Jaw Angle Implants

Q: Dr. Eppley, I have a question about the jaw angle implants that worries me, I consulted a few Maxillofacial surgeons in my country. Some of them said to me that implants under the masseters muscles (for aesthetic reasons, not deformity corrections) is a bad idea, one of them even called jaw implants malpractice. The main argument is that due do the fact the those are the strongest muscles in the body and are constantly active (and mine are even hypertrophied) and will apply constant pressure over the implants, sooner or later it will lead to complications, that the main of them is bone erosion which will lead to relapse at the the best or more severe bone loss at worse.

I’v also been told:

- The procedure is quite aggressive and the masseteric muscles never recover completely from it.

- The procedure will cause mouth closing/ opening problems and chewing problems. 

- The scar tissue that will created from the procedure will add 5 mm~ of width to both sides of my face, which will lead to an unaesthetic result, even if the implants will designed for vertical length only.

- The implants will cause thinning of the masseters over time, which will cause further health complications (I don’t remember specifically).

I would appreciate your reply to those concerns. Is the procedure really that dangerous? 

A: The simple answer to almost everyone of your jaw angle implants concerns is that none of them are true or are based in any biologic or clinical reality. While it is true that jaw angle implants are placed under the masseter muscles, this does not lead to chewing or muscular dysfunction, underlying bone erosion, or aesthetically undesireable scar tissue formation. The only negative masseter muscle issue that I have ever seen, and it is an aesthetic one is that the pterygomasseteric sling can be disrupted if one is not very careful in their placement. This can lead to bulging above the jaw angle when biting down as opposed to the bulge being over the jaw angle point normally. Other than this potential issue I have found having placed, modified and removed many jaw angle implants that they are as safe and effective as any other type of facial implant.

Dr. Barry Eppley

Indianapolis, Indiana

Corner of the Mouth Lift

Q: Dr. Eppley, Can you answer a technical question about lip lifts? Is there a difference between a corner mouth lift (smile surgery) and corner lip lift? Do you perform these type of lip lift surgeries?

A: In answer to your questions, a corner of the mouth lift and a corner lip lift sound very similar but there is a subtle difference. A corner of the mouth lift evens a downturned mouth corner by removing a small strangle of skin just outside of the mouth corner. A corner of the lip lift creates more visible vermilion at the tail of the upper lip (and can be combined with a corner of the mouth lift) by removing a small strip of skin kist above the lateral vermilion lip edge. Some people only need a corner of the mouth lift while other people only need a corner lip lift. Then there are some people who need a combined corner of the mouth lift combined with a corner lip lip lift because their whole side of the lip is turned down. I have performed a lot of both of these and you have to pick the right procedure for the lip problem. Often times I see patients who had the wrong type of lip lift performed.

Dr. Barry Eppley

Indianapolis, Indiana

Skull Reshaping

Q: Dr. Eppley, I am interesting in a skull reshaping procedure for a flat side to the back of my head. In my pictures you can see the difference between the two sides of the back of my head. I want to see if you could make the smaller side of my head (left side) look the same as the bigger side (right side). My ear on the flatter side also sticks out nore. Even though it would cause me to have a large looking skull I wish to find a sense of normalness.

A: Thank you for sending your pictures. You have a classic case of plagiocephaly with left occipital flattening and contralateral right frontal flattening. (cranioscoliosis) The skull reshaping treatment for it is an occipital augmentation on the flatter side. The protrusive ear can be set back in a more traditional setback otoplasty with conchs-mastoid sutures. I assume when you mean ‘make the smaller left side of my head look the same as the bigger right side’ you are referring to using a standard/semi-custom implant or bone cement to do so. I think I would use one of my preformed occipital implants that I use for plagiocephaly cases. It is not as perfect as a truly made custom implant from a 3D CT scan but it can make for a major improvement and lowers the cost of this skull reshaping surgery somewhat.

Dr. Barry Eppley

Indianapolis, Indiana

Hairline Advancement

Q: Dr. Eppley, I am interested in a frontal hairline advancement. I have no issues with hair loss. My hair hairline simply dips back into in the middle and that’s where I drew a line if that was eliminated on my picture. I have some breakage on the edges from hats and headbands, but nothing permanent. It grows back instantly. Is this possible? 

A: Thank you for sending your picture. Where a hairline advancement works the best is exactly where your hairline issue is….in the center of the frontal hairline. This is because the best mobility of the scalp comes the center where the maximal its release is done down the middle all the way to the back of the head. This is due to the limits of the incision and resultant scar. In order to keep the scar from extending all the way down to the ears, most hairline advancements cut back no further than the high temporal region. As one gets closer to the end of the scar the amount of scalp advancement disappears.

Given where you have put the markings for the desired hairline end point I think is a very achievable goal. Scalp elasticity always determines how much the hairline can be moved but a 1 to 2 cm forward movement is possible in most people.

Dr. Barry Eppley
Indianapolis, Indiana

Rib Removal

Q: Dr. Eppley, I am interested in rib removal surgery to get rid of my lower ribcage which sticks out. I do have a few questions about the surgery.

1. I know rib removal isn’t as common of a procedure as tummy tucks or breast augmentations, how many of them have been done?

2. What are the reasonable cosmetic expectations? 

3. I’ve done some research and have read that in some patients it creates permanent pain. Is this sometimes the case? 

4. Also, is there a chance of uncontrolled bleeding from the operation? 

5. What are some common complications? 

A: Rib removal surgery can be done to be used for grafts in various facial reconstuctions (usually rhinoplasty) or for cosmetic contouring of various ribcage protrusions. The fundamental difference between these two types of rib removal are the length of ribs removed and the number and location of them. In answer to your specific questions:

  1. Ribcage contouring by rib removal is a very uncommon cosmetic procedure but i do about 3 to 3 case of it per year. I do many more rib removals for rhinoplasty and jaw reconstructive procedures.
  2. The success of rib removal for improved ribcage shape depends on the exact ribcage anamoly. How many ribs and what areas can be removed vs. what is the source of the problem, and how well these match up, determines how successful the procedure can be.
  3. I have not seen a rib removal patient who has permanent pain and this most likely relates to rib removal for chest surgery which is done differently. (and at a higher rib level since they are interested in entering the chest cavity….a goal that is the exact opposite of aesthetic ribcage reshaping)  This usually involves rib bone removal not rib cartilage removal in lower ribcage reshaping. In cosmetic rib removal or any rib graft harvest great effort is made to preserve the neurovascular bundle which runs along the bottom of each rib. Nerve injury or neuromas can be a source of chronic pain.The lack of permanent pain in aesthetic rib removal should not  be confused, however, with the fact that there is some significant pain after the procedure. I attempt to limit this immediate postsurgical pain with the injection of Exparel long acting local anesthetic into the surrounding tissues as well as intecostal nerve blocks which usually lasts about 72 hours
  4. There is no chance of uncontrolled bleeding from this type of surgery.
  5. The complications from this type of surgery are essentially aesthetic….how does the scar look and how effectively has the ribcage protrusion been eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Brow Bone Augmentation

Q: Dr. Eppley, I’m interested in having brow bone augmentation to give it a deeper and more masculine appearance. I understand that there are various materials available, and I was wondering if you could kindly answer these few questions:

1) Which material would allow for the smallest scar?

2) I understand that custom silicone implants will provide the most dependable results, but will hydroxyapatite (HA)  be able to provide a similar augmentation?

3) Which would also have the cheapest overall surgical cost – silicone, HA or PMMA?

4) As I’m leaning towards HA, could you also provide the cost of getting this procedure?

Thank you!

A: When it comes to your questions on brow bone augmentation the answers are as follows:

  1. A silicone brow bone implant can be placed with the smallest scar. Because of its preformed shape it can be inserted and positioned with a limited incision or endoscopic technique. All other forms of brow bone augmentation (except fat injections) require a wide open scalp incision technique with a long scalp scar.
  2. Hydroxyapatite can provide a good brow bone augmentation if one can tolerate the coronal incision to have it placed. This is a liquid and powder mixture that must be carefully applied and shaped. To do so requires wide open visibility.
  3. A preformed silicone implant would provide the most economical approach since it has the shortest operative time to complete.
  4. I will have my assistant pass along the cost of the different brow bone augmentation procedures to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, I am seeking a sliding genioplasty or chin reduction revision. After a sliding genioplasty 18 months ago and two bone burring operations to reverse it (6 and 12 months after the original surgery) there are still areas of bone, on either side of my chin, that were not shaved back to create my original narrow shape. I am left with a wide bulky chin, the excess skin and tissue have sagged from over the past year. Now, after my most recent operation, I have even more tissue. I am always advised to go back to the trio of surgeons who did it but after this I really do not want to. There is a huge miscommunication and when they discuss things in Spanish, in front of me, I no longer trust them. I just want to have my normal looking chin back. Do you perform this type of revision and reconstruction surgery? How often?

A: While you did not state exactly the method by which your two chin revisional procedures were done, I suspect they were by an intraoral bone burring method. While you should have had the sliding genioplasty reversed by redoing the osteotomy and setting back where it once was, intraoral bone burring was destined to create exactly what you have now…a broader flat chin with soft tissue excess. The proper solution now is a submental chin reduction technique where the chin bone can be narrowed and the excessive chin soft tissue removed.

This is a sliding genioplasty and chin reduction problem that I see and treat regularly. It would be helpful to see some picture of your chin and to know the exact details of all three of your prior surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal

Q: Dr. Eppley, I am interested in rib removal surgery to reduce my protruding ribcage. How risky is this procedure? What are the complications/healing time? What would the results look like? How much, on average, would this cost? What other medical issues would be affected by the surgery? Sorry so many questions! Also, I live in Idaho how do you work with out-of-state patients? 

A: Rib removal is not a dangerous surgery but, like any surgery that involves rib manipulation, it does cause some considerable discomfort. This is magnified when both sides of the ribcage are operated on at the same time. The best method of postoperative pain management I have found is the use of Exparel injections as intercostal nerve blocks done during the surgery. This is a local anesthetic that lasts for 72 hours after its placement. One could expect that it would take up to month after surgery until one has fully recovered. There will be a scar for the incision needed on both sides which would be about  6 to 7 cms long. The goal of the surgery is to remove ribs number 8 and 9 to reduce the subcostal protrusion.

My practice has many patients from all over the world for various types of plastic surgery. Patients usually come in the day before the surgery to have a face to face consultation and have surgery the next day. Whether you would stay overnite in the facility depends on whether you are traveling alone or with someone. I would anticipate your stay here to be no more than 2 or 3 days after rib removal surgery before returning home.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Implants

Q: Dr. Eppley, I am interested in getting breast implants. However I’m terrified of losing sensation in my boobs and not be able to breast feed. What are the chances I will lose sensation? Also I’m worried my implants won’t look symmetrical, what are the chances this will occur. Because of these concerns that’s why I’m trying to find a doctor that I know cares about my results and does the best job that they possibly can!

A: Breast implants are placed in a partial submuscular position which means there is no chance of any interference with the ability to breastfeed. Loss of nipple sensation, while a risk of breast augmentation surgery, is very uncommon in my experience and only patient in the past twenty years has reported it to me. The biggest reason for revision in breast augmentation surgery in my experience is implant asymmetry. That risk is about 5% to 7% and is highly influenced by how much breast asymmetry one has initially and whether there is any existing breast ptosis. (sagging)

An important consideration in having breast implant surgery is that there are risks like any surgery and one should have a full understanding of them before undergoing the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Silicone Testicle Implants

Q: Dr. Eppley, I have had a Mentor saline-filled testicular implant for approximately three years. While the implant has been relatively trouble-free, I do have some issues with it. I tend to get some occasional soreness due to the hardness of the implant. Also, as you might imagine, it is somewhat akin to having a nerd ball on one side and a superball on the other. Additionally, the implant, even though it was the largest size available, is perhaps one-third to one-half the size of my natural one. In other words, it’s far from a matched set. What options are available to me? Thank you very much for your help.

A: Soft silicone testicle implants feel a lot more natural than saline implants for sure. As for size I obviously do not know exactly what size your existing saline implant is by dimensional measurements. (saline is done by volume instillation) But the largest silicone testicle implants is 4.5 x 3.5 cms which would seem to be more than adequately large. It would be hard to imagine you would need a testicle implant bigger than that. (although custom ones can be made of any dimension) The pocket for the silicone implant replacement will need to be bigger than your current pocket but it should be no problem expanding the existing scrotal capsule.

Dr. Barry Eppley

Indianapolis, Indiana