Frontonasal Augmentation

Q: Dr. Eppley, I am interested in implants for a frontonasal augmentation effect. Would it be possible to place a nose bridge implant so that it extends onto the forehead and fans out, so that it kind of gives the effects of a forehead augmentation as well? I am look to create the look of deeper set eyes. Also, how much for each of those procedures? Thanks.

A: I suspect you are referring to augmentation of the glabellar region of the forehead just above the nose. While both areas can be augmented concurrently (frontonasal augmentation), they can not be done using a single implant or through the same incisional approach. While such an implant can be custom designed, one has to consider the logistics of it surgical placement. Such a frontonasal implant would be too big to pass it into the forehead through an open rhinoplasty approach. Conversely an adequate nasal pocket could not be made from any type of superior or scalp incisional approach unless it was an complete corral scalp incision. These are general statements and I would have to know more about the exact forehead and nasal areas you want to augment to determine their applicability to your aesthetic facial needs.

Dr. Barry Eppley
Indianapolis, Indiana

Custom Forehead Implant

Q: Dr. Eppley, I am interested in a custom forehead implant. My goal is to widen my forehead and make it look a bit more square. I also want some more central fullness. How do you decide to make these measurements on the implant in the design?

A: Of all custom facial implant designs, I find none ‘trickier’ or more difficult from an aesthetic standpoint than the male custom forehead implant. The design and having a satisfactory aesthetic result is much easier in females. What makes the male custom facial implant, and the male forehead implant, so aesthetically difficult is several factors. Anatomically, most men want a bit wider forehead and not a convex one like a female. This means that the anterior temporal line must be crossed in the implant design. If not, widening in this lateral forehead area may create an abnormal frontal bossing effect. The anterior temporal line is the bony boundary of the forehead. Crossing it to widen the forehead spills the implant over into the temporalis muscle/fascia area. While it is necessary to do this there is the judgment of where should the implant should end, how thick should it be, what shape in this transition should it have and there is a need to have a fine feather edge at the implant to soft tissue transition area to avoid a visible edge on the outside. These are all considerations in the implant design that women don’t have. Psychologically the risk of revisional surgery in all male custom facial implants is 25% to 33% and in the forehead this probably increases to 50% in my experience. This is always due to aesthetic issues of how the result finally looks no matter how much thought and effort was put into the initial custom implant design. It is also complicated in some male who have little patience for the time that it takes swelling to subside to see the actual final forehead shape.

Dr. Barry Eppley
Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, I am interested in rhinoplasty surgery.There are two main things I would like to change about my nose, that you will see from these photos. I have a small bump on the bridge as my nose, but I also really want to change the tip of my nose. My nose isn’t too wide or anything, but the tip and the bump are my two biggest concerns. The tip is the part I am most worried about and have been hesitant about rhinoplasty in general for fear that it won’t look natural after surgery.

A: Here is some imaging for your rhinoplasty. Your rhinoplasty is not quite as simple as ‘just take away the bump and lift the tip’. One of the reasons you have a bump on the bridge of your nose is because you have a very low radix or frontonasal junction. (the area above your bridge) This is part of your overall more recessed mid facial development. The bump is actually a pseudohump. It appears to be a hump because the bone above it is deficient. Just taking down the bump will make your nose look too low in this area. While some hump reduction is needed, the area above the hump must be augmented with carriage grafts as well. (radix augmentation) Your nose is also long with a hanging columella. The end of the nasal septum must be shortened to allow for any tip rotation upward as well as retraction of the hanging columella. With the hump reduction the tip absolutely must be shortened and rotated upward otherwise your nose will look even longer.

Dr. Barry Eppley
Indianapolis, Indiana

Rib Removal Surgery

Q: Dr. Eppley, I’ve been looking up videos and articles about your most well known rib removal surgery patient just for entertainment. It must get frustrating having to deal with so much misunderstanding and arrogance among people who couldn’t perform such a difficult procedure, and knowing there’s many doctors who do it privately. I just wanted to thank you again for making my life a little easier by not having to worry about corset training. I know I’m still in the recovery stage but I’m usually in a recovery stage these past few years. I have a general question, how often do you do rib removals a year?

A: There is no question that there remains a lot of ‘mystery’ and misconceptions about rib removal surgery, particularly amongst surgeons who often view it as dangerous and ill advised. (of course they have never actually done the operation or ever taken even a single rib for any purpose) Having done it many times over the years I have a unique perspective on it and its outcome and value to patients. In each and every case I have done, patients have had satisfactory outcomes and no complications. That is all the vindication that I need that the surgery is both safe and effective in the properly selected patient.

