What Facial Procedures Do I Need For A Male Model Look?

Q: Dr. Eppley, I am a 25 year old male. I am interested to coming to see you for some procedures to help me get the model look. I have some areas of my face I am unhappy with. One being the width of my face (too wide) and the other being the contour of my forehead/supraorbital rim/temple/eye area. I read a method of making wide face slimmer by zygomatic osteotomy. I read bone heals itself in new position after zygoma osteotomy so I wondered is it possible to do zygoma osteotomy and shift the entire zygoma arch upwards slightly (and also inwards)? I believe this would give a good high but narrow cheekbone appearance, as I don’t want flat cheekbones. 

My next problem is my forehead/eyes/temple area. My temples are very hollow and I have asymmetrical supraorbital rims. The supraorbital rims protrude which are more apparent due to hollow temples. My forehead is very backward sloping, despite it being protruding and having prominent frontal sinus area. 

I had considered options of frontal brow bossing reduction and then adding custom made implant on the forehead extending from forehead to supraorbital rims or to the temples. I always wanted supraorbital rim implants because I like the look of small squinty deep set eyes. I do not want to look feminine. I have added pictures of my forehead and eyes and pictures of how I want my eyes/forehead to be. I had an endoscopic browlift as an attempt to create the model look few years ago (because the surgeon said it would create a model look) but I feel it didn’t and needs to be reversed. I can’t work out what makes male model have eyes like that? They have strong foreheads, and is it the supraorbital rim that makes them have that model look? Along with a more hooded eye, and supraorbital rims that blend into the temple area? I really would appreciate your expert advise on this because you seem to be so knowledgable on your field.

A: I think there is no question that what makes for the so called ‘male model look’ is facial skeletonization…meaning an enhancement of facial skeletal areas such as the forehead, brow bones, cheeks, chin and jawline/jaw angles. As for the forehead in general, a backward sloping forehead angulation is not desirable regardless of what degree of brow bone prominence one has or does not have. A fuller more vertical forehead shape that allows for a noticeable brow bone break is the most masculine of all forehead shapes.

A endoscopic brow lift would work exactly against this type of male look as brow elevation and retro movement of the frontal hairline, particularly in a forehead that already has a backward inclination, will usually make it more feminine appearing. You may have discovered that in your own experience.

Blending the supraprbital rim/forehead into the temporal regions would be relevant for the high anterior temporal one but for the low one or the classic zone of temporal hollowing. That is much more effectively treated by standard subfascial temporal implants.

As for the zygomatic bones/arches, I do not feel that yours is wide and there would be little benefit to try to move the bone to accomplish any external aesthetic benefit. If you want further enhancement at the anterior zygomatic or high zygomatic arch levels, that would need to be done with a custom designed implant. That would be far more effective, predictable and have a much more rapid recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Why Are Jaw Angle Implants Done By So Few Surgeons?

Q: Dr. Eppley, I am specifically looking for angle of the mandible implants (jaw angle implants) to increase the width of my jaw as well as increasing the vertical height to give it a more angled, defined look to my otherwise high, weak jawline. I am wanting to have a simultaneous chin implant to compliment the jaw implants. 

While I can find endless information on chin implants, jaw angle implants seem rather non-existent and very few plastic surgeons perform them which has me a little apprehensive as to why this is. Would you be able to tell me more about this wrap around style implant and the advantages/disadvantages of having this over a simultaneous angle of the mandible/chin implant?

A: The history of chin and jaw angle implants are quite different even though they are located on the same bone. Chin implants are ‘end of the bone’ augmentations that are easy to predict the outcome, simple to place and have minimal morbidity and recovery because the overlying muscle and soft tissue cover and disruption is small. The first chin implant was developed in the 1960s and was and continues to be the most recognized and  important bony facial profile enhancement technique. Chin implants have gone through many different designs and shape changes over the years to meet the differing needs of many different types of aesthetic chin problems.

Jaw angle implants, conversely, are very much the opposite of chin implants. They are ‘middle of the bone’ augmentations whose aesthetic reqiurements are harder to predict, require more skill and experience to place, and have more morbidity and recovery because the largest muscle on the face (masseter muscle) is being disrupted.The first jaw angle implant was introduced in 1995 without any design changes since then…with an original design (width only) that is inadequate for most patient’s jaw angle deficiencies. (vertically short)

With an increasing public demand for more complete jawline enhancement, there is a need for  neeawareness offew surgeons however have ever performed them or had any training to do so. My experience with jaw angle implants and overall jawline enhancement in general is considerable as I have focused on changing how jaw angle implant surgery is done through new implant designs and the surgical techniques in placing them.

The fundamental difference between using a preformed 3-piece or a custom one-piece jawline enhancement is the connection between the chin and the jaw angle augmented areas. If one wants a perfectly straight line between the chin and jaw angle, then a custom jawline implant is the approach of choice. Custom implants are also needed when the dimensions of the jawline changes are desired exceeds the size or shape of what is available ‘off-the-shelf’.

Dr. Barry Eppley

Indianapolis, Indiana

Are Custom Jaw Implants Worth The Higher Cost?

Q: Dr. Eppley, I exhibit a weak jawline and recessed chin. I have had several consultations with doctors in the Los Angeles area. The most logically sounding consultation seemed to be a custom jaw implant. I see that you do this procedure yet also use off the shelf products as well. My question is…is a custom implant truly superior and does the higher cost justify this type of implant? The doctor made a compelling argument for custom implants however the price was extremely high. Look forward to your reply.

A: The key decision between off the shelf and custom jawline implants is in what you are trying to achieve. Depending upon the nature and magnitude of the dimensions of the jawline changes desired, only a custom implant will work for some patients. In fact, in some of these patients they should not have the procedure at all unless they go a custom fabrication route, For others, a custom implant may have no significant aesthetic advantage and off the shelf implants will work just fine. You would have to supply me with the exact jawline changes you are seeking and some pictures to better answer your question about what will work for you.

When it comes to cost, it is important to realize that custom facial implants today are not significantly more expensive than preformed off the shelf implants. Why? While the material cost of the custom implant is higher than the material cost of preformed implants, they are capable of being surgically placed ini half the operative time. Thus the extra cost to design and fabricate a custom jawline implant is partially offset by the savings of a quicker operation. You also have to consider the risk of revisional surgery, where if it were necessary due to an aesthetic issue, any savings from using off the shelf implants would be completely wiped and exceeded.

Dr. Barry Eppley

Indianapolis, Indiana

Can Jaw Angle Implants Break From Boxing?

Q: Dr. Eppley, I had jaw angle surgery and it was over-resected. I want to reconstruct my jaw angle (vertical height) and widen my front chin .  I have a before and after x-rays of my mandible and I want to have it reconstructed as before. Also I want to get rid of my titanium screws. I enjoy boxing and i am really worried about this reconstructing surgery.  

1) Can silicone be broken or bent or destroyed by punches?

2) Can silicone be moved or migrated by punches? Even if I get a 3D customized fit and screws attached? ( I’ve heard that it happens quite often)  

You told me before that silicone would never move no matter how hard it is traumatized  and I can enjoy every sport. However I’ve seen many cases of silicone implants moving. If your word is true please explain me how does that work.

A: While I don’t know where you are getting your information about jaw angle implants, I can only tell you what I know based on my experience answering questions and treating patients from all over the world in the past two decades with this type of facial implant surgery. I have yet to have an actual patient or an inquiry where someone has had jaw angle implant displacement from trauma. Perhaps this has happened to someone in the world, but I have yet to ever hear about it or treat anyone for it.

The apparent negligible incidence of silicone jaw angle implant displacement can be explained by an understanding of its biomaterial composition and the biology of encapsulation around it. The solid silicone elastomer of facial implants can not be fractured or broken, regardless of the imposing force, because it is not a brittle material.  You can take a hammer to a facial implant and you simply cannot break into pieces. The bonds between the silicone molecules are flexible nor rigid. Thus when I say putting a silicone implant against a facial bone acts like a bumper, that is because of what it actually does and behaves like.

The long-term stability of any facial implant is ultimately determined by the body creating a layer of scar around it, a process known as encapsulation. This capsule (layer of scar) is what holds the implant in place and preventing future migration or displacement. The purpose of screw fixation of facial implants is to hold the smooth surfaced material securely in place until this enveloping scar tissue forms. For most patients, the screws beyond this point (6 weeks or so after surgery) have little value. But in the patient who may be exposed to some periodic facial trauma (e.g., boxing), the screws add extra insurance against any potential risk of implant displacement

Dr. Barry Eppley

Indianapolis, Indiana

Can A Right Jaw Angle Implant Be Made To Match My Left Side?

Q: Dr. Eppley, I have a minor case of asymmetry to my jawline .the right side of my mandible is angled higher and shorter in length to my left side. My right side is also weaker than my left side . if there is one thing I am pleased with about my right side it would be the shape. I like the shape of my right side better than the left. My question is is there any way my right side can be made the same length and just as prompt as my left side? And can my left side be made to shape my right side?

A: There is only one way to do what you want to do with precision for improving your jaw angle asymmetry….and I would submit that without this precision for your ‘minor case of jawline asymmetry’ it should not be done. Computer designing of the right jaw angle implant could be done using left side as the model from a 3D CT scan. Only a computer design process can match up the jaw angle sides. In short, you need a custom right jaw angle implant.

Dr. Barry Eppley

Indianapolis, Indiana

What Can be Done For My Asymmetric Eyes?

Q: Dr. Eppley, I have sent you a lot of pictures and will try to explain my questions! I definitely have some skull asymmetry. The back of my head is kind of flat and it looks really weird when I have s short haircut. I also feel that the space between my chin and neck is very small.

I also have facial asymmetry and one side is bigger than the other. One eye is than the other although I feel both sides of my face are not matched. My neck on the lower eye side also feels tight and I can’t move my head straight.

It’s a mess and doctors here say I was born like this but it has gotten worse over the years.

Thanks for reading this. Hope to here from you.

A: By your pictures and your description of symptoms and physical findings, you appear to have a relatively classic case of craniofacial scoliosis caused by occipital plagiocephaly as an infant. There are three potentially improvable craniofacial problems:

  1. The back of head flatness can be corrected fairly well through skull augmentation by either bone cements or a custom skull implant.
  2. You asymmetric eyes (orbital dystopia = one eye lower than the other) is improveable by orbital floor augmentation with or without eyelid elevation. Fortunately the eyebrow appears to be in a symmetric position.
  3. The tightness in your neck may be unsolveable. Unless there is a very distinct and palpable band (cord) along the sternocleidomastoid (SCM) muscle (i.e., band torticollis), the tightness may be a function of congenital shortness of the neck muscles. If there is a band, then it can be surgically released although this would be an unusual finding in an adult. One non-surgical option to consider is Botox injections into the tightest area of the SCM muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Would It Be Beneficial To First Try Injectable Fillers Before Getting Facial Implants?

Q: Dr. Eppley, you and I spoke previously about temple implants. cheek implants, and forehead fat grafting. You did some imaging for me as well, and I realize you understand my goals in reshaping my face better than anyone. With this said, I would be interested to see how the overall look of what we discussed previously would first look by using injectable fillers to achieve the results in widening my face and adding more volume.

A: The issue with fillers for augmentation of various facial areas is one of pure volume and the associated costs. When it comes to small areas like the lips (1cc) or even the cheeks (2ccs), voluminization by hyaluronic acid-based fillers is reasonably cost-effective even though the effects will not be permanent. Beyond these volumes one has to look to the use of a filler like Sculptra to achieve a broader or wide-based facial volume effect. While these longer-lasting particulated fillers can achieve better volume enhancement of the cheeks and temples, the need for multiple treatments to achieve their effects and an increased risk of reactions to the implanted ‘seeds’, it is usually better to venture into the realm of injectable fat grafting where there are no volume restrictions or risks of any injectate reactions.

Dr. Barry Eppley

Indianapolis, Indiana

Will Insurance Pay For My Tummy Tuck After Weight Loss?

Q: Dr. Eppley, I am intersted in finding a physician that can do A Fleur De Lis tummy tuck with hernia repair after weight loss for “reconstructive repair” that will accept and submit to insurance. I know there are lots of patients getting this covered by insurance. It is how the surgeon submits it to insurance. Educated staff staff do know how to submit as medically necessary and not cosmetic. I was just wondering if your office was one that was able to do this procedure and have insurance cover it. Having a hernia, rashes, back pain, etc. is how it is covered, reconstructive, after weight loss is how it is worded. Thank you for your response.  I don’t need to waste my time or the physician’s if they are not experienced in this area.

Fleur-de-lis Tummy Tuck Dr Barry Eppley IndianapolisA: While I appreciate your perspective, from someone who does this for a living, it is not true that any one that wants it can just get it approved by insurance.  And there are not lots of patients who are having this surgery being covered by insurance. The latest plastic surgery journals report that less than 20% of all bariatric patients ever have some type of a tummy tuck and even fewer are able to get it approved through their insurance.

There is not magical statements or way to juggle how its coded to make it medically necessary for insurance.  There are very specific ICD9 codes for the diagnosis and CPT codes for the procedures. There are no guarantees that insurance will cover it no matter how it may be coded. It is not a function of ‘how it is worded’. Insurance does not care how it is worded. What they care about is does the patient meet their very specific criteria and have the medical documentation to support the procedures that are coded for. The criteria are well known and published and include two main issues:

1) An abdominal pannus that hangs over the groin and onto the upper thighs. (photos from three different angles)

2) A history of skin rashes under the pannus that has proven refractory to topical treatments over a 3 to 6 month period. (photo documentation of the existing rash and medical records that show it has been treated for at least 3 months)

Any insurance submission that does not include these two minimum criteria will be automatically denied.

If approved, insurance provides coverage for an amputation abdominal panniculectomy (infraumbilical panniculectomy), not a fleur-de-lis tummy tuck which is an extension of a panniculectomy. Any modification/extension of that basic procedure will be at the patient’s expense.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Type Of Chin Implant?

Q: Dr. Eppley, I am interested in chin and maybe jawline implants. Do you favour the intra-oral or extra-oral approach for chin implants? Also, do you use silastic or porous implants? I have attached some pictures so you can see how short my chin is.

A: The first question to decide before one considers how to augment the jawline is exactly what type and degree of changes does one seek. As you can see in the attached imaging, you could just do chin augmentation only (side view prediction) vs. total jawline augmentation of chin back to the jaw angles. (oblique view prediction) Your chin is so short because your entire lower jaw is underdeveloped so your jaw angles are rotated up and backward (high) as well. There is also a debate to be had about your chin as to whether that should be done with an implant or a sliding genioplasty. Therefore, options include:

Chin implant only

Chin and jaw angle implants (performed)

Total jawline implant (custom)

Sliding genioplasty alone

sliding genioplasty combined with preformed jaw angle implants

But when it comes to using jawline implants of any configuration, silicone implants are far superior to Medpor and a submental approach (vs intraoral) is easier with a quicker recovery. The small skin scar is inconsequential.

Dr. Barry Eppley

Indianapolis, Indiana

Does Fat Grafting Help In Linear Scleroderma Of The Face

Q: Dr. Eppley, In elementary school I was diagnosed with Linear Morfia but I have also heard the doctors call it scleroderma as well. I am now in college and it effects the right side of my face. I notice it on my forehead, under my eye continuing down to my cheek and a little on my nose, on the corner of my lip, and also some places under my chin and on my neck. The places on my neck are barely noticable so I’m not sure if they are even fixable but all other places I think would be able to be improved. I’m not sure what procedures would be needed but I’ve heard a lot about fat grafting. I would love to hear from you on what you could possibly do for me to make me feel better about it. I am attaching a picture of the left side of my face to compare to the picture of the right side of my face. Thank you for your time. 

Facial Fat Injections for Linear Scleroderma Dr Barry Eppley IndianapolisA: Fat grafting is the best treatment that we currently know for the soft tissue atrophy that linear scleroderma causes. Since fat loss is a big part of the tissue thinning effect it creates, it is logical that fat replacement would be a key part of its treatment. Harvesting fat by liposuction and then processing it for concentration is how injectable fat grafting is done. Injectable fat grafting is very versatile so it can be placed almost anywhere on the face.I have done this many times for linear scleroderma and it is certainly the one treatment that can help. While historically any treatment for linear scleroderma was recommended to be done once the disease processhad burnt itself out, my feeling is that fat grafting should be done even if the atrophic process is ongoing. It may help abort further tissue atrophy. Sinjce fat grafting is harmless since one’s own tissues are used, there are no adverse effects with its use and it can be repeated as many times as is necessary for optimal soft tissue volume restoration.

Dr. Barry Eppley

Indianapolis, Indiana