Your Questions
Your Questions
Dr. Eppley, I am interested in a custom jawline implant that extends the entire vertical length of the jawline. I wanted to know if I would be a good candidate without orthographic surgery. I just want more vertical length and do you do any kind of computer generated simulations of expected results. Also can someone have sliding genioplasty along with an implant like a wraparound to add length all the way around the jaw?? Thanks
A: If you want length along the entire jawline, it would make the most sense to do a custom jawline implant that wraps around the entire jawline. While you can have a vertical lengthening sliding genioplasty combined with custom jaw angle implants that does not make the most sense either economically or for having a smooth and continuous jawline from angle to angle. A one-piece jawline implant that crosses the chin would make for the smoothest lower edge all the way around from jaw angle to jaw angle.
You probably don’t need as much vertical length as you think. A 5 to 6mm vertical lengthening of the entire jawline can create an effect much greater than you would think. It is because it covers such a large surface area of the jaw.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you offer tear trough implant via transconjunctival approach? If so do you still use a screw to anchor the implant? I had both lower eye lid blepharoplasty via transconjunctival approach in 2010. Now I have a moderate amount of tear trough deformity. I am considering implant not filler. Is this procedure done under Local/Mac or General Anesthesia? How often is this procedure done in your office? Thank you very much.
A: Tear trough implants can be placed through a transconjunctival lower blepharoplasty approach. In most cases they can be secured with microscrews through this approach. This is a procedure that is done under general anesthesia. I have dine many tear trough implants and my new designs for these implants make it possible to more easily place them through either a transconjunctival approach or an intraoral approach which I prefer. The original and still used designs of tear trough implants were developed long ago before the use of injectable fillers made awareness of the tear trough deformity what it is today. The best design for a tear trough implant is one that wraps around the medial orbital rim as well as goes over the anterior surface of the orbital rim down onto the upper maxilla.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implant revision surgery. I had Medpor jaw angle implants put in to correct asymmetry and enhance my small jaw several years after corrective jaw surgery. After jaw surgery my plate came off on the right side and needed to be replaced and I lost some bone. The surgeon used the same size implants on both sides and was suppose to build up the back right side of the jaw with hydroxyapatite paste. This did not happen. I still have the asymmetry on the right side in the back. I overall like the implant on the left side. Can you create a custom implant to correct the deficiency on the right side without removing the original implant? Also, I really dislike my chin the orthognathic surgeon gave me as it curves up and I would like it brought down a little. The surgeon who did my Medpor implants said he could correct my chin. I decided not to pursue him since he missed correcting my asymmetry in the first place.
A: It is a valid jaw angle implant revision concept that one could place one implant over the other in the jaw angle area. The key issue is whether a 3D CT scan will ‘see’ the Medpor material clearly enough to allow an accurate custom fit to be made. The only way to answer that question is to get a 3D CT scan. Sometimes Medpor material is not seen well or looks very fuzzy with irregular outlines.
For your sliding genioplasty it sounds like you need the sliding genioplasty to be vertically opened as it is over rotated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My question is about the possibility of ribcage expansion surgery. Would it be possible to lengthen the bone of each rib and the clavicle in order to increase the width and overall size of the chest? In a similar to fashion to Jaw advancement surgery? Aside from cosmetic reasons I would think it could have health benefits related to increasing the space for the organs which would over time grow to fill the extra space much like when someone donates a kidney and the remaining one eventually grows to near double the size to compensate. I figured you would be a good person to ask since you are well known for performing the rib reducing surgery of Pixee Fox.
A: Ribcage expansion is not a viable operation. You can not increase the length of the ribs or the clavicles for a variety of medical and anatomic reasons. The one most significant reason is that the ribs can not be stretched out or their length increased due to the rigid attachments to the spine in the back and the sternum in the front. It is not similar at all to that of jaw advancement surgery which operates on a freely mobile and terminal bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am interested in exploring corrective surgical measures in order to minimize a facial asymmetry. I have attached a current photograph, in addition to two x-rays taken several years ago for dental work. These illustrates the cant of the maxillia & mandible. There is also a front/back asymmetry to the cheek bones as they appear to have grown/developed differently over time. This has caused jaw pain, compounded by bruxism, and damage to my teeth in general; not to mention a life long aesthetic concern. I am interested in hearing the your interpretation, possible solutions and any other guidance that might result from this cursory review. Thank you.
A: I can appreciate your facial asymmetry which is more easily discernible in your x-rays. You have an obvious skeletal-based facial asymmetry that is easily seen in the cant of your occlusion. In treating this type of facial asymmetry, the first decision that has to be made is whether you are going to treat the fundamental cause of the problem through osteotomies/bone repositioning or whether you are going to leave the occlusion alone and do camouflaging procedures around it. This decision influences everything that would be done and how it would be done.
In treating the fundamental problem, maxillary and mandibular osteotomies needs to be done to level out the occlusion and straighten the lower part of the face. Whether this would require orthodontic preparation or can be done with the way your occlusion is now requires more information. Once that is done then a second stage for other procedures such as rhinoplasty may be needed.
In working around the existing occlusion and its cant, the longer or shorter side of the lower jaw needs to be changed. (whether the long side needs to be shortened or the short side lengthened remains to be determined) This would be combined with a rhinoplasty and other facial asymmetry procedures that may be deemed helpful.
As you can see the two choices are radically different and what you want to do with your occlusion is the key decision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have attached a before and after computer morph of my desired rhinoplasty changes. I understand that the aim is very ambitious, my question is whether what this change is possible. I would like the following done:
1) Flattening of the dorsal hump and increasing the nasofrontal angle,
2) Decreasing tip projection slightly and dropping nasal tip slightly to prevent nose being too upturned after,
3) Lowering the caudal border of the columella using cartilage grafts and in doing so lower the ‘point of subnasale’ in order to achieve two aesthetics effects: a) Reducing the ‘hooked’ appearance of the nose which is caused by a curved contour of the base of the nose from a profile view and b) Reducing the upper lip length (my upper lip length throws off my entire facial proportions and makes my chin look too short) Would this need to be combined with alar base lowering so that the subnasale isn’t unnaturally low compared to the nostril bases?
4) Nostril reshaping in two components: a) shortening the nostril length in the sagittal plane and b) lowering alar rim using alar rim graft to compensate for the vertical columellar increase and to improve the natural alar rim retraction that I have.
Are all these things conceivably achievable? And if they are, can they all performed in the same procedure?
A: Let me discuss your rhinoplasty objectives as follows:
- Eliminating the dorsal hump, smoothing the dorsal line and deepening the nasofrontal angle can be done. The most challenging of these is deepening of the nasofronal angle.
- Decreasing tip projection by dome resection and lowering the nasal tip by cartilage grafts can be done.
- While the columellar border can be lowered by cartilage grafts, it will not reduce upper lip length. Such upper lip length reduction can only be done by a subnasal lip lift which must be done as a separate procedure from an open rhinoplasty.
- While alar rim grafting can improve alar rim retraction, I know of no procedure that can shorten the front to back length of the nostrils.
Performing all of the maneuvers described in a single rhinoplasty procedure is common.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Medpor chin implant removal. I had a Medpor chin implant placed over 10 years ago and I really hate it. It is too big and is not in line (literally) with my overall facial features. Moreover, the implant is visible when I smile. While my profile looks pretty good, the look of my face from the front is what bothers me. I would probably prefer to have the implant removed without another implant being placed. Would that be possible without serious droopiness of chin tissue? The chin implant used was the smallest one available and it has been carved down already. It has been fixated with 2 screws. Question for you (since I have read on the internet that you are experienced in successfully removing medpor implants) is whether or not you consider this procedure to be possible in my case and if you are willing to help?Would you require a CT scan of my jaw prior to surgery? Thank you so much for your time and I hope that you are willing to answer my questions and hopefully help out.
A: Thank your for your inquiry about Medpor chin implant removal. I have removed many Medpor facial implants including Medpor chin implants. The key question is not whether it can be removed but whether any other management should be done to the chin given the expansion of the soft tissue pad. While it may have been a small Medpor chin implant , these implants are still relatively large. Thus its removal poses a very real risk of chin ptosis. This leaves you with three treatment options:
Simply remove the chin implant and see what happens.
Remove the Medpor chin implant and replace with with a smaller and much more narrow chin implant.
Remove the implant and perform either a mentalis muscle resuspension (if it was initially done intraorally) or a submental tuck. (if performed from below through a submental incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How can somebody surgically achieve the male model browbone look? When it comes to this type of brow ridge, it seems like it’s not the protrusion but also the low position that gives an aesthetic and masculine “vibe” to the eyebrows. You can see the effect I’m trying to achieve by looking at the photo below
Is the male model brow look achievable through a specific type of implant? I’ve read online that it’s more because of the rectangular shape of the orbital rim. If that is correct, could the orbital rim be reshaped for that matter, namely for purely aesthetic concerns?
A: You are correct in that lowering of the superior orbital rim is just as important as any amount of horizontal projection increase to achieve a stronger male model brow look. This can only be done using a custom brow bone implant design made off of the patient’s 3D CT scan and then inserted through an endoscopic approach.
The key dimension in this brow bone implant design is that it must sit as low as possible on the brow bone on the inferior edge. This requires a periosteal/periorbital release across the brow bones similar to that used in an endoscopic browlift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting Restylane fillers to improve the appearance of the bags under my eyes. But, I am not entirely certain if Restylane or other injectable fillers are suitable. In looking at my pictures do you believe that Restylane could be a solution? Thank you!
A: I do not believe that injectable fillers under your eyes are a good treatment. While the objective may be noble to try and smooth out the undereye area, what will occur instead is the creation of large balloonish lower eyelid bags making the entire situation worse. I have seen this too many times. The effective treatment is a lower blepharoplasty to partially remove some of the herniated fat pads and reposition other parts of the fat over the infraorbital rim.
While injectable fillers have a role in correcting undereye hollows, they do not work well to help camouflage bags in my experience. Placing injectable fullers around the bags will usually lead to creating ‘filler bags’ with the whole undereye area looking fuller or bloated. While such filler can be removed by hyaluronidase enzymatic digestion, it is usually best to avoid this problem in the first place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a successful Medpor square chin implant put in three months ago. It gave my face better balance and a much more masculine look although my chin was not that small before the surgery. I have quite a defined jaw but not a square and as sharp/symmetric and balanced as I would wish. My plastic surgeon here does not do jaw angle implants so I am considering flying in to you. Can jaw angle implants make good definition without making the face look that much bigger?
A: What you are likely referring to is a vertical lengthening jaw angle implants that provides sharper jaw angle definition but does not add much width to the jaw angle. This is what I call the jaw angle defining implant and is uniquely different than the standard widening jaw angle implant which has been around for two decades. By today’s aesthetic standards this traditional jaw angle implant style is poorly designed and does not work well for most patients. It often creates a jaw angle is wider and rounder (fatter) but not more sharply defined. This is why I designed the vertical lengthening jaw angle implant style as that is what most men and women are seeking today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a pediatric cranioplasty for my young sone. You stated that bone cement would be the best option for a younger patient. Why is this the preferred choice instead of an implant? If we did this for our son would he have any issues in the future? For example- could he play football and would physical roughness or a tumble off his bike, or any other mild head injury pose a health risk with the bone cement? Also you stated that we would have to go thru insurance with a predetermined level of approval. This could be difficult considering the doctors we have spoken to consider this to be a cosmetic issue. Could it be something we electively do for our son? I am just devastated that we blindly trusted his doctors and did not helmet him! I am heartbroken that my lack of action has left his head deformed. I know you can’t give an estimate without a proper consultation but I am serious and intend to be very aggressive about this before it could possibly effect my sons esteem and quality of life so could you give even a rough or general estimate so that I know where my family needs to be financially to even consider seeing you?
Thanks again for your time!
A: In young children with growing skulls, the use of hydroxyapatite cement seems the most biologically appropriate for a pediatric cranioplasty as the cement will integrate into the bone. (bone will actually grow over it and it will become incorporated into the bone as it grows) Thus both short and long-term there would be differences in the skull’s growth nor affect its structural integrity. A custom made skull implant in many ways is ‘simpler’ because it is reshaped this makes the surgery easier. But the long-term fate of such an implant on the skull’s growth is unknown as it has never been done to my knowledge. Whether it would affect the skull’s growth or would in any way affect the function of the skull bone is unknown. It may well be that it does not but there is no way to predict that up front.
Because of the cost of hydroxypatite cement, the need for a pediatric anesthesiologist and its performance in a hospital (in adults I simply do this in my surgery center), the cost of such surgery would be astronomically high and out of the economic reach of most families. For this reason every effort should be made to go through the insurance predetermination process. With insurance submission you never know what they will or will not approve. I have seen such cases go both ways. (approved vs. denied)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I intend to make the brow bone augmentation , but I have doubts as to what material you prefer. I want to know if there is the possibility of having contact with patients of this type of procedure? I’m curious to see how the result was , as the photos that are on this site do not show at various angles. Thanks.
A: When it comes to brow bone augmentation the type of material used is largely irrelevant per se. What matters is the surgical approach (open scalp incision vs endoscopic), amount and shape of the desired brow bone augmentation, cost and the risk of revision. All of these factors put together will ‘control’ the material of choice. I have used every material for brow bone and forehead augmentation that exists and they all can work in the right circumstances. Each material option has their own advantages or disadvantages, none are perfect. The material chosen does not control the shape or the result, just how easy or hard it is to achieve it.
Young facial reshaping patients are notoriously discreet about their surgery and few will allow their pictures to be shown or will talk about it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was looking into your procedure for fat grafting for Coccydynia. I have pain around my coccyx and sitting down is painful for me. I’m looking for a pain relief alternative to having the coccyx removed. I wanted to know exactly how the procedure is done.
A: There are two methods fat grafting to cover the coccyx with the intent of providing increased padding over the bone. The first method is dermal-fat grafting. There is where a strip of skin and fat is taken (usually from the abdomen) and implanted over the coccygeal bone through a small incision. (dermal-fat grafting) The second method is injectable fat grafting where fat is harvested by liposuction, processed and then injected into and around the ccocygeal bone. The success of both methods would be based on how well the fat survives. I have done both numerous times and there are advantages and disadvantages with each method. Dermal-fat grafts usually survive better but require a harvest site and an open incision to place. Injectable fat grafting is incision-free but its survival over the pressure point of the coccygeal bone, which is also frequently sit on, is less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve also been looking into custom jaw implants to add some vertical length to my ramus and chin. However I’ve noticed that in the vast majority of these cases the results tend to look unnatural and often times asymmetric. Whilst I was confused about seeing the asymmetry in several of these custom implants (surely the designing process would have attempted to avoid any asymmetry?), this is less of a concern for me as some of the results I have seen are symmetric and thus I think with the right planning that can be avoided. However, what is bugging me is the synthetic ‘afters’ of most of these custom jaw implants. I don’t know how to describe it other than that it sometimes looks very ‘plastic’ which of course it is. Also I’ve noticed that a lot of these cases look very ‘bloated’, almost as if they have bruxism caused masseter hypertrophy. But why do the silicone implants create this unnatural looking effect through soft tissue? Even where augmentation isn’t extreme, the really sharp mandibular border that the implant creates doesn’t seem to look real. Is there anything to be said here about eliminating this effect?
A: Jaw angle asymmetry is the norm in jaw angle implant surgery not the exception. Whether the degree of asymmetry is significant or bothersome to the patient will vary widely. I have seen patients with small amounts of asymmetry have multiple surgeries to try and make it perfect while other patients with larger amounts of asymmetry are perfectly content with it. My experience is that if you are a young male you will fall into the former category and will not rest unless it is near perfect. While making custom jaw angle implants definitely helps decrease the risk of postoperative asymmetry, it does eliminate it completely. There is the implants design and then there is the actual placing the implant. I have an enormous experience with jaw angle implants and even I have a 10% to 20% risk of jaw angle asymmetry particularly when it comes to implants that create any vertical lengthening of the jaw angle.
Most people that seek jaw angle enhancement need vertical lengthening and not just width. All current commercially available jaw angle implants create width only and are inadequately designed in my experience. But that is what is available to almost all surgeons so that is what gets used. This wide rounded angle implant creates a fatter jaw angle not a more defined one in most cases. I am to sure what you refer to as ‘really sharp jaw angle implants’ since no such style of jaw angle implant is currently available to my knowledge. I have my own line of vertical jaw angle implants and often will custom design them to get a sharper and not rounded jaw angle look. That begin said, not every face can end up with a more defined jawline look. The heavy the face or the one with thicker tissues will never get a very defined jawline/jaw angle effect from any type implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Permalip implant removal. I had 4mm Permalip implants put in my upper and lower lips this past year. It has not even been a year but I would like to get the upper implant removed. It causes a crease when I smile and my smile looks restricted and very unnatural. I have been doing a lot of research and you seem to have quite a bit of experience with the Permalip implant.
I had a few questions:
1.) how long would my upper lip be swollen for/how long would it be noticeable.
2.) how quickly could I start again with filler
3.) Will my smile go back to normal or will it stay restricted from the lower implant still being in?
4.) what is the cost of the removal of the upper implant only?
