Your Questions
Your Questions
Q: Dr. Eppley, I am interested in cheek implant revision surgery. I would also like to ask you if you think I could change my submalar cheek implants out for a malar implant or combo one? I wanted the high cheek bone look not the heavy mid face cheekbones. I’ve had to compensate by using a lot of fillers. I know you use many different styles of cheek implants that you have designed. Some of them look like they augment my cheek area that I want augmented. Are they silicone? What is the difference between this and Implantech Terino shell? Do you use screws and how long would I have to stay in town if I had you perform this procedure? Lastly, can it be done with sedation not general? Sorry for all of the questions.
A: These are silicone cheek implants that differ from malar shell cheek implants by having an infraorbital and zygomatic arch extension, creating a higher and ore model like cheek look. A single microscrew is usually placed through the implant at the maxillary posterior buttress bone for assured stability in the easily healing phase while the implant pocket is forming. This is a facial augmentative procedure that can be done under a deeper form of IV sedation. However the anesthesia needs to be adequate enough to allow for the proper implant pocket creation and placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my implant placed three weeks ago. It was a silicone implant large size with wings. I can barely move my bottom lip up and I can’t speak well for that reason. I have strange nerve pain that goes through the left bottom lip when i move it. The sensitive pain comes from the left side where the end of the wing is placed. If I touch it I get a nerve reaction on my lip. Moving muscles around it causes it too. Note- I am still numb on my left lip and chin. What is your advice? Attached is my before and after picture. I don’t like how projected it is and the huge crease it creates on my bottom lip.
A: While it is fairly early after your chin implant procedure, you have several concerning symptoms that speak for an early intervention with a chin implant revision. First and foremost you should have never had a chin implant for your chin augmentation. Your horizontal chin/jaw deficiency was so severe that a very large implant would have to be used that places too much stress on the chin soft tissues and the lower lip. But that issue aside you also have nerve pain which suggests the mental nerve may be impinged on by the wing of the implant.
You have three options for your chin implant revision:
- Downsize the implant to a small size and better style,
- Remove the implant completely, or
- Remove the implant and replace with a sliding genioplasty which was the correct chin augmentation procedure from the beginning.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One year ago I had a sliding genioplasty with 5mm advancement. I previously had iposuction under the chin ten years before the sliding genioplasty. I still have fullness under the chin and lower jaw region and lack 4mm or 5mm in chin projection to meet the lower lip and possibly 2mm in length.
I would greatly appreciate your views on the ideal way forward in considering these options:
1. Sliding Genioplasty revision to further advance 5mm and lengthen 2mm. Concerns mentalis muscle drooping, narrowing of chin from frontal view. Possible advantages of stretching muscles/skin to reduce that under chin/jaw fullness.
2. Custom medpor chin implant of 5mm with wings to add more width to chin. Concern won’t reduce the fullness concerns.
3. Neck lift, incision under chin tightening and or removing/shaving digastric muscles and submandibular glands. Concerns would need further incisions around ears to pull skin tort.
Would option 1, 2 or 3 be optimal or option 1 or 2 with option 3?
Ideally I’m after more chin identity and less fullness around that lower third of jaw/chin.
I have also had a CT scan which shows no chin fat as a concern and the submandibular glands are not abnormally large.
I have attached photo images and x-rays.
I would appreciate your opinion as to the most suitable surgical option to move forward and greatly appreciate your advice and time.
A: In looking at your pictures and video, the correct procedure for you is #1 and a modification of #3. A sliding genioplasty revision would be preferred over any form of an implant as it will stretch out the muscles and skin under the chin. That will help under the jawline and chin fullness.
For under the chin liposuction is often not completely adequate. What you need now is a submentoplasty. This is a procedure where a small incision is made under the chin, fat directly removed above and below the platysmal muscle and the platysmal muscle tightened. You do not need a formal necklift nor modification of the digastric muscles or the submandibular glands. This will work well and be synergistic with a secondary sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 21 year old college student. I’ve always been conscious about my side-profile, specifically the chin area being weak, and was thinking about pursuing a chin implant. In addition to whether you think a chin implant is appropriate, I was hoping you might be able to tell me with you expertise whether a chin implant would help reduce mentalis muscle strain or the dimple that appears from holding my bottom lip up when my mouth is mostly at rest. I have read online that it should, but have received mixed/unsure messages at consultations in my local area. In other words, I would like to have a smooth chin line at rest following the strengthening of the profile. Thanks!
A: Thank you for your inquiry and sending your pictures. A chin implant is exactly what you should NOT do. That is the wrong treatment strategy for your jaw problem. You have a very horizontally short and vertically long chin which is associated with lower lip incompetence and a mentalis strain. The correct treatment choices are either orthognathic surgery (braces and move the entire lower jaw forward) or a sliding genioplasty.
Assuming you do not want to change your bite, a sliding genioplasty moves the chin bone forward with vertical shortening AND improves lower lip competence and the mentalis strain. It is probably a fairly big movement (10 to 12mm maybe more) but a chin implant offer none of these important functional improvements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We had previously discussed a facial reshaping surgery consisting of verical jaw angle implants, infraorbital-malar implants and a glabellar implant. Last week I had a second consult with another plastic surgeon that also specializes in facial implants as well. He offered very similar plan to you with only minor differences. I do have a few questions/confirmations i wanted to bring up after looking over the surgery plan:
1. The jaw implants for me would have both vertical and horizontal dimension?
2. Are the vertical and horizontal dimensions given in mm’s? if so, what are the ranges of each dimension? what size would you use for me?
3. The semi custom infraorbital-malar implants will be 5mm?
4. The other surgeon recommended a subperiosteal midface lift with the infraorbital-malar implants. Would you also do the subperiosteal midface lift?
5. How many screws to secure jaw implants? infraorbital-malar implants? the glabellar implant?
Thanks for your time and answers.
A: In answer to your facial reshaping surgery questions:
1) Every standard jaw angle implant style offers both vertical and width augmentation changes. What makes the two basic styles different (vertical vs widening ) is the ratio of the vertical and width dimensions. Widening jaw angle implants provide more width than vertical length. Vertical jaw angle implants offer more vertical length than width.
2) Every facial implant, regardless of style and size, has very specific millimeter measurements which are provided by the manufacturer on their website complete with drawings and measurements. The best jaw angle implant style for you would be vertical jaw angle implants of the ‘large’ size. (11mm vertical, 5mms width)
3) The semi-custom infraorbital-malar implant will be 5mms at its thickest portion.
4) Every infraorbital-malar implant that is placed through a lower eyelid incisional approach is closed with a ‘subperiosteal midface lift’. Some surgeons chose to specifically call it as part of the procedure and even charge a separate fee for it. But, by definition, making the pocket for the implants requires raising a subperiosteal midface pocket to insert the implant. When the tissues are closed over the implant by sutures to the bone this is what constitutes the subperiosteal midface lift. It is an integral part of the procedure, some surgeons just chose to call it a separate procedure.
5) Jaw angle and glabellar implants generally only require one screw. The infraorbital-cheek implant may also only need one or possibly two. The judgment about the total number of screws is made at the time of surgery based on the stability and fit of the implants to the bone. Probably the correct number of screws will be 8 not 6.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in knowing more about the custom jawline implant recovery process. I was looking at some of the before and after photos of custom wrap around chin and jaw implants on your website/RealSelf, they look amazing. Part of me says, I should do the whole jaw and be done with it.
I would highly appreciate if you would explain to me one more time a detailed recovery timeline, progression of healing process such as what to expect in first few days to first few weeks and months, along with most common complications and possible worst complications.
A: I will sum up the custom jawline implant recovery process, which is largely related to facial swelling, by this phrase…‘There will be more swelling that you can imagine and it will take longer to go away that you ever want’. If you embrace this concept then you will be well prepared for the surgery. To put specifics to it, 50% of the swelling goes down by 10 days, 66% to 75% by three weeks and 90% to 95% by 6 weeks after surgery. I do not judge, nor do I ever do any revisions, until the final result is truly seen three months after the surgery when all swelling, tissue shrinkage and psychological adaptation to the new look has occurred. Most patients will feel comfortable going out in public somewhere between 10 to 14 days after surgery.
The most common complication after a custom jawline implant is the inability of some patients to tolerate the necessary recovery process. They can feel it is ‘too big’ and want to rush to an early revision. (downsizing or removal) While this does not happen to all patients it probably occurs in about 25% of them and can pose a stressful recovery process for both surgeon and patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male interested in brow bone reduction. i have actually seen five surgeons….I vaguely talked to a plastic surgeon about it while I was getting basal cell removed from my nose. You mentioned the incision and that great thought needs to be put into it being done in a male. After talking to surgeons I am a little confused about the scar. One surgeon suggested either one of two things, a cut around the whole top of my head or multiple smaller incisions called endoscopy. He told me the same thing that we need to really think about it but he was referring more to male pattern baldness which is unknown. Then I went back years later and he told me he wouldn’t work on me. Another surgeon said he’d make an incision so thin that I could be bald and it wouldn’t be noticeable. Another surgeon said the same thing but I believe he said he’d just make two incisions at the top of my forehead and kinda do an endoscopy type thing and pull up my brow…burr it down and remove calcium deposits. He said the way they were going to do it was that my forehead would appear smaller because my hairline would come down which sounded good to me. I think when I was a baby and since my head is large…I know there was a problem with me crowning when I was born…I think since my head was soft like all babies are it affected the way my hair grows to…..my hair grows down not straight up…..so I can’t grow it very long at all…matter of fact I generally have it shaved on the sides at a 1 or 2 guard….I am afraid that you would see the scar. I am also aware that there are hair grafts and I am wondering if that could be useful in my case. Make no mistake the biggest problem is my brow…..its just two low, kinda grows downwards, and just looks extremely heavy. I only get one life and I really need this done. I don’t want to make a mistake and fix something, but look unnatural or have a scar I have to worry about. I’m not looking for a miracle…..before I turned 16 my brow wasn’t developed like it is now but my head was still wide…..i just want a more normal, natural, attractive, and vibrant appearance.
