Your Questions
Your Questions
Q: Dr. Eppley, I am in need of a sliding genioplasty to treat sleep apnea. Can a sliding genioplasty be billed to insurance at all?
A: The question that you are asking is whether insurance will pay for your sliding genioplasty as a medical necessity for your sleep apnea. That is not an unreasonable question but one that can only be determined by the submission of a predetemination letter to your insurance carrier. To do this requires the following information to be submitted:
1) Pictures (which you have)
2) Sleep study results that show you have a high AHI
3) X-rays which show a short jaw.
Once I have this information then a pre letter can be submitted. Only the insurance company can make the decision for approval or denial for the sliding genioplasty but they must have all of the required information for you to have any shot at all of potential coverage.
As an aside, I am not aware that a sliding genioplasty is a primary procedure for improving sleep apnea. It may offer some mld improvement but major skeletal advancement through maxillomandibular osteotomies is usually what is required to make a major improvement in severe sleep apnea problems. A sliding genioplasty is an anterior pull procedure while maxillomandibular osteotomies are a push procedure which is more effective for opening the airway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction. I was wondering if it’s possible to even out my forehead and make it smooth and symmetrical? I am bothered by the sides areas of my forehead which I have marked in the attached pictures.
A: What you have are prominent anterior temporal lines on each side of your forehead. This is not really due to a prominent forehead per se but due to a deficient temporal muscle on the side. This makes your forehead look very square and boxy. Rather than burring down the temporal lines (forehead reduction) I would recommend extended temporal implants to build up the area beside the forehead. This would be simpler and would create a more masculine forehead as opposed to burring down the bone and making your forehead rounder. (although that could be done based on your personal choice)
The aesthetic problem with temporal line reduction is that it will require a scalp incision to be done which is challenging to place in male without some visibility. Conversely the small temporal incisions for placing extended temporal implants are in the temporal hairline and are much less of an aesthetic concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about custom facial implants. Is there a standard “ideal” facial structure dimension the digital system will use? Will you send me an image of the implant and how it will fit my chin? I would have a scan sent to you. Most custom facial implants are ready in 3 weeks? Is this correct? Thank you!
A: Even though custom facial implants are designed on the computer, the computer does not have any innate knowledge as to what looks best for any patient. It is up to the surgeon to create the dimensions of the implant, the computer software does not do that. It merely makes the implant by the dimensions that the surgeon provides. This is a common misconception by many patients. What the computer software will do is make the implant have a perfect fit, be smooth on its outer surface, adjust for any bony asymmetries and make for a smooth edge transition from implant to the bone. But no software yet can create for the patient some ideal design that will produce the best aesthetic change for the patient.
Custom facial implants usually takes about three weeks from getting the 3D CT scan to having the implant sterilized and ready for implantation. We usually arrange for an actual surgery time once we start the implant design so the surgery process runs expeditiously.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin, cheek and jaw augmentation. Like others, I am looking for exceptionally square, strong and masculine jawline to bring my facial aesthetics to the next level. I already have a fairly low body fat percentage (around 7-8%) but have always had slight TMJ on my right side and for as long as I can remember wanted to really strengthen my face.
Would I be a good candidate for a jaw, cheek, chin augmentation, and/or rhinoplasty to strengthen and balance my face? Or should I address the slight TMJ issue first? Which procedure or combination of the aforementioned would lead to the highly coveted male model facial look? I’ve attached a photo with the front and both sides of my face as well as a goal photo for reference.
A: I have done some imaging looking at rhinoplasty, cheek, and total jaw augmentation for your review. You have a good face for these type of changes because your face is already skeletonized, just disproportionate. The jawline change will require a custom wrap around jawline implant. Whether this would achieve the male model look that you desire is open to one’s interpretation
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw augmentation. I want to change my whole jawline to make it like one of the men in my goal photos. Up until this point I was assuming the custom wrap around jawline implants would achieve it, but since I shaved my beard off to see what I had, I am unsure if it will even be enough. Do you think I need any other procedure like lefort, jaw advancement, chin wing etc. Do I have a recessed jaw/chin, or is it just generally underdeveloped? I just don’t know, but I’m willing to get whatever jaw augmentation procedure I need.