5.) Have you removed quite a few implants and are there ever complications?
Thank you!
A: In regards to Permalip implant removal:
- There should be very minimal swelling…unlike the original placement.
- You may return to getting injectable fillers 6 weeks after the implant is removed.
- I would anticipate that your smile will return to normal. This is a mechanical obstruction issue.
- My assistant will pass along the cost of the procedure to you tomorrow.
- Once the implant is removed I have yet to see any complications that have resulted…other than the lip will become smaller.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull augmentation. I have a depression on the back of my skull which has bothered me for numerous years. I have had it since birth so it has not been caused by an accident. I would be interested in injecting PMMA to fill the area or inserting an implant, however, I am worried about the side effects, especially since it is not a common procedure. I have long hair, will the incision cause a bald spot on my hair line? Is there anyway to make another incision which does not affect the hair? Is PMMA safe or could my body reject the substance? Would an implant stay in place with only soft tissue holding it in place? Is this procedure possible under local anesthesia? The reason I ask is I have a surgery planned for August under general anesthesia, and I am told general anesthesia sessions must be spaced 6 months apart, however I would like this surgery sooner than that. Thank you for your time.
A: Filling in flat spots on the back of the head (skull augmentation) is one of the most common of all aesthetic skull reshaping surgeries. It can be done successfully by either bone cements or implants based on the size of the defect and patient preference. Most patients opt for either custom or semi-custom silicone implants because of their ease of insertion, smaller placement incisions and lower risk of palpable implant edge transitions. The body does not reject such implants although there is a very low risk of infection. The implanted materials doe not affect overlying hair growth. Any potential hair growth alterations lie along the incision line. These type of skull augmentation procedures are best done under general anesthesia not local anesthesia. I am not aware of any medical validity to the need to space a general anesthetic six months or any number of months apart.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip reduction. I had persistent dryness and swelling on my lower lip. A biopsy was performed the report of which is below. Since considerable amount of tissue was removed during biopsy my symptoms have improved somewhat. However the problem is still not resolved completely. My lower lip is still very bulky. So I am thinking if a lip reduction surgery or vermillionectomy of the lower lip would help me.
A: Thank you for sending your pictures and describing your lip symptoms. A lower lip reduction can definitely help the symptoms of cheilitis by removing the abnormal mucosal tissue. The degree of symptom improvement is based on how much of the abnormal (dried) mucosa that can be removed without creating any significant lip distortion.
I would think subtotal lip reduction first before considering a total vermilionectomy which will cause some lower lip color distortions. A vermiollionectomy can always be performed secondarily of the lip reduction does not provide significant symptom improvement.
Reducing the lower lip is often performed under local anesthesia. Resorbable sutures are used to close the incision which take a few weeks to dissolve or fall out on their own.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the temporal artery ligation. I have previously had a treatment for this from a vascular surgeon about 1 month ago and I am not happy with the results. I believe this is because I only had a single point ligation on either side and from reading through it seems this rarely works unless you are lucky.
At the moment the arteries are approx. 50% reduced from before, and don’t seem to bulge up as much when I drin and are much quicker to reduce in size, but I can still feel pulsations so I presume I have some backflow here. Also, the left side seems to snake a bit further across the head all the time now.
Can you let me know if I would be able to have a further ligation done and if this will resolve the issue ? The reason I am contacting you primarily is because your cosmetic background as I understand further cuts would need to be made towards the top of the head where they are more visible. I am concerned about scarring here as from the last operation I was left with scars approx. 2cms long although they don’t bother me very much as they are close to the hairline.
A: Thank you for your inquiry. Please send me some pictures of your temporal regions for my assessment. As you have mentioned it almost always requires more than a single point of ligation in my experience. In fact, I have never done a temporal artery ligation using only a single point ligation. Whether additional points of ligation would be beneficial can only be determined by actually doing it but I would suspect that it would.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had written to you earlier regarding defining my waist (my original email is attached with my pictures below). As you can see from my pictures, my ribcage is quite wide in frontal view. I would like to decrease the width of my ribcage to give more femininity (narrowness) to my upper body, as well as to give some length to my short torso. My protruding ribs don’t bother me, it’s the width that I dislike.
I am 5’3″ and I am 120lbs. I am not overweight and I don’t intend on losing any weight. I’ve always had an athletic body, I am naturally driven to exercise and I have a healthy relationship with food.
I would greatly appreciate your thoughts and advice, as well as what improvements I could achieve with surgery.
