Your Questions
Your Questions
Q: Dr. Eppley, I’ve read a lot of your responses on RealSelf, as well as sifted heavily through your blog and website. I appreciate you taking the time to read about my situation.
I am Chinese and as I grew into a teen I started noticing that my facial structure is very asymmetrical. My chin is in the centre however, the angle of my jawbone is different on both sides. Though not severe, it is still quite noticeable. My cheekbone on one side protrudes more than the other..
I understand that you are well aware of the aesthetic desires of most east asian cultures – by that, I mean the v-shaped chin and jaw line, as well as a slim malar area. My question to you are:
1). is it feasible to have facial bone contouring surgery on just one side of my face so that my features can become symmetrical?
2. As I am still quite young and my skin elasticity is quite good, would my “excess” soft tissues and skin around the cheekbone area and the jawbone area also “shrink” in size to stick to the reduced bone structure?
Many patients on RealSelf or those who have undergone malarplasty seem to come to you for advice regarding their ‘sagging’ of tissue on your website. I am definitely not keen on having one side of my face extra saggy.
3. Do you employ the same techniques as those in China and Korea? How can I avoid sagging like a bulldog and getting a double chin with these procedures?
A: In answer to your facial bone contouring questions:
1) It is possible to do facial bone contouring on one side on the face if that is indicated, I do it all the time. A 3D CT scan would provide a good diagnostic evaluation of your facial structure to best answer that question.
2) Generally younger patients do better with soft tissue contraction around reduced facial bones. But there are limits at any age of how much bone can be reduced and successful tissue contraction around it to occur.
3) The bone techniques used (osteotomies) for facial bone reductions are not unique to any country as there are only so many ways to do any surgery. What is likely unique is the individual approach taken for each patient and the balance struck between the amount of facial bone reduction done vs the soft tissue risks of sagging vs the patient’s aesthetic goals. Having expanded my experience with some training in China they tend to be very aggressive because many of their patients do have really big cheekbones and jaws. But not every Asian patients does so the exact same operation for everyone will have some slightly different aesthetic outcomes. (e.g., soft tissue sagging)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question I was hoping you could shed knowledge regarding delayed jaw implant infections. I had jaw implants placed two years ago and just yesterday I noticed some tenderness on the right jaw implant, specifically more on the bottom/underneath, in the middle of the jaw line (as opposed to any tenderness at the back of the mandible). No noticeable swelling as of yet, and no trauma to speak of…..but I did get over a bad bacteria-based throat infection about three weeks ago, so hoping the bacteria didn’t travel and infect the implant. In your experience, are late-stage (over at least a year) bacteria (so non trauma initiated) jaw implant infections a pretty regular occurrence? Anything I should really watch out for before seeing a doctor?
A: In my experience such potential delayed jaw implant infections have not occurred…unless there is some small opening in the original incision lines inside the mouth. (that is known or unobserved) The occurrence of blood borne infections seeding an implant would be extremely rare. I am sure in the annals of surgical history it has happened but not something that would ever be considered either common or expected. To make an analogy, think of all the women in the world that has breast implants and the common illnesses that occur but yet we don’t hear about such delayed implant infections occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley ,I might just take this moment to get a full understanding of the silicone custom jawline implant by asking some questions:
1. The common problem of bone erosion with silastic implants is eliminated if the silastic implant is customized and fixed with screws?
2. Custom made silastic implants are made to last a lifetime inside the patient? In other words, there is no need to replace them unless the patient desires to do so.
3. In my case the silastic implant would be inserted intraorally since the PEEK implant will be extracted this way?
4. You would let me be involved in the designing process from start to finish and will show drafts and answer emails if the patient tries to engage you in the design?
5. You are willing to design implants that do not just provide volume in the right places but also correct asymmetries between the facial halves?
6. Do you have any computer program that could reasonably project how a finished implant design (for both the cheekbones and the mandible) would make my face look before we manufacture the implant?
7. Your finished implant design can be scrutinized and revised, if necessary, until we are both satisfied that it would fulfill my aesthetic wishes?
8. Implants are made well in advance and would only be manufactured with my explicit consent?
Kind regards
A: In answer to your silicone custom jawline implant questions:
1) All implants on the jawline, regardless of their composition, create some degree of passive implant settling and even bony overgrowth particularly back at the jaw angle area. These are natural phenomenon when placing implants on bone that is most manifest on the mandible. The concept of ‘bone erosion from silicone implants’ is both misunderstood and erroneous.
2) All implants for the jawline (silicone, Medpor, PEEK etc) are permanent materials that do not undergo degradation of the material over time. From a material standpoint they are lifelong devices.
3) If your PEEK implants were inserted intraorally then silicone implants can be done as well.
4) to 7) I have a very specific protocol on how custom implants are designed with patient participation. I have attached a document which explains the details of this process that every custom implant patient is required to read and sign before the implant design process is ever started.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an otoplasty done several years ago to correct my protruding ears. When I saw the results, I was disappointed and thought my ears were undercorrected. I decided that I wanted another operation. We did the operation again 3 months after the previous operation, which I think caused my antihelix to thicken. nI don’t mind that my antihelix is thick, I do mind how close my ears are to my head. I also developed a telephone ear deformity. All I would like to do is return back to how my ears looked before, but I know that might be difficult. How difficult would it be to return it the original shape and protrusion or something close to the original shape and protrusion?
A: I would need to see pictures of you ears, both now and before, to better answer your question. But I think the question is not whether your ears can return to their initial preoperative state, because they can’t, but how close or what type of result, could such an otoplasty reversal come to it. There is no going back home, so to speak, there is only how much closer to home can you get. Very few surgeries are ever 100% reversible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i am writing to you for some possible assistance. I was reading a thread just now that was posted a few years back about bulging temple veins. One of the gents on the forum talked about how he went to you for treatment for his” wiggly worms” on his temples. I have the same issue much more mild though on my right side, i thought i would ask you if you know anyone personally that resides in my area that does this procedure and is very good at it? It is a old post so i was curious, has treatments become more advanced since then? Like it can be done with lasers now or is done with just a trip to the surgeon office? I don’t know the first thing about all this and that is why i have come to you, i don’t mean to bother you. This gent spoke very highly of you and thought i would enquire.
A: What you are actually referring to are known as prominent temporal arteries, not veins. This is the type of prominent vasculature that occurs most commonly in men in the temples and forehead region. The only technique for their reduction/removal is my multipoint ligation technique. I could not tell you whom in your geographic area may perform this temporal artery ligation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for the informative consultation a few days ago, I am currently in the process of narrowing my choices. I just had a few questions.
1.) What are the odds of long term side effects with genioplasty vs jaw implants? Is one significantly safer than the other?
2.) Would a custom jaw implant benefit my chin as well? If yes, would it benefit my chin to the extent a genioplasty would?
3.) Would a custom jaw implants be much better than standard implants in terms of symmetry?
A: In answer to your questions:
1) A genioplasty (chin) and jaw angle implants carry with them different risks. I am not sure I would ever say one is safer than the other but because the jaw angles involve an implant and the chin is done by moving one’s own bone, jaw angle implants carry a risk of infection than a bony genioplasty does not.
2) By definition a custom jawline implant wraps around the entire jawline from angle to angle and crosses the chin. An implant can create the same amount of horizontal augmentation that a sliding genioiplasty but also can widen the chin which a genioplasty can not do. (it actually makes the chin more narrow from the front view)
3) One of the benefits of a custom jawline implant approach is that it is one piece, using standard implants is a three implant approach. This reduces the potential risk of asymmetry both by its design and placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young female and am interested in lip advancements. I just have a few questions about the lip advancement procedure. I have pretty full lips. I have lip implants in currently and I like them. However, I would like my lip size to be a lot bigger. I don’t like fillers at all and, after reviewing what is offered, I am most interested in the vermillion advancement. My questions are:
1) Would this option of lip enhancement be good for a young person who dislikes lip fillers?