I attached the best pictures I could take with my phone, I hope they are good enough. Based on them, can you tell me if any of my goals are possible (and what procedure or combination of procedures I would need). If any of the picture’s quality is good enough, is it possible to have a ‘predict my face’ and get a morph of what is maximally possible with custom implants? I really want to achieve a jawline that of one of my goal pictures.
My ultimate goal is to achieve a front jawline as close to any of those goal pictures as possible. And the side profile to have as much of an L shape as possible (male model look). Currently whenever I am in public I push my jaw out as much as possible and also bite my teeth to flex the jaw, it is a small improvement but is too much effort for me to maintain all day (not to mention I shouldn’t have to resort to that just to look less ‘bad’)
Note: I also plan on having other procedures done (rhinoplasty), but right now I am most concerned about jaw augmentation, as I think that will have the biggest impact, and then get the other procedures.
A: Your pictures do not show an abnormal lower jaw that is significantly underdeveloped or would be in need of major orthognathic surgery. To achieve your aesthetic goals you need jaw augmentation by any of the conventional implant methods. There is nothing more powerful and than a custom jawline implant and that would be the ideal approach for you. But the more economic approach to a more complete jaw augmentation is that of a square chin and jaw angle implants. This could also be effective for you since your jaw shape is not overlying deficient and enhancements at the chin and jaw angle areas would go a long way towards a more defined jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper and lower blepharoplasty surgery about two years ago. My upper eyelids have scars, the left eye is worse than the right. Another surgeon said the right eye just has some extra fat that needed removed. I have very high cheekbones and when I smile or laugh I still have extra skin below my lower eyelids that bunches up and makes me look a lot older than I really am. I didn’t know if that could be fixed by doing a little tuck. The only problem is I do have dry eyes. I also had a neck lift which I was very pleased with but my double chin seems to be coming back. The other surgeon I spoke with said he would do a chin tuck up. I would go ahead and book with you because I have read all the great reviews about you and I’m not really satisfied with my current plastic surgeon.
A: Thank you for sending your pictures. What I see are upper blepharopasty scars that are not in the eyelid crease line and are above it. The actual appearance of the blepharoplasty scars are not atypical but because they are high they are ore noticeable than they otherwise would be. Unless there is more skin to remove (and there is in the right eye) the scars ca not be lowered or made less noticeable. While a pinch lower blepharoplasty can be done, whether there would be any worsening of your dry eyes is unknown. It often is not a good idea to do an operation based on excess skin that appears in facial animation. While that may be effective during smiling, the critical question is what impact that may have in eyelid position when you are not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very interested in having a surgical procedure to make the width of my lips longer. (mouth widening procedure) I am fully aware of the pros and cons of this procedure but the pros do weigh out the cons. I’m just enquiring more information as to the procedure such as how long I would be out of work for and is this a procedure that I would need to have done frequently?
A: The mouth procedure to which you refer is technically known as a lateral commissuroplasty (mouth widening procedure) where the corners of the mouth are opened up at the skin level and the vermilion/mucosa lining is brought out to make the horizontal length of the mouth from corner to corner longer. (wider) When you speak to ‘do I need to have it done frequently’ you are likely referring to the potential for scar contracture which may require secondary release. While this is a risk, it is not an expected outcome and hopefully would not occur. Thus a successful mouth widening procedure would be a one time procedure with permanent effects. As a general rule the horizontal width of the mouth can be increased about 5mms per side for a total of a 1 cm mouth width increase.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had contacted you months ago inquiring about temporal artery ligation. But I had to reconsider that procedure because the artery on my left side now appears when doing physical activities or with heat but not as bad as the right. And even down the middle of my forehead. So now I was wondering if you do fat transfers to the entire forehead and if you thinks this could help with my appearance. It seems that I suddenly have lost fat in my forehead which is making these arteries appear worse.
A: Fat transfer is not known to be an effective treatment to camouflage prominent forehead arteries and veins. While this seems like it would work, it does not in my experience. This is because it is difficult, if not impossible, to put the fat on top of the arteries. Rather it ends up going around them and does not result in decreasing theie visibility. Temporal artery ligation is the best approach for prominent arterial vessels of the temporal and forehead area. It is also far simpler as it directly treats the problem…the vessel themselves.
Temporal artery ligation is usually done under local anesthesia using small 5mm incisions to isolate the arterial branches and tie them off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buttock augmentation. I am a 53 year old athletic woman who had liposuction years ago that left me with misshaped and sagging buttocks. A skin lift four years ago helped just a little, but, as photos show, still a big problem. I am wanting to fill out my buttocks but keep an athletic look, since the rest of my body has good muscle definition. Is there a buttock augmentation procedure that will enable me to continue to do extreme sports?
A: The residual problem with your buttocks is a volume issue not one of a skin sag. The dilemma you have is that of two treatment options, fat grafting and implants, one of the them (fat grafting) is not a viable option due to your very lean body. Buttock implants, while effective, poses both a recovery and potential physical activity limitation (during the long recovery process) for what your physical standards are. (extreme sports) It would probably take three months for a full recovery. Given these issues, I do not see any method of buttock augmentation that will work for your specific physical needs. While full gluteal muscle function will return, the impact of intramuscular buttock implants is suspect in very highly athletic people.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about skull reshaping surgery. In my opinion I’ve got quite a bit to do on my skull as I guess about 60% of my skull needs filler. My head slopes down from the centre of my skull on the top of my head to the back of my head. Also from the back of my head to my ears has flat spots and low spots that need to be filled on both sides. On both sides of my head above my ears is needs to be filled as it slopes abit to the top centre of my head. Hope this makes sense. I can draw pictures If that helps or a Ct scan might be needed. Also I live in the United Kingdom which would mean I would have to fly over. Would that have any effect on having the operation then having to return to the UK?
A: From your pictures, I can clearly see your skull shape concerns which are located onj the back half of your head. I would not think that the skull area involved is as much as 60% surface of your head (probably closer to 1/3) but that is a moto point. Your skull reshaping needs could only be done by a custom skull implant procedure. That is the best way to smoothly and evenly augment your skull contour issues. That requires a 3D CT scan from which the actual implant is made through a computer design process.
I have many patients from the UK for a variety of procedures including various forms of skull reshaping. There are no adverse effects from air travel on this type of aesthetic skull procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pubic liposuction. I had a tummy tuck over ten years ago and my pubic area is rather puffy and i would like to get liposuction to remove the fat that completely sticks out on each side of the seam in my pants or it is disgusting in my bathing suit. I have an appointment with another plastic surgeon but I like all that you have said about this after tummy tuck problem so you seem to be experienced in what I am looking for.
A: It is very common after a tummy tuck that residual fullness of the pubic region is seen. This is because the fat content of the pubic region has not changed (tissue thickness) while what lies above it has. Since the narrowest portion of a tummy tuck is usually the scar line this makes the unaltered pubic region more evident after surgery. While many patients think that the pubic fullness is persistent swelling from the tummy tuck, this potential cause can be eliminated once one is six months after their tummy tuck. Pubic liposuction is the solution to the puffy mons and is tremendously effective at reducing its profile and making it flatter.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I underwent an 8mm sliding genioplasty three years ago. Overall I consider it a big improvement for my face, but now instead of lacking a chin, I have a step-off deformity on the right jawline. It is quite visible (you have to look straight to it thought). I could live with it but I’d also be much free from concern if I could get rid of it. Is there any way to fix and unify my jawline, preferably without major surgery? Thank you very much. Kind regards.
A: Step-offs along the jawline after a sliding genioplasty are common particularly the greater the horizontal movement and the more steep the osteotomy cut is. The simplest method to treat these jawline irregularities after a sliding geniplasty is to fill in the defect from an intraoral approach. There are a variety of material options but hydroxyapatite granules or the layering of porous mesh over it is the most common way I do it. It is a surgery but I would not consider it major surgery compared to a sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about chin implant surgery. I recently had a small central chin implant put in and I am about 3 1/2 weeks post-op. I really dislike the shape and am wondering if an extended chin implant would have been a better option. I have shadows/dents on either side of my chin.
A: There are numerous styles to choose from for chin implant surgery. Obviously selection of chin implant style and size are critical in getting the optimal desired aesthetic chin augmentation effect. While a central chin implant is often a good choice for some women, it does not provide any augmentation effects to the side of the chin since it does not extend past a vertical line dropped down from the corners of the mouth on the bone. Since you are seeing shadows/indents on the side of the chin, this would strongly suggest that this indeed a chin shape or chin style issue. The question is at just under four weeks after surgery whether this is too early to make a final judgment about the outcome of your chin augmentation procedure. I would give it a full three months after the initial surgery date before making a final judgment about the decision to change your chin implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of forehead augmentation. I have a slight depression in the middle of my forehead which in certain lighting becomes obvious. I know it is not big but it still bothers me. I have attached a video of it so you can see what I mean. What is the best method of forehead augmentation for it?
A:Thank you for sending the video which shows a circular dip/depression in the middle forehead. I have seen this before and it does represent a bit of forehead bone depression. While there are a variety of ways to do forehead augmentation, the most important consideration is to avoid any scar in doing so. This leaves us with an injection method of fat which is scarless, simple and can be reasonable effective if not overdone. The most important issue in your case is to make sure the downside of any procedure never makes the problem worse or trades off one aesthetic problem for another. The biggest downside of fat injections is the unpredictability of how well they will survive (although they usually do well in the forehead actually) and this a very ‘safe’ risk since it does not worsen the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about possible chin implant erosion. I’m a female patient in my thirties. A few years ago I had a medpor chin implant inserted. I was wondering whether I could ask for your input since I understand you are one of the most prominent surgeons when it comes to both craniofacial as well as plastic surgery.
I had a cone beam scan performed a while ago because of some concerns about my teeth. There appears to be (what looks like) a ‘step off’ in the bone at the lower frontal teeth roots, but I’m not sure if I’m seeing this/interpreting this well – I might misinterpret the scan. Could this step off be caused by the chin implant? (It concerns a medpor chin implant). I drew a red arrow in the scan where I appear to see some kind of step off/change in the bone level. I appreciate your opinion. Thank you very much.
A: That stepoff you see is a classic example of chin implant settling (many refer to it as chin implant erosion which is an inaccurate term) This illustrates that despite the biologic nature of an integrated implant material like Medpor, implant settling can and does occur just like occurs in silicone.
By bone resorption I assume you mean periodontal (gum recession) and radiographic evidence of lower alveolar bone levels. Whether that is a function of the implant I would initially doubt it as the implant sits much lower than the root level. The usual symptoms would be more pain and tooth sensitivity not alveolar bone resorption. But to qualify that answer I would need to see a front view picture of the cone beam to assess the implant’s location under/over the tooth root levels.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I would like to get deltoid implants, I’m a fairly tall at 6’1 but my shoulders are lacking. I have a narrow frame and would like silicone implants to widen my shoulders by 6 cm all together. I saw where a doctor from South Korea does deltoid implants by placing an incision under the armpit and uses silicone implants over the shoulders to reshape them and widen them. I would like to do 3 cm on each side like that surgeon does. I want to maximize my shoulders as much as possible while not over doing it. I would like to see if my clavicle growth plates have fused though before I get the implants to make sure I still have some growing room, thank you and hopefully you get back to me.
A: Deltoid implants are indeed placed through a posterior axillary incision. The implants are placed under the fascia up over the central region of the deltoid muscle. As you may know there are no off-the-shelf preformed deltoid implants that are commercially available in the U.S. due to low patient demand. What I use are Implantech’s silicone contoured carving blocks Style 3. Their greatest thickness are 2.1 cms. While a 3 cms deltoid implant can be made by them that is going to raise the cost of the implants by a significant amount. You will have to decide if the extra 9mms is worth the additional cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested, I think, in a custom jawline implant.The attached photo includes a Photoshop direction I would like to take with a custom jawline implant. Is this achievable or just very wishful thinking? Also, would you suggest a neck lift or would such an implant eliminate the loose muscle/fat under my chin. I’m looking forward to making a decision on this very soon and moving forward. Thank you very much!
A: What you are demonstrating by your Photoshop effort is pretty much what is possible with a custom jawline implant. It is not wishful thinking. Such a custom implant will pick up all the loose skin in the neck particularly back along the jawline and jaw angle area. It will also do so under the chin as well. How effective it is at ‘eliminating’ this loose skin has a lot to do with the size and dimensions of the implant. It does so because the increased surface area of the implant requires greater soft tissue coverage and it pulls it up from below not downward from the face. A bigger bone surface requires more tissue coverage and it has to come from somewhere. Fortunately for the jawline it comes from the neck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to surgically contour my facial bones, specifically from the zygoma and below. Unfortunately, where I am going they do not do temporal reduction bone surgery. So in order to achieve the look I am going for, long and thin, I was wondering, to what extent may the sides of my head be reduced without removing a lot of muscle, mainly temporal bone?
A: Contrary to popular perception, temporal reduction is done by removal of muscle not bone. The fullness of convexity of the head above the ears is a combnation of bone and muscle but the ratio is weighted more towards the muscle and not bone. The thickness of the posterior temporal muscle in men can be anywhere from 7 to 1 mm thick. In contrast the thickness of the bone may be only 3 to 5mm thick. You can demonstrate this by getting a CT scan to see the tissue makeup on the side of your head.
To really make a difference in temporal reduction surgery, you remove the entirety of the posterior temporal muscle not burring the bone. Bone reduction will make little if any difference in its width, muscle removal can make it completely flat. Interestingly, removal of the posterior muscle has no long-term effects on mouth opening as the much larger anterior portion of the temporal muscle remains.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Exploring options as part of the decision making process, I understand an alternative to the custom jawline implant would be a sliding genioplasty along with Gore-tex posterior mandibular angles and a mandibular body piece to go between the angle implant and the chin. The advantage, I believe, would be a somewhat more natural looking ‘mentolabial sulcus’ (more of an ’S’ than ‘V’ shape) and chin.
Do you think a sliding genioplasty could give me the chin width shown in my Photoshop image? I believe the chin can be split vertically and a piece of bone inserted between the halves to increase width.
Do you think the custom wrap-around implant would give me the length, width, and projection I am after, as good as a sliding genioplasty with Gore-tex angles?
As much as I want to avoid adding complexity to the surgery, I do want the best looking and most natural looking end product/result.
Your thoughts would be greatly appreciated.
A: While there are different approaches to a total jawline enhancement effect, using any form of a three piece approach (chin and two angles… or in your description a five piece approach) is, just frankly, an historic and problematic approach to achieving the jawline effect you seek. I have done over the past twenty-five years every conceivable method for chin, jaw angle and total jawline augmentation surgery. In almost every case, the custom jawline implant method is far superior to any other method or combination of jawline surgery methods for the following reasons:
- An important aspect of the total jawline enhancement look that you are going for is smoothness of the jawline from one angle to the other. A one piece implant can do that. A hodge podge of bone cuts and implants will leave a jawline irregular and asymmetric with absolute certainty.
- Every aesthetic surgery has risks of of revision which are cumulative based on the number of procedures done. While a custom jawline implant does have a risk of revision for aesthetic reasons, it is a single risk of around 15% because it is a single implant/procedure. When you combone five procedures together, as you have described, the cumulative risk from that approach will approach 100%.
- Gore-tex implants, even if they were available in the right size and thickness (which they are not) are soft and compressible. To vertically lengthen the jaw angles as you desire you need something that not only has the right shape but can push the overlying muscle and skin downward and then maintain it. Gore-tex is not the material for that job.
- While a sliding genioplasty can be split in the middle and bone grafted, the inferior edge transitions back along the jawline will not be smooth. Besides that issue you will need a bone graft harvested which must come from either your skull, rib or hip.
- The impact of a sliding genioplasty or a custom jawline implant on the labiomental sulcus are perfectly similar. The labiomental sulcus is a fixed anatomic structure whose effects from any procedure below it will remain the same.
Dr. Barry Eppley
Indianapolis, Indiana