Reverse Otoplasty

Q: Dr. Eppley, I am interested in making the ears more prominent (reverse otoplasty) from the front. My ears are barely visible, hiding behind my face at an odd angle and have always been insecure about it. I was wondering if it might be possible to to maybe build up the bone underneath the ear or any other method to make them come out farther than my face to an ideal angle? Thanks in advance.

A: Ears that naturally are back too far (minimal auriculocephalic angle) or those that have had an otoplasty that is overdone are treated in a similar manner. A reverse otoplasty technique is used where an interpositional cartilage graft is placed between the released antihelical fold cartilages. (cadaveric rib cartilage) This will push the outer helical rim outward and make the ears more noticeable from the front view.

This is an ear procedure that is done by making an incision on the back of the ear and exposing the curved cartilages. The cartilages are then scored to release them and a cartilage is placed between them to push the outer half of the ear outward. The key to success with this procedure is the interpositional cartilage graft. 

Dr. Barry Eppley

Indianapolis, Indiana

Skull Reshaping

Q: Dr. Eppley, I am interested in a skull reshaping procedure. I have an odd shaped head that is long from front to back. I think I have a form of craniosynostosis that went untreated as a baby. What can be done now for it? I have attached pictures for your review.

A: Thank you for sending your pictures. As you know your head shape is a direct reflection of having had untreated sagittal craniosynotosis. This is why the back is so long and the forehead is slated backwards. While you did not include a front view, it is also likely that your head is fairly narrow in width as well.

What you may know is that it is no longer possible to treat your skull shape like is done in infants…a total skull reshaping by bone removal and expansion. That is done done in adults as that approach is reserved for when the bone is very thin and malleable.

This leaves you with several options. First, can the back projection be reduced enough to make a noticeable difference? The answer as to whether that is an option is how thick is the bone as this will require an x-ray to answer. Other options include upper forehead augmentation and skull widening but these may be not as important as reducing the projection on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Upper Blepharoplasty

Q: Dr. Eppley, I was wanting to know if you procedures for the upper eyelids (upper blepharoplasty) would qualify for insurance coverage. My insurance company said it should since it’s affecting my vision. I just wondered if you accept that. Just for the upper of course. Thank you for your time.

A: Whether insurance would pay for an upper blepharoplasty can not be determined by the patient asking them. It requires a complete written predetermination process submitted by the surgeon which must include visual field testing by an opthalmologist/optometrist that clearly shows visual field impairment as well as pictures that show sufficient hooding of upper eyelid skin. As a general rule it is very difficult for patients under age 65 to qualify today for what was once a common insurance coverage procedure. Only the insurance company can actually tell you based on the submitted information whether they would cover it or not. Talking to your insurance agent or the benefits office does not constitute an approval or whether it will actually be covered. They always say it will be covered ‘if there is a medical reason for the surgery’ when the patient calls and asks. But only the predetermination department of the insurance company can answer that question based on submitted information.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Implants

Q: Dr. Eppley, I am interested in jaw angle implants. I’m looking for a small width increase to my ramus/jaw line and possibly a genioplasty. I feel that my chin is under projected for a male but I dont want to overdo anything either as I want it to look natural which is what I’m more interested in bone fusion than implants. In terms of implants, is it a a high risk procedure for the jaw implants? 

A: When it comes to creating width to the jawline, there is no other method than to use implants. Jaw angle implants pose similar risks like that if any other facial implant, they have no additional risks than the standard risks of infection and aesthetic concerns. (asymmetry and size issues) that all facial implants share.

 The one issue that makes the different than some facial implants (nose and chin), although the same for other facial implants (cheeks and temples), is that there are two of them as they are placed in pairs. Thus they have double the potential risks as that of a chin implant for example. This is most notable as it relates ti symmetry between the two implanted sides.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Implants

Q: Dr. Eppley, I’ve been wanting breast implants for awhile now. My family all have bigger breasts than me and I’m the one with nothing. I don’t want really big breast but big enough for me to have my self esteem high. And I wanna feel good about myself. I’m 19 years old. I am a young mom. I plan to have not in the future. I wanna still be able to breast feed and look natural. Any suggestions will you help me?

A: At 19 years of age you can certainly have breast implants and they can even be silicone  implant if so desired. What determines a natural look is based on the patient’s interpretation of that term but generally that means not too big for your body. What that would be for you I can not say since I don’t know what you look like or what your breast size goals are. I would need to see pictures to help make that determination. And then ideally you should be sized before surgery using volumetric implants sizers.Breast implants, regardless of their size or shape, do not interfere with the ability to breast feed. They are placed under the muscle, way away from the ducts of the nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Sliding Genioplasty

Q: Dr. Eppley, I am interested in a sliding genioplasty. (I think) Please see attached pictures of my frontal and profile view. In the first three pictures, I am pushing my lower jaw out forward, which is normally how I rest my face to create the illusion of a stronger profile/jawline. The next 3 pictures depict what my jawline looks like if I bite down normally. The end look that I desire is a masculine/defined jawline. I wanted your insight on what would be most aesthetic for my face/what would make me look the most ruggedly handsome. I look forward to hearing back from you soon.

A: Thank you for your inquiry. Based on your pictures I would recommend a sliding genioplasty combined with small widening jaw angle implants. That will accomplish what you are showing by thrusting your jaw forward for the chin as well as add some complementary width to the back of the jaw. I would prefer a sliding genioplasty in your case as the chin augmentation increase you are demonstrating by a jaw thrust create both a horizontal and vertical chin change. This is best done by moving the chin bone down and forward. While that does not widen the chin, that does bot appear to be a chin dimension change you are seeking since a jaw thrust does not widen it either.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Reduction

Q: Dr. Eppley, I am interested in forehead reduction. I wanted to inform if it’s possible to help me with the following. I have a bulged forehead, that looks bigger than the one’s of people I generally see. Maybe it’s scaphocephaly, I’m not sure. I’ve attached a photo. Is it possible to reduce it to a more normal appearance? You mentioned a  ‘conservative change’, would it be possible to go even further? Would an operation cause a large scar? How much recovery time would be neccesary? What would roughly be the costs for such an operation?

Thanks! 

A: Certainly some reduction of the forehead bulge with or without some brow bone reduction can be done. (forehead reduction) I have imaged a conservative change to see if I am going in the right direction. When I do computer imaging I like to demonstrate what I feel is the minimum amount of change that will occur. More may be possible but a patient’s decision for surgery should be based on the least amount of change they can accept.

To do forehead reduction an incision has to be made somewhere and this is actually the biggest decision in the surgery as to where to place it so it the most aesthetically acceptable.

Most of the recovery (swelling) should have resolved by 7 to 10 days after surgery.

My assistant will pass along the cost of the surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Paranasal Implants

Q: Dr. Eppley, I have seen before and after of paranasal implants and it seems the goal is to make the face look less flat? I do plan on getting these done. Also I have recessed jaw and my maxilla is basically normal and my bite is fine but I am going to get it checked with an jaw surgeon. So no type of midface implants makes your maxilla look more forward?

A: Looking vertically longer is one thing, having more horizontal projection is another. Your original inquiry asked the question of a longer maxilla which is an increase in the vertical dimension…which is not possible. Many types of implants give the midface more horizontal projection or bring it forward. You have been using confusing terms in your descriptions. It is now clear that you mean increased horizontal projection of the midface. This can be done using a variety of midface implants including paranasal implants, maxillary implants, premaxillary implants and combinations of any of these midface implant styles. The best way to bring the midface forward is through the use of a custom midface implant which augments the entire midface bone above the maxillary teeth level.

Dr. Barry Eppley

Indianapolis, Indiana

Shoulder Width Reduction

Q: Dr. Eppley, I am interested in shoulder width reduction. I wanted to consult you for a surgery which I still do not know anything about and, as much as I researched, I have not found much about it. I am a transgender girl and I have a big complex with respect to my wide shoulders. I have a female body but still my shoulders look broad (not muscular but really broad) and I think it is the part that is disproportionate to my body. I have been researching about surgery to reduce broad shoulders but can’t find any information on it. I heard that you performed a complicated rib reduction intervention on a model and wondered if you could intervene on my bones. But this time on the collarbone to get it to look narrower. Is this surgery possible? Do you know if it is available in America or anywhere else? Here in Europe nothing is known yet. Thank you very much for your attention. 

A: What you are referring to in regards to shoulder width reduction is to shorten the clavicle, the bone that runs between the sternum and the shoulder. By removing a segment of this bone, the shoulders will move in a bit and create more of a rounded shoulder look. This requires an incision over the clavicle on each side and the use of a metal plate to hold the bone back together as it heals. It would also require a prolonged recovery as one might predict considering that it creates a controlled clavicle fracture on each side.

While such a surgery can theoretically be done (it is just a spin off of the treatment of clavicle fracture), I have never performed it nor have I ever heard of it being done anywhere in the world. It would take an extremely motivated patient to undergo his surgery on an aesthetic basis considering the scope of the procedure, the creation of small scars in a visible area and the recovery involved.

Dr. Barry Eppley

Indianapolis, Indiana

Mentalis Muscle Strain

Q: Dr. Eppley, I have the problem of mentalis muscle strain and distortion after a sliding genioplasty advancement. I want to improve it by the mentalis resuspension method but only by an intraoral incision. Because I did the sliding genioplasty surgery my mentalis muscle is strained and looks distorted when I close my mouth or pout my lips and also there is too much ower teeth show. My doctor who performed my surgery will improve my mentalis muscle strain by cutting some muscle at my chin. And then he said that the mentalis muscle resuspension is not suitable for me. Is that true?? When I rest my mouth it’s normal and my lower teeth show but but when I try to close or pout my lips my mentalis muscle strain appears and my chin looks distorted. Which method is suitable for me? Should I allow him cut my muscle?

A; It is correct that a mentalis muscle suspension procedure is not what you need to improve your mentalis muscle strain. Rather you would likely benefit from a mentalis rmuscle elease and dermal-fat grafting procedure to prevent recurrent muscle contarcture.

Dr. Barry Eppley

Indianapolis, Indiana