2) Can I have a vermillion advancement with Permalip implants in?
3) How big would I be able to make my lips with the vermillion advancement? I would want a big difference.
4) Would I lose any current lip projection (volume forward/pout), after the advancement?
A: In answer to your lip advancement questions:
1) Short of injectable fillers and implants, a surgical lip advancement procedure is the only option for making one’s lips bigger.
2) A vermilion advancement can be done with lip implants in place.
3) As a general rule, lip advancements can increase the vermilion show of the lips by 4 to 5mms on the upper lip and 3 – 4mm on the lower lip. Lip advancement are very powerful procedures for increasing lip vermilion show and their perceived size.
4) Lip advancements will not decrease the forward projection of the lips.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am still considering having the buttock implant removal. I really wish I had done it at the same time as the facial implant removal.
1. Have you removed many subfascial buttock implants?
2. If so, are there many potential complications with this surgery?
3. Will I need drains?
4. Is there much pain afterwards?
5. Would I need to stay in Indiana long? It would be great if I could just stay 3 days or so. Or would I need to stay to have stitches removed?
A:
In answer to your buttock implant removal questions:
1) I fortunately have rarely just removed buttock implants without some form of replacement. So I certainly have not done ‘many’ and never hope that I have to.
2) Like all implants removals anywhere on the face or body, there is going to be generalized tissue deflation/flattening effect. Your cheeks are a good example fo what happens when you remove the underling support from a projecting prominence.
3) A drain is not needed.
4) Any postoperative discomfort will be a fraction of what its as to place them. Your facial implants are a good example of what ti expect.
5) You should be able to go home in one to two days at worst. All sutures are under the skin and are dissolveable.
Dr. Barry Eppley
Indianapolis, IndianaButtock
Dr. Eppley Q: Dr. Eppley, Can you please give me some information on custom facial implants? If I decide to go ahead with the procedure how much time do I need in the USA?
From the date that I arrive –
to have the CT scan,
to manufacture the jaw or skull model ?
To sit together and design the implant
To manufacture the implant
To operate
To leave hospital
To be able to leave USA ?
I am extremely concerned about infection – because I have just had cervical disc put into my neck. An infection my spread to them and create a big problem causing them to be removed.
Also extremely worried about pain – that is the one thing keeping me from going ahead – how can we totally control this ? Can I stay in hospital of the first couple of days so that I can get stronger IV pain medication \?
A: In answer to your custom facial implant questions:
1) The design and manufacture of custom facial implants is a 4 to 6 week process. Therefore patients get their 3D CT scan in their local geographic region and send it to me. I then take the scan and do the design process. Patients only come here for the surgery for the obvious practical reason.
2) The design process is done in sessions with engineers from 3D Systems. Patient do not directly participate in these actual sessions. I then take the design files and share it with the patients for their input. We have three design sessions to come up with the final approved implant designs.
3) The surgery time for a custom jawline implant is 2 hours.
4) If you are coming by yourself, and given your immediate pain concerns, you would stay overnight in the surgery center. This surgery is not performed in a hospital as that changes the cost of surgery significantly.
5) You would fly home when you are comfortable doing so. Each patient is different but I would give yourself at least 5 days after surgery before leaving.
6) While infection is always a concern in jawline implant surgery, I would have no concern about it spreading to your cervical disc implants should it occur. When occurring it remains localized to the implant pocket.
7) While the most common postoperative custom facial implant issues are aesthetic in nature, infection is the one medical issue that we pay a lot of attention to try and avoid through a host of strategies. But infection is not something that ever occurs immediately, its occurrence is always in the range of 3 to 6 weeks after surgery…a time that surprises patients as they think they are well past it at that point.
8) While every patient is different about pain, that has never been a postoperative issue that has been a problem with any custom facial implant patient. You may every well be different in this regard although I would think your cervical disc surgery would have been far more painful than jawline important. While one would receive IV pain medication in the overnight stay int the surgery center, there is no capability to go to a hospital for IV pain medication after the first night after surgery.
9) Pain is not something I worry about in any patient as that seems to be well controlled by standard pain medication. What I do worry about is that few patients are psychologically prepared for the large amount of facial swelling that will occur (from the patient’s perspective) and the duration of time that it takes to go away. This can be very psychologically destabilizing for some patients…and they are always the male patients that have the most difficulty with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple questions about some problems I have with the lower third of my face and lip area. To begin with, I’ve noticed that my lips have begun to age. My upper lip looks quite long, and I’ve always had a downturned mouth and aging has exacerbated it. I look extremely sad/angry, even when I’m not. I have vertical maxillary excess, causing bite problems and lip incompetence too.
Is there anything I can do to fix all this? I was thinking a combination of a corner lip lift, upper lip lift and facelift would address the lip problems, but I would still need something done for my maxilla, to shorten it and help with the lip incompetence.
Thank you very much for your attention.
A: If you have maxillary excess that needs to be treated and would be beneficial to do so, that is what you need to treat first. All the external changes of the lips and face need to await that fundamental skeletal change. You would only do the lip and facelift procedures first if you knew that you were never going to have a maxillary impaction procedure. I would need to see pictures of your face to provide a more qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to ask are cheekbone reductions always bound to have some sort of sagging of the midface area or incur premature aging?I thought I had done enough research on zygoma reduction before deciding to undergo the procedure. I knew there would be risks or trade offs, but I didn’t know it would be this bad.The L-osteotomy surgery I had included a 4mm removal of bone on each side. My front and 45 degree cheekbone was not prominent. Only the lateral of my cheekbones was quite prominent, giving me a strange wide and manly face shape. Why is it that my front cheeks sagged so much after the surgery?
A: When the whole cheek bone has been moved in, depending on the facial type, the risk of soft tissue sagging is a real one. That is whole skeletal support for the midfacial soft tissues, particularly the front part of the cheeks. By your own admission the front part of your cheekbones was fine but it was the back part (posterior zygomatic arch) that created the issue. Thus it would been better to just have the posterior arch osteotomies done with inward positioning as that would have caused no soft tissue sagging at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lip lift in early December 2017. The surgeon took out 7mm of skin in the center of the upper lip. And now it seems that the nasolabial area looks bigger and mouth corners look down turned. I would like to know if the Double Duck would be a good option for me, when can I get the surgery and if you could perform this surgery, how much would it be ?
A: Thank you for sending your pictures, particularly that of the preoperative markings. When this amount of skin resection is done with a flat inferior border in a subnasal lip lift, it can cause an apparent over corrected appearance to the central upper lip and the sides of the lip are left ‘behind’. This creates an upper lip central to side vermilion disproportion and can also cause a downturning of the corners of the mouth. (too much central lip pull)
A strategy to improve to improve your upper lip shape could include the following:
1) Extended corner of mouth lifts with lateral vermilion advancements
2) Subnasal scar revision to try and move the scar line inside the nostril on each side of the columella (this is really a modification of the Double Duck Lip lift procedure)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope I can ask you this: I just had a Facial fat transfer 2 weeks ago. My surgeon is on holiday now. Please help me. I was walking today and I came into a storm with around 38 km/h of wind. Often the wind blew directly in my face for around 20 minutes. Do you think that killed some of the 2 weeks old fat? Thank you so much and warm regards.
A: The simple answer to your question is that I doubt external cold wind could adversely affect the volume retention of a facial fat transfer procedure…at least on a limited time exposue. You are undoubtably drawing this potential analogy from technologies such as CoolSculpting where cold temperatures are used to aid in some fat reduction. While seemingly a relevant analogy it is not. These are devices that are applied directly to the skin and held there for a duration of time to really lower the temperatures of the tissues under the skin. That is quite different than an external wind chill, which while dropping the skin surface temperature, would have a much harder time dropping the temperature of the deeper subcutaneous tissues if only ‘applied’ for a relatively short period of time. Much longer exposures, however, would be likely to do it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In Korea, there are few clinic that offers posterior cheekbone reduction with 5mm sideburn and cut inside the hair (the posterior cheekbone reduction.) Many clinic in Korea also do not offer this method of surgery.
What are the risks of this method of surgery as I am interested in making my face smaller? The clinics I have consultations with told me that there are many revision case because people can feel and see the broken arch bone at the hairline or there is non connection of bone. Is this true? What other risks??
A: Thank you for our inquiry. I have done many isolated posterior zygomatic arch osteotomies (posterior cheekbone reduction) to narrow the width of the face on the sides. (but leaving the anterior cheek bone alone) I have not yet seen the complications which has been told to you such as bone edge visibility or palpability. By definition with plate fixation there is a non-connection to the bone but that is irrelevant as the bone is stabilized and there is always a non-connection of the bones no matter whether it is done in isolation or with anterior cheekbone reduction osteotomies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in V-line facial contouring. There is a popular procedure in South Korea that offers a procedure called V line which slims the jaw and chin to make it doll like and I am very interested in getting it done in June 2018. I contacted several clinics in Korea and the procedure is much cheaper there when compared to USA. However, I am nervous going to a country I have never been before by myself. Before making a decision, I want to know my options for the in state surgeons. How much would facial contouring cost at Eppley Plastic Surgery Clinic?
A:Thank you for your inquiry. What you are referring is known as V-line facial contouring or V line jaw surgery of which I am very familiar. Whether you are a good candidate for that procedure depends on your pictures, x-rays and aesthetic goals. Be aware that when you go to South Korea they are going to do the procedure whether you are a good candidate or not. They treat everyone the same whether they are Asian for not or whether their bone structure can benefit from the procedure or not I have treated many Caucasian US women who went there only to have a result they did not want and then had to be secondarily reconstructed. Cost aside I would first determine if what you want to achieve is even possible with your facial structure. It will be a difficult problem to secondarily correct if the operation has never had a chance to achieve what you want.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tear trough injections using injectable fillers. I have deep tear troughs that I think would benefit by them. I have attached some pictures for your review and recommendations.
A:Thank you for sending your pictures. Fillers or fat is not a proper procedure for your under eye concerns. What you have is overall fat protrusion of the lower eyelids with tear troughs. (medial orbital rim indentations) These are really pseudo tear troughs that are magnified by surrounding infraorbital fat protrusion. Any attempt at filling the tear troughs will likely just make your overall lower eyelids look even more puffy than they are now. The correct approach is lower blepharoplasties to remove the herniated fat and transpose it into the tear troughs with some lower eyelid skin removal/tightening.
In my opinion the only role for an injectable approach to your lower eyelids is to ‘prove’ that lower blepharoplasties are the better treatment. Given that injectable fillers in the eyelid can take a long time to resorb I would be hesitant to even try such a treatment as you would have to have puffy eyes for some time. It would be better to just proceed with lower blepharoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a Peri-Pyriform Implant. As shown in my X-rays, I had Lefort1 osteotomy last year. I also had cheekbone reduction, mandibular reduction, and chin augmentation back before that. I am planning to remove the titanium screws before I get the Peri-Pyriform Implant. I do not know if that is necessary and I would love to hear your professional opinion regarding removing the titanium screws. I am also interested in getting cheekbone implant. I found a surgeon in Asia who places a Medpor implant below the lower eyelid area (the dark circle area, rather than the actual cheekbone area which is located below the outer eye corners) to give the patient a more convex midface and a more youthful look. I am wondering if we could discuss the possibility of getting the same implant along with the Peri-Pyriform Implant during our virtual consultation. Thank you very much for your time and consideration. I look forward to speaking with you soon.
A: In answer to your questions about the Peri-Pyriform implant::
1) It is not necessary to do a separate maxillary plate and screw removal if you do not want to. I can do that at the time of the implant placement.
2) The subcheek and peri-pyriform aperture implants can be done all in one procedure with the same surgical access.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I am a 21 year old Asian girl who thoughtlessly underwent cheekbone reduction surgery and jawbone reduction surgery in Korea. After six months of healing, I’m finding that my cheeks are sagging and it is making me look a lot older than I am.
I’m not sure what to do. I’m depressed and regretful of my decisions. The cheekbone reduction was conducted via L osteotomy, with an oral and sideburn incisions. I’m hesitant about cheek implants as I’m not very keen on putting foreign objects in my body. Even though I am young, I am desperate. Would a cheeklift/soft tissue cheeklift be beneficial in my case.
A: Thank you for your inquiry. Your cheekbone reduction reversal options are limited. You have to re-establish bone support to lift the soft tissues back up, a cheeklift is not going to work. You either reverse the osteotomies or place some form of a cheek implant. But either way you have to build the bone back out somehow, you can not lift the tissues around it successfully in a young person. Implants are easier but revise osteotomies are more ‘natural’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have three questions regarding the titanium screws for may custom jawline implant.
1. Are they custom-made to different lengths, since they will be penetrating at three different spots of varying thickness along the mandible? (Ie. 14mm/12mm at the gonial angle, ?mm at middle of mandible, and 4mm at chin, so they don’t over-penetrate or under-penetrate)
2. Is there a torque limiter on your drill to prevent fracturing the bone?
3. Can we place the six screws as follows?(on pages 6 and 7 of the pdf file below, which I have marked up)
A: In answer to your screw fixation questions for your custom jawline implant:
1) These are 1.6mm diameter self-drilling screws whose maximal length is 8mms. They are placed through portions of the implant were it is thinnest to accommodate the screw lengths.
2) These screws are smaller in size than Abraham Lincoln’s jaw on a penny. Thus the risk of bone fracture is not a concern.
3) All of the potential screws locations you have indicated are not viable options as either the implant is too thick or there is no point of access to do it. (center one) I have attached an imaging picture of what are the locations that can be used based on implant thickness and available screw lengths.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a rhinoplasty and lip lift procedure that I am unhappy with. I wanted my nose to be narrowed and instead the surgeon rotated it up and shortened it. It now looks wider at the tip. I want it to be much more narrow. I think a slight alar base reduction would look nice in conjunction with narrowing the tip and de-rotating the tip. Also, the lip lift did not lift my upper lip enough. I am hesitant to pursue another lip lift procedure as it may complicate the revision rhinoplasty and make the tip appear more upturned by pulling the columella and nostrils down. I’ve consulted with several surgeons who have advised me that this will be a very complicated procedure. I would love to know your thoughts on what, if anything, should be done. Do you think you could narrow my nose (possibly alar base) and bring the tip down to look this way? This was the “projected outcome” photo. Thank you very much for your time!
A: I think the first concept you have to grasp in that after a primary rhinoplasty the obtaining of a dream or ideal nasal outcome is probably not realistic. Whether it was ever a realistic goal initially I can not say as I wasn’t involved in that process. Now you are looking to recover from an over correction in a nose that is now scarred and is short of cartilage structure. Getting the tip of the nose back down is a lofty goal in itself and will require significant cartilage grafts to do so. That will be an accomplishment by itself. Making the more narrow is probably not going to happen as much as you would like. For a revision rhinoplasty, now a reconstruction project, one’s goals should be more modest.
I would certainly agree that any further lip lift efforts should be delayed until well after the revision rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana