Your Questions

Q: Dr. Eppley, I am a former patient of yours when you performed a breast augmentation/breast lift with saline implants in 2004.

I have experienced some changes to my breasts in recent months.  I have lost fullness at the top of both breasts and can now feel both implants along the bottom folds and lower sides of both breasts. Both breasts are still symmetrical and of equal size and fullness. The changes do not appear to be a result of deflating.

I can only assume that I need to consider replacing my implants.

I do not anticipate the need for additional lift or procedures as my nipples are in place.

I would like to inquiry about the general cost associated for a replacement breast implant surgery to determine if I want to move forward with a consultation at this time.

Any information would be appreciated.

A: Good to hear from you after all these years. With 16 years of service out of your indwelling saline breast implants that is getting them into more ‘senior citizen’ range as very few saline implants make it to 20 years without deflating. Replacing them with highly cohesive silicone implants will restore upper pole fullness as well as improve much of their wrinkling. My assistant Camille will pass along the cost of the surgery as part of this email.

The good news is that, unlike the first time which involved making the tissue pockets, they are already established so you should have minimal to zero pain with their replacements.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m a young women and very interesting in doing a few procedures with you. I’m going for a face with more “modelesque” features with the appearance of more prominent bone structure. I don’t want to look too masculine or sharp. I have a decent bone structure but there’s still baby fat in my face which I believe covers it, it’d like it to be stronger and keep my youthful look and don’t want to remove any fat if I don’t have to. 

I’m looking to get a custom zygomatic-orbital rim implant, custom jaw angle implants, and a sliding genioplasty with you. If fat removal is necessary than I may consider that too depending on your inputs. Roughly, how much would this cost? 

I have a mild recessed chin. I want a more defined bone structure so I can look more sultry and modelesque. I’ve provided photos of women with such bone structure. I’m not looking to replicate them , simply get a result with a likeness to them.

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

1) The jawlines you are showing can only be achieved by a custom jawline implant. Those are linear and connected jawlines between the chin and jaw angles. That can not be achieved by separate procedures on the chin and jaw angles even if the jaw angles were custom made. Economically it makes more sense to have one custom implant made that can do the entire jawline.

2) Since I do not have a full view of your face it is hard to say what type of ‘cheek’ implant you need. Most likely you may mean a cheek-arch style implant rather than an infraorbital-cheek implant as the goal is to get that linear higher cheekbone look.

3) There may be a role for a buccal lipectomy to help the desired cheek look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a young male and I’ve been dealing with severe anxiety since my teenage years due to the size of my skull, which I find too small. Hitherto, I thought there would be no way to fix that, but I’ve learned about your work, so I browsed your gallery and what I saw was absolutely amazing. Basically, the idea would be to lightly increase the width of my head and to give some volume at the back of it. I want you to ask you several questions :

1) Can the implant be kept for a lifetime ?

2) What is the look of a typical scar after healing ? (scarring is not so much an issue, and compared to how the skull enlargement procedure would benefit me, I wouldn’t care so much)

3) Is there a risk for the implant to “slide” ? I suppose it is attached to the skull solidly, so no, but still unsure.

4)What would be the typical cost for such an operation, including the price of an implant ? I guess this may vary drastically upon the complexity/nbr of implant and the difficulty of the operation.

5) Silly question but : is the thickness of the implant a modifiable parameter ? If I want quite a thin one for instance ?

Thank you for your time, looking forward for an answer ! Hope you have a great week and congratulations for your work.

Best regards,

A: Thank you for your inquiry and detailing your head shape concerns and objectives. In answer to your skull augmentation questions:

1) Custom skull implants are made of solid silicone that will last a lifetime and never need to be replaced due to material degradation or breakdown.

2) Custom skull implants are typically placed through remarkably small incisions given the size of the implants that heal remarkably well. Many people only envision the traditional use of full coronal incisions that are used in craniofacal surgery but that type of scalp incision is almost never used in aesthetic skull reshaping surgery.

3) Custom skull implants do not become displaced or ever slide around. They are firmly fixed to the bone and/or fascia and actually get tissue ingrowth through them.

4) My assistant Camille will pass along the general cost of such surgery.

5) The design (footprint and dimensions) of custom skull implants is done in any way that achieves the patient’s aesthetic goal, That is why they are custom designed and made individually for each patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young woman who has an abnormally narrow face / skull / forehead. My skull is considerably narrow while the width of my forehead is abnormally small which makes my forehead with a bulging deformation. The more I get older and the more it becomes unbearable. I wish I could find a solution in order to make this face more normal, balanced and harmonious. I recently discovered that skull  implants I exists. Until this day I did not know.  I would hope to widen my forehead at the level of the sides of my forehead and as well as my head size. I understand that it is not necessary to carry out a heavy operation because I think that it is just an insertion of materials on the surface since it is not even a question of touching the cranial box but simply of inserting materials under the skin? What is it possible to do dear doctor?

A: Thank you for your inquiry and sending all of your morphed pictures. Fundamentally your suppositions are correct in that there are custom head widening implants made just for the very purpose you described and have imaged on yourself…a complete head widening effect from the forehead back along the sides of the head.(see attached implant designs)  You are also correct in that their placement is under the scalp on the bone in the forehead and on top of the temporalis muscle on the side of the head.The width increase you are demonstrating is probably no more than 5 or 6mms at the widest part above the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a dramatic chin augmentation as I have a really short chin.

A: Thank you for your inquiry and sending your pictures. A significant chin augmentation is generally anything north of 10 to 12mms. Your chin deficiency is probably in the range of 15mms. Such can augmentation are best done by a composite approach combining a sliding genioplasty with a chin implant overlay were the bone movement serves as the majority of the movement and the implant overlay adds to it but equally importantly keeps the chin from becoming too tapered and narrowed due to the bone movement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My lower lip sags since I had a silicone chin implant removed over 5 years ago. I only had it in for 9 months. Since then I have trouble making my lips meet and my mouth is usually gaping open. I went to a maxillofacial surgeon a couple years ago who said he thought it was caused by scar tissue in my mouth from where the implant was removed and there was nothing that could be done. Could it also be caused by my mentalis muscle?

A: Thank you for your inquiry and detailing your concerns. Chin soft tissue sag and/or lower lip incompetence is not uncommon after a chin implant is removed albeit for just a few weeks or nine months after implantation. Once the soft tissues are surgically elevated off of the bone and then the soft tissue support is removed (implant) this can happen. The key question is whether intraoral soft tissue suspension can be effective. It can be but it is more effective if some type of soft tissue support is placed underneath it such as a very thin small piece of material (e.g., medpor sheet) to which the soft tissue pad can stick to so that it doesn’t exclusively rely on the muscle suspension for uplifted success.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I hope this finds you safe and well. I’m a young man who would like to look the best I possibly can and have long considered cosmetic surgery but never quite pulled the trigger. Part of it is that I’m fairly confident in my appearance to start and have worried that augmentations could end up making things worse instead of better. Still, I find myself carefully adjusting my face by how I hold my jaw or flex my cheek muscles under my eyes or pout my upper lip, not just in photos but almost constantly when I’m with other people.

In wanting to look like the best possible version of myself, I’d love your professional input, but I do have some ideas. I’ve attached 6 photos of my face in sunlight (no makeup or filters) relaxed and not biting down on my cheeks to help show you what I think could be improved. My main concern areas are the under-eyes/tear-troughs and my jawline/chin as well as balancing some facial discrepancies (mostly in these areas). I tend to trust all that Golden Phi Ratio stuff, and I’m assuming that helps guide your work as well, so the closer I can get to that, the better. I’ve considered fillers, but I think I thought implants might be more effective (and cost-effective) for what I’m looking for. Hopefully you appreciate thoroughness and this isn’t overkill, but I figured it would be most helpful for me to split comments up photo by photo since they’re all different angles.

Photo 1: Front-facing. You can see there isn’t a lot of structure beneath the eyes making me appear a little hollow and tired. This is worse on my right side with my right eye appearing to droop a bit, especially the lower lid and outer corner. My lower eyes/eyelid also have a mild bulgy kind of appearance I’d like to mitigate. The midface is somewhat flat whereas I’d prefer I looked more awake, even, and contoured. The tear troughs are rather prominent as well. You can see my left cheekbone has more structural integrity than my right; the entire right side of my face is just a little droopier overall, even that corner of my mouth is a bit lower. Also, while not super prominent here, my nasolabial folds are getting a little deep. To address all of this, I’m sure you have recommendations, but my assumptions would be a custom jawline/chin implant, cheek/orbital rim implants, and philtrum shortening/upper lip lift possibly with some filler. The overall goal being a more balanced/movie star/contoured appearance. I do definitely want to be wary of any jaw or cheekbone implants being too wide since I already have relatively close-set eyes. 

Photo 2 is a three quarter profile turned to my right. You can see my right cheekbone is a little less developed than my right and my left jawline isn’t quite as strong as my right (see Photo 4), it even manages to make my chin look slightly weaker from this angle. Again, the under-eye/orbital rim/upper cheek area could be built up more and the philtrum area is a little long. 

Photo 3 is the left side profile. Another view of how the jaw could be strengthen and cheekbone/under-eye area given more structure. 

Photo 4 is the three quarter profile turned to my left. My face is more attractive from this angle. You can see the left cheekbone and right jawline are sharper, Even so, you can see the way the lack of structure is worse beneath my right eye and how, really, all myall my features get more delicate beneath my brow bone. It suits my nose well, but everything else could be strengthened a bit so long as we keep everything well-proportioned. 

Photo 5 is the right side profile – not bad, same notes really, jaw and cheek/under-eye could be stronger. 

Thanks for taking the time to read this novel. I look forward to connecting, hearing your perspective, and learning what’s possible! 

A: Thank you for your inquiry, sending all of your pictures and detailing your facial concerns and objectives:

1) Your facial assessment is correct in that you have facial imbalances manifest as a negative orbital vector, under eye hollows with associated flatter anterior cheeks and a deep labiomental sulcus which is associated with primarily a vertically short lower chin/jawline.  Many of these facial structural symptoms people try to compensate for by facial posturing (holding the lower jaw open to elongate the face, sucking in the soft tissue below the cheeks to make the cheeks appear more evident) just as you describe yourself doing. (see attached facial vectors of deficiency)

2) These facial symptoms fundamentally come down to facial skeletal deficiencies of infraorbital-malar hypoplasia and a vertically short lower jaw.

3) What you have is very common in my experience and is treated by custom infraorbital-malar and jawline implants +/- midface defatting. (see attached imaging as one version of change)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you perform orthognathic surgery? I came across some very interesting comments from you on Realself posts. I started my orthodontic treatment over a year ag.. I refused to accept extractions and accepted IPR instead. Two orthognathic surgeons that I was recommended to by my orthodontist saw my case and called it “common” and “nothing to worry about.” They suggested a sliding genioplasty instead to aid with my lip incompetence, and assured me that jaw surgery was unnecessary. I accepted. I ended up undergoing two sliding genioplasties in one month. This is because the first time turned out to be a total mess. My chin had been advanced too much (8 mm), and that was after I had refused a 10mm advancement. The second one turned out better (5 mm), but now I have ended up with chin ptosis. My lip incompetence is worse than ever before. I drool without realizing it and have trouble sleeping at night. Recently I’ve been waking up at night, gasping for air. After paying closer attention to my x-rays, I noticed my airway is very narrow. Shouldn’t that have been taken into consideration? Wouldn’t jaw surgery help with my narrow airway? I had no idea what to look for before, but after doing research, I learned that a narrow airway may lead to sleep apnea. I fear that I may have sleep apnea. A part of me feels like I’ve been neglected multiple times by several professionals. I found hope in your responses to several posts on Realself regarding v-y lip advancement, mentalis resuspension, and jaw surgery. I hope you can help me. Thank you for your time. I appreciate it so much.

A: Thank you for your inquiry, sending your pictures and detailing your concerns to which I can say the following:

1) While I have only limited information (a few pictures and a lateral cephalometric x-ray) it would be imprudent for me to make any in-depth comments about your candidacy for orthognathic surgery. All I can see is that you have a very significant flare to the upper and lower incisors and did not wish to undergo extractions as part of your orthodontic therapy. Thus with your current occlusal state orthognathic surgery is not an option. Perhaps that may have been different had extraction therapy been done where bimaxillary surgery may have come into play. That is a question for the orthodontists to answer.

