Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a revision rhinoplasty. I have a silicone nasal implant and a PTFE forehead implant. While I like the improvement from my forehead implant, it has the unintended consequence of making my nose look too sunken in.
As such, I’m looking at a revision rhinoplasty to give me a higher bridge. I’m also looking for some extra glabella augmentation. After doing some research, I have narrowed it down to either a rib graft or GoreTex. However, this is where my dilemma arises, and I have a few of questions:
– Are you comfortable with using either of these materials for a revision?
– Between a rib graft and GoreTex, which implant material do you think will provide the best aesthetic outcome?
I have read a few people comment that GoreTex can provide more customizable results – do you think this is true?
– Lastly, would there be any issue if either nasal implant material overlapped with the current forehead implant?
Thank you for your time!
A: While both a rib graft and Gore-tex material can be used to augment the radix/glabellar region for your revision rhinoplasty, it would make the most sense to use an alloplastic material since a portion of it will be resting up against the forehead implant material and the lower portion on top of the silicone implant. It would also offer intraoperative adjustability, permanency and the best chance for a smooth transition of the lower forehead into the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have prominent ‘ridges’ in the temporal region of my forehead (see example in attached image). Please could you advise on my options for reducing the prominence including thoughts on best method for a good outcome, either as a one off long term correction or ongoing ‘management’ and associated costs, and the degree of confidence in achieving a good outcome.
A: What you are referring to are the anterior temporal lines along the sides of the forehead. They are the near 90 degree transition between the sides of the bony forehead and more vertical temporalis muscle. They represent the attachment of the temporalis fasica and muscle to the side of the forehead. Temporal reduction in appearance can be done by either direct reduction by bone burring or augmenting the upper temporalis muscle with either injectable fillers, fat injections or temporal implants. The choice between reduction vs augmentation depends on how you want the contour of the side of the forehead/upper temporal region to be.
It would be easier to reduce the appearance of the temporal lines by augmenting the upper temporal region by either fat injections or extended anterior temporal implants. Bone burring will require an incision for access which is hard to hide in the forehead/frontal hairline region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a few questions regarding jawline augmentation. I’m looking for a custom wraparound implant to enhance my lower third, and and give me that sought after “male model” look. Angularity and sharpness are very important to me, and from my research online I was hard pressed to find very many implant results that showed the angularity/sharpness that I was looking for. My question is if an individual had an acceptable body fat (8-10% or lower), and started off with an average jaw/chin could something like the two photos I have attached be reliably achieved by a skilled surgeon like yourself. Secondly, are implants the best route to achieve this look, or should should other procedures be considered. Thanks and have a wonderful day.
A: The key to getting great jawline angularity from jawline augmentation is that one has to have the right kind of face for it…meaning a very lean face with little fat….just like the two pictures that are have attached in your email. A custom jawline implant, whether it is three separate implants or a single piece, is the only way to achieve this degree of jawline angularity since no standard chin or jaw angle implants are designed to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Eight year ago I had a sliding genioplasty, and it left me with an unpleasant rounded shape in the center of my chin. Six years ago I had the plates removed, and the chin’s unpleasant shape remained as it was.
I have contacted local doctors about correcting this shape, but none seem too confident that it could work. From doing research online, it seems like I may have chin ptosis (I certainly have the same droopy look) although I’m not sure if that’s accurate.
I am wondering if you who has expertise in this type of issue, believes that it can be corrected with a high chance of success.
I have attached some photos for illustration. In the picture with 3 images, the first is before anything, the second is after the sliding genioplasty but before the removal, and the third is current.
In the picture with two images, both are current and show the chin dimpling that I have.
I would greatly appreciate it if you could let me know if you think there is a good chance that I could return my chin to the pre-surgery look (in other words, where the base is flat).
Thank you very much!
A: You do not have chin ptosis. The chin shape you currently have is that of the bone which now appears more narrow/tapered because of the forward movement of the chin bone. This is a very common aesthetic sequelae of a sliding genioplasty…which is usually fine for a female but may be bothersome for some males. The only way to treat this shape is to round off the front of the chin to be flatter.
The chin dimpling issue is difficult to treat but it is best done by release and fat grafting at the same time as the chin shave.
It is important to realize that you are never going back to the chin the way it was before the sliding genioplasty. It is just a question of how much improvement can be obtained towards that goal. I can provide you no assurance of what the degree of success would be…the surgery should be viewed as a gamble and only undertaken with full acknowledgement of that aesthetic risk.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting deltoid implants. The look that I am going for is aimed at the appearance of wider shoulders to improve my waist-hip ratio, rather than increasing the overall mass of the deltoid muscle. So I have two questions with respect to that:
1) If a custom implant is used, what is the limit to how wide the shoulders can be made?
2) Is the width created by the implant independent from the width potentially created by muscle hypertrophy? In other words, if I achieve lateral deltoid hypertrophy through weight training after having the implant placed, will my ‘new width’ be the implant size + any new muscle size I have gained?
3) If a subfascial implant is used, will it a) show up unnaturally if I drop down to 8% body fat or so, and b) obscure any potential aesthetic definition (such as muscle striations) that I might otherwise obtain with low body-fat?
4) From an aesthetic standpoint, do you think that there can be too much shoulder width?
5) Another concern is that the implant may make the shoulder muscles look too big; so I think I am asking whether there any techniques that can be used to maximize the perceived width of the shoulders while minimizing the perceived size of the deltoid heads themselves, i.e. I want the width but not the unnatural and disproportionate deltoid size.
A: Almost all deltoid implants have to be made in a custom fashion since there are no true preformed deltoid implants available. When placing deltoid implants the limitation of its size is based on how much the overlying fascia can stretch as well as the length of the incision used to insert them. Any muscle hypertrophy added after the implants are placed will create a cumulative effect.
The deltoid area has a fairly thin subcutaneous layer so low levels of body fat may expose the outline of the implants.
I cam certain there is a limit to how much shoulder width is aesthetically pleasing. But the more important issue is having an implant that blends in well to the surrounding tissues regardless of its size.
I think when you are trying to create a distinction between muscle size and shoulder width you are trying to make a critical difference which does not exist. Deltoid implants, or any body implant for that matter, just isn’t that specific. Deltoid implants create a indistinct mass effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I will eventually be having a cosmetic surgery to correct my recessed chin and have started to look into the nearest and most reputable institutions that perform sliding genioplasty surgery. Yours was one of the most promising I have come across thus far and will likely be one that I consider. I would like to know, based on the two pictures I have sent (very limited information I know), what type of procedure you feel would be most efficacious. I feel that my chin is adequate in terms of height and structure and the only improvement necessary is postural. I would greatly value your assessment.
Thank you for your time should you choose to read and respond to this.
A: Thank you for your inquiry. Your chin is of adequate height but still a bit horizontal short because you have a fairly steep mandibular plane angle. The most aesthetic treatment would be a sliding genioplasty to bring your bony chin forward with a slight bit of vertical shortening. (which you can aesthetically tolerate. Computer imaging would confirm to you how that chin change would look so you could determine for yourself if such a change is beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been experiencing a feeling of discomfort and pulsation from the facial artery on the left side of my face for about 3 years now. I have been to vascular doctors and when they report nothing wrong with my blood flow they dismiss it like its nothing. I have been dealing with this problem for a long time and I feel like I can’t live my life or function because of it. Apparently most doctors see my problem as nonexistent. But i saw that you had a case study on “Facial Artery Ligation for Prominent Pulsations”. And all thesymptons you described are exactly what I am experiencing. The blood vessel is noticeable on my face. The pulsations are annoying, although not painful, and I feel like it also effects the way I smile. I need advice. You are the ONLY DOCTOR I have researched that seems to know about/ how to fix this problem. Thank you.
A: I certainly have treated multiple patients with prominent and/or symptomatic facial pulsations with facial artery ligation. The case study you have described is a good illustration. Please send me some pictures of your face where the location of the problematic facial vessel is. By your description it is located just to the side of the mouth, just as was described in my case study. That is the facial artery as it crosses up into the face and is the location where it usually bifurcates into the labial artery as it continues to head northward towards the nose. This is the facial artery ligation location that is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle implant removal surgery last year, and they were removed early this year. The biggest issue is the disruption of my pterygomasseteric sling which is most noticeable when I clench my teeth.
Anyway, after a fair bit of research online, I’ve since accepted that it is not possible to fully fix this. My question is – could fillers be used to camouflage or minimize the disruption? If so, would Radiesse or Sculptra be suitable fillers? Finally, what would be the longevity of these fillers and how much will they cost?
Thank you!
A: Reattaching a contracted masseter muscle after jaw angle implant removal is certainly a challenge and usually only partially successful. How well the masseter muscle can be pulled down is a function
Filling in the muscle defect below the new level of the masseter muscle can be done by injectable fillers or fat injections. The first thing you want to do is to use a hyaluronic-based filler (e.g., Juvederm XC, Voluma) as this has the least risk of irregularities and has an assured dissolution time or can be reversed by hyaluroidase injections in the event that you do not like the result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had orthognathic surgery last year. (LeFort 1 osteotomy) This has left me hanging soft tissue, no jaw line, crooked nose, enlarged nostrils, flared nostrils, toothless smile, thin bottom lip and can’t even close my mouth without feeling pain, as though someone is pulling my chin backwards through my skull.
A: While I am just looking at a front view picture, you have many of the potential sequelae from the intraoral incision used for a LeFort I osteotomy which includes flared nostrils, widening of the nasal base and upper lip sag. This occurs because of the degloving incision and detachment of the facial musculature to the bone…not because the bone was moved back too far. (although that may be a contributing issue of which I can not speak since I don’t know the skeletal movements done) The nasal asymmetry can arise from a septal deviation caused by the bony movement.
Given that you are nearly a year after this surgery the soft tissue changes are stable. There are a variety of procedures to deal with these nasolabial changes from nostril narrowing, lip lifts and rhinoplasty surgery. Unless there is a significant bite issue, I would focus on the soft tissue issues and leave the jawbones where they are.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been looking into various procedures for augmentation of the upper face as the area surrounding my eyeballs is recessed in relation to the eyes. It is my understanding that the area surrounding the eye is comprised of the brow ridge (superior orbital rim), the lateral orbital rim (bone that extends from the edge of the brow ridge) and the inferior orbital rim (area under the eyes). One area which I am not sure about is the boney area that stretches around the side of the eye before joining the inferior orbital rim area, what is this bony area called?
I know that this entire skeletal area can be mobilized with the Le Fort 3 procedure, however this is not something that I would like to pursue due to the risk factors involved. My question is to what extent the effects of a Le Fort 3 can be replicated by the use of custom made implants? I know that implants can be used for anterior projection of the inferior orbital rim and the cheekbones, and that custom brow ridge and custom lateral orbital rim implants can be made. However, is there any way to advance the area of bone directly horizontal to the outside corner of each eye, to ‘encapsulate’ the eye so to speak from that side? Also, to what extent can the inferior and lateral orbital rims be reasonably advanced without it looking unnatural or proving problematic? Finally, what is the most economical way of combining custom implants to provide a total augmentation effect? So can a combined brow ridge and lateral orbital rim implant be fashioned etc.?
A: The inner orbital area is not a rim area per se. Rather it is comprised of the nasal and lacrimal bones as well as the frontal process of the frontal bone.
A LeFort III procedure does not change the entire orbital rim area. Rather it is a naso-maxillary-inferior orbital rim skeletal advancement. While this can be good procedure for you get children and even some adults that are affected by congenital craniofacial conditions, it is not an aesthetic procedure nor appropriate at any age for non-craniofacial anomaly problems for a host of reasons including its risks.
Custom onlay orbital rim implants would be the only way to safely and effectively augment all of these facial areas. The design of these type of orbital risk implants must take into consideration primarily how they would be placed (access incisions) and to make the augmentation look natural. That usually means not having them too big and having smooth transitions to the surrounding bone off the implant edges.
Such a ‘mask’ custom facial implant would be put in a segmentalized manner. How that would be divided is based on the access by which they are placed. Thus brow bone/lateral orbital rim, inferior orbital rim-molar, and maxillary-nasal base would be a three-piece approach to such a custom facial implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis repair. I had a surgery for chin implant one year ago. It was a silicone implant and surgery was done from inside my mouth. I also had a dimple in my chin which I asked the doctor to get rid of. He put the implant, but it was too big for me so the wound from inside my mouth wouldn’t heal. I had to get the implant removed just after two weeks of getting it done. He said I would have to wait six months until I could put a new one in. Somehow the dimple i had in my chin is not there anymore and my chin looks completely different from what it was before. It has been a year and a half now and I’m not happy with it. But during this year and a half, it seems that it got uglier from what it was before from when i just got it removed.
I only had the implant for two or three weeks as the wound wouldn’t close. The doctor tried to stitch it back a couple times but the stitches wouldn’t stay and I could literally see the implant when I opened my mouth. I luckily didn’t get any infection. He told me that I could get a chin implant again in six months but obviously I never went back to him since then my chin keeps getting a worse look, I don’t know what to do.
A: Thank you for sending your picture. What you have is true chin ptosis as you initially suggested. You have four chin ptosis repair options at this point:
1) Do an intraoral chin ptosis repair. This is usually marginally successful because you have both detached and some stretched out chin tissues.
2) Do a submental chin ptosis repair. This is done from below by removing the soft tissue overhang. It is very successful because it removes loose tissue but does so at the expense of a submental skin scar.
3) Do a combined intraoral ptosis repair with a small chin implant. This is more successful than #1 because it adds support low on the chin bone for the resuspended chin soft tissues.
4) Do a sliding genioplasty. This is like #3 but uses your own bone and not an implant to create the support for the uplifted soft tissues. This probably offers the most successful outcome of all options listed but is the most ‘invasive’.
The reality is that it will be difficult to go ‘back home’…meaning going back to where you started before the chin implant was placed. That is probably a complete impossibility. Options #3 and #4 offer the combination of creating a chin augmentation effect that you were originally seeking and also solving the chin ptosis problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a L-shaped silicone implant rhinoplasty donea year and a half ago. There have been no major complications, but I’m looking for a revision for a better aesthetic outcome. My biggest issue is that the implant seems too ‘narrow’, and I’m looking for a new implant that’s wider and longer to give me a more masculine nose. My questions are:
– I know that many surgeons favor rib cartilage, but I’m honestly not fond of such an invasive procedure and lengthy recovery (especially the scar). If I only want a synthetic implant material, which one would you recommend (silicone, Gore-Tex etc.)?
– Apart from my bridge, I’m hoping for a more pronounced radix and glabella. Could this procedure be done at the same time as the rhinoplasty?
– Finally, I’m looking to increase my nasolabial angle. Could a small implant be placed under my nasal spine to bring the base of my nose forward?
Thank you!
A: In your revision implant rhinoplasty the question is whether any standard nasal implant would suffice for your needs or whether a custom nasal implant would need to be made. I would need to see some pictures of your nose to make that determination. I believe all of your revisional nasal objectives can be achieved with a new silicone implant that has the right dimensions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in bicep,tricep, deltoid and pectoral implants all done in one procedure. I have a couple of questions about these types of body implants.
1. Are the solid soft silicone implants you use “gummy bear” (cohesive gel) style implants or more solid than that?
2. In your experience approximately how long would it be before someone (including intimate partners) would not generally notice the scar? A week (after the hair regrows?) or many months?
Thanks,
A: In answer to your body implant questions:
1) Body implants are made from a very soft (low durometer) silicone that is in a solid implant form. They are not gel-filled like breast implants which is very low durometer silicone put into a bag because it can not maintain a solid form. Body implants feel just slightly firmer than a contemporary gummy bear breast implant but only slightly so, They are design in feel to be like muscle tissue.
2) While you will always have fine line scars from the insertion sites they do got through a period of redness from which it takes months to settle down and look their best. Thus you should think of it a several month process, not one of a few days or weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in sliding genioplasty revision surgery. I had a sliding genioplasty done five years ago for aesthetic chin contouring. A subsequent fat injection was done over the lower margin of chin for further chin contouring a year later. Afterward, I have functional disorder of the lower lip and chin so I took my doctor’s advice on removal of miniplate and screw via intraoral incision. The disorders of the lower lip and speech persisted. So I took my doctor’s advice on steroid injection for scar adhesion release which provided no improvement and made it even worse.
Now I feel tight while talking and eating. There is a line between my lower lip and chin. Muscle below the line will rise and stick to the line while talking, therefore I have difficulty talking smoothly. Some doctors said since I have had two surgeries via intraoral incision, there may be something wrong with my mentalis muscle and scar adhesion. Please diagnose my symptom. If there is something wrong with mentalis muscle or possible scar adhesion or else, please help me, because you are a master in this field. I need your help. In fact, I don’t know what to do next. I hope to talk smoothly. I pray to God for it. Hope you can help me. Hope to receive your e-mail as soon as possible.
A: While I have not seen any pictures of your chin, your story is not unfamiliar to me. This sounds like scar adhesion/contracture in the chin soft tissues. This is particularly evident in the tight and deep labiodental fold. This is a problem of both and now lack of supple tissues in this area. In my experience treating this problem, I advocate for your sliding geniplasty revision releasing the intraoral adhesions over the chin bone and muscle and placing a dermal fat graft. This now only releases the tight tissues but brings in new and unscarred tissue to make the tissues more supple/soft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a corner of mouth lift. On one side of my mouth as I have an asymmetrical smile. The corner is low when I am not smiling but it gets worse when I smile. I have attached two pictures which show the asymmetry both smiling and not smiling.
A: Thank you for sending your two pictures. Your mouth at rest and when smiling show that the root cause of your mouth asymmetry is weakness of the zygomatic major facial muscle. This muscle is responsible for lifting up the corner of the mouth when smiling. Since the muscle is weaker on the one side, the corner of the mouth droops down slightly when not smiling but becomes really magnified when asked to animate. (smile) Thus the mouth asymmetry is much more apparent when smiling.
