Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting head width reduction surgery, cheekbone reduction surgery as well as surgery to augment the back of my head. The first photo I attached is in regard to head width reduction and cheekbone reduction surgery. From the info on your website, I see you do removal of the muscle after the yellow line in my photo. I am curious to know if you can do removal of muscle after the red line in my photo. Also, I will always have very short hair on the side, since it make my head looks smaller. How visible will the scar be after the width reduction with my short hair?
I had a cheekbone reduction before but my surgeon didn’t reduce any more cheekbone after the first blue line in my photo due to concern of nerve damage. Since most of the width of my face is in between the two blue lines. The cheekbone reduction i had is largely ineffective in making my face more symmetrical and narrower. I was wondering if you are able to reduce the cheekbone between the two blue lines where my previous surgeon was concerned with nerve damage
Lastly is in regard to the augmentation of back of my head, my current head shape is similar to the baby in the second pictures. I am curious in getting a custom implant to make my head look more normal.I consulted with a craniofacial he advised me against a custom implant because of high risk of infection. How high is the infection rate of these implants, and How much will total cost of this specific surgery be including getting a 3d CT scan, a custom implant made, and all the other fees including surgeon fee?
A: When it comes to temporal muscle reduction, the actual line of reduction is from the top of the ear angling upwards to just behind the temporal hairline along the forehead, so it is in front of the red line that you have drawn. Most of the incision is behind the ear and it is done largely endoscopically above it.
The cheek bone a you are illustrating is the tail end of the zygomatic arch where it attaches to the temporal bone. If this part of the cheek bone is not fractured inward with the front part, little change in cheek bone width will result. An osteotomy is done in that area through a small incision at the junction of the beard skin and non-hairing skin. The temporal branch of the facial nerve runs in front of this incision so there is no risk of nerve injury. This is actually a standard approach to cheek bone reduction osteotomies as both the front and back ends needs to be cut and moved inward.
I have done many custom occipital skull implants as well as many other implants for other skull augmentation areas. I have yet to see an infection so the claim that they are prone to a high rate of infection has not been my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery. I have a very boxy figure and I am a model. I am looking to get more of an hour glass figure and gain more confidence in my appearance. As of now I refuse to take photos straight on because they make me look wide, but I strongly believe having those ribs removed will assist me in achieving those goals. Right now my measurements are 34C bust and then my hips are 38″ at the smallest point of my midsection I am 26″, and when my personal trainer measures me at my “real waist” it is 33″ I am 5’9 and 133lbs. I would really like to have a better figure, but with wide hips and my ribs I feel like it is difficult without the surgery. What is your professional opinion?
A: I think you who feel and know your own body better than anyone has the best perspective on what may be of benefit to an improved body shape. the question is not whether rib removal will be effective but exactly what ribs are best to remove. I would doubt that 11 and 12 are the ones as they lie too posterior and do not really wrap round the torso. Thus their removal would have no benefit to bring in the sides of the torso. More likely it is ribs 8,9 or 10. If you could send me a picture of the ribs marked on your ribcage (with a Sharpie) where you feel the greatest reduction is needed, that would be very helpful in determining the exact rib numbers to be removed for your rib removal surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a medium sized Implantech Terino Extended Anatomical implant placed about a year ago. I am interested in getting jaw angle implants and was wondering what style you think would best meet my needs. I like the flared out look of the Implantech Lateral Mandibular Angle implants, however, it also appears that I could use some vertical drop down given by the Posterior Mandibular Angle implants. It looks like the off-the-self posterior implants offered by implantech give 0.36mm of added width. Would this posterior implant give me the flared out look from the frontal view while dropping by jaw angle at the same time?
A; I do not find that any of these types of jaw angle implants would provide a ‘flared out’ look. They can add fullness to the jaw angles but they are not the style of jaw angle implant that can provide an angular flare, particularly if the implant provides any vertical lengthening. A different style of jaw angle implant is needed for that jawline look which is not currently commerically available for off-the-shelf catalog availability.
Dr. Barry Eppley
Indianapolis, indiana
Q: Dr. Eppley, I was writing interested in learning more about facial asymmetry surgery. I noticed that one side of my face is a bit fuller than the other. It manifests in the forehead and the jawline. I am wondering if it is advisable to do anything about these types of asymmetries or is it best to just ignore them. I have attached some photos to provide some examples of what I am referring to.
A: The answer to your question about facial asymmetry surgery and whether it is worth it depends on the degree that it bothers you, what would it take to make a correction and what are the risks in doing so. In terms of improving any facial asymmetry it is infinitely easier to add fullness than it is to reduce it. This is particularly true in the forehead due to surgical access. (incision needed to do it) It is less true in the jawline since the incisional access is intraoral. I would need to see better pictures of your face (non-smiling straight on picture) to do a computer imaging analysis to see if you feel such changes would be aesthetically beneficial and what type of facial changes those would be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a chin reduction for the vertical height of my chin as well as making the projection smaller when you look at my profile. I also have a chin dimple right in the center of my chin that I want removed and smoothed out. I am a 23 year old female. What can be done for me to achieve this? Also, I worry about loose skin after the reduction, what can be done to avoid that? I have a very tight jawline and I do not want to lose the definition.
A: Chin reduction can only be done only one of two ways from an incisional standpoint. Either it is done from an intraoral (inside the mouth) or a submental (under the chin) approach. Which is best depends on the dimensions of the bony reduction and how much, if any, excess chin pad tissues may result. I only see a frontal view picture attached and I need a side view picture (non-smiling) to determine what the horizontal reduction needs are if any. Most effective chin reductions are done from a submental approach to address this soft tissue concern.
The chin dimple is best treated simultaneously with fat injections to try and reduce/eliminate it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you could give me your opinion on the use of Aquamid. I’ve noticed in the US it isn’t FDA approved and have read about complications on the use of this injection product. My surgeon wants to use this around my jaw as my custom jaw implants have produced some dents and hollows around the point of the jaw to “fill them out”. However as a patient I am very skeptical on this although it sounds rather straight forward.
A: Aquamid, like all injectable filler materials is straightforward to place. It is just a question of whether the potential problems they can create are equally straightforward to solve.
All so called permanent fillers that create their effects by the placement of non-resorbable particles are prone to their own unique set of problems such as lumps and eventual tissue reactions. While it may never happen, and probably statistically won’t, when it does it will be a challenging problem as the material can not be removed from the tissues. There are many reasons Aquamid is not approved in the U.S. but, even if it was, I would likely never use it. There are numerous other options out there to use to help augment custom jaw implants that don’t have these potential problems or have a better proven track record. (e.g., fat injections, small mesh implants, Radiesse and Bellacol injections)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 68 years old. Several years ago I was diagnosed with Graves Disease and am currently in remission (forever I hope). However, due to the disease, medication, age and possibly genetic, my hair has become very fine and thinning all over. This in turn has accented my VERY flat back of the head and top. I cannot wear a headband because there is no where to hold it. The band slips off. My face looks much larger due to no balance of the skull. I will probably have to wear my hair short because it will not hold any style. So I am looking into reshaping. I am becoming more of a recluse due to this as I feel so unattractive. If you could tell me what augmentation approach would work for me. (similar to the female full back of the head that you show in your example) What also would be the most cost effective method to do it? I would certainly appreciate it. Thank you for your time.
A: Skull augmentation of the back and top of your head can be done with an implant. While a custom approach would be best using a 3D CT scan, that does add to the cost of the procedure. The most cost effective method would be with the use of preformed skull implants. Having done many custom skull implants over the years, I have a variety of preformed implants available that are close enough in shape that they would work for many other patients. By cutting peripheral slits in the preformed implants, like a fan, they can be made to lay flat and flush on just about any curved skull shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. I had two prior jaw surgeries (one orthognathic with sliding genioplasty). My mentalis muscle has been weakened and my lower third (chin particularly) looks bulkier because of this. There is some excess soft tissue around my chin as well (skin, maybe some fat). I’ve been thinking about mentalis muscle re-suspension, when I stumbled across this article which explains an alternative of Vertical Wedge Excision of Chin Ptosis.
This seems to me like a minimally invasive procedure with dramatic results that comprehensively addresses all laxity (muscle and skin). I wanted to ask you for your opinion on this, since I am worried about the longevity of the result when no sutures are used to resuspend the mentalis muscle. Perhaps a combination of both would be the way to go? Would you be able to perform this procedure preferably under sedation rather than general anesthesia as it involves no bone work? Also, since I am not from the States and would like to travel only once, would you be able to give me an indication of the approximate cost? I have attached here a picture for your reference – my problem seems to be largely excess soft tissue around the chin which makes it longer, bulkier horizontally and vertically and even asymmetrical, similarly to the pictures shown in the article that I linked above.
Thank you for your advice in advance.
A: Chin ptosis is a multifactoral problem that has different anatomic variants. Thus there is no one single best chin ptosis correction procedure. The first important classification is whether the chin ptosis is associated with a lower lip sag or not. If there is no lower lip sag there is no benefit to mentalis muscle resuspension or trying to move the chin tissues back upon the bone.
The next important chin ptosis classification is whether there is excessive chin tissues or whether there is a normal amount of tissue volume. If the overhanging chin tissues are normal in volume, and their resection may be associated with causing a lower lip sag, then resuspension should be done. When the ptosis is caused by excessive chin tissues then resection would be the appropriate approach.
When it comes to resection of the chin pad, it can be done horizontally (under the chin), vertically (as shown in the article) or through a combined vertical and horizontal technique. (inverted T) There is no question that adding a vertical direction to the chin pad excision provides an additional element of chin pad reduction that is helpful, it is just a question of the scar that can result from it. Once you go vertical, the scar is going to be noticeable since it is above the submental region. Whether the scar would be aacceptable depends on the magnitude of the excessive chin pad and the patient’s skin type. This article, which does not really describe a novel technique in my experience, shows a single case done on a Caucasian female. The resultant scar can be quite different in men of certain ethnicities.
But regardless of technique, any soft tissue chin work can be done under local/IV sedation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facial artery pulsation on my face near my nose that has been bothering me for quite some time now. After reading your case study of facial artery ligation, I would like to get it ligated if possible. It is around the region of my cheek near my nose. I do have a hard time believing its possible to ligate such an important artery as it supplies blood to the skin and tissue of the cheek. If ligation is not possible, I would love to explore the alternatives. Maybe a fat transfer over the artery might work? I would be grateful for you opinion.
A: Please show me a picture of the area on the face where the pulsations exist. The facial tissues have such an extensive blood supply that any single artery ligation does not have a compromising effect. It is more of an issue of how easy is it to get to and would a single point of ligation be effective. Most likely you are talking about a branch of the facial artery as it courses upward around the mouth and the side of the nose. While it can be safely ligated there is the issue of back flow from the tissues that it supplies. Fat transfer for coverage is a good alternative consideration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for the info on my bad temple implants. I want to remove the temple implants completely and just get cheekbone implants on the arch. But can you tell me, will this have to be two operations? First remove temple implants and then do ct scan to make a model of my cheekbone skull area? Because I want custom cheek implants. I worry if I do both in one operation it will be complicated because the ct scan will show the silicone temple implants (which will be near where the cheek implants will be placed). Do temple implants show up in CT scan? And therefore will the protruding temple implant area show up in the 3D model of the skull that is made from the CT scan? I want to come see you to one remove temple implants completely, and two get custom cheek implants high up on my cheekbone arch. Is that possible?
A: It will not be necessary to do two operations. A 3D CT scan can be done in which the existing temple implants will be seen but they can be electronically removed. Thus custom cheek implants can be made even if your temple implants are present.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am thinking of getting orbital rim implants to improve my lower eye hollows socket area and mainly to raise my lower eyelids so less scleral show is showing…
Can cheek implants placed very high have the same effect of pushing up lower eyelids? Give a less round eye look?
Also will there be lower eyelid retraction after orbital rim implants?
A: It is important to understand that neither orbital rim or cheek implants is going to drive up the lower eyelids to improve scleral show and give the eye less of a rounded eye look. In fact, one of the potential side effects of these implant procedures when done through a lower eyelid approach is lower eyelid retraction. If technically done well and orbicularis muscle resuspension and lateral canthopexies are performed with closure, lower eyelid retraction can be prevented and may even help with less scleral show. But bone-based implants can not push up on the lower eyelid and improve the level of the lash line across the eyeball. The bone levels lie well below the lash line of the eyelid. This is a common misconception which can be verified by pushing up on he cheek tissues and you will see that it does not change the position of the lower eyelid. (unless you really push up far which is not a realistic surgical effect)
Dr. Barry Eppley
Indianapolis, Indiana