Chin Ptosis Correction

Q: Dr. Eppley, I am interested in chin ptosis correction by reduction of bone through burring or shaving (to reduce blunt and  long chin) and chin resection for removal of excess soft tissue to correct my chin ptosis. I had a sliding genioplasty and ever since I have always had a problem when I talk or smile. My chin pad or mentalis muscle drops below my chin bone. It’s a problem that I hate so much! I though the sliding genioplasty would ix the problem but it didn’t. It also made my chin look loner not shorter. 

As part of the chin reduction, I would want a prejowl chin implant, medium size by Implantech, secured with screws for forward chin projection.

A: A: In regards to your chin ptosis correction, I think you are spot on for what will solve your chin concerns. Only a submental resection of the overhanging chin pad will get rid of the ptosis that you have. Adding a chin implant will have a complementary effect in that regard as well as provide some forward chin projection. Horizontal chin augmentation is another method that can pick up or fill out a loose chin pad.

Dr. Barry Eppley

Indianapolis, Indiana

Temporal Implants

Q: Dr. Eppley, I am  interested in temporal implants. I wanted to know if you have picture of the scar like one year after surgery? Or just a picture of the scar, to know what it will look like. I like to keep my hair shorts, and I wonder what it will look like? As a second question, would therapy to heal scar would help making it less visible?Also, as a third question, what would be the shortest I can keep my hair on the side to hide the scar? 0.5 cm or more? Thanks.

A: I do not have a picture of a temporal scar after implant surgery. I have seen several of them long-term and many of them are virtually undetectable even on very close inspection. I can also say I have never been asked to do a scar revision on the scars after temporal implants. If one has hair there would be no need to do any form of topical scar therapy on the incisions. This is impractical and unnecessary for scalp scars. If the temporal hairline scar heals very well (and it should) you should he able to wear your hair as short as you would like without concerns about visible scars.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, We had previously discussed that a button chin implant would be an option for me if I wanted to make the bottom of my chin appear less squared off.  I tried the filler as you suggested and actually really liked the rounder/pointier shape… but since I feel like my face is already long, adding that vertical height to create the pointer shape wouldn’t be my first choice.. 

1) Would it be possible to do something similar with a chin reduction technique so that the chin becomes somewhat narrower/rounder/more feminine and maybe slightly reduced vertically (vs an implant or filler that would require augmentation to add that shape onto my chin)?

2) Would it be possible to do this from an intraoral incision?  I saw examples on your blog using an intraoral approach as well as submental and wasn’t really sure what category I’d fall into… 

3) If an intraoral approach is possible, what are common complications/complaints you see or hear the most from your patients? Are any of these permanent?

A: In answer to your chin reduction questions:

  1. A chin reduction can reshape the chin, making it less square and reducing the vertical height.
  2. To do it intraorally, it would have to be an osteotomy technique where a wedge of bone is removed from the middle of the chin. This keeps the bottom of the soft tissues attached to the bone so there is not ptosis or sagging afterwards.The submental approach is simpler but does involve the scar on the underside of the chin.
  3. The intraoral approach will involve a slightly longer recovery and will create some temporary numbness to the chin and lip. Such numbness if not usually permanent in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Browlift

Q: Dr. Eppley, I have some lateral brow questions.

1) What are the most common complications or patient complaints associated with a lateral brow lift in your practice? Are these permanent?

2)  Will the temples/forehead be numb after a lateral brow lift?

3)  Approximately how many millimeters of lift can I expect?

4) Will my hairline be lifted? If so, how much?

5. I just wanted to confirm that the tail and some portion of the arch/point of the brow are adjusted – meaning the brows aren’t just lifted at the bottom of the tail causing the brows to become straight/flat… It seems from looking at online pictures the results vary greatly from surgeon to surgeon so I am guessing there is room for some tailoring to the patient in the operating room.

A: In answer to your brow lift questions:

  1. The most common issues after a lateral or temporal browlift procedure are adequacy of the lift (how much lift was achieved) and the potential for widening of the scar in the temporal hairline.
  2. I would imagine that there is some temporary numbness of the skin in the direction of the temporal browlift but that is not an issue that I hear patients mention.
  3. The amount of lift obtained from a temporal browlift is variable, anywhere from 2to 3 mms to 5 to 7mms.
  4. While the hairline should be lifted as much as tail of the brow, the distance between the hairline and tail of the brow stays the same…thus it is not really noticed.
  5. Temporal browlift results are indeed highly variable and it is not an exact science. The fundamental problem with this technique is that the best and most predictable way to do it (making the incision along the front edge of the temporal hairline and excising skin doing the lift there) is rarely where the patient can accept the scar line. Thus putting the incision back in the temporal hairline is usually necessary and this is where the lift becomes less effective. To make it effective the incision and skin removal has to be bigger because the point of lift is further away from the brow.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant

Q: Dr. Eppley, I’m about 6 weeks after placement of a custom jawline implant. To be honest, I’m not too thrilled about the results and would like to possibly schedule a revision surgery with yourself. First off I’d like to tell you the situation with my custom jawline implant. On the positive side, in terms of the added bulk along the jawline, I think it’s perfect. There are two main issues I have which I would love your feedback on how to improve. The first is that I feel the lateral projection/width of the angles is not big enough. At about the 3rd week after surgery, I think it was at the perfect level. But after a few more weeks passed, I lost that added width and and angularity and now the angles blend in with the jaw, giving my face a big U look, rather than adding any angularity or sharpness. The second is that because I lost the added width at the angles, the newly added vertical length of the chin has my face now with a stretched out/elongated look. While the projection of the chin is fine, I feel the length really needs to be shorten about 1.5mms or so.

Can I ask your feedback on what you would recommend on terms of design to rectify these issues? To get better sharpness at the angle, should we increase just the lateral projection or also increase the thickness?  How do you think would best to handle the chin? Again, the jawline itself looks much better and defined but I would really like to fix the angle and chin issues.

A:  The first thing I would tell any custom jawline implant patient is to wait a full three months before contemplating any revision. It takes time for all of the swelling to subside and the tissues to contract back down around the implant. There is also the accommodation phase of adjusting to a new look. Between all of these factors how one feels at just 5 weeks after surgery may change…I have seen it happen.

That being said, what you have learned is that while computer designing is a great and only way to make a total wrap around jawline augmentation, there is no accurate way of predicting what the final aesthetic result would be. The computer has no innate knowledge of how to make those dimensional changes and that input must come from the surgeon based on his/her experience.

What you do know now is what effect the current design has created. Those dimensions are critically important when contemplating a revision/replacement implant. What would be important to see, and it is of critical importance, is where you started and what you look like now. That information helps gauge how the dimensions of the chin and jaw angles have had an initial impact and will play a critical role in knowing how to change the current implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Revision Rhinoplasty

Q: Dr. Eppley, I’ve been diagnosed with lupus and ITP. However, my platelet count was always low (lowest was 12) back in 2013 when I went for my blood work to have a rhinoplasty. I was prescribed steroids to take to increase the count and undergo surgery. So I think I had lupus back then and it affected my platelet count. Every time I wanted to have surgery, I would just take the steroids for about a week prior to surgery. I’ve had 2 rhinoplasty, breast augmentation, upper and lower eyelid surgery, and mid-face lift. But now I am now taking plaquenil and prednisone (50mg) for the past 6 months. I am interested in revision rhinoplasty, zygoma reduction, and jawbone reduction. I am little afraid since this time I am taking medications for my lupus. If my platelet count is above 100. Is it safe for me to have those surgeries?

A: I think you have to recognize that at least two of these surgeries (zygoma and jawbone reduction) are major bone surgeries that can cause a lot of bleeding and require better healing potential that any of your prior aesthetic procedures. Since they are elective I would be very cautious about undergoing them. Plaquenil and prednisone are major anti-inflammatory drugs that can have negative impacts on healing, particularly at the doses you are taking.

If your platelet count is acceptable, I would only undergo a revision rhinoplasty first to see how the surgery goes. That would he a good test before ever proceeding with the more major facial bone surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Implants

Q: Dr. Eppley, I am researching jaw angle implants and am seriously getting ready to choose a doctor. I consider you to be one of the top few in the nation, and have read your blog on how you’ve never experienced a tear with the masseter sling with jaw angle implants. However, is there still some roll up?

Another well respected doctor has told to me that no matter what there will be a bit of roll up, but did not clarify whether or not that implied no tearing.

A: To clarify the issue of the masseter muscle sling and its potential disruption, you first have to differentiate whether you are talking about width only jaw angle implants or vertical lengthening jaw angle implants. With width only jaw angle implants, it is not necessary to strip the tissues off of the lower border of the mandible. Thus there is little to no risk of any masseteric muscle sling disruption/roll up/retraction issues. With vertical lengthening jaw angle implants or total custom jaw angle implants, that is a completely different issue. By definition it is necessary to elevate the sling attachments off of the border of the mandible and the massteric pterygoid sling is disrupted. This is unavoidable. Whether there will be some muscle rollup depends on how much vertical jaw angle lengthening is created by the implant. If it is 5 to 7mms, for example, then the rollup will really be minimal. But if the vertical lengthening is 15 to 20mms, then it will be more significant. (more visibly noticeable) It is important to remember that the masseter muscle can not lengthen, that is a physical impossibility. So the longer the jaw  angle is lengthened, the more the original position or even roll up of the muscle may be seen when biting down.

A complete tear or retraction of the masster muscle is a slightly different situation. For this to occur the entire attachments of the masseter muscle must be detached from the angle point forward to the mid-body of the mandible as well as high up onto the lateral ramus. The angle point attachments are quite significant and not easily dissected off of the bone. With aggressive degloving of the posterior and inferior mandibular borders (and I might add this is almost always done in sagittal split ramus osteotomies in orthognathic surgery) the risk of a more substantial masseter muscle retraction may be seen where the lower end of the muscle is seen up almost at the level of the earlobe when biting down.

Dr. Barry Eppley

Indianapolis, Indiana

Subnasal Lip Lift

Q: Dr. Eppley, Can a corner lip lift combined with a subnasal lip lift bring about the same results as a gullwing lip lift if you want to try to do avoid as large of a scar at the vermillion border as possible?

How much can alar retraction be corrected in millimeters? If oyu have an exceptioally severe case is it possible to do two operations the same way if someone wants exceptionally large breast implants they can get implants the first go around and then have the skin stretch, then replace implants later with larger ones? In the case of the nostrils, is it possible that the first time will not fit a large enough graft but this can be replaced later on down the road after the nostrils have adjusted? 

Is there a procedure that can correct  masculine and broad shoulders for a female that wants a more petite upper body? Something like clavicle reduction?

A:  A subnasal liplift combined with an extended corner of the mouth lift is a  way to create a similar effect as that of the lip advancement procedure. (gullwing lip lift) The subnasal lip lift substitutes for placing the excision of skin across the cupid’s bow area. Lateral vermilion advancements brought inward from the mouth corners is still needed but they do not encroach onto the more visible and delicate cupid’s bow area of the upper lip.

Alar retraction is treated by the placement of alar rim cartilage grafts. They will create a several millimeters of correction. More significant alar retaction may need to be treated by the placement of composite skin and cartilage grafts to roll out the inner lining. (which is where the skin portion goes. This it is not like your breast implant analogy at all.

There is no operation to reduce wide shoulders. A bony reduction is not possible because that impinges on the moveable shoulder joints.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Lift

Q: Dr. Eppley, I am interested in getting breast implants but am uncertain if I need a breast lift also. I saw a breast augmentation patient you had done who looked somewhat similar to me and she was able to have a good result with large implants alone. I was wondering if I might obtain a similar result. I have attached some pictures of my breasts for your opinion on this matter.

A: Thank you for sending your pictures. I think you just have too much ptosis (sagging) to avoid a breast lift with your implants. The key is the level of the nipple to the inframammary fold. If the nipple is at or just a hair below the fold level, implants can create a bit of a lift or at least not create the appearance of breast tissue sagging off the front of the implant. But when the nipple is really below the inframammary fold (and in your vase it is by several centimeters), the implant will merely drive the already hanging breast tissue off the front if it…making a not so good breast appearance even worse. While I do many breast lifts, I really don’t like them for women due to the scars and try to avoid them when there is a good chance that a women may get by without it. But unfortunately I just don’t see that being a good option for you. (implants with no breast lift)

Dr. Barry Eppley

Indianapolis, Indiana

Facial Plate Removal

Q: Dr. Eppley, I am interested in facial plate removal as part of other cosmetic facial work being done. But I have four titanium plates in the left side of my face from a previous facial trauma. Can I have those facial plates removed at the same time as the cosmetic work as well.

A: Indwelling metal facial plates can be removed during any upcoming facial procedure. The only question is where these plates are located, what access would be needed for their removal and would the trauma of trying to remove them be worse than just leaving them alone. One never knows if the plates have bony overgrowth on them and whether the screw heads that have been used to place them have been stripped. (making them difficult for a screwdriver to get a good purchase on them) With four plates I can going to assume that the metal hardware is likely around the cheek and orbital area.

In most cases in which patients have no symptoms from their indwelling facial plates, facial plate removal is more for self-relief or are being removed because of surgical convenience. For these reasons I needs to think carefully as to whether the trauma induced by facial plate removal makes it worthwhile.

Dr. Barry Eppley

Indianapolis, Indiana