A corner of mouth lift is a static procedure that is done on a structure at rest. Since your problem is much more of a dynamic nature, a corner of the mouth lift will provide better symmetry at rest and less so when smiling. But despite its limitations a corner of the mouth is all you can do for your mouth asymmetry concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am potentially interested in some form of a forehead augmentation procedure. So this is what I’m working with the last picture shows an example of what I’m looking for in regards to a forehead change . I’ve scheduled a hairline lowering procedure but my forehead will still “slope” backward obviously. I don’t know if this is because of my eyebrow bone or what but I have no clue where to start or what would be the best course of action. Hairline lowering and eyebrow bone shaving? Hair transplants? I really don’t want to do the whole cement implant thing and was hoping there were other options. I’d really like your honest opinion because I’m impressed with what I’ve seen on your website in regards to forehead augmentation. Thank you and best wishes. Let me know if you need better pictures please.
A: With you modest backward inclination to your forehead the result you demonstrating/seeking definitely involves upper forehead augmentation. There is no other way to augment the forehead without adding something to it.
The alternative is to reduce the brow bones (and leave the forehead alone) which in your case is actually a viable idea. With even 4 to 5mm brow bone reduction you will go a long way to achieving that look. Augmentation is still preferable but brow bone reduction is not a bad alternative if you are strongly opposed to any forehead augmentation material.
Either way, forehead augmentation or brow bone reduction, it is best to do it with the hairline lowering procedure. Otherwise you are going to have to go through the hairline scar twice which may not lead to the best scar outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I’m contacting you because I believe you may be able to offer some advice on my sliding genioplasty procedure.I recently went through with a revision genioplasty and I am currently recovering, it has been 1 week since the surgery. The surgery went well however I am concerned and merely certain that my surgeon did not move the chin forward enough to truly support the loose skin on my chin and the mentalis muscle. I specifically asked him to put the chin back in the same position that it was in prior to any revisions and I provided numerous X-rays and pictures, however I can see and feel that it’s not in that position. I raised my concerns to him but they are telling me to give it more time because it’s swollen and I cannot tell the final result right now.
I am aware that it is swollen, and I do have a follow up visit on Tuesday with the doctor where x-rays will be done. If I find for certain in the x-rays that the chin position is still off from the desired projection to support the mentalis muscle, what do you think is the best way to proceed forward to revise it? I would really like to get it revised immediately before the bone starts to heal back up. I’m just not sure about how to go about requesting this from the doctor and avoiding additional fees. My surgeon clearly mentioned that his precision will be within half a millimeter of the desired outcome. I’m concerned that it’s not but I do not know if I will be able to get them to correct it even if the X-rays prove that it’s further off. I believe it is about 2 millimeters from the projection of the original position but another issue is that I can feel that the chin bone points slightly up instead of down which would be inline with the rest of my jaw. A simple 2 millimeter plate increase seems like it will fix the angle and projection issue.
I understand that some of these questions don’t really have direct answers, but if you can offer me some advice/recommendations, that will be useful.
Also I’m wondering, if the doctor agrees to increase the projection and the surgery is done within say 3 weeks of this original surgery, do you think it would be possible to do it under local anesthesia? I’m wondering because it seems like it would be a easy procedure as no bone cutting should be necessary and just exchanging the plate size should suffice.
Thank you for your time, I will look forward to your response.
A: Thank you for the detailed information on your recent sliding genioplasty surgery. However I do not provide advice or recommendations on patients who are under the active care of another physician. That would be inappropriate as I can only comment on what I would do, not what another surgeon would or should do. Your questions are best handled by addressing then directly with your surgeon who I am sure would appreciate that you are having that discussion with him.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I had a fat transfer (fat grafting) procedure done in years ago where fat was removed by liposuction from my abdomen area and transferred to my buttocks. However, Since the procedure my abdomen area has never been the same. It now have lumpy, unappealing, uneven skin around my abdomen area due to the aggressive liposuction and would like to know what is the best treatment available for me to try and correct this irregularity and if you can help me? I do have pictures I can send to you of what my abdomen area now looks like.
A: Aggressive liposuction on the abdomen is prone to irregularities when the subcutaneous fat layer gets too thin. Trying to get enough fat for adequate volume for buttock augmentation often requires an aggressive liposuction approach.
Contour deformities have been around on the abdomen since liposuction was developed over forty years ago. They have always proven to be a difficult problem that often defies any significant contour improvement. Options includes secondary small cannula liposuction with adhesion releases alone or done in conjunction with fat grafting or some form of mini tummy tuck for skin tightening. I would need to see pictures of your abdomen to make an assessment and recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a L-shaped silicone nasal implant placed a year and a half ago. There have been no major complications, but I’m looking for a revision for a better aesthetic outcome. My biggest issue is that the implant seems too ‘narrow’, and I’m looking for a new implant that’s wider and longer to give me a more masculine nose. My questions are:
1) I know that many surgeons favor rib cartilage, but I’m honestly not fond of such an invasive procedure and lengthy recovery (especially the scar). If I only want a synthetic implant material, which one would you recommend (silicone, Gore-Tex etc.)?
2) Apart from my bridge, I’m hoping for a more pronounced radix and glabella. Could this procedure be done at the same time as the rhinoplasty?
3) Finally, I’m looking to increase my nasolabial angle. Could a small implant be placed under my nasal spine to bring the base of my nose forward?
A: Undoubtably your current nasal implant is too ‘small’ lacking both adequate height and width. That is a reflection of the nasal implant style and size. With silicone nasal implants there are many different styles and sizes that can likely fulfill your aesthetic nasal needs. With the right implant the radix and even up into the glabella can be augmented. At the same time as the revision nasal implant surgery is performed, a premaxillary implant can be placed on top of the nasal spine to help open up the nasolabial angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in coming for rhinoplasty surgery. I only want to change the bit from the nostril tip to the bit where it meets the lower lip. Currently my nose is like this. I want a shorter area from nose top to the top of lip and a nicer angle like this. I researched something can be done to make this area similar to above. Is that true? What kind of material can be placed where the green is in the diagram below to give this nicer angle? Do you know if it can be done?
A: As best as I can tell from your description of your nasal concern and objective, you want to change the nasolabial angl as well as the shape of the infralobular-columella region. It is a bit difficult to reconcile your description with the picture examples you have provided. But the rhinoplasty diagram you have provided shows a columellar strut graft. Depending where that cartilage graft is placedm the nasolabial angle and shape of the nasal tip can be changed. I would need to see a side picture of your nose and do some computer imaging to have a more clear idea of your desired rhinoplasty changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a crooked and prominent nose (dorsal hump, droopy tip) and I was wondering if there were any ways of making it more harmonious to my face, without having to go through a rhinoplasty surgery, since I kind of like its shape, but it definitely does not fit my current facial structure (weak midface. orbits and chin). I suppose this would be the hard way to create a harmonious face, but would facial implants ,for example, be an effective way for that matter? I was thinking about your Custom Midface Implant(http://eppleyplasticsurgery.com//custom-midface-implant) for this reason. Could it help make a nose appear less prominent?
A: Bringing the midface forward could potentially cause a slightly less protrusion of the nose through the illusion of the surrounding elevated base around it. This may create improved harmony of your face particularly in the presence of a deficient midface. I would go to the case study to which you refer and see if that made that patient’s nose look less protrusive. It is unlikely, however, that it would have a facial effect that would be as significant as a rhinoplasty which directly changes the shape of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I may be interested in custom facial implants in the future. But I have an unusual but relevant question about them. I have vertical orbital dystopia which makes my eye asymmetry pretty obvious. As far as I know, having consulted with some doctors in my area, correcting such an issue requires invasive craniofacial surgery and includes fixation with surgical plates around the orbital area and possibly the cheekbone. I’m not really sure I’m going to go through this operation in the future but in case I do, will it be able to have implants around my upper facial (supraorbital ridge, infraorbital rim implants, cheekbones) area ? To put it simply, can custom-made implants be created so they can fit over titanium plates connecting bones from a previous osteotomy?
A: In designing custom facial implants, the exact location of the plates and screws will be visible on the bone on the 3D CT scan. Any implant design can be made to fit over them and their presence will not cause any design or implant insertion issues. In fact in some cases the location of the fixation devices can act as a locater for the exact position of the custom facial implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wonder if there is a less invasive skull augmentation procedure that a custom small implant that will benefit my situation. I have also read about the use of tissue expanders and PMMA. Based on what I have seen, this seems to be less evasive and possibly more cost effective. How much of a lift be obtained at my Crown area from that type of procedure? Can you tell me the pros and cons of this versus the Bumpit implant? Are there any potential health risks more commonly associated with either procedure? Also, I’d like to know how long you’ve been performing these types of procedures and how many of these you have performed. I appreciate your help with this as it seems to be a huge undertaking and obviously something I’d like to explore at length prior to making a decision.
A: The reality is that any method of skull augmentation is similarly invasive as the fundament concept is the same. The more relevant question is what is the most effective method that has the least amount of risk or potential for revision. By far a custom implant surpasses every other skull augmentation method in my experience. It offers superior results and eliminates many of the problems from the use of bone cements and can get a more effective augmentation. There are no health risks for skull augmentation. All risks are local and confined to the site of implantation and would be typical for any implant placed in the body. (e.g., infection, overcorrection/undercorrection, asymmetry etc) I have been performing skull augmentations for over twenty years and have switched in the last five years to 90% being done by custom or semi-custom skull implants. I have performed over fifty custom skull implants during this more recent time period of skull augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 25 years old and four years ago I underwent orthognathic surgery (lower jaw advancement) and a chin osteotomy because the lower part of my face was receded and short. In terms of proportions the surgery has been a relative success. However, since then my oral commissures (mouth corners) have been pulled downwards and are not in line with the middle part of my lips. To give you an idea, the mouth corners go as low as the gum area of my bottom teeth. The mentalis was re-suspended after surgery so perhaps that’s why the middle part of my lips has not been affected. As you can see the rest of my face has not yet aged so this pulled down mouth corners look very unnatural and give the illusion that my upper lip is very long whereas the actual distance between my nose and upper lip is normal.
I was wondering if there’s a solution for this? Something that can pull my mouth corners up to be in line with the middle part of my lips?
A: The only way that the corners of the mouth (and the sides of the lips) can be pulled up is through vermilion advancements and/or corner of the mouth lifts. This works by removing skin and moving up the vermilion border. This does create a very fine line scar at he vermilion-cutaneous junction which actually does better in men than women due to hair-containing skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I considered jaw angle implants a few years ago and was told that the maximum width on standard implants was 11mm. This is not wide enough for the correction I would need. What is the maximum width that one can do with custom implants?
A: The historic maximum width of standard or performed silicone jaw angle implants is 11mm and that remains true even today. When it comes to custom jaw angle implants there is no limit as to what can be designed or potentially inserted. The facial soft tissues can stretch a large amount and the only limitation to jaw angle width that can be done is aesthetic and not anatomical in nature.
It is critically important in jaw angle implants that the desired dimensional changes are carefully considered. Width has been the historic jaw angle dimension that can be augmented. But that has changed recently with the introduction of a vertical jaw angle implant line that is designed to specifically augment this jaw angle area as well. More patients need vertical rather than width increases as this dimension goes a long way to creating a more defined jaw angle shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had facial reshaping surgery consisting of rhinoplasty, chin reshaping and jaw angle implants done in Thailand three months ago. Whilst my facial structure has improved, I am not satisfied with my results and I think some of the the reasons why are that the Asian plastic surgeon is not as familiar with western faces and also males and I feel like I have obtained a more Asian female facial struxcture.
I am very happy with the new jaw angles that have been created and the slightly wider lower face. Generally I feel that my lower face has become a little too round and fat and not the square defined shape which I was looking for. Which I think is from the jaw angle implants that they have used.
– I believe you are so well written on the internet, that it makes me have confidence in you and what your doing compared to my other surgeon; i guess it is just about agree what needs to be done
For the chin I don’t really notice any difference and I still feel the chin is still quite round – I was hoping for a more squarer shaped chin. It should be noted that I lost nerve sensation on this for a period of time which is now starting to come back, but hope that I wouldn’t have a similar experience again. Would a square chin implant be more appropriate to create a more squarer chin?
I think the cheek implants used may have created a more of an Asian female facial structure with round cheeks. They used the combined submalar shell medium implant. I would Welcome your opinion in regards to this?
Therefore what would be your recommendations? Could I have revision facial surgery six months after the original procedure? Do you think this is advisable?
I have attach my current photos as well as some pics of other people that is more alike to the facial shape/desired look that I am trying to achieve. You will notice all of them have a more square chin, squarer shaped face and less round cheeks
I believe you are so well written on the internet, that it makes me have confidence in you and what your doing compared to my other surgeon; i guess it is just about agree what needs to be done.
A: Quite frankly for the chin, jaw angles and cheeks, you had the wrong facial reshaping procedure/wrong implants for what you were trying to achieve. I will say first that the facial goals you were seeking to achieve are probably not obtainable to the degree that you would like or have shown in the ideal pictures. But in aiming for that type of look the procedures done had no chance of even getting close to that look.
For the chin, you can not make a chin more square by reducing it. That may seem to make theoretical sense but the soft tissue does not follow the bone shape in a reductive procedure. You would have to use a square style chin implant and, it would have to be modified, to create that near 90 degree turn back to the jawline to make it really it that square. Even the existing Implantech square chin implant is to soft/round at the corners to make it look ‘sharply’ square as you have shown in the goal pictures.
For the jaw angles that is a completely incorrect implant style. That widening style jaw angle implant, while widening the lower face, will just make it rounder/fatter. It will never create a sharply defined jaw angle shape as you desire. What you are deomstrating is a vertically longer and wider angles that has a 90 degree shape. Such a jaw angle shape does not exist and would have to be custom made to do so. The new vertical lengthening jaw angle implants would be a lot better than what you have and may be acceptable. This is a new style that is not yet in the catalog.
For the cheeks, you have gotten ‘female’ cheek implants which create an ‘apple cheek’ look and not a higher angular shape. This is a common mistake when it comes to doing cheek implants in males. A different style/shape of cheek implant is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read on the internet that you specialize in mentalis muscle resuspension surgery in case of lower lip ptosis. I have developed ptosis as a result of revision jaw surgery and genioplasty and the result is that I’m showing approximately 4mm more of my lower incisors that I did before. In addition, my chin goes in a weird shape when I’m trying to close my lips (“witches chin deformity”) even though I do not have a deficient chin. (See attached photos) During the first surgery my doctor overdid the forward movement of the genioplasty and during the second surgery, the second surgeon burred the bone of the chine in order to reduce the forward projection again (he was not able to do a reduction genioplasty because the first genioplasty was too assymetric). This is what caused the problem.
I wondered what the approximate success rate of ptosis correction surgery is for cases such as mine. In how many % of the cases is such surgery successful? How many mm elevation of the lower lip can be achieved on average? Many thanks in advance.
A: Thank you for your inquiry. Correction of lower lip sag and a mentalis muscle deformity of the chin pad are very difficult problems to improve that often have low success rates. It was not very prudent of your surgeon to burr the chin bone down after the sliding geniplasty as this has caused a loss of bony support and soft tissue collapse. This is why you have chin pad deformity when trying to close your lips. The lack of chin projection and the lower lip sag are intimately related.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was looking to get an Endotine midface lift. Does the you use this technie? I’m young and had Ultherapy which caused my cheeks and nasolabial folds to droop. I would like to do a cheek lift but not through under eye incisions because I read there is risk of eye droop. And also don’t want the shelf look under my eyes. I saw on here the Endocrine midface lift was mentioned which is what I’m looking for! Thank you
A: Thank you for your inquiry. There are many different types of midface or cheek lifts that use different incisional approaches and tissue lifting techniques. The Endotine midface lift uses a resorbable device to help lift the cheek tissues. It is placed through a combined intraoral and temporal incisions. The intraoral incision allows access to lift the cheek tissues off of the bone. From inside the mouth the Endotine device is inserted and its prongs engage the loosened cheek tissues. It is then passed over the cheek bone and up into the temporal area where it is secured to create the cheek lift. You are correct in that no eyelid incisions are needed to do the procedure.
The operation is somewhat similar to that of placing cheek implants using much of the same dissection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a Box Osteotomy procedure. I realize this is not a routine operation but I was wondering whether you have ever performed it before and what criteria a patient would need to have to be eligible for such an invasive procedure? I am a male, with no deformities or large abnormalties but my mid face ratio isn’t very good so was looking into ways to improve it as mid face shortening isn’t possible. My eyes are less than one eye width apart from one another. So I just wanted to know a little about the procedure and whether theres any possibility of me getting it, or if its too dangerous and only done on very deformed patients. Thank you.
A: Thank you for your inquiry. When you say ‘Box Osteotomy’ I assume you are referring to orbital osteotomies done in cases of congenital hypertelorism. This is an operation for severe craniofacial deformities and is not appropriate for aesthetic eye spacing issues. It is a major surgery that requires a frontal craniotomy to perform it. Just by the description alone you can see the the magnitude of the surgery far exceeds any aesthetic eye concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 35 years old and am seeking a unique transgender facial reshaping procedure. I had a chin reduction ten years ago and it was left slightly uneven. Last year I went to have it fixed along with my mandible contoured. Now I feel my face is too thin looking especially in the prejowl area. Its a very sharp contour somewhat V shaped. Before it was more U shaped and it looked better. I am seeking to widen my lower face. I am not sure if I would need a prejowl implant, a jaw implant or custom jaw implants. I am also a transsexual and being the reason why I had it reduced, I have lived very successfully as a female for many years. Have you worked on transsexual people before? Please see attached images. I am looking to restore to my old face.
A: We have a significant number of transgender facial reshaping patients in my practice. Just based on the two pictures you provided the difference seems to be largely in the jawline behind the chin. While I have not yet viewed a side profile, the horizontal projection of the chin does not seem to be changed very much if at all. I suspect that the lower facial restoration would involved bone augmentation from just behind the chin (prejowl area) all the way back to the jaw angles. Whether just widening the prejowl alone would be enough I can not say just based on these two pictures alone. I would have to see some more pictures from different angles and then do computer imaging on them to see exactly what type of lower facial change looks best to you.
Dr. Barry Eppley
Indianapolis, Indiana