I look forward to hearing from you.
A: Thank you for sending your pictures. If I interpret your description and objectives properly, it is the width of the ribcage rather than its anterior protrusion that is your concern. This concern is a bit different than the classic desire for a reduction in the anatomic waistline. (ribs #11 and 12 and sometimes part of #10) or reduction of an anterior lower ribcage protrusion. (ribs # 7,8 and 9) Rather it is a reduction in the width of the ribcage further up at the sides. (ribs # 8,9 and 10) While this technically can be done, this is the area where partial rib removal has the greatest potential for exposure of the pleura (outer lining of the lung) as this is where the lower lobes of the lung exist. So the potential risk of a pneumothorax is greatest in this area. Whether rib removal in this area for aesthetic purposes is worth that risk is an issue up for debate. This area of rib removal is also different in that the incision to access it would be on the sides directly over the area. (which is not necessarily an aesthetic disadvantage)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi there! I have a few questions as I start thinking about the procedures:
1. I want to do back of the head augmentation, top of the head augmentation, and also forehead augmentation – will this make my head too heavy?
2. What are common side effects of the materials used (I will not be opting for implants) – are there natural biomaterials available?
3. How many of these procedures do you do annually? Over the past 2,3 years?
4. I will also be getting other procedures done with other specialists for the eyes and nose – do you recommend coming to you before or after rhinoplasty and how long should I wait in between?
Thank you very much!
A: Thank you for your skull augmentation inquiry. In answer to your questions:
1) Any material added to the head, implant or otherwise, is not going to make your head feel heavier.
2) If you eliminate all synthetic materials then the only natural biomaterial would be your own fat. Its well known side effects is resorption and lack of permanence.
3) I perform 50 to 75 aesthetic skull reshaping surgeries per year…and each year the number is increasing.
4) I would wait either three months before or three months after this type of surgery before doing other aesthetic procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask you a question about a transgender patient that I have scheduled for a rhinoplasty and chin reshaping. She would like a more rounded anterior chin to give a more feminine appearance. I was planning to make a submental incision and just drill down the parasymphyseal inferior edge to reduce the square appearance to a more rounded appearance. I know you do quite a bit of facial contouring and I would love your thoughts on this case please. I have attached planned areas to show where I plan to reduce.Thank you so much!!!
A: There are two chin reshaping approaches to changing the genetic male chin from square to a more feminine tapered look:
1) Inferior border osteotomies (use a saw not a burr as you need to take a lot more bone than you think) I This is not actually the best approach because it does not narrow the chin that much. But you can up the aesthetics of the result by placing a small central chin button style implant (3/4mms) which helps create an overall more tapered appearance. (the ying and the yang effect so to speak)
or
2) T-design intraoral osteotomy (midline resection) This is the best method that will instantly change a flat square chin into a more tapered chin in a ‘scarless’ fashion.
I done a lot of both and either one is better than what she has now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an injectable rhinoplasty procedure. I’ve been researching injectable fillers and I constantly see them being advertised as being able to last up to a certain number of months. From what I’ve read though, these fillers are resorbed over time. If I get 1 syringe of Radiesse, how much of filler can I expect to remain after 6 months? Or, more importantly, when would I need to do a repeat injection to maintain a good aesthetic result?
Anyway, I’m hoping to get fillers to raise my radix and provide a smoother transition between my nose and brow ridge (the area just above the nose bridge and between the eyebrows). Based off your experience, which filler be the best for such an augmentation?
A: While it is trie that almost all injectable fillers have a limited duration, some do have documentation of lasting longer than others. The longer lasting ones are the particulated fillers, such as Radiesse, whose duration should be a year or even longer. In the radix of the nose, which has little motion, one should anticipate that duration which is confirmed by my clinical experience. I think Radiesse is a very good filler for the radix and would be my first choice for this form of injectable rhinoplasty
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom cheek implants. Last year I got a custom wrap around jaw implant which produced a nice flare towards the back part of the jaw. I like the beefed up jaw, but now feel my cheekbones could be a little wider to balance my face out a bit. As a trial, I had the cheek area filler injected to try out the look (a total of 2 cc’s of Juvederm). It was a step in the right direction, but I thought for the long term it might be better to go with implants (perhaps custom) and that I could get a little more projection than I got from the filler. Do you think cheekbone implants might be a good idea and should I be concerned that the implants might show themselves through the skin down the road? I have attached a Photoshop rendering of me with larger cheekbones. What do you think?