Thank you so much.
A: Let me help clarify the thought process for you about the approach and the scar that would need to be used to adequately perform your male brow bone reductiono surgery. First the procedure. The only approach to brow reduction that is going to work for you is not just simple shaving, that simply will not be enough and will not create enough of a difference. So throw out any suggestions about an endoscopic or limited incisional approach through your scalp. Your brow bone reduction needs to be an osteoplastic brow bone setback technique. Nothing short of this going to work. Second the incision. A osteoplastic brow bone setback technique needs wide open surgical exposure to perform adequately. Your incisional choices are either a full coronal scalp incision from above (almost ear to ear) or a mid-forehead incision through the deepest horizontal skin wrinkle that you have. The surgeon who told that a full coronal scalp incision could heal so well that it would be invisible if you are bald…is flat out wrong. That is complete fantasy and misinformation. While they can heal well and look good with hair, the scars often get widest in the temporal area and would never be well hidden with thinning hair or if one is bald. Given your concerns about the scalp scar I do not consider this a good option for you. This leaves with the mid-forehead incision which I consider to be the safest aesthetic choice. You already have horizontal forehead wrinkles so a scar that would look like one of them is a wider choice.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have just read your comment about “Nasal Depressor Septi Muscle Release for Nasal Tip Animation Deformity”, I was wondering if separating the depressor septi muscle would not only stop a nasal tip droop when smile but also stop the tip from being pulled downwards while talking?
A: Nasal depressor septi muscle release, in theory, should also help somewhat with nasal tip deformity from talking as well. Although a more qualified answer would require seeing videos of your face while you are smiling as well a talking to look at the nasal tip movement that occurs.
It is also important to realize that there are two other muscles that also attach to the base of the nose, the nasal alas dilator and the superior quadratus, which can also create muscle movements that affect the base of the nose and how the tip may move.
The appropriate approach to your nasal tip concerns should be Botox injections. First treat the depressor septi muscle alone and see what happens with smiling and talking. If this is not completely effective than the lateral nostril bases should be injected to see if this produces a more complete elimination of nasal tip movement.
However
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheekbone reduction surgery three years ago and I was left with these gaps/non unions. Of course, the gaps need to be closed and the bones repositioned and plates need to be used to hold the bones together. I have heard that I need to do this ASAP because the bones become dead. Right now I cannot afford surgery and I am saving money for a reconstructive surgery in the next year or so. How would you fix the problem and is it true that the bones become dead? How urgent it is? My face is sagging too.
A: It is certainly not true that the zygoma/zygomatic arch would become ‘dead’ if it is not reattached to bone segments urgently after the cheekbone reduction surgery. The bone does not become dead per se, it remains alive but it will lose some bone mass/volume since it is no longer performing a supportive function.
But the for the sake of argument let us make the assumption that the bone did die if it is not reattached. At three years after the surgery this would have already happened and fixing it now would be an irrelevant issue. Therefore I don’t see the urgency to undergo ‘urgent’ zygomatic reconstruction at this point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have jawline reduction surgery scheduled for next month. Could you answer a couple questions about the surgery? Can you have a look at the CT once more. The root of the last tooth on left mandible seems to be pretty close to the outer border of mandible.
1)How many millimeters would it be safe to reduce on that point? Considering the nerves and risk of fracture in the future?
2)So the cortex parts of the bone seem to be the thickest. Will the bone adapt (create more cortex bone after part of it is shaved off? (afraid of fractures…)
A: In answer to your jawline reduction questions:
1) The bone that is removed in your type of jawline reduction is from the inferior border of the jaw not the lateral border.
2) 4 to 5mms would be safe from a nerve protection standpoint. None of this bone removal places the bone at risk for future fracture. Not enough bone is being removed for that to be an issue.
3) The bone will not grow a new or thicker cortex. As stated in #2 above, this is not a surgery that places the bone at risk for fracture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had mid facelift and a temporal cranioplasty area several years ago. I was filled all up the side from each ear to the temple area and about 3 inches in depth. I did not like the result as it felt monstrous so I asked for it to be removed. My surgeon asked if I wanted it removed or burred down and I specified removed. However, it feels as if quite a bit of the implant material is still in there and, several years down the line apart from still feeling like Frankenstein, I have a widened hairless scar on each side. More recently my hair seems to be thinning on the sides of my head in the area above the implant only. I have just got to menopause so this is evidently in part hormonal but it is definitely only in a specific area. I am really worried I am going to lose my hair. Please can you tell me if you have come across this issue before. I really look forward to hearing from you.
A: It is not uncommon to have widened temporal scars but this does not really have anything to do with the temporal cranioplasty implant material. It is just the nature of putting a vertical incision in the temporal area for some patients. It is also be partially related to how the incision was handled both in its making as well as its closure. Even if there is any residual implant material there it is not a known source of hair loss and has never been in my cranioplasty experience.
If you have residual implant material and would like it removed and well as performed temporal scar revision, I can certainly do that at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a horizontally short chin and not very well defined jawline. Having made some very rudimentary measurements I would say I would like my chin advanced horizontally forward about 12 – 15mm. Due to the distance a sliding genioplasty seems out as an option. As I would be quite happy to have a better jawline as well as more prominent chin a wrap around jaw implant sounds like a good option to research.
I have a few questions:
1. How many wrap around Jaw implants has you done?
2. How many of these led to complications?
3. What is the mean full recovery time?
4. What is the mean recovery time to reach the point where I would not look post op anymore eg should be happy going out in public.
5. What would be a full ballpark cost for the procedure both with a standard and custom wrap around implant? I would like this to include everything eg implant, hospital fees, Mr Eppley’s procedure cost, anaesthetists cost, screws etc.
A: Thank you for your inquiry about a custom wrap around jawline implant. Bringing the chin out 15mms with any type of implant is a ‘stretch’. (no pun intended) The tightness of the chin soft tissues would safely permit a 10 to 12mms change more ideally. In answer to your questions:
- I have done over 50 custom wrap around jawline implants.
- In terms of medical complications, I have not yet seen an infection or permanet nerve injury. However, such implants do end getting revised at the rate of 10% to 20% due to postoperative aesthetic size or shape issues.
- Full recovery in most cases is 6 to 8 weeks.
- Most people look reasonable by two weeks after surgery
- My assistant will pass along the total cost of the surgery to you later this week.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a plastic surgeon who has a patient that wants to do hip implants. I just want to confirm that you put them under vastus lateralis fascia, over muscle, like calf implants. Any tips as this is new to me? A Canadian plastic surgeon describes placing them under TFL muscle. This seems risky to me.
A: The options for placement of hip implants are limited and are really subcutaneous in location for most patients in my experience. If you look carefully where most people want them it is higher that the upper extent of the vastus lateralis. It is either over the trochanteric depression or even slightly behind and above it. In theory the TFL is more anatomic to the hip augmentation region but placing them under it runs a real risk of chronic pain not to mention the limited augmentative effect that will result from the tight fascia over it. Using an incisional approach high and behind the augmentative site also avoids any risk of running into the lateral femoral cutaneous nerve.
While it is always nice to have an implant deeper in the tissues, the hip region doesn’t provide any good and safe options to employ that concept. The other important implant feature of the hip region is that it needs to be of composed of an ultrasoft silicone polymer. (solid but feels like an ultra cohesive breast implant) For this reason I have them all custom made to get the dimensions needed and the right implant feel. It also makes them easier to insert with a small incision.
I hope this is helpful,
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. My brow bones are way too low. The ends of my brow don’t curve back behind my eyes much, they are more horizontal. Also I don’t know if you would call it my mastoid process or what but the part of my skull where the ears connect to skull and downward and upwards from there is too wide and it makes my face look wide. Basically I’ve noticed that most peoples ears are back set behind their cheek bones while mine are actually out a little further which gives my face a very wide look and makes my neck look too big for my face. Also since my head is so wide in the back it almost appears that it is my hair …it’s deceiving. I don’t know what all can be done but I also have calcium deposits on my forehead one of which gives me a pretty bad looking knot.
A: From a forehead standpoint, your brow bones can be reduced and reshaped and the entire forehead can be smoothed out. That can be done very effectively. The only question is the surgical access to do so. This will require some form of incision either on the forehead, at the hairline or back in the hairline. Such a decision to do so must be weighed very carefully in a male.
From a mastoid standpoint, I do not think that its impact is creating the effects that you think. I think your entire skull base is wide and this is what is creating the excess width issues. While the prominence of the mastoid bones can be reduced it will not create the facial and neck narrowing effects that you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tailbone fat grafting. I am very thin and have a prominent tailbone. It sticks out and is painful to sit for any period of time. I have seen an orthopedic surgeon who suggested I have it removed or reduced but that procedure scares me and i hear it is very painful afterwards.
A: I have done numerous cases of soft tissue augmentation to the coccygeal area for coccygeal pain (coccydynea) using fat. There are two fat grafting approaches to adding fat to the tailbone, injection fat grafting and the placement of a dermal-fat graft. The type of fat graft chosen depends on the coccygeal area one is trying to build up. If it is directly over the tailbone prominence then a dermal-fat graft is best used. That may or may not be combined with some end of the tailbone reduction. If one is trying to buildup in the peri-coccygeal area (around the tailbone) then fat injections would be better as they can cover a broader coccygeal area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal surgery. I had the procedure done last year and do not like the way it looks now. Is the zygomatic arch after being reduced reversible? if not would a cranial facial reconstruction surgeon be able to reconstruct the zygomatic arch with plates to widen the midface to support the soft tissue? I have attached two photos of what I look like before and one photo of what happened to me after surgery. I had my cheekbone and jawline reduced which was a HUGE mistake and now looking to rebuild my face.
Thank You.
A: I have seen and treated numerous women and men who have had facial bone slimming surgery, such as cheekbone reduction, and wanted to reverse it. In short, cheekbone reduction reversal is very difficult to get the zygomatic body elevated back out and fixed into position with plates and screws…difficult but not impossible in some cases. But whether this is possible is best determined by getting a 3D CT scan to see exactly where the zygomatic bones look like. As for the jaw angles the only treatment option is vertically lengthening jaw angle implants for restoration to replace the missing bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast implant and lift revision. I got breast implants with a lift six months ago. My biggest issue now is how they look when I bend over. That was the whole reason I got implants. I nursed for a year and went from a D to less than an A. They looked very odd and fleshy. Now I am much bigger and they still look fleshy and saggy.
A: Thank you for sending your pictures. While I have no idea what you looked like before your breast surgery, you have a reasonable breast lift and implant surgical result. The implants may be slightly high or the lift is slightly low and one could argue for some improvement by adjustments of either one or both. The implants could be lowered or the lift can be redone to move the nipples higher up on the breast mounds and tighten some more breast skin. But either way, it is common and expected that when you bend over the natural breast tissue will fall off/pulls away from the implants. That occurs in most breast augmentation results whether they have had a lift or not. Expecting the implant and breast tissue to move together as a unit when you bend over is not a realistic result for most women.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some facial reshaping questions. Are cheekbone and v-line surgery (zygomatic arch reduction + jawline reduction + genioplasty) the only ways to reduce the size of the face? How much would temporalis muscle reduction help? I am a Korean-American female looking to reduce the size and change the shape of my face.
A: Facial reshaping surgery to reduce or thin the face consists of a variety of bone and fat procedures. From a facial bone standpoint, cheekbone and jawline reduction (chin to angles) are the acknowledged facial reduction procedures. They do no necessarily reduce facial size per se that much but does reshape it or make it look more narrow.They are other companion fat reduction procedures of the neck and midface as well. (buccal lipectomies, perioral liposuction, neck liposuction.
Reduction of the posterior tenporalis muscle above the ear makes the profile of the head more narrow and less convex in the frontal view. While it is not a facial procedure per se, it can be effective at making the entire craniofacial shape more narrow. It can be a good complement to the other aforementioned facial reshaping procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I emailed you previously about a lip lift I received from another doctor at the end of last year. I was very unhappy with the length of my upper lip which has not changed since. I have another new issue now, my scar. It has come to my attention that it has recently widened and thickened. So now I have a terribly high lip, and also a terrible scar! It’s been a very terrible emotional roller-coaster for me, as you can imagine.
You were very nice and helpful when I reached out to you initially for your input. So i wanted to reach out to you again for your opinion on some research I’ve been doing to potentially help my situation.
I was wondering what you thought about performing a z-plasty scar revision on either side of my columella, the would essentially help thin out my scar, and ALSO potentially lengthen my upper lip, while partially camouflaging the scar within my philtrum creases (if this makes sense).
I’ve attached a few recent photos of my concerns, (sorry i don’t look overly enthusiastic in my pics!)…. I’m curious if you think this could work for me, of course in a few more months time (possibly a year), I do realize I’d have to wait before I do another surgery.
A: I remember your upper lip lift concerns from just a few weeks ago. While it may seem like an eternity to you, you are still very early in the healing process. I would not expect any changes in your upper lip length at this point. This is a process of 3 to 6 months, not 3 to 6 weeks after the procedure. The only thing you can and should do at this time is use your tongue to push out the upper lip under your nose as a form of upper lip stretching.
In regards to any form of a z-plasty scar revision, this is a procedure that lengthens scars by changing the scar line in z-shaped pattern. Besides the issue that this will not really be effective for upper lip lengthening, it will also creates more scars that would become even more visible than the scars yo already have. The philtral columns are not a crease but a raised skin ridge so this is not a good place to put any scars. Therefore, this is not a viable treatment approach for your concerns.
The most effective strategy for your lip lift at three months after surgery is to do either fat or PRP injections underneath the scar/nasal base followed a month or two later with a scar excision/re-closure. This will give your lip plenty of time to relax, drop a little and give the tissues more healing time to better respond to scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital dystopia correction. I am writing to enquire about the correction of my severe facial asymmetry that has been bothering me for quite long. I did not even think it was possible to correct uneven set eyes until I saw the before and after photos of the black gentleman you treated with orbital correction.
Please allow me to ask some questions: Did the former mentioned patient also receive a brow lift? What procedures next to orbital correction will I additionally require if I want to achieve the best possible eye symmetry? Is the reduction of only one cheekbone reasonable in my case?
I look forward to hearing from you.
A: Your right orbital dystopia is associated with a low right globe, right upper eyelid ptosis and lower right lateral canthal position. But the brow position above the lower eye is not lower but symmetric to the opposite side.
Therefore the treatment approach would be orbital floor augmentation, right lateral canthoplasty and right upper eyelis ptosis repair. Whether the cheek on the affected side would benefit from augmentation as well can not be determined based on your submitted pictures. At the least it is less important than the other mentioned orbital dystopia procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fixing a problem that has developed after jaw angle implant surgery. Here are some photos of the area. The first is with my teeth clenched, and the second is when they are relaxed. The rest are an attempt to demonstrate the deformity with the light available in my living room. I would be happy to take more photos if necessary.
The deformity was evident a few weeks after surgery, when the swelling subsided, and I was informed by the surgeon that the masseters would remodel. They have not changed. It feels to me also that the insertion point in the mandible is too anterior, creating a bulge in the cheek when really I wanted a hollow, and instead bulk posteriorly.
I feel the position of the implants is great. The issue (to me) is that the masseter muscle does not sit over the angle of the implant. I feel like I have two mandibular angles.
A: What you have is masseter muscle disinsertion from the jaw angle implant procedure. In the process of putting in the implants the pterygomasseteric cling has become disrupted and now the masseter muscle has retracted up over the implants. This is a well known aesthetic sequelae from the pro cedure that does happen in some patients. It is not usually possible to move the masseter muscle back down over the implants, it is scarred and contracted upward. I have tried that procedure from a neck incision numerous times with variable and limited success. The only really effective treatment at this point is Botox injections to try and shrink down the size of the muscle that becomes evident when clenching or chewing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom midface implants. I am 28 years old. Before double jaw surgery, I was diagnosed with Class III malocclusion. I underwent a Lefort 1, BSSO of the mandible and genioplasty involving advancement and rotation. What I noticed after double jaw surgery was that the rest of my midface was ‘left behind’ by the procedure, and appeared sunken and unnatural.
So the following year I got a zygomatic sandwich osteotomy for anterior projection of the cheeks which managed to make a huge difference and restored some balance. However the result still looked odd, mainly because the orbital region was left behind which made my eyes appear somewhat bulgy. So towards the end of last year I got orbital rim implants that extended out laterally to cover the bone to the outside corner of the eye. Again this made a big difference to my sunken under eye area, but it didn’t reduce the appearance of prominent eyes at all. I was confused for a while after this, but then I realized that perhaps the reason why the implants didn’t help the bulginess at all was because they were placed in front of the infraorbital bone. Visualizing it, I imagined that the implant needed to be placed on top of the orbital rim, pointing upward and forward rather than just forward. This thought came to me after thinking about the counter clockwise rotation that I received. I went on to think that maybe I should have got ‘counter clockwise rotation’ of the area around the orbital rims just like I did for the lower part of the midface. It wouldn’t be true counter-clockwise rotation of course, but the effects of the implant would mimic that in the sense of pulling the infraorbital margin upwards and forwards, rather than just providing more volume to the front of the upper midface.
The other issue I noticed only after going through double jaw surgery and the orbital rim implants was that the ‘inner’ part of the upper midface still appeared recessed. By this I mean the position of the junction between the ‘flat’ part of the midface and the nose itself, stretching from the medial side of the eye, all the way down to the base of the nose. I did a bit of research on this and found out that the Lefort 2 osteotomy is equipped to mobilize the nose including the nasal bone and the frontal process of the maxilla in addition to the lower maxillary region. In other words, the junction I am referring to is the groove at which the frontal process of the maxilla sharply changes direction to form the top part of the nose. This ‘groove’ or ‘junction’ sits too far back into my face, giving a flat appearance to my midface, only the lower part of that groove was fixed with the Le fort 1.
So there are two questions that I have about the issues I have discussed:
1) Whether an infraorbital implant can be custom made to give upward and forward projection from the infraorbital margin, and whether you think that this is a better option to fix the appearance of bulging eyes than just a standard orbital rim implant design
2 – Whether any sort of custom made implant can be placed around the area of the groove between the nose and the horizontal part of the midface, running all the way up the midface, to simulate the effect of a Lefort 2 osteotomy. I noticed in some of your posts that implants can be fashioned to replicate the movements of a Lefort 3 osteotomy, so if there are any ways to move the area mentioned forwards, I would be eager to go through with it with you.
Thanks so much for your time Dr. Eppley.
A: Thank you for your inquiry and detailed description of your facial surgery history and anatomic concerns.. In summary you have done a variety of procedures that have been chipping away at a total midface advancement. Custom midface implants can be designed just about anyway one wants based on the soft tissue stretch and tolerance of the tissues. Whether it is to raise up the infraorbital rim or fill in the paranasal-maxillary region, they can be so designed to do so. A 3D CT scan would show exactly the positive augmentative midface changes you have accomplished as well as the parts of the midface that have been left ‘behind’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Following research on Skull Contouring, I write to seek your advice on how to progress matters further with you, I currently live in the UK.
From my research I believe I have a degree of the common condition ‘sagittal crest deformity’ I would like to smooth out a bump located on the top of my head near the back, ideally via a small incision at the back of my head followed by bone burring.
I also observe a further bump which is very small, located close to the above, on the back of my head near the crown. I attach photos as I’m sure these will prove useful for your evaluation purposes.
Your thoughts would be much appreciated, I look forward to hearing from you in due course.
A: Thank you for your skull contouring inquiry and sending your pictures. You have correctly identified your skull deformity as that of a sagittal crest deformity. Its treatment would be as you described as a bone burring reduction through a small posterior scalp incision. The amount that the sagittal skull bony crest can be reduced would depend on the thickness of the sagittal crest bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital migraine surgery. My story starts 20 years ago with a car crash taking the windshield out with my head and then a few years later I was at stop light and a drunk driver rear-ended my car. My head rocked off steering wheel causing severe whiplash. For years I was treated for migraines with no relief. About 10 years ago was finally diagnosed properly with occipital neuralgia. I’ve had 4 nerve blocks over the past few years with some relief except this last one went haywire. My doctor said that the occipital nerve is just angry from injections but it too is very painful. The pain starts in the center o my neck base up to my right ear. I can show you from the outside exactly where that nerve is. It throbs in the same place during every flare. When its not flaring, its sore and tender. It hurts me at least 3 times a week. My doctor thinks it’s a good idea and supports a visit to see you.. She also said she would be happy to send my info to you if needed. My latest MRI was last fall. Trust me I’m a veteran with this condition and I’m over it. That’s why I’m begging for help from you
A: Thank you for detailing your migraine headache history and symptoms. Just based on your description I could not imagine a patient with more specific symptoms that would be most likely to get some relief with occipital migraine surgery. (nerve decompression) The fact that you can precisely pinpoint the exact location of the pain, that it is consistently reproducible and gets some relief with injection therapy speaks favorably for a positive response to migraine surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lower face reshaping surgery. My lower face is very heavy. My biggest concern is my double chin and round lower cheeks which look like a chipmunk. I am Interested in chin and/or jawline liposuction and maybe a small chin implant. Also, I have a very boulbous nose tip. I dislike how my nose looks from the front view but am not interested in a full rhinoplasty. Maybe just a nasal tip plasty or nostril reduction will do. I am looking for treatment suggestions to improve profile and a subtle refine nose tip. I have included some pictures for your review and suggestions.
A: Thank you for sending your pictures for consideration for lower face reshaping. In addressing your lower facial concerns, I can see the benefits of defatting it with a combination of submental liposuction, buccal lipectomies and perioral liposuction. This would be combined with increasing chin projection slightly through a vertical lengthening chin implant and a tip defining rhinoplasty. This combined approach will provide improvements in the shape of your lower face through narrowing and lengthening it as well as concurrently addressing the wide nasal tip concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to shorten the midface? Is there a surgery for midface shortening? If so how much can be done? I don’t have a gummy smile, just a long distance from my eyes to my mouth. I plan on getting jaw advancement to lengthen my lower face, but I still think the midface would be out of proportion. Would a rhinoplasty and lip lift help? I don’t have any pictures, but I hope you may give me a general idea as a plastic surgeon. I understand I would still have to see one in person eventually.
A: There is a midface shortening surgery that is based on vertically shortening the length of the maxilla. This is known as a Lefort 1 impaction procedure that is used in the gummy smile patient to treat vertical maxillary excess. This does not appear to apply to you. Other than this skeletally based procedure, only a camouflage approach may provide some benefit. Procedures such as a rhinoplasty and a lip lift can be of some benefit to create a midface shortening effect depending on the shape of the nose and the length of the pper lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am perusing further information about your silicone Pectus Excavatum implant surgery. My questions are about the cost of the procedure and other normal questions such as recovery time and the amount of pain those who have the procedure are under. Does the implant go under or above the muscle? Also, how many times have you performed the procedure?
A: Thank you for your pectus excavatum implant inquiry. The cost of the surgery is highly influenced by how the implant is made, whether it is done by a 3D computer design method or a silicone elastomer moulage technique. My assistant will pass along the cost of either approach to the surgery to you next week. Regardless of how the implant is designed, most of it is placed over the depressed sternum where there is no muscle. If any portion of the implant goes beyond the sternal edges it will go on top of the pectoralis major muscle. It can not go under the muscle due to the tight attachment of the pectorals major muscle to the edges of the sternum. This is not a procedure that is associated with much pain. Recovery time is determined by what activity you are trying to recover to do. Most strenuous activities that involve a lot of arm motion and strain should be deferred until 3 to 4 weeks after the procedure to avoid the development of a serums. (fluid collection).
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reconstruction. I had a motorcycle accident caused a de-gloving injury and tore my skin down off my forehead in a triangular fashion starting at the widows peak tearing down over right eye stopping at mid eyebrow and on left side across and down ending next outer edge of left eye between outer edge of eyebrow and left eye itself.
A few things… my left eye you see the eyebrow is high and it creeps up higher as day goes on at night it becomes quite pronounced. This eyebrow creep was initially mediated with botox injections after orbital fracture surgery. Ten years ago a plastic surgeon took a piece of my skull over my left eye about 3 inches behind hairline to rebuild area fractured under left eye. This area of skull is now an indentation about 3×2 inches oval shape concaveing about a 1/4 inch depth that is trouble some to me and keeps me from cutting hair as I would like (short) has odd sensations to feel and is deformed enough to bring attention same as eyebrow .
I have a similar situation of strange sensation’s over my left eye it is hypersensitive. My brow as a result of the emerge nay nature of accident was sewed together in flight for life travel and although curative left me with funny brow lines that are mess matched and the creeping eyebrow.
A separate issue came about from skin cancer surgery on left side of nose and has left my face dropping pulled or distorted on the lower left. See the nasolabal fold is not equivalent nor within normal range of normal nonequivalent range. It caused a pulling too from under left eye and in conjunction with orbital surgery left the field under left eye different then right eye.
I further think I should look at my nose it was broken 2 x and my left nostril runs at far less capicity then right. I always have to clear my throat and feel dripping of mucus especially when sleeping down my throat.
I was hoping for some help with breathing and stopping the sinus draining down my throat as well as more balanced face and correction of indentation and brow.
A: Thank you for sending your picture and providing the detailed description of your facial concerns. To ensure I have an accurate listing of your concerns and their potential facial reconstruction treatments, I enumerate the following;
1) Skull Defect From Bone Graft Harvest Site – This is a partial thickness skull defect from the removal of the outer table of the skull from the bone graft harvest. This can be completely built out/leveled by the application of hydroxyapatite cement.
2) Left Eyebrow Elevation/Asymmetry – This is the result of the transection of the frontal branch of the facial nerve from the oblique laceration that went down to the outside of the eye. This cut directly across the path of the nerve that is responsible for forehead movement. This has resulted in permanent paralysis of that side of your forehead. Over time the paralyzed eyebrow continues to retract upward due to lack of any downward muscle pull. While motor nerve function can never be restored to the paralyzed eyebrow, it may be possible to realign the scar line so that the eyebrow is brought down lower and the horizontal wrinkle lines match up better.
3) Left Eyebrow Dysesthesia/Sensations – Like the frontal branch of the facial nerve, the large sensory supraorbital nerve coming out of the brow bone has been similarly cut. While the nerve ends are long past being able to be repairs, the trunk of the nerve where it comes out of the bone could be released from the scar and perhaps this may improve the strange sensations.
4) Left Lower Eyelid Contracture – The left side of the nose was reconstructed with a rotational nasolabial flap. This is a concept of ‘robbing Peter to pay Paul’. As a result there is a relative tissue deficiency between the lower eyelid and the nasolabial fold, making it tighter than the other side. An effective treatment strategy would be fat injections to try and loosen up the tissues.
5) Nasal Airway Obstruction – I can’t obviously know what the inside of your nose looks like and this will require a CT scan for evaluation/confirmation of internal nasal anatomic obstruction. Septal straightening and inferior turbinate reduction surgery may be appropriate
These are my initial thoughts,
Dr. Eppley
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding custom wrap around jaw implant to improve asymmetry and enhance jawline.
I have fractured right sub condylar part of the mandible 6 months ago. It has healed nicely although I believe I lost some bone which is causing slight assymetry compared to the left part of the jaw (loss of hollow cheeks and slightly ”fatter” look on the affected jaw). While the assymetry might not be huge, I would like to have it fixed.
I’m wondering if custom jaw implant could be better option that orthognathic surgery, as I would like to wider my jaw and lengthen the chin in the process. Could the perfect symmetry be achieved with jaw implants only?
A: In looking at your x-ray as well as knowing the natural history of healing subcondylar mandibular fractures, you have not ‘lost bone’ per se. Rather, as is common with these type jaw fractures, you have lost vertical height (top of condyle to jaw angle) as it has healed. (partial condylar collapse) In short, the vertical height of the mandibular ramus is now shorter. This is the current source of your jaw asymmetry.
That could be treated by either a standard small vertical lengthening jaw angle implant or a custom made one.
Certainly any form of jaw implant would be far more effective to simultaneously lengthen the chin and widen the jaw than orthognathic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. I have deformities in my skull that I would like to change. I don’t know if my skull is changing still or what caused my skull to change into this shape. But I have my brow bone sticking out in the front, the right side of my head to stick out more than my left (which if you see my right eye its more into my skull than my left eye), and I have my skull is not flat on top. I have not been to the doctor about these issues yet. Seeing what my current options are to fix this and if you have any insight on my skull defamation.
A: I can not speak to why your skull has developed this way, I can only address how you would treat it. Your strong brow bones can be reduced through an osteoplastic brow bone setback procedure. The right temporal protrusion can be reduced by a combination of total muscle and subtotal bone reduction. The top of your head is the biggest challenge, as some height reduction can be done, you can never get it close to being flat.
Dr. Barry Eppley
Indianapolis, Indiana