2) Obstructive sleep apnea is a multi factorial condition of which a single piece of information (narrow airway seen on a lateral cephalometric x-ray) is way inadequate to make an accurate diagnosis. A formal sleep study is needed to determine if you have sleep apnea, whether it is central or obstructive in nature and what the appropriate treatment might be for it. It is a big leap to go from looking at the lateral cephalometric x-ray to assuming one would benefit by upper and or lower jaw advancement surgery for presumed sleep apnea.

3) Just like changing a big chin implant to smaller one (or removing it completely), subtotal reversal of a sliding genioplasty can cause lower lip incompetence. (even though that was what it was done to treat) I have heard this postoperative development from numerous females that have had subtotal sliding genioplasty reversals when the amount of forward movement was excessive. With the soft tissue elevation from the bone to perform the osteotomy, this is not totally surprising when the bone is then partially setback. Such lower lip incompetence is evident in your pictures. The question is now is whether an intraoral chin resuspension would be an effective treatment for you. While it is not always a 100% successful procedure, it is always a procedure that does not make anything worse and usually provides some improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in gynecomastia reduction surgery with nipple reduction at the same time. But did have one concern that another physician raised regarding a nipple reduction – specifically, the physician was very hesitant that such a procedure was worthwhile considering the risks (which he described as a 20% chance of necrosis of the nipple following such a procedure) – I would be curious to hear your assessment of this risk (or others) as pertains to a nipple reduction procedure before I make a decision.

A: I am not sure at all what is the origin of the statement by a surgeon of ‘there is a 20% risk of nipple necrosis when nipple reductions are performed with gynecomastia reduction’ for the following reasons:

1) Nipple reduction in a male almost always means nipple amputation, the complete removal of the projecting nipple, thus there is no nipple left to have any necrosis. I can only assume what this doctor is more likely referring to is ‘areolar necrosis’ or difficulty with the nipple reduction site healing. This has not been an issue that I have ever seen.

2) This ‘statistic’ is based on what I do not know since there has never been anything published in the plastic surgery literature in that regard or any other literature since the performance of male nipple reduction in gynecomastia reduction is so rarely done.

3) The relevancy of potential vascular compromise to the nipple-areolar complex is based on what type of gynecomastia reduction is being performed. If an open gynecomastia reduction is performed through an inferior areolar incision, where the nipple-areolar complex is left with a thin layer of tissue underneath it and it depends on vascular inflow from the surrounding dermis (where half has been cut off from the inferior areolar incision). then one would have reason to consider there may be the potential for vascular compromise from the healing nipple reduction site. But this issue becomes moot when the gynecomastia reduction is performed by liposuction without a direct areolar incision.

4) But when in doubt one can always delay the nipple reduction for a week or two after surgery since it can easily be done as an office procedure under local anesthesia. (where the chest is largely numb anyway for awhile)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about the shoulder width reduction surgery. I am very insecure about how broad my shoulders are. I’ve always wanted a delicate, feminine shape so that I could wear whatever I wanted to without feeling like I had to hide a part of myself. For reducing the width of your shoulders, is the restraint of ~ 4-5cm removed per operation, or in a lifetime? Would repeat surgeries be possible if a person wanted to remove more than 4-5cm? As you can see there is a very drastic difference between my shoulder width and hip width.

A: Thank you for your inquiry and sending your picture. Your question about whether one should have a second clavicle reduction surgery is an interesting one and I can not speak from personal experience having never done it as such as the issue has never arisen before. But I would see no reason why one could not later have a second shoulder width reduction surgery if one desires at the same osteotomy site. Obviously the goal the first time would be to make that unnecessary taking out 3cms oer side. I think you might be surprised how much difference that can make and hopefully the consideration of a second surgery for you remains a theoretical one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young male seeking help and guidance about my skull shape. I am concerned about the top portion of my skull, it looks like i have a ridge / bump on the sagittal structure. I was never aware of my skull shape until i recently shaved my head due to some thinning and balding. This makes me concerned about my appearance, and i was hoping you could take a look at the attached photos and if you could recognize sagittal ridge and i would like to know if bone burring would be a effective way to reduce this. 

A: Thank you for your inquiry and sending your pictures. I don’t think you have a true sagittal ridge and this is just the way your head is shaped which is a bit more peaked. (see attached) But that does not mean that out can not be reduced as normal sagittal ridge bone is adequately thick  to do so. The key question is whether such reduction is enough to make you feel better about its shape. (see attached)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Ok with Botox, in some instances it can cause poisoning and permanent nerve damage. I think if we use a high dose the risk is higher of botox spreading to other parts in the face. If you remove part of the muscle, what % of the muscle are you removing. Is it 10%, 50%? Has any of your patients(younger and older), experienced any chewing problems. Can chewing issues develop?

A:In answer to your questions:

1) Every drug has a known LED. (lethal effective dose) For Botox that has been shown in laboratory animals to be around 35,000units of extrapolated to humans by weight. So a few hundred units injected into a human is not going to cause any of the symptoms to which you describe. (poisoning or permanent nerve damage)

2) I assume you are referring to the posterior temporal region which is the only temporal region where muscle can be technically and aesthetically safely removed. Typically 100% of the muscle is removed to get the maximal effect which is what many male patients need/desire. But there is a technique for subtotal reduction where about 50% of the muscle mass is left.

3) No patient will complete temporal muscle reduction ever experienced any masticatory (chewing) dysfunction….nor would I expect them to.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had class 3 orthognathic surgery when I was a teenager – my lower jaw was moved backward and my upper jaw was moved forward. A sliding genioplasty was also performed at the same time. I’ve since fully recovered. I suspect this may have left me with excess fat deposits under the neck which could be removed. I also suspect I never had a particularly well developed lower jaw to begin with. My questions are:

   – Do you have experience with lower face surgery on prior orthognathic patients?

   – I suspect the visual change, at lease in profile, from improving the neck/jaw angle would be significant. Is it possible/advisable to try to project this along with additional procedure(s) (e.g. jaw implants)?

A:Thank you for your inquiry, sending your pictures and detailing your objectives. I have done lots of orthognathic surgery in my career but have undoubtably have done more post-orthognathic surgery jawline reconstructions and aesthetic jawline augmentations. Orthognathic surgery is a functional occlusal operation that can have some aesthetic benefits as well but which are relegated primarily to the sagittal plane. (side view) I have seen many after orthognthaic surgery patients with altered jawlines from sagittal splits and sliding genioplasties as well as jawlines that lack definition and width particularly. While I haven’t seen your 3D x-rays, what counts is the objective to which I have attached one version of an overall jawline/neck change as a starting point for discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello,I’m inquiring about a service you offer. Since I was young I’ve had a dented skull which is pretty largely visible but I manage to hide it fairly well & it’s not really noticed ever. But I will foresee the need the surgery one day if I ever go bald lol, so I’m inquiring on cost for this services? I’d say it’s a good 3/8 inch dip with 2 inch circular diameter. 

I would love to get this handled one day but I just don’t have thousands & thousands to fix it. But hoping if price is right that I can go in a correct this.

A:Thank you for your skull dent inquiry and detailing your head shape concerns. But your description that is a fairly small skull indentation (roughly 5 x 5 x  1cms) which could be filled in with different types of materials and, if one is able, could even be done under local anesthesia or IV sedation. The most economical material would be PMMA bone cement. While many skull augmentations and defects are done today using custom made implants that adds considerably to the cost. PMMA bone cements is how I used to do all skull onlays so it may an older technique but still effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley: I would like to ask several things in detail.

I also uploaded my pictures and CT of my head and picture of head of female that I want to have.

First, second and third file uploaded are pictures of my head

And fourth and fifth file is pictures of female’s head that i want to have.

Please see my head pictures and the pictures of a female and give me exact answer about whether the surgery can make me satisfied.

1. Safety and problem of thinner skull after the surgery really matter sir. I heard from many korean plastic surgeons who have Ph.D in plastic surgery said that head reduction is dangerous and there is no way to do that.

I have never seen korean plastic surgeon who perform skull reduction surgery.

So I would like to know how and why it is safe.

And as far as I learn through your website it burs or remove the bone of the head which surrounds and protects a brain.

I really wonder whether this surgery makes skull much thinner weaker and lower the protectional function of the skull from outside physical attack.

And I would like to know whether when it fails  it leaves permanent injury or brain damage.

2. I think to have a much smaller head, temporal, occipital and sagittal reduction in terms of skull reduction to make a female head that I really wants. Please let me know whether the head that I want to achieve is possible by the surgery or not, by objectively considering the female head of the pictures that I uploaded

3. How much the head reduction is possible on sagitally occipitally and temporarily  in mm scale?

4. What is a total cost of surgery that includes everything from surgery cost, hospitalization cost to any other cost that i need to pay.

Thanks. I would like to recieve the answers as soon as possible.

A:Thank you for your skull reduction inquiry and sending your pictures to which I can reply:

1) Your questions about the safety of skull reshaping surgery are common and understandable. A surgeon who has never done this type of craniofacial surgery can not  truly speak for its safety and/or effectiveness but I can. Others may have an opinion but I have extensive experience in actually doing it. Removing the outer cortical layer of the skull does not weaken it in any appreciable way as that is about 1/3 to 1/2 of the total skull’s thickness. The issue is not one of safety but of how effective it can be in terms of the patient’s aesthetic objectives.

2) The critical question in every skull reduction patient is whether it will be effective enough. Just looking at your picture and an ideal female head example does not really tell me much. Both have hair which masks the actually head shape so this information alone doesn’t help much.

3) Without seeing a 3D CT scan of your skull and making measurements (you have only attached a 3D face CT image) I can not say where and how much of the skull bone can be reduced. Temporal reduction is the easiest to comment on because in that skull area it is the muscle that is reduced which  creates the most dramatic change. (posterior temporal muscle is removed and the anterior muscle thinned which produces reductions of at least 5 to 7mms per side)

4) Whether total skull reduction would be effective injections your case I can not yet say. It would take a 3D skull CT and then comparing it to a 3D CT scan of a Korean female to best answer that question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am based in Canada and my background is Indian. I have thick skin and my original nose was wide AND long! I’ve had 3 surgeries (Primary in India and two revisions in Canada) but the result is still bulby looking, the tip still long. I was wondering if you are comfortable operating on patients with thick skin, and with previous surgeries. (revision rhinoplasty)

A: Thank you for your inquiry and detailing your rhinoplasty surgery history. The question is to whether any surgeon (myself or anyone else) feels comfortable performing revisional rhinoplasty surgery but whether they feel they can make a difference and justify the putting the patient through a 4th rhinoplasty. Admittedly a thick skinned nose that has had 3 rhinoplasties, all in an effort to make it shorter and thinner but without great success, does not bode well for any further surgery finally making the ‘big difference’. But that basic issue aside, I could provide a more qualified opinion by seeing some nose pictures, and as best as you can recall, having some information as to what did they do in the last two surgeries to try and make it better?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello and how are you?  I am emailing you as suggested by Camille with my inquires and photos. First let me begin with the background. Overall, I am happy with my face and think I am approaching this from a decent baseline but I was wondering if it is possible to enhance it with a change that can still be subtle. I am seeking the chiseled jaw look. Although I am a male, I was inspired Angelina Jolie’s chin projection  jawline very much (although she may had other work done along with a low percent body fat).  I am wondering if chin and jaw implants (specifically the jaw implant that emphasizes a stronger angle as opposed to increased width)  or wrap around implant would give me my desired look. My concerns is having a swollen face look even after the healing has completed or having a drastic change. One thing to note myself is that I had fillers placed, my last round was over a year ago in the chin and jaw lines, hopefully this won’t be an impediment to your assessment.  Below is a list of questions along with a video.  Also note, there is a picture from the RealSelf website of a prior patient.  I put it up there because it is one of those cases where the before or after is too drastic!-hence my desire for subtlety. Any feedback is greatly appreciated!

1 I am scared about nerve damage, can you comment on that, particularly your success rate and experience with this? -especially if the implant is a wrap around. 

2 I am also scared about the swelling and realizing it will take months for it to get back to normal only to see that my new face is a swollen look.  How common is that concern, how do you counsel? 

3 Is it possible for changes I desire to be achieved yet subtle so it’s not obvious to others or does that defeat the point? 

4 Is it possible for computer imaging to show what I will look like after the implants?

5 I am also physically active, I assume I won’t be able to lift weight six to eight weeks after? or would it be longer?

6 How often are people not satisfied with their result and thus request a removal?  Does their face go back to normal?

7 Roughly how much could this cost (i.e what is the most expensive this could be?)

8 I live in NYC, thus this impact your practice given COVID, also how long would I have to stay and how soon could I go back home? 

9 I also suffer from psoriasis and on an immunomodulator suppressive therapy, thus does that play into any factor?  Do people immunologically react to the implants?  Can all the incisions may be intraorally only?

10 Do people feel the implant ? 

11 Does having some filler in the face complicate the surgery?

12 Also you will see in the video that my face gives ME the impression that I have a fatty chin when I have been told that is not true, would implants incidentally ease the appearance?

Thank you Dr. Eppley,

A: In answer to your custom jawline implant augmentationquestions:

1) The only nerve of any relevance is the mental nerve which controls feeling of the lower lip. This implant is passed under that nerve which can cause some short term temporary numbness in a few small cases but not permanent loss of feeling.

2) While the swelling can be considerable from a patient’s perspective most of the significant swelling is but a few weeks (2 to 3 weeks) where one may feel a bit distorted. I can say that I ever recall a patient months down the road that ever look ‘bloated or just had a fat face as implants expand the tissue. But it is true that thinner faces always end up with more defined results with smaller sized implants.

3) Your question is based on the common misconception that other people are a lot more observant than they really are. Just because you know you had a jawline implant doesn’t mean other people can even tell almost regardless of the magnitude of change for two very specific reasons…1) people can only recognize plastic surgery procedures that they know exist (99.9% of the world would never believe a total jawline augmentation change is even possible) and 2) everyone is a lot more concerned about themselves than about you. They are a lot more worried about themselves not looking right or looking good most of the day than they are perceiving any change you may have done.

4) It is a requirement than every facial reshaping patient undergoes computer imaging. But your perception of the role of computer imaging in facial surgery, which is common, is inaccurate. Computer imaging is about setting the target…what is the patient’s goal? As the old motto goes one can not hit a target they do not have. I have no preconceived notion of what type of change you want and frankly I don’t care what your jawline augmentation goal is. I only care about what you want so I can strive to achieve it. That is the real purpose of computer imaging. We may or may not hit the target exactly but we have a much better chance if I know what it is. Such a philosophy takes on the greatest relevance in custom facial implant surgery where the creation of specific implant dimensions are required.

5) Your assumption in regards to working out/weight lifting is inaccurate. You can do any of these activities when you feel comfortable to do so. Such activities will not displace the implant nor interfere with its healing.

6) Almost no one ever requests a removal. They may want it revised bit almost never just removed.

8) Other than requiring patients to have a negative COVID test before surgery, there are other unusual preoperative requirements. The goal is to get the patient home asap, usually within a few days. There is no advantage or need to remain here. You want to get home to recover on familiar ground.

9) The would depend on what type of immunosuppression you are on. But I can assume since the treatment is for psoriasis that it is a more contemporary drug regimen as opposed to prednisone etc. Implants do not evoke an immunologic reaction and no one develops an immune reaction to the implant materials. Implants can get infected which is often confused with being ‘rejected’ or developing an ‘immune reaction’. I rarely place jawline implants through an exclusive intraoral approach since that has a higher rate of infections. While the back incisions are placed inside the mouth, the front incision is placed under the chin.

10) No more than you can feel your own jawbone now.

11) The location of synthetic fillers is irrelevant in regards to both designing an implant or surgically placing it.

12) I would defer to computer imaging to visually answer the question as to what will happen to your ‘fatty chin’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your reply and your feedback about the photos! And i think you are right that I do not have a true sagittal ridge but it looks a bit more elevated at the sagittal structure. But it still affects me negatively, and I am still interested in the surgery. In order to be more informed about the sagittal ridge bone burring procedure, i would like to ask you 2 questions.

1. Is it necessary for me to make a CT scan of my skull in order to determine if it is possible to perform the surgery? 

2. Will there be a visible scar left on my head when the procedure is done? (I assume, yes)

Thanks in advance!

A: 1) The only reason to ever get a CT scan (2D CT scan, no contrast) on a midline sagittal elevation is to determine if enough bone can be safely reduced to make a difference. In other words one wants to make the elevation is due to thicker bone not because the underlying bone has gotten thinner. While I have never seen such a situation in which the bone is too thin to operate it is always better to be ