Your Questions

Q: Dr. Eppley, I came across your website and found some of the results of occipital bone reduction surgeries (I could not find a case similar to mine though). As you could see in the attached picture, I have this protrusion that spans all the back of my head up to my neck. I would like to hear from you what could be done to fix it, in as much detail as possible.

From my search on your website, it seems that the solution is through bone burring of a maximum of 6 mm only at the spot of the maximum protrusion. It seems in my case that this will not make a big difference as there will still be some protrusion. Right?

A: Thank you for your inquiry and sending your picture. What you have is an enlarged nuchal ridge line which is the bottom of the exposed occipital skull bone. Most people do not realize how high the back of the skull is which corresponds to the same level as the brow bones in the front. (which is the bottom of the skull in the front) The bottom of the occipital skull (nuchal ridge) is the thickest part of the entire skull so much more bone can be removed here than in other skull areas. (10mms or more) Which would produce a noticeable and likely worthwhile result as I have shown in the illustrated attachment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I wish to one day undergo this procedure to correct my skull shape, mainly my flat back of the head. However, I would also like work on temporal, sagittal, and frontal (all 4 options in total). My main question was since I couldn’t find anything on your website about all 4 procedures being done at the same thing; is this even possible and if it is, how would it be done? Separate or altogether? Thank you and have a good day.

A: It is not uncommon to work on multiple areas of the skull at the same time, whether this be for augmentative or reductive changes. The limiting factors of multisurface skull reshaping is the location and length of the scalp incisions needed to do it and how much the scar can be stretched at any one time in augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a consultation on earlobe reshaping/revision. I was born with a tag on my left ear and it was removed when I was an infant. As I have gotten older and lost my hair, it bothers me more now because there is no symmetry. Attached are some photos of both ears. I can come any time for an in-office consultation. I appreciate your looking at my photos and giving me your advice.

A: Thank you for your inquiry and sending your picture. I think the best way to make the left earlobe look better and more symmetric is to do a wedge resection of the deformed/scarred part of the left earlobe.That would create a better earlobe shape. It may make it a bit vertically shorter than the right side but the earlobe would have a smoother appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am four months post infraorbital rim/malar implants removal, and my cheeks still feels a bit bloated. I assume swelling may be a big factor, but I feel that is an appreciable capsule that is causing fullness and an imprint of the implant. Here are my questions: 

1. Will the capsule go away on its own, and if so, about how long does that take? 

2. Can steroid injections be used to dissolve the capsule (whether or not it’ll go away in its own)? 

3. Are steroid injections safe? I’ve been told they can cause atrophy. It seems some doctors will inject into scar tissue but soft tissue swelling. Do you agree with that assessment? 

4. Is scar tissue and the capsule the same exact thing? 

A:  In answer to your post infraornital-malar implant removal questions:

1) Capsules can take 12 to 18 months to fully resorb.

2) Steroid injections are not a known effective treatment for capsular resorption.

3) Like all medications, steroid injections have well known side effects which primarily include soft tissue atrophy and contour deformities as a result.

4) A capsule is an organized layer of scar tissue to any implant that has a very distinct collagen formation and four layers of such collagen formation to it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I had a Lefort 1 surgery done a month ago which left me with fuller cheeks. I want to get my slimmer face back and was wondering what could be done. Hopefully I would be able to achieve my former look. I could attach before pictures if you would like. Thank you have a nice day.

A: Thank you for you inquiry and sending your pictures. A LeFort 1 osteotomy, by definition, moves the lower base of the upper jaw forward, meaning there are certain fascial changes that will occur to the bone right above the teeth roots. (base of nose moves forward, tip of nose may rotate more upward and fullness will appear in the lower cheeks) How significant these facial changes are depends on the amount of forward movement one has. I don’t know your degree of maxillary movement but t hat issue aside I can make the following comments:

1) It takes a minimum of 3 or 4 months until all of the facial swelling subsides AND the overlying soft tissues shrink back down around the reshaped bone. You will know more by then how whether what you are seeing now resolves or merits surgical improvement.

2) The surgical improvement would be to remove the plates and screws and contour down the bony step off located in the under the cheekbone area which is where you see the new fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an ear reconstruction. My last surgery was done six months ago. I would like a revision to make it look better. Please let me know if you can help with protruding, rim, hair removal.

A: Thank you for your inquiry and sending your pictures. I assume you had a traumatic injury and the soft tissue part of the ear  reconstruction was done using a rotation scalp flap, which is why there is hair on the back of the ear. Th thickness of the folded rotation flap makes the helical rim very thick. (protruding rim) That could be improved by removing the skin from the flap from the rim all the way down to the postauricular sulcus and replacing it with a split-thickness skin graft. That should thin out the rim as well as get rid of 100% of the hair on the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What type of jawline reduction do I need? In my prior facial feminization surgery they did jaw reduction but the inmprovement is not enough to really make my jaw area less masculine.

A: Good meeting and talking you this past weekend. As per our discussion I have attached some imaging looking at what I envision for your jawline reduction/reshaping. Your excessive jaw size is really in the anterior 2/3s of the jaw, particularly having had prior jaw angle width reduction. I would hate to amputate your jaw angles off in the traditional v line surgery approach as, while that creates the most dramatic jaw reduction effect, it also can create loose tissues over the angles/neck as well as gives a high jaw angle look which for Caucasian women today is not the desired jawline look they seek. Thus I would consider a modified approach using  a t-shaped genioplasty with vertical and midline wedge resections as well as inferior border removals back to but not including the jaw angle bone. I would need to evaluate a lateral cephalometric and panorex x-rays to make measurements as to the feasibility of these two intraoperative jaw reshaping techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I asked this question because I have had intraoral incision before for the Medpor chin implant. The intraoral scar looks no good.

I was wondering if it’s possible to remove the implant and use sliding genioplasty after it completely healed? Will the intra oral incision again makes the scar worse? I heard some people described its like glue in the mouth…

Thanks!

A: In answer to your questions about sliding genioplasty:

1) Generally the intraoral incision would not look worse. But that statement is said on a general basis as I have no idea what your intraoral scar looks like. Suffice it to say it would probably not look better but slash probably not worse. 

2) While you can certainly stage the implant and the sliding genioplasty it would make more sense to put the two together since chin implant removal provides all the access for the sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a general question for you regarding PMMA for skull reshaping. Does PMMA last a lifetime? Are there ever cases where there are infections or consequences years later?

A: PMMA material will last a lifetime as it can never degrade or breakdown. I have never seen any long-term medical consequences with its use in 30 years such as delayed infections or any other adverse soft tissue responses.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think that the most prominent issue is the lower eye however I think that the right cheek is also “flatter” because the right malar bone is not as prominent or is smaller or “set back”.  I also think that the hypoplastic bone structure extends to the top right of the skull. For instance, the top right of my forehead doesn’t match the top left.

The point about a flatter cheek on one side wouldn’t show as much I think from a front on photo.  

So I think skull reshaping may also be required in addition to any work on the face.  

In terms of the question about what was done previously.  This was cheek and brow augmentation I think using a bone cement called hydroxyapatite.  I was operated on by two surgeons during one operation.  One doing the bone augmentation, the second an eye surgeon specialist did left and right blepharoplasties and a right canthal suspension to raise the canthus of the right eye higher up the face. 

There was a fat prolapse under the eyes and this also contributed to the appearance of asymmetry.

The brow and cheek augmentation was the cheaper of two treatment options presented to me and was the only one I could afford at the time.  The second, more expensive option would have required the production of a custom “implant” that would have augmented the hypoplastic bone more generally in the face and skull.  

Obviously I am only a layman but I think with the approach that I opted for the results cannot be guaranteed and of course only augmented the cheek and brow bone in an attempt to reduce the appearance of the asymmetry as opposed to generally correcting it. 

The other approach with the “implant”  (I’m not sure that is an accurate word for it) designed based upon analysis of scans of the skull would have fixed the issue more generally and I think the results of how it would change the bones near the eye are probably more accurately predictable.

A: Thank you for your detailed response. Your biggest component of your facial asymmetry has always been your VOD. (vertical orbital dysopia) which affects more than just the position of the eyeball. With a lower orbital box the brow bone/forehead/skull is pulled down and the cheek is flatter that side. That is all consistent with the VOD.

Your are correct in that your original facial asymmetry surgery was a patchwork approach to the problem, which helped, but predictably left it uncorrected as the solution did not ideally match the problem. You are also correct in that using a 3D CT scan the fuller extent of the bony problem can be addressed to provide the supportive foundation. Your prior lateral canthoplasty is a good example of just pulling up the soft tissues without underlying bone support results in less than optimal result and one that is not well maintained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here in my country plastic surgery almost not developed and I hear people dying at hands of inexperienced surgeons. Yes really it happens here. I don’t know how it happens even with plastic surgery but sadly it happens. So I have only choice to go abroad. I have forehead asymmetry as you see in pictures. Asymmetry not only visible but greatly effected how I look. Basically my skull lacks symmetry that caused bumps and holes around my head. Thankfully most of them under my hair area. When wear glasses especially new ones (which I normally because of astigmatism) I literally see difference between my ears location and end of glasses. My ears located approximately 0.7 to 1 cm difference. I think asymmetry caused my astigmatism and my teeth problems. My teeth don’t stand on each other freely. What you see is my teeth’s normal standing position which have ~4mm gap. Anyway, my biggest concern is my forehead which looks awful and pictures could not show how I look in reality. X-ray image just happens to be in my phone which was taken before I went military service. I have several questions: 

– I have allergies and do forehead correction surgery might cause any complications? 

– Which method is best in terms of longevity and price: Traditional pmma, prefabricated or silicon implant? 

– How long it takes to all job done? How long I need to stay in hospital? 

– Will it have complications at later life? 

– Do implant or cement fall off if I engage combat sports like box? 

– Can bone cement or implant removed later if needed? After 20-25 years. 

Thank you for your attention.

A: Thank you for your inquiry, sending your pictures, and detailing your concerns with the focus on the forehead. As best as I can tell from the pictures the forehead asymmetry is on the right side which I have circled in an attachment. Whether this forehead asymmetry is treated by bone cements or a custom forehead implant I can answer your questions as follows:

1) I am not aware of any negative relationship between allergies and any form of skull implant materials.

2) A custom solid silicone forehead implant is the superior method because it offers the most precise correction of the asymmetry with placement through the smallest possible scalp incision. The only reason to choose bone cements is for a somewhat  lower cost although a larger scalp incision is needed.

3) There will be no complications later in life.

4) Neither a custom implant or bone cement will become displaced or ‘fall off’ with trauma.

5) Either forehead augmentation material can be removed at anytime after surgery regardless of the length of time later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Exactly, like if we were to look at each other face to face i don’t want my face horizontally wider.(making me look more masculine) I want the difference when you look at me from the side “vertically” going lower near my back jaw to make everything a little smoother. I’ve gotten my cheeks and chin implants done but am now seeking mandibular (jaw) implants which is why I am looking to you.

A: Thank you for your inquiry and sending your pictures. What you are seeking is vertical lengthening jaw angle implants whose main effect is vertical but, by definition, have to add some width so the implant can attach to the bone. These are a standard type of jaw angle implant whose effect is for patients just like yourself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing regarding your expertise on mentalis resuspensions, chin fat pad resuspensions, interoral shortening vestibuloplasty & sliding genioplasties. 

Two years ago I had a free gingival gum graft performed. The periodontist also did an extensive and complete mandibular vestibuloplasty as part of the gum graft that included the intentional detachment of my mentalis muscles and a full and deep blunt finger dissection of the vestibule from rear molar to rear molar. 

I have now significant discomfort and dysfunction. My lower incisors, all show when I talk or open my mouth. I had immediate speech dysfunction and a pronounced lisp following the vestibular deepening. My lower lip does not close properly. I have to throw my lower lip up to get it to close to the upper lip. I drool constantly and have to suck it back in. The lips both have changed shape completely and sag down noticeably like a very old person in their 80’s, I am half that age. My lower lip has changed color to a darker hue and is very dry looking. I can’t keep food out of the sides of mouth and my tongue can’t clear it. My chin is a completely different shape. It’s flat and a lot tissue has gathered at either lower corner. It’s like my face was cut off and it just sags down. 

Years earlier I had a chin implant put in extraorally from under the chin. I had it removed extraorally as well due to aesthetic concerns as it was far too big and the wrong contour to my face.

I am wondering what, if anything, I can do. In my research it seems I need a mentalis resuspension in combination with one or more other procedures including perhaps a fat pad resuspension, vestibule shortening & a sliding genioplasty, To be honest I would rather not do a sliding genioplasty if possible but most surgeons seem to recommend it to take up loose tissue. A question I do have is – Is it possible to do a mentalis resuspension without doing a sliding genioplasty? 

Any advice would be appreciated.

A: Thank you for your inquiry and detailing your surgical history and current problems to which I can say the following:

1) On a conceptual basis you have to go back and look at the origin of the problem and then adapt a treatment that is focused on reversing it. As you have described with the deepening vestibuloplasty from molar to molar the tissues have indeed been released and lowered. So efforts along the line of a shortening vestibuloplasty would seem appropriate.

2) While it is true that any form of chin augmentation (implant or genioplasty) can help with the success of mentalis resuspension, I wold be cautious about that in your case. Your history would indicate that you should limit the variables in any corrective approach. You have already learned well that not everything always goes according to plan, despite the best intentions, and you certainly don’t need to develop any new complications from a procedure that you do not feel is essential. In other words, you do a chin augmentation IF it remains an unfulfilled aesthetic desire. I cannot pass judgment on that ‘need’ based on a single frontal picture.

3) A mentalis resuspension can be done without a sliding genioplasty and most of the time is done without it. It can be useful to apply a sheet of ePTFE on the front portion of the chin to give the tissues something to grab into to help hold it. But I would certainly not use a sliding genioplasty for that purpose unless that was already desired to be done anyway. (which has you have already stated it is not)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in infraorbital implants with high vertical augmentation (approx. 6mm). I was wondering if that is possible for everyone or if there’s a risk of the implants touching the eyeballs if they implant rim border is too high? 

Many thanks 

A: Thank you for your inquiry and describing your objectives. A 6mm high height on a custom infraorbital implant is not rare in my experience.  At such heights or higher I have not seen the potential problem of touching the eyeball.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom jawline and custom bilateral infraorbital malar implants. How are the implants placed? Would they all be through the inside of the mouth or would the infraorbital implants be done through the lower eyelid? I don’t want my eye shape to change or for there to be an increase in sclera showing – is this something you’re always able to avoid?

Thank you,

A: A custom jawline implant in a male is typically placed using three incisions, two in the back of the mouth and one from outside under the chin. The combined infraorbital-malar implant is typically placed through the lower eyelids…unless it has only a very small infraorbital extension and/or does not saddle the infraorbital rim.

The most common use of lower eyelid incisions by plastic surgeons is in older patient with lower blepharoplasties where tissues are removed of which increased scleral show or lower lid margin rounding is a well known risk and is not a rare postoperative development. It is very different in young people who have stronger tissues and a stout lateral cantonal tendon who get custom implants where no tissues are removed and lower eyelid support is being added. As a result increased scleral show is not an expected problem and often the reverse occurs…an elevated lower eyelid or decreased scleral show. (if it existed beforehand)

Dr. Barry Eppley

Indianapolis, indiana

Q: Dr. Eppley, earlier this year I had a forward-sliding Genioplasty. Myself and the surgeon had agreed on a projection of 8mm, but during the operation the surgeon decided that 6mm would be better. I wasn’t convinced by this decision at the time of leaving the hospital and I’m still not convinced now. 

To be fair, I can see a positive difference which is wonderful! However, I still believe that 8mm would have been the better choice and I’m overall disappointed by what could have been. What do you suggest I do next, if anything at all? I would very much appreciate your professional opinion. Kind Regards, 

A: Thank you for your inquiry and sending your before and after pictures. I can appreciate your sentiment that 8mms was a good choice for advancement given the amount of natural chin recession you had. While not achieving the ideal chin augmentation goal there is some solace when the operation goes on to heal uneventfully. Presuming your interest is in improving the result you have (which is what you are exploring) one ‘advantage’ of the prior surgery is that you have a very clear idea as to what 6mms achieved. That then allows you to re-evaluate the original premise of whether 8mms was the ideal choice or perhaps even more would be better. With the new number in mind your options are obvious to re-do the sliding genioplasty or top it off by adding a small chin implant on the front end of it. I can make arguments either way but at an added augmentation of 2mm to 4mms at most, adding a chin implant on the front of it seems an acceptable choice given the reduced magnitude of the surgery. But I have seen plenty of patients make similar movements by re-doing the sliding genioplasty as they were strongly opposed to an implant. There is no right or wrong about either option, it is all about whatever makes the patient feel most comfortable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a thin/athletic female, but due to very high hip bones have severe hip dips where I essentially have two hip curves. I am aware that there is hip and bbl surgeries, but my worry is that because of my very high hip bones and wide ribcage, I wont have much of a waist if I get implants to help the dip dips; my hips would start directly under my ribcage. I have seen where you do rib removal, but was wondering if he has any experience in hip impingement or bone shaving. I wonder if a combination of high hip bone shaving and then a hip dip procedure could get me the hour glass shape I desire. I’d love to know your thoughts on if this is something even possible, and how realistic it would be.

Thanks!

A: Thank you for your inquiry and detailing your concerns. What you are referring to is reduction of the outer curve of the iliac crest bone leaving intact the anterior and posterior crestal areas. This is known as iliac crest reduction or hip bone shaving. This could be combined with hip dip implants. That is certainly possible even though I have never yet had that specific combination requested yet. Please send me some pictures of your hips form assessment and computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, You said that it was impossible or not recommended to bring the eyes closer in those suffering from hypertelorism 1. But could it be possible to increase the distance between the eyes for those who suffer mild hypotelorism? 

A: Orbital box osteotomies in adults, whether it is to bring the eyes closer together or further apart, are treacherous from an aesthetic standpoint. Numerous aesthetic tradeoffs exist (e.g., long coronal scalp scar, bony irregularities) for which the tradeoffs do not seem worth the benefit. It is not impossible, just not advised.

To illustrate that point I saw a patient recently who had orbital box osteotomies as an adult for mild hypertelorsim. She is now on her 5th revisional surgery to manage the aesthetic tradeoffs. Her eyes are better but…

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, is it possible to eliminate or mitigate scleral show by cheek augmentation and infra orbital rim implants? I would like to avoid eyelid surgery and when I “push up” the soft tissue on my cheeks under my eyes, I achieve the “hunter eyes” look I am after😄 But it seems to me the only way that can be achieved, is by attaching soft tissue to the implants so instead of pulling down the eyelids it pulls up the flesh. Is it possible or is it just crazy talk? Thanks for your time.

A: Infraorbital rim implants, if they add vertical height, do help push up the level of the lower eyelids. (mitigate scleral show) This effect is also supported at the time by soft tissue cheek suspension to the lower eyelids. It may not be equivalent to the effect created by pushing up on the cheek tissues from below by hand but it definitely helps.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Part of my problem with my profile is my lower lip is too recessed as well.  Can the sliding genioplasty address the lower lip recession as well?  The attached pictures show what could be accomplished with only a modest amount of vertical lengthening.  The lower lip advancement should be considered when deciding how much horizontal projection to give.  I saw this video and the surgeon in this video said the labial mental fold would appear less with sliding genioplasty because you are bringing it forward and down instead of just forward as in a chin implant.  Will the lower lip move forward as well in sliding genioplasty?

I provided a link showing that I would like the osteotomy cut to reach more posteriorly just underneath the nerve to reach farther back to give a more broad appearance.  See 1:19 in the video.  I would also like the cut made in such a way that there is continuity in the bone.  You can also come up more so it’s a few millimeters below the tooth root.     I’m not sure if the bracket’s you ordered are for a specific dimension.  As far as specific dimensions I was thinking 8-9 mm vertical and 7 -8 mm horizontal. 

A:It is clear that you have some basic and common misconceptions about what a sliding genioplasty accomplished. So let me provide you with some basic understanding of what the procedure does and does not do:

1) It will NOT bring the lower lip position forward. Lower Lip position is primarily controlled by the lower teeth. Thus the only procedure that will bring the lower lip forward is a sagittal split mandibular osteotomy (orthognathic surgery) which pulls the whole lower jaw forward with the teeth. A sliding genioplasty is a bone cut beneath the lower teeth which moves the chin bone but does not change the bite relationship or move the lower teeth forward.

2) The depth of the labiomental fold (better described as the labiomental sulcus not a fold) is controlled by the attachment of the mentalis muscle to the bone. Any type of chin augmentation procedure (implant or sliding genioplasty), by definition, moves the bone or soft tissue chin pad below forward BELOW the attachment of the mentalis muscle or below the labiomental sulcus. Thus any form of horizontal chin augmentation is goin to make the labiomental sulcus deeper. That is unavoidable. In the case of a sliding genioplasty which is also providing vertical elongation the deepening of the labiomental sulcus may be mitigated somewhat. (not made appreciably deeper) That being said what is going to happen in your case? Because of the chin bone movements it will probably not get any worse but I would not count on it betting better either.

3) When it comes to the osteotomy cut, I will make it as to what I know is best. Your key misunderstanding on the sliding genioplasty bone cut is that you must stay way below the mental foramen to avoid cutting the intrabony course of the nerve (and resulting in permanent  lower lip numbness) and you must equally stay below the tooth roots enough to avoid creating permanent numbness of the lower front 6 teeth. But no matter how the osteotomy cut is done it will NOT make the chin wider. A sliding genioplasty that brings the chin forward and down will result in the chin becoming more narrow…this is unavoidable.

4) How much the chin bone can come forward and down will not be known until actually doing it in surgery. You have a naturally very small chin and the large chin implant has undoubtably caused some typical loss of 1 to 2mms of bone. While I agree that a total 8 to 9mm forward and perhaps equally vertically downward may be optimal, whether that can be safely achieved in surgery remains to be seen. You can’t just move the chin out in space, part of it must remain in contact with the bone above it to heal and avoid substantial bone resorption.

In conclusion you are under the illusion that a sliding genioplasty can do more that what it can really do. The purpose of the sliding genioplasty in your case, as opposed to going right to the entire custom jawline implant, is to lessen the implant load on the chin with the second stage custom jawline implant. It is not being done necessarily because it will create a better aesthetic result than the one stage custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I am here to see if jaw implants will work to achieve the specified looks I desire. My greatest concern is exactly how I will look like after the surgeries. I am fearful that the implants needed to achieve the ideal looks which I desire will somehow not look proper or good on me after the surgery. Therefore I believe that seeing myself with the implants that I require/desire/request to achieve my desired looks on my face i believe this would eliminate all my concerns. I have provided you with a set of 7 photos, 4 of them show my current state without surgeries, the other 3 show the ideals of mine, that I am seeking to achieve. I believe photoshopping my side profile to the side profile specified by 2 of the photos as well as show how the front of my face will look like after the jaw implants have been done on the sides, so seeing an image of the front of my face as well as side view with implants, would be so so appreciated. thank you again for taking time to hearing my concerns.

A:Thank you for your inquiry and sending your pictures. While the ideal examples you have shown all have different types of jawline shapes, your overall concept is to have more definition to your jawline particularly at the corners. (chin and jaw angles) I have done some initial imaging just looking at one type of potential jawline change for you to ponder. Such a jawline change can be stronger or less defined but for now all we are trying to do is see if any type of jawline change would be aesthetically beneficial.

I would also caution you that computer imaging is not done to show the very exact result that will occur.The purpose of computer imaging is frequently misunderstood by patients. Computer imaging is done to help determine what the patient’s aesthetic goals are. It is a method of visual communication to help your surgeon understand what your specific goals are. It is not necessarily an accurate predictor of the final outcome. It establishes goals to aim for which may or may not be completely achievable based on human tissue responses to surgical intervention that lie beyond that of what computer software can account.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi! I am interested in the 2 step occipital skull augmentation and was wondering if it would be possible to have this procedure done under local/sedation rather than general anesthesia. Thanks!

A: Thank you for your inquiry. Larger skull augmentation procedures are not operations that lend themselves to a pleasant experience or good surgical outcomes when attempted under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two lumps on my forehead for about 7 years now. They don’t bother me on normal lighting but when there’s a bright/sharp lighting, they are very visible. This has really been distressing and I’m very keen to get rid of these. What are the treatment procedures available for them? 

I have attached the pictures as well.

A: Thank you for your inquiry and sending your picture. You have the classic forehead horns or eminences. There are two approaches to elimination them. One approach is to burr down the bony eminences through a small hairline incision. The other approach is to build up the forehead above the brow bones around them with a thin layer of bone cement or a thin custom implant. Which approach is best depends on how you feel about the rest of the shape of your forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi Dr. Eppley, I’m interested in chin implant removal and then a sliding genioplasty. I would like to use a submental incision, and I was wondering if this is possible?

A:Thank you for your inquiry. The question as to whether a sliding genioplasty can be done externally from a below (submental incision) is an interesting one and not the first time I have heard that question. When coming from below there are three technical challenges/problems:

1) degloving of the soft tissues from access (which provides the blood supply for the bone to survive

2) angle of the bone cut

3) application of plate and screw fixation

Having done lots of submental bony chin reductions, I can envision how all three challenges can be overcome as long as the bone movement is not excessive….although I have never yet done the sliding genioplasty operation from this approach myself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had reached out to you awhile ago regarding my chin issues. I have attached an x-ray imagine that I think shows my issues with the drooping chin tissue/ptosis. I’ve previously had some regrettable chin surgeries including a small implant and then the removal of that implant and a sliding genioplasty. If you have the time to give me some advice that would be awesome.  My main concern is that my chin looks too long and droopy when smiling especially. Thank you for your time. 

Kind regards,

A:In theory the sliding genioplasty after the removal of the chin implant was intended to solve the chin ptosis. But the amount of forward chin movement was so modest (albeit appropriate for your face) that I would not have expected that to provide improvement of the chin ptosis unless it was combined with mentalis muscle tightening/lift. (and even then it was not a guaranteed improvement as the bone movement is so small) At this point the only assured improvement of the soft tissue overhang is an excisional submental chin tuck.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fixing the lower part of my face with a corrective chin implant and jawline custom made to obtain masculine appearance.

A:Thank you for your inquiry which your doctor forwarded along to me. In looking at your pictures and the thicker skin you have you are not never going to have exactly the ideal lower jaw shape that you have shown in your examples. But you can make considerable improvement with your naturally shorter chin and jawline. The most effective way to get the best jawline shape and more masculine appearance is a two stage approach. First have a sliding genioplasty done to bring the chin way forward and down. That alone will produce a big improvement and serves as a foundation onto which a second stage custom jawline implant could then be done to wrap around the whole chin/jawline to get the best jawline shape and definition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a primary rhinoplasty in eight years ago in the Middle East. The surgeon straightened out my bridge and tucked in the nostrils a bit. Over time, the tip drooped more than the original nose. The nostrils were still quite wide.

I then had a revision rhinoplasty there years later by another surgeon. The surgeon lifted the tip and reduced the nostrils. It looked quite ok and I felt quite attractive but the nose was still quite long and the nostrils still a bit big. He wanted to shorten the tip and further tuck in the nostrils after 1 year, because he first wanted to check how my nose healed in that year.

I then had a third rhinoplasty with the same surgeon. He shortened the length and further tucked in nostrils. As this has healed, the tip is still overprojecting and now looks bulby. It is also drooping a bit with a fullness (slight hump) which I’m guessing is scar  tissue? This time around, there seems to be an unevenness in my nostrils as well.

Attached are my current pictures. I’d really appreciate a realistic view of what is possible for an improvement.

A: Thank you for sending your pictures and detailing your rhinoplasty history and current concerns. What is most revealing about your 3 rhinoplasty surgeries is what happened from the second to the third one…and this is very common in thick skinned noses where further tip shortening is desired after multiple procedures. Unlike the first two procedures where sequential improvements were obtained, after the third surgery new problems developed that were not present (or recurred) after the first two procedures. What this speaks to is that at some point in any revisional procedure the balance between improvements vs tradeoffs becomes less favorable. In an effort to take the procedure to an even better level (and you can not be faulted for asking to do so) the benefits are just not realized or some form of negative shape changes occur. In the spirit of the old saying..’past history predicts future behavior’…this provides a note of caution about a 4th rhinoplasty endeavor.

Does this mean no improvements in the shape of your nose is not possible? I can not yet say whether I can provide such improvements as I need to know what was done in rhinoplasty 2 and 3. You should be able to get those operative notes from your surgeon for my review.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, There is the area on the back of my head which is a 3 inch by 3 inch indented area. If just that part could be corrected the rest of my skull is all fine. 

A: Thank you for sending your pictures which clearly the indentation on the back of your head. While there areas seems small (3 x 3 inches) it is actually bigger than it seems when trying to build out a skull contour that is smooth and confluent with the rest of the bone around it. While a custom skull implant is the ideal way to build that indented area out for the reason mentioned, its is reasonable to use bone cement to do so for the same of economy. Fortunately I built my experience in skull augmentations using bone cement long before custom implants existed so this is a technique of which I am very familiar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have had a hyaluronan injection (product name: Restylane) in my brow bone a few months ago.

● Do I need to remove the hyaluronan for a 3D CT scan? 

● If it needs to be removed, I will need to ask my doctor to give me a hyaluronidase injection to dissolve hyaluronan before the 3D CT scan.

A: You do not need to worry about the injectable filler in your brow bone areas as that will not interfere with the 3D CT scan imaging. It is a non-radiopaque type filler which is invisible to the scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young caucasian female interested in learning if there are ways to surgically increase the size of the eyes, specifically their width. My eyes currently are very small with a rounded outer edge. I wear winged eyeliner to try to widen the appearance of their size, but I think you will still be able to see in the attached photos their true edge and the “blank space” their small size leaves in my face. There are a few other procedures that I might pursue in the future to remedy that amongst other imperfections (rhinoplasty, lip fillers, potentially methods to widen my mouth and shrink my forehead if possible), but firstly I’d like to know if there are ways to increase the size of the eyes, arguably the most important facial feature. I’ve included photos of myself as well as photos of people with an eye size and shape that I like (large, pointed inner corner and outer edge)– there are a million examples of course of people with large eyes but I thought it might be helpful. My weight varies a bit in the photos but the size and scale of the eyes of course remains the same (I’m usually the middle weight). I also included a digitally altered photo of myself with just the eyes edited a bit wider. This may or may not be helpful because that kind of result might not be possible with surgery, but perhaps you might be able to convey to what extent a result like that would be possible. 

Thank you for your time and assistance.

A:Thank you for your inquiry, sending your pictures and detailing your eye concerns/objectives. While there are many types of eyelid adjustments that can be done, the one dimension that is very refractory to change is lateral eye width. The eye corner can be moved up or down but changing its width has different implications. And there is a good anatomic reason for that being so. There is an intimate relationship between the eyelid and the globe (eyeball) in which the eyelid needs to be tight up against the eyeball at all times. That is to prevent the globe from drying out or developing associated symptoms. (chronic tearing) While the outer part of the eyelid can be surgically lateralized that would likely pull the corner of the eyelid away from the globe particularly if a lateral canthopexy was done. Even if a lateral canthoplasty was performed the bony lateral orbital rim would need to be changed and such a lateral pull would also likely make the eye look more narrow vertically…which is diametric to what you are trying to accomplish overall.

While your request is not uncommon, I do not have a surgical technique to accomplish your goals in a safe and reliably effective manner.

Dr. Barry Eppley

Indianapolis, Indiana