Cheekbone Reconstruction

Q: Dr. Eppley, I had cheek and orbital reconstruction on the left side of my face three weeks ago for an old cheekbone fracture. The left area of my face that you worked on is still about 40-50% swollen. I also am still numb in my left lip area and on occasion I feel tingling in my face.

My questions are is the numbness and tingling a normal part of the healing process and if so, how long can I expect that to continue? How long until the swelling goes down completely? Can I take anti inflammatory medicine and use ice packs on my face to help the swelling go down? Will the ice affect the fat injections? Lastly, will the asymmetry of the left side of my face eventually match the right side of my face because as of now, the left side of my face is making it appear that the right side of my face is the side that is flattened? 

A: You are recovering exactly as how I would have expected after cheekbone reconstruction (with cheek implant and fat injections). At three weeks after surgery only about 50% of the swelling will be gone. It will take a full three months to see the final result for all swelling to go away. Also I would expect some lip numbness to be present at this point but that will eventually go away with more time. Anti-inflammatory medication and ice packs will not make it go away any faster. This is a process of time for complete healing. I do not judge the result until three to four months after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty Grafting

Q: Dr. Eppley, I have few questions about rhinoplasty grafting. A few surgeons that prefer implants have told me that they do not prefer diced cartilage wrapped in fascia because the cartilage tends to flatten and the borders are irregular.  Other surgeons have said that it lasts a lifetime if placed correctly.  What has been your experience and what do you prefer as a natural substance?  Also, does skin thickness have anything to do with implant extrusion?  My skin is thin but my implant was placed properly and very well because there is no deformity and the skin is smooth.  Also, what is alum from a cadaver?  I have heard that this is something relatively new.

A: It is impossible to beat your own cartilage as the best natural and permanent nasal augmentation material in rhinoplasty grafting.. How to best shape the cartilage for the desired result depends on the source of the cartilage, the amount that can be obtained/needed and the surgeon’s ability to work with the material. It is not as simple as just using cartilage any way one wants. If one can harvest a nice straight piece of rib cartilage then that would make the perfect dorsal augmentation method to carve and shape. But many pieces if harvested cartilage are not straight and be diced and wrapped to ensure a straight result. It has not been my experience that diced cartilage grafts flatten out and create irregular borders. I will not use any type of cadaveric material for nasal grafting so I can not comment on its use.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Implants

Q: Dr. Eppley, I am considering Jaw angle implants and have a few questions for you. I previously had upper jaw surgery, orbital rim and chin implants done. I feel that my jaw needs augmentation to fit in with the rest of my face, I am struggling to find a surgeon with great knowledge in jaw angle implants and am considering traveling abroad for surgery. If I were to fly to you for surgery how long would I have to stay in the USA before returning home? Also with Jaw implants I hear talking can be a struggle after surgery, how long realistically can I expect this to last? In so far as jaw angle implants type I cannot decide whether I would benefit best from lateral only or both lateral and vertical lengthening? Also the degree of augmentation (small/medium/large). I have attached photos, please can you advise. I am also interested in having the plates from my jaw surgery removed, would this be possible alongside jaw implant surgery?

A: Most patients who come from afar for jaw angle implants surgery return home within a few days after surgery. While patients will experience some difficulty with chewing in the first few weeks after surgery I am not aware that patients have any signficant talking problems. You did not really provide enough pictures to make a full analysis of your face as the all important front view is missing. But as best as I can tell from the pictures provided, medium size lateral width only jaw implants would be my initial impression for your facial needs. While plates and screws from prior surgery can be removed during jaw angle implant surgery I would need to see x-rays of their locations to properly find them. As long as not too much bone has overgrown then they can be removed.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant

Q: Dr. Eppley, I have had custom jawline implant (chin and jaw angle implants) made and placed and I have included my before surgery and after surgery pictures. I am very happy with the chin portion. I also like the jaw portion, but feel like it left me with a sort of puffy look versus the more v shaped jaw i was looking for. I know it isn’t possible to look like Brad Pitt or a male celebrity, but I at least wanted to try and emulate the general characteristics. Just going off of what the implants did, I figured going a few mm more in width and couple mm in posterior drop would be beneficial, but of course I defer to you.  I have attached some pictures of the general look I am going for, and would appreciate any comments on what you think would look good for me. Also, in seeing my pictures, do you think I would benefit from the temporal augmentation with implants? Or is it something you don’t think would add much? I have always appreciated your expert and honest advice.

A: Your jaw angle implants did not get close to your desired result because they did not go back far enough and had no vertical drop. Thus they may you look ‘puffy’ but did not add any angularity to the jaw angles and don’t really match the chin that well. Also the inplant design appears to be connected on the left side but not on the right for some reason. Without dropping the entire jawline from chin on back to the angles you will not improve your posterior jaw shape. In essence you need a connected wraparound cusyom jawline implant that is better designed for your objectives.

If you increase your jawline than I would agree that the width of your temporal and lateral forehead region is comparatively too narrow. Extended anterior temporal implants would provide a good balance with a new posterior jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Necklift

Q: Dr. Eppley,  I am 49 year old male and in good shape but yet I have a really bad sagging neck. Attached are photos of my neck from the front and both sides.  I’ve always had a sagging neck and had liposuction done 24 years ago so the fat under the neck is not great but the muscle and skin sag.  I’d like a sharper jaw line.  I consulted with a surgeon here who stated that to achieve a sharp jaw line, I’d need a full facelift and that a neck lift alone would only achieve a partial result.  This doctor stated that I should get a facelift and I don’t want a full facelift – I just want the neck tightened up.  Thanks for your time.

A:  Thank you for sending your pictures. The dilemma that you have is a common one for many men. They want to improve their neck and jawline but don’t want the facelift operation to do so. They believe that a ‘necklift’ will solve their concerns. What the plastic surgeon told you was correct…partially. You can only redrape the neck and jowl skin up over the existing jawline through a lower facelift procedure. The concept of a full necklift is really the same as a lower facelift….they are one and the same. There are other neck tightening procedures but they achieve their effects by making changes below the jawline.Thus they tighten but never really truly lift the neck…achieving only the partial result that your plastic surgeon correctly informed you of.

This dilemma leaves you with two options. First an isolated submentoplasty can be done from under the chin which will tighten up the neck angle but will have no effect on making the jawline sharper or more prominent.  (neck angle change) The other approach to augment the jawline with the submentoplasty. This would be particularly beneficial in your case as your jawline/chin is somewhat vertically deficienct. Improving the prominence of the lower jaw through a wraparound jawline implant with a submentoplasty will make the entire jawline stronger, will pick up loose skin in the neck and create a sharper neck angle.

Dr. Barry Eppley

Indianapolis, Indiana

Temporal Implants

Q: Dr. Eppley, I hope this email finds you well. I have always been self conscious of my small head and weak Jaw. I recently had custom jaw and chin implants placed 7 months ago. I am happy with the results, especially with the chin, but would like to go with something bigger at the jaw with more support at the side between the jaw and chin. I assume I would need an inferior drop to the jaw, where my prior implants had none.  I wanted to know how feasible this is to do from a safety standpoint and how the recovery would be compared to the original?

Regarding my forehead, it narrows inward and is concave compared to my zygomatic arch. I saw that you perform temporal implants with amazing results. I just wanted to know if these implants will feel natural once they are placed?

Finally, what kind of costs am I looking at for these procedures? I would want custom implants again for the chin/jaw but I don’t know what you would recommend for the temporal area. I would of course defer to you for both decisions. Finally, how much would these procedures cost in total if done together versus done staged? 

A: Thank you for your inquiry. I would need to see pictures of you to give specific answers but I can provide the following general comments.

Since you have indwelling jaw angle implants in place that do not appear to provide any vertical elongation, new jaw angles can be placed. It helps that you have existing pocket so, in theory, the swelling and recovery would be less. (I assume your custom implants are made of silicone. Releasing the implant pocket and dropping the jaw angles down further is not a safety concern.

Based on your description of your temporal deficiency, it sounds like it goes all the way up to the forehead. Thus what you need would be what I call extended and Zone 1 and 2 temporal implants. All such temporal implants are placed on top of the muscle but under the fascia. Patients do not report any problems with such temporal implants feeling unnatural.

As for cost I am a but unclear as to how your current chin and jaw implants were made when you say custom. I assume this was done off of a 3D CT scan. If so that same scan can be used again. I will have my assistant Camille pass along the cost of the procedures if done together during the same surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Contouring

Q: Dr. Eppley,I am interested in forehead contouring.  I have a hard lump at the centre of my forehead for the past eight years now. it is not really big but it is noticeable. Please i need a surgery for this because I have been experiencing a hard time with my life with this forehead lump. I have attached some pictures from different angles so you can see my forehead lump.

A: Thank you for sending your forehead pictures. I can clearly see your central forehead lump. There are two ways to do your forehead contouring to get rid of this central lump. First the forehead lump could merely be burred down to the contour of the surrounding forehead. The other approach would be to build up the area around around the lump so the entire central forehead area is smooth. (fill in the two grooves on each side of the lump) Which way is best depends on how one prefers the shape of their forehead to be. The other consideration is the surgical access to do either one. Both could be done through a small incision at the edge of the frontal hairline. (irregular pretrichial incision) to blend in at the edge of the hairline.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Augmentation

Q: Dr. Eppley, I believe I have an underdeveloped jaw. In 2008 I had a chin implant which I feel was not correct and seems to sit on my face. Also there is a dip where my chin ends. My jaw is very undefined and seems to blend into my neck. Last year I wanted to get it fixed again. And the surgeon was adamant the chin implant was sufficient but he said I really needed a face lift. I have deep lines from my nose to chin which I hate. Within only a few days after surgery including liposuction to the neck the lines reappeared along with the fat along the neck and jaw. I approached the surgeon and sadly he said what’s the problem you look Younger. Although that was not actually what I was looking for. I have already spent a lot of money and looked and felt no better. I have also had huge issues with my teeth when my wisdom teeth grew impacted causing infections and damage to the other teeth. I am currently having all of these teeth removed at my local dentist. I do have an overbite but was never referred to an orthodontist, my dentist simply removed about 6 teeth when I was a child.  I would love to hear your opinion and find out whether you feel there are options available to help balance my face. I am 36 years old and this has really affected my confidence. Many thanks!  

A: Thank you for your inquiry. I am sorry to hear that your plastic surgery experiences were not more favorable. In looking at your pictures and your age, the real facial rejuvenative effect would have come from total jawline augmentation not a facelift. Your lower jaw is very short with still significant chin retrusion and high jaw angles. Even with the chin implant in place, whose size is unknown to me, you are still 8 to 10mms short. I think you would be better served by a sliding genioplasty with vertical lengthening jaw angle implants or a total wrap around jawline implant. The key for real facial improvement would be lower jaw augmentation to bring your lower face into better balance and proportion with the rest of your face. You are not a candidate for orthognathic (maxillary or mandibular osteotomies) due to lack of adequate teeth and the need for significant orthodontic preparation even if you had adequate teeth for the procedure. Plus as an adult it is a long orthodontic preparation process before surgery that can create other dental problems. (e.g.,periodontal recession). This you can not really have your lower jaw ‘corrected’ .Therefore you need to do a camouflage approach to the lower jaw deformity by moving the chin bone forward (sliding genioplasty) and augmenting the deficient jaw angles. (jaw angle implants) This keeps your existing teeth where they are and cosmetically makes the lower jaw more advanced and aesthetically balanced.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy Tuck Revision

Q: Dr. Eppley, I am seeking a tummy tuck revision. I had a tummy tuck a year and am not happy with the results as you can see in my attached pictures. I hope they will help you see my concerns. My stomach is not flat. My muscles were not tightened and there is still excess skin. One concern is if the belly button can be reattached to the abdominal wall where it should be. And then to have stomach muscles tightened. I had a c-section  25 yrs ago and muscles were never tightened? Thank you.

A: From your pictures, there appears to be a midline rectus muscle separation and the belly button looks like it became detached at the base or scarred off the abdominal wall. Hard to tell about any loose skin but the tummy tuck incision is very long and low so I would assume that some significant abdominal skin was initially removed. There is no question you can have a tummy tuck revision with your rectus muscles tightened from your tummy tuck scar (it is a long way from way down there but it can be done) And the umbilicus can be reattached back down to the abdominal wall. That is by far the easier part which will make it deeper or more indented

Dr. Barry Eppley

Indianapolis, Indiana

Chin Implant

Q: Dr. Eppley, About 2 years ago I had a chin implant put in during a rhinoplasty revision in Miami.  It looks great BUT the lisp NEVER went away.  It resolved to about 90% and continues to have good days and bad.  The chin implant is a medium size. I’ve spoken to a neurologist as well and he does not feel this could have anything to do with mental nerve irritation as there is no area of numbness.  At this point I’m quite frustrated and got a CT hoping to see some gross abnormality or slipping of the implant.  The CT shows only a slight periosteal reaction (not-osteo per the radiologist) on the right and a .5cm asymmetry of implant riding posteriorly on the right. Could this be the cause of this? I do notice a corresponding limitation to my ability to retract my lower lip on right.  Searching the internet, you seem to have the most facial implant experience so I wanted to get your opinion as general consensus thus far (including a speech pathologist) seems to think replacing it with an implant that projects less would be the answer. 

A: This is not a postop problem with chin implants that I have personally seen before. I would not feel that the size of the chin implant nor its position is the problem. There are lots of chin implant patients with gross asymmetry of their implants and they don’t have any speech issues. Conversely there are patients with huge chin implants that don’t have a lisp either. It sounds like there is a mild weakness of the marginal mandibular branch of the facial nerve, which affects the retraction of the lower lip, which can be a source of a lisp. That is a lower lip problem that I have seen before. Recovery of a marginal mandibular nerve weakness, which is a monofasicular nerve, will have reach its potential by two years after surgery. Thus I would have no confidence that any manipulation of your indwelling chin implant would offer any improvement in your current speech issue. You can, of course, prove or disprove that conjecture by replacing the current implant that you have. But the chance of improvement to me would be very unlikely.

Dr. Barry Eppley

Indianapolis, Indiana