What used to be a procedure that was done once or twice a year is becoming a procedure that I now do about once a month. As the public becomes more aware of it and the procedure comes out of ‘hiding’, more patients are interested in having it done.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping Surgery

Q: Dr. Eppley, I am interested in facial reshaping surgery.I just wanted to make an enquiry about possibly having some cosmetic surgery with you in the coming months. I’ve been to a few plastic surgeons here in my country but I am having difficulty finding the right surgeon to operate on me. Having looked through your website I was very impressed with the before and after pictures of his patients and am now considering flying to America to have the surgery.

I noticed he seems to offer a lot of different types of facial implants which I am most interested in. I’m just wondering is there a limit on the amount of procedures that can be carried out at one time? I would be looking to enhance and refine several features on my face and finding a surgeon that can perform a lot of the procedures I’m interested in in Europe is very difficult.

I was hoping that you review some photographs i’ve edited myself and let me know if he thinks the result I’m looking for is possible. My goal is to install more classical features onto my face and to create a more chiseled, symmetrical bone structure with the most natural result possible so as to avoid a ‘surgery look’.

A: Thank you for your inquiry. One can have done any number of facial procedures at one time, albeit bony change or soft tissue. Even with doing a large number of procedures simultaneously, the concern is not usually looking overdone but whether enough change has occurred to satisfy the patient’s aesthetic goals. The concern about being overdone is largely relegated to anti-aging facial surgery not the type of facial reshaping surgery that younger people undergo such as you are considering. In the spirit of expectations, let me go over your morphed facial images to review what is and is not possible. You have illustrated the following changes on your face:

1) Hairline Advancement – what you have shown is reasonable although be aware that the greatest forward movement in the hairline is in the center and not in the temporal areas. Once can expect about a 1cm forward movement in males which is about what you are showing.

2) Rhinoplasty – dropping the dorsal line and shortening and rotating the tip is an achievable goal as you have shown.

3) Submalar Hollowing – removing the buccal fat pads with perioral liposuction will help but it needs to be combined with a zygomatic arch augmentation to have an effect that goes further back on your face.

4) Upper Lip Advancement – this procedure can set the vermilion-cutaneous border where you want it so that outcome can be obtained.

5) Jawline – In trying to achieve a more defined jawline (stronger chin and prominent jaw angles) you are showing the type of change that is not possible. What you have done is to vertically shorten the entire jawline and create a degree of jawline sharpness that can not be done. You just can’t vertically shorten the middle portion of the jawline like you have shown. While the squareness and greater projection of the chin is possible and well as the vertical elongation of the jaw angles, the vertical height of the middle portion of the jawline can not be changed. Either a custom three piece jawline implant (chin and two jaw angles) or a custom one-piece jawline implant (with a thin connection between the chin and jaw angles) would create a much improved definition of the jawline albeit not as vertically short or quite as sharp as you have morphed.

Dr. Barry Eppley
Indianapolis, Indiana

Forehead Augmentation

Q: Dr. Eppley, I am a 21 year old girl, but I have a masculine forehead. I am interested in forehead augmentation and brow bone augmentation with bone cement. Could you tellI am a little girl, 5 feet tall, and I have a pretty small forehead. Also I was wondering, after the procedure will there be permanent metal or titanium in my forehead? Lastly, what is the general recovery time like? Thank you for your time!

A: Such forehead augmentation can be done using bone cement materials which are like putty and are shaped and allowed to harden during surgery. There are no metal materials that are used. The recovery from this type of surgery is largely just about the swelling that temporarily occurs around the eyes and forehead area. (the eyes do not swell shut) Most patients come in the day before the surgery, have surgery the next day and stay over night in a hotel the night and first day after. One can go home fairly quickly in a day our two after the surgery. It is not a procedure that is usually associated with much discomfort. In fact the forehead will be numb for awhile rather than painful.

Dr. Barry Eppley

Indianapolis, Indiana

Facelift

Q: Dr. Eppley, Hello!  I’m 46 but I feel like I look 76 years old.  I don’t know if a filler or mini facelift would be the answer. I just want to smile without all the wrinkles. I have tried lasers, dermapen and ultherapy. I’ve tried fillers but am not happy with the results.  Thank you for your time.

A: You certainly don’t look 76 but I can see your concerns. What you havhe done is prove that nothing short of a surgical procedure would be of benefit. Non-surgical treatments like injectable fillers, energy-devices for skin tightening many other options have their place in facial rejuvenation. But there does come a time when what they can do is beyond their capabilities. Your own experience with them has proven their limitations in anything but the most early signs of aging.

You have reached the point where, if you are going to do anything, it must be surgical which involves skin removal and tissue tightening. And you don’t really want to waste time and money on limited procedures such as many of the so called ‘mini facelifts’. They also have their role in facial rejuvenation but the results they provide will be ‘mini’ and short lived also. What you need is a lower facelift to completely tighten the neck and get rid of the jowls. Ideally this should be combined with laser resurfacing over all other facial areas that are not undermined from the facelift procedure. Anything less will end up with disappointing results.

Dr. Barry Eppley

Indianapolis, Indiana

Premaxillary Augmentation

Q: Dr. Eppley, I’m looking to get augmentation to the base of the nose (the area directly below the bridge/nostrils) to ‘rotate/push’ it forward as seen in the picture. (per maxillary augmentation) I’ve seen pictures of paranasal and peri-pyriform implants, but those involve augmentation of the sides of the nose, and that’s not something I do not want.

Can I check if my aesthetic goals are possible, and if so, what options are available for doing so? I understand that you do custom designed implants, but are there any off the shelf alternatives to those? 

Additionally, could fillers be used in the interim to simulate what an implant would do? This is something I would like to consider to see if I would like the augmentation before proceeding with a more permanent implant.

Thank you!

A: First, what you are trying to augment is the nasolabial angle or the nasocolumellar-upper lip junction. This is more commonly referred to as the central premaxillary region or the anterior nasal spine specifically. This has been done fro decades using a wide range of materials from autogenous materials like cartilage and bone to allogeneic materials like irradiated cartilage to a wide range of synthetic msterials. (e.g., Gore-tex, mersilene mesh, silicone implants) They all can work in such a small area. There would certainly be no reason to make a custom implant for this small areas. Whatever the implant material would be it would be ‘custom made’ or hand fashioned at the time of surgery out of any of these materials.

You can certainly test the benefits of premaxillary augmentation by using any of the injectable fillers. They may not create exactly the effects of any implant material which would have more of a push on the overlying soft tissues than softer injectable filler materials.

Dr. Barry Eppley

Indianapolis, Indiana

Sliding Genioplasty

Q: Dr. Eppley, I had a sliding genioplasty and jaw augmentation using hydroxyapatite several years ago. The jaw is asymmetric and bumpy, and the chin was moved up instead of just forward. I wanted to have the HA paste along the jaw re-contoured if possible, and the genioplasty revised to give me some more vertical height and more projection too if possible. I also have loose skin on my neck from the massive amount of swelling that I had after the procedure. If you could give me a breakdown of the procedures id be so grateful. (Jaw HA paste contouring/ revision Sliding genio / neck lift/tightening) thanks!

A: The angle of the bone cut on the sliding genioplasty obviously created a vertical shortening effect as the bone was brought forward. Moving the chin back down and out further can be done by a repeat of the sliding genioplasty. The HA granules appear to have been used to try and create a posterior jaw angle augmentation effect. HA onlay application to the bone very often creates an irregular surface contour as it heals and bone grows into it. The HA granules can not be removed per se but they can be contoured (burred) down to create a smoother contour. As for the neck, it is impossible for me to say what may be beneficial since I don’t know what your neck looks like. Real neck tightening comes only from a lower neck/jowl tuck-up. I would assume you are young so this procedure seems a bit aggressive for your age but the problem may warrant it.

Dr. Barry Eppley
Indianapolis, Indiana

Cranioplasty

Q: Dr, Eppley, I am interested in a cranioplasty procedure.I have a depression on both sides of my skull and the back goes in little also. I have thick hair which covers it up. but, it really bothers me. I’m not sure how my skull go the way it did. but I would like to know if its can be fixed and is it safe. I was also reading about Osteobond from another plastic surgeon. what do you know about that…. thanks.

A: There are two cranioplasty materials to fix skull depressions/contour issues, bone cements (like Osteobond) or a custom silicone skull implant. Having done hundreds of skull augmentations, I have largely moved away from bone cements for many aesthetic skull augmentations due to access and contour issues with them. To properly place bone cement materials, a long scalp incision is needed. This is the only way to place and properly smooth out the intraoperatively applied and shaped bone cements. Putting such bone cements in through small limited incisions is prone to a near 100% irregular contour occurrence. The large the skull augmentation the bigger this contour problem becomes. Custom made skull implants solve these problems by being perfectly smooth (because they are computer designed) and can be placed through smaller incisions than bone cements. While both cranioplasty materials can be successfully used for your described skull shape issues, it is important to understand how and why they are different.

Dr. Barry Eppley
Indianapolis, Indiana