Also Do you think a buccal fat removal procedure would help with the excess jowl tissue?
A: It is not rare that after a jawline implant, where the lower face has gotten wider, that one notices that other parts of the face are out of balance a bit. As a general aesthetic rule, the width of the jaw angles should not be greater than the width of the cheeks/zygomatic arches. This has clearly happened in you and is the genesis of your inquiry. You have proven by both injectable filler and computer imaging that cheek augmentation would be beneficial. To get the best fit to the bone and have the least risk of implant show, custom cheek implants would be preferred. This is particularly true in what you are showing in your imaging as this is a high cheek look. Most standard cheek implants are made for women and they highlight the lower apple cheek area primarily.
Jowling will not be improved by a buccal lipectomy. The buccal fat pad is situated much higher than the jowls. Jowling has to be treated by either direct liposuction or smoothing out the jawline from a small lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having a large skull reduction done, running from all the way back to midfront and all between the temporal lines. I know that this sd a rather large area. How long time does it take before the final result is apparent? I guess that depends on how much bone thickness is removed? And is it possible to harm the result in the recovery phase by being hit or bumping the head? I occasionally play contact sports, and work as a laborer.
A: Regardless of the skull surface area involved, it takes a full three months to see the absolute final result from a skull reduction procedure. Generally about 50% is apparent by 3 weeks after surgery and 80% is apparent by 6 weeks after surgery. But it takes a full three months for the last bits of swelling to goal away and the scalp tissues to shrink back down. As a skull reduction only removes the outer cortical layer, there is plenty of inner cortical bone left for support. Thus this does not place your skull at any increased risk of injury from light or occasional trauma events…and probably not even from more severe impacts as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants placed last year and it has given the region much needed volume. However, I still notice that there’s still some mid-face sag that I would like to correct. I’ve researched various options like mid-face lifts, but the one thing that really intrigued me was thread lifting. Can I just check if you’re family with such a procedure, and if so, could it be used to adequately address a mild amount of mid-face sag?
Thank you!
A: I am very familiar with the threadlift procedure and the devices to do it. It has always been and continues to be intriguing to many potential patients because of its minimally invasive nature. It will always be compared to what are perceived analogues to it including a lower facelift and a cheeklift.
While it can create a very mild cheek lifting effect, the duration of this effect is very temporary and does not provide much of a sustained result. Simply pulling up on the tissues is not a good substitute for actual deeper tissue support and/or skin excision. This has proven to be certainly true for the many versions of thread lifts that have been promoted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My main discomfort right now after my rhinoplasty is a frontal headache. It is quite severe and persistent since I got out of surgery. Do you think it would be relieved by taking off my nose guard? Is this common following rhinoplasty? Thanks for any thoughts you have.
A: Having a frontal headache is not a postoperative symptom that is common after rhinoplasty surgery. While you have had multiple facial procedures (chin, cheek and jaw angle implants) as well as a rhinoplasty it could be related to any or all of them. But rhinoplasty would be the potential culprit by anatomic proximity. I could only envision that the rhinoplasty with the nasal bone osteotomies could be the source. Fracturing the nasal bones so close to the forehead certainly sounds like it would give one a headache. Other aspects of your surgery could also create a headache due to the congestion caused by a septoplasty and inferior turbinate reductions.
Whether removing the splint would be a solution I do not know although there is only one way to answer that question. I hate to do it because it will cause more swelling but if your symptoms do not have improvement in another day that is what we should probably do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I would like your opinion on what procedures might help me achieve a more chiseled, rugged and defined face. (aka facial masculinization) I have chubby cheeks, my chin I feel is weak, and I would like more definition in my jaw. In my picture I have had filler inserted into my chin about a month ago, however it hasn’t had made the difference I’d hoped for. Overall I’d like to ditch the round, baby faced look in hopes of a more handsome and masculine look. The second picture is an idea of the look I’d like to work towards. Any advice is much appreciated.
A: Thank you for your inquiry and sending your pictures regarding facial masculinization. The first insight that I can provide is that you are never going to achieve the facial look as you have demonstrated in your ideal male face image. You don’t have the right soft tissue overlay (thin fat layer) over your facial skeleton. Your facial soft tissues are thicker and thus they will never look as defined as the male model’s face.
That being said there are some realistic improvements that can be obtained and the approach to do it is based on a combination of the 5 male skeletal highlights and fat reduction surgery. The use of cheek, chin and jaw angle implants combined with buccal lipectomies and perioral and neck/jawline liposuction is the maximum aesthetic facial changes that can be done with the goal of sculpting the young malke face that is softer, rounder and less defined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to create the male model cheekbone look, and I know that cheek implants would be the best way of doing this. However, as I understand it, an overly large facial implant can tend to look unnatural. My thoughts here are in terms of increasing the lateral projection of the cheekbones with a zygomatic sandwich osteotomy (ZSO) and then sculpting the actual cheekbone shape with a custom made implant. Do you share my view that this is the best way to go about creating prominent, male model like cheekbones without making them look unnatural?
A: When using the term male model cheekbone look, this usually implies a high cheek prominence marked by a prominence zygomatic arch prominence which extends back towards the ear. While I would agree that moving the zygomatic arch outward by osteotomy with an anterior implant (in front of the osteotomy) is one way to create that type of cheek augmentation, that is the ‘hard’ way to do it. It is easier and equally if not more effective to use a custom cheek implant design to create that type of zygomatic/zygomatic arch augmentation. Then the arch can be augmented in a tapering fashion back to the ear without any risks of an edge transition between the implant and the osteotomy location in the combined osteotomy-implant method.
But if done well, both types of cheek augmentation approaches can help achieve the male model cheekbone look in the patient with the right type of facial anatomy (thinner face)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had always assumed that nothing could be done to fix my lazy eye/ptosis by recently I was googling around and found that their was plastic surgery for this as well. I’m the guy who was interested in a bunch of procedures last month, including a custom implant for forehead augmentation to add to my brow ridge/eye brow protrusion for deeper set eyes, and I’m still interested in having that done. albeit I don’t want to add too much protrusion as I have some already.
Regardless I was curious to know if it was possible to get an asymmetrical eyelid ptosis fixed at the same time as the custom forehead implant?
Baring in mind the ptosis is mild-moderate, however isn’t caused by orbital dystopia(my pupils appear to be in the same horizontal plane in the vast majority of my pictures), and I’ve also noticed my eyebrow seems to sit a tad bit higher on the eye with the ptosis, could you in anyway lower the brow a bit to offset this and even it out while placing the forehead implant?
If you cannot do anything about the eyebrow being a bit higher that’s fine because I also wanted to do an eyebrow hair transplant combined with a temporal browlift to get rid of my eyebrow arches. After reading up on the two procedures it seems to me like they would allow me to trim my eyebrows to appear even, given I get enough grafts put in.
Is this realistic with an eyebrow hair transplant and temporal browlift?
Could these two procedures be done in conjunction with the ptosis surgery and forehead implant? Would it be better for me to have these done separately?
A: It is always best to do eyelid ptosis repair in an adult as a separate procedure. This is procedure where fractions of a millimeter count and doing it under local anesthesia so the surgeon can see the position of the eyelid as the sutures are placed is critical. So I do not recommend eyelid ptosis repair at the time of forehead augmentation.
It is not possible to lower an eyebrow or really adjust eyebrow levels when doing forehead augmentation. As the forehead and brow tissues are being expanded it becomes impossible to make adjustments to the eyebrows, whether it is lifting or hair transplants, at the same time and be effective in doing so. To make an analogy this is a little like trying to put the roof on a house where the foundation and the sides walls are not completely erected. Thus the finishing procedures of brow lifts and hair transplants should be deferred to a second stage after the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am planning to get custom chin and jaw angle implants and I have some queries regarding flying in from overseas.Firstly, typically how long does it take from the initial consultation to get scheduled in for surgery? I’m hoping to fly in around mid January, so I am wondering what the deadline would be to make my first consultation in order to get scheduled in at this time. Secondly, how long should I plan my stay for recovery? I plan to travel by myself and I’m assuming I will be fine to manage myself post surgery?
Thank you.
A: To get custom chin and jaw angle implants made for surgery, that is a process that typically takes 3 to 4 weeks after receiving the patient’s 3D CT scan. This is why almost every such patient gets their 3D CT scan where they live and the sends it to me to get the implants designed and made for surgery.
Having a large international practice, just about every patient that comes from afar does so by themselves. So your situation would be common. For custom chin and jaw implants surgery I would advise an overnight stay in the surgical facility so you can return to your hotel room by yourself the morning after surgery.
Dr. Barry Eppley
Indianapolis, Indiana