: Dr. Eppley, The side profile shot is taken of what I consider my weaker side, though the left side has only slightly better bone and muscle definition, it is a noticeable difference. Its something I have been conscious of all my life – lowering and pushing my jaw forwards in photos etc and now as I get older, it appears to be more noticeable. 

I’m not looking for a wide angular jaw bone as I have an oval face and a fairly small head size so that would look weird. I’m relying on your aesthetic appreciation of my request based on the following considerations to hopefully provide a stronger, but normal looking, less saggy and symmetrical jaw line.

1. To gain a slight vertical lengthening of my jaw line
2. Consider the amount/effect (if any) of slight vertical lengthening of my chin with this procedure. Or will this make my face unbalanced?
3. To further enhance the weaker right hand side to correct the slight bone and muscle asymmetry to match the left side. 
4. Determine if I would benefit aesthetically by a slight chin projection to help the overall balance and proportion of my face?

Hopefully, if this can be met it will take up some of the slacker soft tissue and negate any surgical lifting and provide balance and proportion? That’s my aim anyway.

I look forward to hearing from you soon.

A: Given your multiple aesthetic needs of your lower jawline, only a custom jawline implant can come close to achieving all of your goals. The addition of vertical lengthening of the jawline as well as some horizontal chin increase can only be done by such an implant. Because the custom jawline implant adds overall bony volume it will by definition pick up some loose tissue along the jawline.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I have some questions having to do with facial reshaping.

1. Is there a limitation in how many millimeters can one widen the cheekbones with a zygomatic osteotomy?

2. Since custom made cheek implants can be created as large as a patient desires, will the dimensions of the implants follow the dimensions of the widening result of the face or more specifically the soft tissue of it? For example, if a patient was to have inserted cheek implants that were about 5 mm wide each, would that lead to a total centimeter increase in bizygomatic width, or more and even less than that?

3. Aside from lip lifts, rhinoplasty and cheek implants are there any other effective ways to give an illusion of a shorter pupil to lips distance that appears long on a face? I was thinking that some work around the eyebrows could be a potentially good idea but I’m not sure how this could be done.

Thank you in advance.
A: Thank you for your inquiry. In answer to your facial reshaping questions:

1) Generally 5 to 7mms of out fracture of the anterior arch can be done before there becomes an obvious step-off externally.

2) In onlay custom cheek implants the overlying soft tissues generally follow on a near 1:1 basis.

3) Without seeing pictures of your face I can say what may or may not be effective in decreasing the pupil to lip distance.

Dr. Barry Eppley
Indianapolis, Indiana

Lower Buttock Lifts

Q: Dr. Eppley, I am interested in lower buttock lifts. mI have been trying to correct my saggy buttocks for over a year now. I have been very athleltic all my life and no matter how toned the rest of my body is there is always a saggy pouch below my buttocks. I had fat injections which didn’t take then I asked my surgeon to excise the sagging skin and fat. But he didn’t emove much at all and it’s basically still the same. I have found your website and it appears you know what you are doing with this. So I am wondering if you can correct this (no implants or anything required, simply removal of that pouch) and what sort of recovery I will be facing?

A: Lower buttock lifts are really the only technique that can improve redundant tissue that hangs over the infragluteal fold or loose tissue just under the fold. Please send me some pictures of the your lower buttocks so I appreciate the issue that you have and where your current lower buttock scar is. Most likely your last surgery simply did not remove enough tissue to see much change. The recovery from lower buttock lifts is really only limited by how much you can bend over after the surgery to avoid excessive pulling on the suture line. One should avoid returning to most forms of strenuous exercise for four to six weeks after surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Custom Cheek Implants

Q: Dr. Eppley, Can you please tell me whether a custom high cheek implants for males can also be adapted to provide augmentation to the under eye area? And also can custom cheek implants be designed to give more volume than other implants as I desire noticeably higher cheekbones whilst still looking natural.

cheek-infraorbital-impalnt-vs-standard-cheek-implant-dr-barry-eppley-indianapolisA: It is actually very common to have an infraorbital extension under the eye as part of many custom cheek implants as part of their design. (compared to a standard cheek implant which is the darker blue one) This can be seen in the attached custom cheek implant image example. Not only can there be an anterior infraorbital extension but often there is a posterior infraorbital extension back along the zygomatic arch as well. By definition custom cheek implants are usually bigger and thus have greater volumes than standard sized cheek implants. It is important to know that the design of the implant and the bone that to covers is more important than thickness or size. It doesn’t matter how big the cheek implant is of it is not the right implant style and design. This is why i do so much custom cheek implants as many patients don’t get the right design of the implant for the look they are trying to achieve.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping Surgery

Q: Dr. Eppley, I asked for your consult about getting a more chiseled and angular face with much more symmetrical proportions through facial reshaping surgery. I had a surgery three month ago including putting in a chin implant, buccal fat removal and very small cheek implants. Unfortunately I didn’t get the desired results with those procedures. In the coming week I’ll go to visit my Doctor again. But it seems that I have to find out my problem and reforming options by consulting with you and then asking my own doctor to do that. Maybe you have gotten my before operation photo so I will send you my present look photos. In my opinion and after watching your videos on Youtube, my chin implant shall be removed and I should get a vertically shortening and horizontally augmenting sliding genioplasty plus jaw angle implants and submalar big cheek implants. Please let me know what do you recommend, even if its possible in details, such as size and shape of implants.

A: The creation of a more defined and angular face is not going to come just from chin and cheek implants and a buccal lipectomy in most patients. These procedures may be part of the solution but they alone are usually going to be inadequate. This could have been predicted before your prior surgery. The creation of a more defined jawline is a big part of creating an overall more shapely face through facial reshaping surgery. What jawline procedures, or other procedures, would be best in that regard must be determined by the doctor who is going to do the surgery. It is not medically appropriate that I provide a list of procedures and specific implants so you can pass that information along to another surgeon. That decision must be made between you and the treating surgeon.

Dr. Barry Eppley
Indianapolis, Indiana

Orbital Rim Osteotomies

Q: Dr. Eppley, I have purchased a book in which you were a co-author of called “Aesthetic Surgery of the Craniofacial Skeleton”. I have an inquiry on a certain procedure that is in it. I am looking to increase the width of my actual eyes (horizontally). (Lateral Orbital Rim Osteotomies) The book entry says you can reduce the width of the eyes by cutting the outer orbit bone and putting it closer in. But is is possible to do the reverse and position it further outward and this would lengthen the eyes?

Do you perform this procedure or have a college that performs is? I really want to make my eyes longer.

lateral-orbital-rim-osteotomy-dr-barry-eppley-indianapolisA: While Lateral Orbital Rim Osteotomies can be done to narrow eye width, it does not work in reverse to make the eyes horizontally longer. This is because of the lateral canthal attachments and the position of the lower eyelids. By moving the bone or corner of the eye outward, you end up pulling the lid margin away from the eyeball. That will cause multiple eye symptoms of irritation, dryness and even excessive tearing. The eye requires that it maintains good apposition of the lid margin right up against the eyeball.

Dr. Barry Eppley
Indianapolis, Indiana

Buccal Lipectomies

Q: Dr. Eppley, I’m a 48 year old HIV positive male who is healthy, have undetectable viral loads, and have been on Atripla for many years. I have always had a full round face and cheeks and was thinking of getting buccal fat pad removal.  (buccal lipectomies) I workout with weights and cardio. I will be getting cheek implants. Do all people on HIV meds get facial waiting? Is buccal fat pad removal totally contraindicated for me?

A: Historically HIV medications did cause a lipodystrophic spectrum of facial lipoatrophy and body lipohypertrophy. Newer medications, like Atripla, have a much lower incidence of causing these fat altering side effects. If your face is round and always has been then I would say that buccal lipectomies are not contraindicated and can be performed without concerns about adverse aesthetic long-term effects..

The key question now is not whether buccal lipectomies should be sone but whether they would produce a noticeable external facial thinning effect. That would depend on how round your facial shape is and where most of the fullness is. I have performed buccal lipectomies in a select few HIV positive patients whose face merited a facial defatting procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Revision Rhinoplasty

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I have had rhinoplasty one year ago. I got the results for what I asked for, my nose was straightened and the hump was reduced. My tip was never corrected as I was told by my doctor there was not need for it. It really seems to bother me and I would like it corrected. Would this be classified as a revision rhinoplasty surgery and would it be more harder to perform then the first surgery?

A: I am going to assume that your original rhinoplasty was done by an open approach. Secondary tip work would be no harder to perform now than during the first surgery. The scar tissue that is present would pose no issues for doing secondary degloving and tip work. Preoperative computer imaging may have been able to show whether tip work as needed.

If your original surgeon performed the tip rhinoplasty it may be considered a revision. But this would certainly not apply to a new surgeon performing the procedure. For the new surgeon this is a new procedure for which he/she has no obligation stemming from the prior rhinoplasty. An isolated tip rhinoplasty is, however, less costly than a full or complete rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana