Your Questions
Your Questions
Q: Dr. Eppley, I am interested in rib removal surgery. How many ribs can a patient have removed all together? I’ve read about your procedure and I would like more ribs removed, rather than just: 10, 11, or 12. I have very strong, prominent, wide ribs that I no longer wish to have. Wearing tight jackets and tight tops make my appearance look much worst. Can you remove more ribs than just these six? What is the cost of this surgery??
A: The main purpose of rib removal surgery in most cases is to narrow the waistline. Ribs #10, 11 , and 12 are the only ones that have any impact on the anatomic waist. Further rib removal (#8 and #9) will not change the shape of the waistline. In addition while the cartilaginous portions of ribs #8 and #9 can be removed, they require a different incisional approach to remove which is either done by a direct incision over them or through a tummy tuck incision.
I would need to see pictures of your torso and for you to point out the ribs that you see as a problem. But rib removal surgery is limited to the lower end of the ribcage with an emphasis on making the anatomic waistline more defined…which is about at the level of the belly button.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implants and cheek implants. I’m 31 years old and I’ve always felt my cheeks and jawline have been a bit “soft” and chubby despite me being rather skinny, so I was hoping you could give me your opinion. I’ve attached a couple images to the post but I’ve also uploaded a file here which includes multiple angles of my face: I wanted to discuss whether surgery might be appropriate on the following areas, given I’m not at all overweight and I don’t think I could address them via weight loss:
1) You can see there is some fat under my chin towards the back of my neck in the first picture when the camera is tilted upwards (I’m 6’1″ tall so it’s fairly visible in everyday life).
2) You can see from the side views that my jawline is quite “soft” and not well defined in general, particularly towards the back.
3) What I assume is the jowl area (labelled in red on one of the images) also seems quite “chubby” and both hangs down below my jawline and makes my lower face wider and less defined than it would otherwise be. There’s also a pre-jowl “hole” in my jawline in the 3/4 view that may or may not be connected with this.
4) My cheek area as a whole just seems quite flat and undefined when seen from the front. There doesn’t seem to be much shape there, it’s kinda just a large empty space.
I’ve had a chin implant in the past (Implantech Anatomical Chin sized large) and I’m generally content with the new position of my chin, but I was told I had an underdeveloped jaw and I assume that is contributing to these issues. However, as the surgery to fix that issue is such a major undertaking I was hoping it would be possible to address these issues via other methods.
I’m curious as to whether these issues are caused by excess fat or by skeletal deficiency? Would liposuction be a good idea? Are cheek implants a possibility to give my cheeks a bit more structure?
I had cheek implants placed roughly 18 months ago, but I had them removed again 6 months ago as I felt they made my face too wide (and a little feminine), particularly when I was smiling. However, we never really discussed the different areas of the cheek that could be enhanced via an implant before the surgery, so I’m unsure if I was unsuitable for implants in general or if the type of implant was simply poorly chosen.
Thanks for your time and apologies for the long email!
A: Thank you for your inquiry and sending your pictures. For our jawline, I think the fundamental problem is that of skeletal deficiency. By your own admission you had a naturally shorter and underdeveloped jawline that ideally should be treated by orthognathic surgery. But, understandably, you do not want to purse that amount of effort. The chin implant has now provided adequate anterior jawline projection but the rest of the jawline behind it remains deficient and actually now has become more apparent with the chin being corrected. Your jaw angles are high and deficient. This creates a relative soft tissue excess/looseness. While liposuction can be done around the jaw angles and along the jawline, it is not really going to reshape these areas. This is an issue of volume deficiency particularly at the jaw angles. Either preformed or custom jaw angle implants are what you really need to complete the total jawline augmentation effect.
Since you have had cheek implants that were not successful, any reconsideration of them should be done more thoughtfully. I would need to see before and after pictures of your initial cheek implant results and to know exactly what style and size of cheek implants that were used. It is certainly true that a cheek implant is not just a cheek implant. There are different styles of cheek implants and, in my experience, most of the available cheek implant styles are not really made for men. (just like most chin implants do not really work well for most women)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I know I am interested in at least a custom jaw implant. I have noticeable facial asymmetry. What procedures will fix the following concerns? Long face; weak chin, asymmetric jaw;flat face; asymmetric eyelids;and no browbone projection.
A: Thank you for your inquiry and sending your pictures. In looking at them your biggest facial deficiency is in the lower third of your face. Your entire lower jaw is short, leading to a weaker chin and lack of any jaw angle prominence. Your face would probably not look as long if the lower third of the face was more prominent. There is also some asymmetry of the lower jaw which is magnified because of its underdevelopment. To best treat this type of lower jaw deficiency, a custom jaw implant made from a 3D CT scan would treat both the lower jaw deficiency and asymmetry at the same time.
The flatter face is partly due to the lower jaw but the lack of cheek prominent contributes to it as well. There is where cheek implants would make a contribution.
I don’t see the type of eyelid asymmetry that is easily improvable by eyelid surgery.
Lack of brow bone projection is best treated by a brow bone implant placed through an endoscopic approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions regarding eye reshaping procedures that I don’t think are talked about. I have always liked wide set, narrow, uptilted, “long” eyes that had an excessive horizontal span with minimal vertical height.
I have attached a photo highlighting some things.
1. Can the space between the eyes(interpupillary distance) be increased for cosmetic reasons?
2. Is there anyway to obliterate an epicanthal fold completely? Not just push it over slightly but actually turn an asian epicanthal fold to a completely caucasian eye with no epicanthal fold.
3. What surgery would raise the lower eyelid closer towards the medial? When I squint my lower eyelid, it brings up the medial lower eyelid. When I see photos of canthoplasties, it seems they elevate the corners of the eyes to create a severe cat-like look that is in the direction of vertical.
4. Relating to the top middle photo of my eyes, you can see a before and after of where I am putting a lateral horizontal vector on my eyes. Can this surgically be done with long lasting results? Again, with canthoplasties, they are done all the time as well as brow lifts but these are always either in a vertical pull or 45 degree angle pull. I’m simply looking for a horizontal pull to create an elongated look.
5. In the photos of the two women, they both have narrow, elongated, medial palpebral fissures but more importantly, the outside of their eyes are very long. There is a lot of white show to the lateral part of their irises, is there anyway to extend and create this for someone that does not have a lot of lateral eye exposure?
6. In the gentleman on the right, he also has a very elongated medial palpebral fissure, even more exagerrated than the two women. can this also be replicated on your average person?
Thank you for your time.
A: In answer to your eye reshaping questions:
1) THE INTERPUPILLARY DISTANCE CAN NOT BE SURGICALLY CHANGED. THAT IS A FUNCTION OF THE MEDIAL ORBITAL WALL BONES AND THE ATTACHMENTS OF THE MEDIAL CANTHAL TENDONS.
2) MEDIAL EPICANTHOPLASTY PARTIALLY OBLITERATES THE FOLD. IF THE L FLAP TECHNIQUE IS DONE TO THE MAXIMUM YOU CAN PROBABLY ELIMINATE IT COMPLETELY BUT AT THE PRICE OF POTENTIALLY ADVERSE AND VISIBLE SCARRING.
3) THERE IS NO SUCH SURGICAL PROCEDURE THAT CAN ACCOMPLISH THAT TYPE OF LOWER EYELID MOVEMENT.
4) THAT IS NOT A CANTHOPLASTY PROCEDURE BUT A CANTHOPEXY PROCEDURE. THAT CAN PULL THE CORNER OF THE OUTER EYE OUTWARD IN A COMPLETELY HORIZONTAL DIRECTION. THE QUESTION IS HOW DOES IT HOLD UP OVER TIME.
5) THE PROBLEM IS IF YOU PULL THE OUTER CORNER OF THE EYE OUTWARD IT WILL LIKELY CREATE A SEPARATION OF THE LATERAL LID MARGIN FROM THE EYEBALL, CREATING A SETUP FOR EXCESSIVE TEARING AND/OR DRY EYES.
6) NO THE MEDIAL PAPLPEBRAL FISSURE CAN NOT BE ELONGATED.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really confused about the types of surgery best suited for me. I do know that my face is too masculine. My cheekbones are too wide, my jaw is angular, and my chin is too long. I have no facial fat or cheeks. I am also wondering about an eye lid and upper and lower lip lift, or some type of lip contouring or mouth reshaping. I like full lips, but my lips seem to protrude and the top lip is really wide when smiling. I don’t know if I need a jaw reduction, chin vertical height reduction, or sliding genioplasty with a reduction in height.I would also like rhinoplasty and possibly a facelift. Overall, my face is just not feminine at all to me and my hair line and forehead looks masculine too. Thanks for your help.
A: Thank you for your inquiry. Based on an assessment of the pictures you sent, let me try and provide you some direction. First of all, let’s start out by eliminating what you don’t need, won’t work or isn’t worth the aesthetic tradeoffs. You would not benefit by a facelift, eyelid lifts or lip lifts. There is nothing you can do about your lip protrusion or how far the upper lip moves when smiling. Your cheek bones are not too wide but they do lack any anterior projection. (fullness) That lack of projection makes you think your cheekbones are wide when they are not. Cheek augmentation here may be beneficial.
Your biggest issue is that your lower jaw is short and angulated downward. This makes the chin horizontally short but vertically long. An intraoral bony sliding genioplasty to vertically shorten your chin and bring it a little forward would be very helpful in getting away from a masculine look.
Your forehead looks masculine to you because it slopes backward. Forehead augmentation to create a more projected and convex forehead shape would make it look more feminine.
In short, your face appears masculine because of its skeletal structure. These are bony issues and changes in the shape of the facial skeleton of the chin, cheeks and forehead would create the appearance of a face that has more anterior projection and less vertical height.
Dr. Barry Eppley
Indianapolis, Indiana