Your Questions

Q: Dr. Eppley, My daughter is 18 and so self conscious of her chin. It appears normal when she’s not smiling but gets large when she smiles. Also when she makes a “duck face” it seems small like the bone structure isn’t big. Is this ptosis? How can this be treated? What is the recovery time?

A: Thank you for your inquiry and sending the pictures. At rest in profile she has a borderline protrusive bony chin in which the soft tissue chin pad becomes protrusive when smiling as a result. This common female chin excess is treated by a submental chin reshaping/reduction technique in which both bone and soft tissue excesses are removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible for the occipital knob to continue to increase in mass or grow?  I ask because more recently I’ve experienced a pressure or pain while lying on back on my head and it is sort of alleviated if I lift up on the area or back of my head.  I can feel the pressure in that area & my neck…is this normal or a situation that you have heard of before?

A: While some patients complain of discomfort from an occipital knob, they are not known to grow in adults to the best of my knowledge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have very hollow tear troughs and I am pale enough that the darkness is noticeable. I’ve done regular fillers in them in the past but was looking for a more long term option to fat graft to them. I am mostly interested in seeing if it is possible.

A: Thank you for your inquiry and sending your picture. While injection fat grafting to the lower eyelids/undereye hollows is an appropriate treatment for them, it is a procedure in my experience with a high rate of irregularities in the unforgiving thin tissues of the lower eyelids for which revision is very difficult to remove and/or eradicate them. Thus it is not a procedure that I am comfortable doing any longer knowing that most patients will end up with the need for a revision. I only treat under eye hollows today with either standard or ustom undereye implants where the issues of irregularities and asymmetries are minimized.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Has you can see from the photos, the center of my forehead caves in. I seem to be a little confused over the type of surgical procedure I require in order to fix it.

A: You are referring to the suprabrow bone break hollow that exists just above your brow bones. While every male has that to some degree yours is magnified by the upper forehead protrusions often called forehead horns. Your options to get rid of it is to either fill the hollow or reduce the upper forehead protrusions…that is merely a matter of personal aesthetic choice.

Assuming you want to fill in the suprabrow bone indentation/hollow, the forehead augmentationoptions ae either the use of bone cements or a custom suprabrow bone implant. Besides cost the one difference that separates these two options as the length of the scalp incision needed to place them. The custom implant can be put in through a very small 4cm incision while bone cements would require an incisional length closer to 15 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw an ear surgery on your site a while back, it was to do with bringing top of ear closer to head, but not by increasing the fold. It was at the point of the helix root I guess, and it mentioned something about people with a bald head, how moving in ear at this point reducing the look of the ear sticking out. So again it wasn’t increasing the fold, it was pulling the helix root area to the scalp. I have an ear with a weak helix root, fold is fine, but ear lops out a bit at top, and I can see how this surgery would fix this, as it’s clearly visible how it’s so weak at his point. Can you send me a link to this surgery on your website, I recall seeing it but can’t locate it now.

A: You are referring to bringing in the top of the ear at the superior helical root area. You are correct in that no traditional form of ear reshaping, like used in setback otoplasties, will work for this type of ear protrusion. You can’t find or bend the cartilage in this area to create that effect because it is not caused by the lack of a cartilage fold. Te technique that I have found to be effective is to reduce the postauricular space by removing skin from both sides and sewing the cartilage to the temporal fascia

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking for a total face makeover to maximize my look and my pic and morph pic uploaded, is it possible to achieve the look of that morph pic realistically? Or whats the maximum bar i can reach? 

Some of my flaws noted were bad chin/mandible, vertically, horizontally, non forward/widen jaw, malocclusion, long midface, negatively tilt eyes and small but fat lips. 

And these are some surgeries I studied that I think might help me. 

DJS/Bimax/CCW Rotation Jaw Corrective Surgery/Lefort 1,2,3 osteotomy/BSSO/Wraparound Custom Jaw Implant/Sliding Genio/Chin Wing/Chin Implant/SARPE/MSE/Lateral Commusuroplasty/Orbital Decompression/Ptosis/Infrainfraorbital rim implants/Canthoplasty /Fillers/Orthodontic treatment 

A: Thank you for your inquiry and sending your morphed facial picture. From a skeletal standpoint I do not find the morphed changes terribly unrealistic. What is important in these morphed predictions is to see more than just the front view. A side and oblique morphed images would also help validate the realistic nature of these morphed changes.

It is not clear where orthognathic surgery, if indicated, has a role to play in these type of facial makeover. Without seeing x-rays and an occlusal assessment, the potential role of orthognathic surgery can not be determined.

In short, more information is needed to provide an assessment of what is and is not possible and how to accomplish such changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a genioplasty along with double jaw surgery 2 months ago, the chin was cut in a way so as to make it narrower (although my chin wasn’t wide at all it was already narrow and feminine) and was increased 10mm horizontally and 15mm vertically. The chin looks very very pointy now, as there is almost no width left and it further sticks out because of the intentional 15mm increase which in my opinion was a bit too much. The surgeon at first only said that I will take it back after a few months and now has denied and is insisting on plate removal. I’ve talked to another surgeon who hasn’t told me his plan yet, I’ll have to physically go to his place and ask, but he said to come as soon as possible. My requirement is to get my lower third to be more angular again. The width of the chin can not be increased now, but I’m hoping that reducing it vertically about 8 to 10mm should make it look much better. I know the measurement 10mm in vertical reduction is quite huge but I’m afraid that without that much reduction the chin will not look good at all. My chin is sticking out from the rest of the jaw and has very very less width, almost none. I also plan to take it back slightly by 3mm or so. I’d be really grateful if you could tell me if it’s possible and advisable to reduce 10mm vertically, and also, when it should be done. I’m 2 months out of my surgery and I am sure that even if the other issues, like the pain in chin and the rolled-in lip, might get resolved in coming months, despite that I will be going for a vertical reduction of the chin as my face looks too long and the chin looks very very pointy and is not going with my wide face. I’m worried about getting saggy skin after the reduction and also any other complications that may arise with a revision genioplasty. Please suggest me the best option and also when to go for the revision.

A: Certainly a 10mm horizonal advancement and 15mm vertical lengthening is going to make any chin more pointy…which would be even more emphasized if narrowing was done as well. In my opinion you do a revision when you are certain that the desired changes is not the desired result AND you have a clear plan as to what type of revision would be beneficial. Without seeing before and after pictures and x-rays I can not make any further constructive and informed commentary about how to improve your current chin situation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Questions for Dr. Eppley regarding PMMA bone cement for skull augmentation: is it safe and permanent? Are there long term complications associated with its use? Why isn’t this procedure not commonly performed? 

A: While PMMA bone cement for skull augmentation is both safe and permanent, it is an aesthetically inferior technique because of its limitations in volume addition, the need for a long scalp incision for placement and a higher risk of contour irregularities. Custom skull implants are aesthetically superior due to more controlled aesthetic outcomes, less risk of contour irregularities and they are placed through smaller scalp incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had infraorbital implants and lower eyelid spacer grafts with canthopexy of which I am very satisfied as they have made a great improvement. I wonder now of custom infraorbitalmalar implants might provide even further facial improvement. I really don’t want to one up my lower eyelid incisions again since I have had such a good result. What are your thoughts on this potential procedure? I know it create a more compact orbit bit what are the other benefits?

A: As a general statement what I would tell any patient who has undergone an aesthetic procedure which has made a good improvement…be very cautious in trying to take a good result and make it a great one. The reward:risk ratio changes and just because you have had a uncomplicated experience the first time is no assurance it will be so the next time.

That being said it would be fair to say beyond a somewhat more compact orbit it provides an extended high cheek look as well. Based on your one limited side view picture I would not be an advocate of this procedure in your case because of the risk vs reward benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a review of my case and photos. Your practice is very appealing to me because you offer a wide array of treatments and surgeries. I want the procedure(s) that give me the BEST chances of reaching my aesthetic goals. I am open to all suggestions. I am specifically interested in learning if I could benefit from facial lipo, kybella, threads and/or facetite OR should I just go straight to a facelift or other surgery. I have attached 5 photos: current frontal, side, 45 degree and smiling pics with areas that bother me marked. I also attached a frontal version photoshopped to show how I’d like my lower face to look. I am not adverse to surgery or down time if the procedure gets me what I want preferably permanently. My only restriction is I want as minimal scars as possible and no silicone facial implants. I am 40 yrs old, 5’2, 123 lbs and have had the following aesthetic procedures done several to many years ago: buccal fat removal of entire pad, open rhinoplasty, upper eyelids, ultherapy of lower face and neck, chin implant and then removal of implant years later. Please let me know if any additional info is needed. Thanks

A: Thank you for your inquiry and sending your pictures. The lower facial slimming effect you are trying to achieve is best obtained by a surgical jowl tuckup procedure. (aka limited lower facelift, mini-facelift etc) All other less invasive procedures you have mentioned are for those that are not ready to jump to a surgical procedure. They do not create the same result but serve as methods to delay a surgical approach until more significant signs of facial aging are present or that their results have proven they are inadequate for the patient’s aesthetic goals.

I have attached an example of such a younger type of limited facelift with a close up of the scars around the ears. (6 weeks postop)

FYI no facial rejuvenation procedure, surgical or otherwise, is permanent. They all degrade over time…it is only a question of how much and over what time does one eventually return to baseline. That would be particularly applicable at a young 40 years old.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am concerned about the asymmetry on my face. My jaw slopes to my right and my right eye, lip, and nostril area are dragged downwards. My right eye is lower than my left, I don’t consider it to be too severe but it is quite noticeable and I would really like to fix it. My right brow, nostril, and lip corner are lower as well. I think an orbital floor augmentation/ implant and any procedures accompanying it would solve my VOD, however I’m not sure if I’m the right candidate. My desire would be for the affected areas on the right to be symmetrical to the left accept for my jaw which I would like address in the future. I am very curious to know your informed opinion and ballpark prices for each of the procedures that would be needed to fix the asymmetries on my right being my lip, nostril, and eye + (brow). A response and price estimation would be greatly appreciated, thank you so much!

A:Thank you for your inquiry and sending your pictures. In the assessment and treatment planning of facial asymmetry it requires a good quality frontal picture (yours does not include the full face, is not current and are very grainy in clarity) and a 3D CT scan of your face to have full knowledge of the underlying facial bone structure. 

But those issues aside, what is equally important is for the patient to make a list of their specific facial asymmetry concerns AND to prioritize them in order of importance. This allows the patient to focus their resources on the procedures that have the greatest value to improvement of their facial asymmetry concerns. 

In short a better picture and knowing your priority concerns would allow some more useful information to be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin implant which is a medical grade silicone implant by Implantech. Over the last couple years my chin has changed. I think the implant shifted. Recently in the last few months I felt a tearing sensation on the left side, along with pain and itching. Now there’s a little divot along the left side and to me it looks like it shifted up closer to my mouth. I’m concerned that it shifted up or scar tissue tore as well as bone erosion. I want it out my face. I’m concerned about my skin not shrinking back after having it for 20+ years and I’d rather not go back to a recessed chin. My mouth is moving normally and I’m not in pain. It does feel weird compared to the left side. I can almost feel it now being closer to my mouth on that left side.

Questions/ideas: 

Can the implant be removed and hydroxyapatite be used to create a chin? 

How about a sliding genioplasty without another implant? 

A: Normally I would get a 3D CT scan of the lower jaw to fully understand the chin position on the bone and what style/size the chin implant is. But since it is clear that you want it removed and not replaced with another implant then the scan will not be useful. The question then is not whether it needs to be removed but what to replace it with and what should those dimensional changes be. 

Hydroxyapatite cement is a theoretical replacement but it is a hard material to control its shape and would only be viable if just a few millimeters of augmentation were needed in the central chin. A more controllable autologous option is a sliding genioplasty. The only question with it is what are the dimensional movements needed. That can be determined by how you feel about current chin look and what contribution the indwelling chin implant is making towards your current chin shape. (which can be accurately determined intraoperatively with its removal) That would then guide the amount of horizontal chin bone advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I was born with a large nose and recessed chin and had rhinoplasty and chin implant twenty years ago.  The rhinoplasty left me with a bump so I had a revision several years later. During the revision he scooped out my slope and took a chunk of my ear cartilage and put it on the tip, and angled the whole thing up. You can now see inside my nostrils. He also narrowed my left nostril at the base and the right nostril now sticks out and up. The tip is kinda pinched-looking and my slope is gone. It does not fit my face and I can’t breathe properly. After the revision he tried to shrink the tip using a steroid injection called Kenalog (0.1 mL).  I think he tried to do the Barbie-style of nose. My left nostril wall is collapsed and I’ve recently found a huge benefit wearing breathe right strips at night. I’m now sleeping through the night and it’s amazing. Several years ago two stitches worked their way out through the tip area on the inside of my nose. That was scary. I feel like the entire nose is unstable. I’ve had a couple consults in my area and they’re not what i need… I need functional and aesthetic rhinoplasty. 

A: By your nose surgery and symptom description you have both functional airway and aesthetic nasal shape concerns. Positive improvement with the Breath Right strips demonstrates that there is internal nasal valve collapse +/- weak lower alar cartilage support. This often happens when the structural support of the nose has been over reduced. This is best approached by the combination of middle vault spreader grafts and batten grafts to the lower alar cartilages using septal cartilage grafts. Septum is the best source and it is unknown to me whether your septum has previously been harvested or not. (I suspect it hasn’t given that ear cartilage has been previously used) This functional surgery can be combined with the needed aesthetic changes which appear to be bridge augmentation, columellar support, tip scar removal and right nostril adjustment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have complex muscular issue on the left side of my head and face, impacting the temporalis and masseter muscles. I had this issue for around 3 years and it currently has caused a TMJ issue. My temporalis muscle is very painful and causes a lot of twitch and it becomes very painful when goes by the ear down to cheek bones. There is a severe muscle pressure putting stress on my ear and jaw. This makes it difficult to do daily task as causes it causee much stress on muscles around the body. My upper cheek is bigger, hurt sand puts pressure on cheek bone as well. When moving my face, the pain gets stronger. I cannot wear a splint anymore as it pushes muscle more towards the TMJ bone and ear. TMJ was clean and steroid was injected and the steroid has caused more muscle issue in temporalis then was there before. TMJ specialist define muscle root cause but cannot seems to get any treatment answers. I have seen a few TMJ specialists and plastic surgeons. In addition, I have occipital neuralgia. I had migraine surgery where the greater occipital nerves were decompressed and the arauriculotemporal nerves removed. Based on your experience, I have seen you have worked on the temporalis muscle and was wondering if you would be able to resolve my issue. Botox was used with some relief which was a good indication the root of the issue was there. it feels like I have a knot around that area. MRI of head and TMJ did not indicate anything. 

A: The critical question is what part of the temporal muscle is involved….anterior, posterior or both. Temporal pain reduction by surgery only works if it exclusively or primarily involves the posterior portion of the muscle. By your description it appears that the anterior portion of the muscle (ear to cheekbone) is the culprit for which muscle reduction/removal can not be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a mouth widening procedure in the future as my mouth is a bit small for my face. What do the finished results of lateral commissuroplasty look like? There are no photos online showing what post operation heal scarring from commissuroplasty look like. Is the scarring bad? If you were face to face with someone is the scar noticeable from 1 feet distance? Please help me, I would like to know bad the scar from commissurplasty is before I determine whether it is really worth scar or not.

A: In my extensive experience with mouth widening surgery, while it is an effective procedure, scars are a concern and just about 100% of patients undergo secondary scar revisions from it. The corner of the mouth is an exquisitely sensitive area for incisions and scar formation. It is not like the rest of lips due to its location and frequent exposure to stretching forces.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is a jaw implant good if you don’t want fillers but want to build up your jaw line? As you age and your skin thins will you see the implant?

A:Jaw implants are made to fit the bone and look like a natural extension of the bone. No one’s skin can ever thin enough to show the outlines of a jaw implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, you seem very experienced in custom chin implants. My question is if you want to increase vertical chin height using an implant, will the implant blend with the sub mental skin under the chin (neck) perfectly using custom chin implant?

A: I am not sure what you mean by ‘blend with the submental skin under the chin’. The implant blends into the bone as that is what it sits on. But I think you mean will the skin from the bottom of the chin from the vertical lengthening stretch out below the chin and not look indented…and that answer would be yes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in thick skin rhinoplasty. I had a consultation that wasn’t successful as he said he was unsure of how the result would come out due to some thick skin. My nostrils are also small and collapse in when I breathe in deep.

A:There are lots of rhinoplasty patients that have thick skin which does not preclude them from having surgery. One just has to acknowledge that there are limitations as to how much nose reduction/reshaping can occur, that postoperative steroid injections may be needed and that it can take up to a year after surgery to see the very final result. With nostril collapse on inspiration this indicates that your rhinoplasty would need batten cartilages grafts or turnover alar rim grafts to support the lateral ala as part of your procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always had facial asymmetry and was unhappy with my profile bc I had a weak chin, so I decided to fix the profile issue. It appears the chin implant, though centered, made the asymmetry worse. I’m interested in trying out jaw fillers (potentially cheek as well if necessary) and visiting the option of removing or correcting the chin implant, as I also THINK it might be too low or angled to low since it seems almost alien to my face and interrupts any facial harmony I had before. Granted, the side view is better than before.

A:Thank you for your inquiry. You are correct in all of your assumptions about the chin implant….in the presence of chin/jaw asymmetry a standard chin implant will exaggerate the asymmetry appearance, it is positioned too low because of the backward inclination of your chin bone (creating more of a 45 degree angled augmentation effect) and it is an implant style that is too wide for a female chin. And like many undesired chin implant results in females it offers an improvement in profile but looks worse in every other facial view.

The question is not whether you are going to remove the chin implant but what are you going to replace it with that would be better. Of that the options are between a custom chin implant vs a sliding genioplasty, each with their own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty procedure. Since the sliding genioplasty is usually done through a diagonal cut as I have seen on the internet, I am interested in knowing if every horizontal advancement always has some degree of vertical shortening? Is it possible to advance the chin just horizontally without changing the vertical dimension? If so, how does the cut look then? I am scared that the side effect of advancing the chin forward might be some vertical reduction. 

Thank you very much for your time.

A:In answer to your insightful sliding genioplasty question, control of the vertical dimension of the chin is affected by the following:

1) Even if not change is done to the vertical dimension with a sliding genioplasty it will usually look a bit longer as it is advanced due to the changes in the overlying soft tissue chin pad. (this is similarly true with implants)

2) The risk of vertical shortening is sliding genioplasty is related to the bone fixation method used. With a diagonal bone cut, if wire fixation or bicortical screws are used (neither of which I use) then vertical shortening can happen as these are bone compression techniques. And by definition almost always happens) If plate fixation is used the vertical dimension is controlled much better because there remains a bone cap with the advanced chin bone segment as the plate allows the chin bone movement due to be done in any horizontal or vertical dimension. (in essence it is a bone suspension method

As you can see this is a geometric function of the bone fixation method used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, hi I was wondering whether if not satisfied with your head shape after removal of the muscle in posterior temporal head reduction (temporal reduction surgery) are you able to have another consultation regarding bone structure or is their certain risks.

A: The posterior temporal bone is quite thin and only a few millimeters can be removed….which makes for a negligible reductive change. It is the muscle removal that makes the major difference. But it can be done but it will not make for any further major head width change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Looking to improve the rounded appearance/protrusion to the chin on the side profile. On the front view I would like to achieve a slightly shorter and more rounded/feminine look to the chin. I also have a chin dimple that I have corrected with filler but it is still slightly visible in certain lighting and I would like to have that resolved.

A: Thank you for your inquiry and sending your pictures. It appears that much of your chin excess is from the soft tissue pad which will take a submental approach and some bone removal as well to adequately reshape it smaller. Fat injections would be the logical approach to the chin dimple which could be performed at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Interested in rib removal. I have a very big thorax for my body size. Is it possible to reduce the scope of the thorax?

A: No it is not. You can’t reduce rib protrusions that high up on the chest wall. This is a common question but is beyond what rib removal surgery can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, when my face is expressionless, I don’t have any visible eye bags, it’s quite youthful. But.. when I smile the fat on my face pushes up and gives me eye bags. I think everyone has them, but for me, I feel these smile eye bags make me look worse. They give off a strong dark shadow when in darker/certain lighting and I really don’t like it. 

Is there a specific/custom midface/orbital implant that can completely eliminate my undereye smile bags? Refer to my photos to see what I mean. 

If there is such a procedure that can completely fix my insecurity?

A: Thank you for your inquiry and sending your pictures. What you referring to is what is known as a dynamic problem for which any surgical approach is a static one….meaning static procedures will not fix a dynamic problem. Surgery is basically done an expressionless faces for which it is designed to treat a problem that is seen in these circumstances. While the concept of building up the infraorbital rim may have some theoretical merit in your situation it is not a procedure I have ever done for this issue, thus I can not speak for its potential effectiveness. But it would seem that further underlying support would not diminish the bulge of undereye tissues that occur when you smile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there typically issues with a jaw implant as one the jaw bone ages and you lose fat and elasticity? Can you see the implant? And do they need replacement? 

A: The answer would be no and no. The implant would never need to be replaced because of device failure. And as you age the soft tissue support provided by the implant is beneficial rather than a detriment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a couple follow up questions regarding both the picture and the operations itself.

1) I’m a little confused by these pictures without labels, is the first one the 8mm advancement and the 2nd one the 12mm? The one that was sent over last thursday was for the 10mm? If that is the case, can I have the front view for the 10mm as Dr. Eppley only did a side view for me for that one.

2) Dr. Eppley mentioned that I have deficient lower jaw growth, which leads me to think that jaw surgery may be an option. I currently do not have any severe jaw related problems (sleep apnea etc. though I do snore quite loud sometimes). What is the aesthetic difference between the jaw surgery and the sliding genioplasty that he recommended? My logic goes like this: If there is indeed no aesthetic difference between the two, then why waste the time and effort to go through Jaw surgery? Are there any additional benefits for me to go consult with a jaw surgeon rather than go through with the sliding genioplasty, with the latter being much more cost effective. What are your thoughts for my case?

3) Given my deficient lower jaw, will the sliding genioplasty accentuate that? In other words, will the lack of a lower jaw become more pronounced after the surgery?

A: In answer to your questions:

1) the pictures are label as pred 1, 2 and 3 in their tags which signify roughly 8, 10 and 12mm horizontal movements.

2) Unlike the profile view, front view imaging can not be predicted based on millimeter movements.

3) Whether orthognathic surgery is an option depends on the state of your occlusion. (bite) If there is no functional bite issues or the bite discrepancy is slight/modest, then orthognathic surgery is probably not an option. But without x-rays, a bite analysis and an orthodontic evaluation the merits or lack of merit to orthognathic surgery can not be precisely known based on external facial pictures. The only definitive way to address this issue, one way or the other, is to get a formal evaluation/workup for it.

4) I would go by what the pictures show you and the effects of the chin augmentation change about its effect on the rest of the lower face/jaw.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Last year I had a tear trough implant placed with the SOOF lifted over it, combined with lateral canthoplasty and lower lid retraction surgery. I didn’t like the outcome of the surgery and had to receive revision surgery a few months ago. This included removal of the implant, restoration of the canthal angles to a more natural position by using drillhole fixation, and a short horizontal lengthening of the eyelid. The SOOF was also raised again to address any any potential hollowness. I had told the Doctor prior to surgery that I did not want the SOOF raised and wanted it to be back in its original position, and he agreed, but unfortunately did the opposite during surgery. The revision surgery was a huge improvement, however I believe that the SOOF lift has left my undereye/midface area looking bloated and fat. Additionally, the creases under my lower lids have disappeared and so have my love bands. I was wondering if it was surgically possible to return the SOOF to its original position without cutting into the canthal incision site where I had surgery before? Could the SOOF be lowered by a lower eyelid incision? Is the SOOF’s fixation to its new, lifted position permanent?

A: That is an interesting question and the first I have ever heard of a patient requesting SOOF lowering. In theory that should be possible with wide subperiosteal release and letting it just drop. That normally would work in the previously unoperated patient but in the situation where it has been deliberately raised it would have somewhere ‘normal’ to go. But having never done such a SOOF lowering procedure my answer is theoretical and not based on any actual clinical experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering what cosmetic surgeries would be needed to achieve this look. I edited the photo on the left to balance the facial features to appear far more graceful from the side: 

Substantial reduction of the nose bridge and depreciation of nasal tip. I realize the reduction shown is drastic and apparent, however I feel that my nose is far too large from the side and this is the best correction. In addition, correct misalignment and deviated septum to improve overall breathing as well. 

Slight chin augmentation to gain slightly more pronounced and remove the “tucked” in profile. 

Straightening of the jawline. Vertical shortening of the jaw bone to obtain the “straight” profile rather than the rounded profile( seen in the pictures). Note: This is the one that is troubling me the most. I am not sure what needs to be done for the jaw in combination with the chin. Some surgeons have commented that jaw shaving is an option. Some have said that fat grafting is the way to go as well but I am having my doubts about this one. Would appreciate your help and thoughts. Thanks:).

A: Thank you for your inquiry and sending your morphed images to which I can make the following comments:

1) As you have suspected that degree of nose reduction is not possible. The large skin envelope controls how much size reduction is possible. Even if it were possible you would likely not be able to breathe through it. A more realistic outcome is halfway between the size of the nose you have now and the unachievable small nose size you have imaged.

2) The modest chin augmentation effect is certainly able to be obtained.

3) Your jawline straightening effect is achieved by an inferior border removal between the jaw angle and chin. That is a very difficult operation to do intraorally and places the mental nerve both in the bone and at its mental foramen exit at some risk. A 3D CT scan would be needed to look at the jaw anatomy and determine exactly where the nerve runs through the bone and see how that correlates to the amount vertical bone reduction that needs to be done.

4) The alternative approach to the jawline, and one with far less risk, is to augment the jaw angle to eliminate the prominent antegonial notch which is the cause of your non-straight jawline in profile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently removed a mandible angle implant and had a retraction in the masseter, I would like to know about the effectiveness of the masseter muscle reattachment surgery.

A: Reattachment of the masseter muscle, once it has been lifted off the bone and retracted, is very difficult with a low rate of success in my experience. A camouflage approach by building up the soft tissue deficit is more effective, again in my experience..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know what the options are regarding shortening the nose and midface. I have yet to see actual nasal shortening described anywhere, rather people focus on tip manipulation for the illusory appearance of a truncated nose, or altering radix position. Post-op from a lefort 1 with counter clockwise rotation or impaction (during which the skeletal housing for the nose would be shortened which begs the question, what happens to the cartilage afterwards?) could a “slice” of the soft tissue nose be excised? Skin, cartilage, and septum. Following this, the nose is then simply adjusted up (the entire structure would slide up) and sutured back together. If there was no excessive gum show prior to the Lefort 1, this would accomplish shortening the nose and midface without inducing any inappropriate levels of tooth/gum exposure. Patient would be left with a small external scar across their nose. 

If this cannot be done, may I ask why? I can only imagine the limiting factor to be blood supply and not wanting a major risk of necrosis, but could the entry point be strategically placed to avoid this? Or perhaps lifting or stretching the artery to gain access without traumatizing it? 

Any help is greatly appreciated.

A: You are asking a classic midface shortening question for which, short of a LeFort I impaction in vertically maxillary excess (which really only shortens tooth show) or a subnasal lip lift (which only shortens the upper lip), there are no other effective procedures for doing so. You are understandably viewing external midface shortening as a structural/geometric exercise…which it is not. The midface soft tissues are not going to shrink or become less so with any underlying vertical structural reduction.

Dr. Barry Eppley

Indianapolis, Indiana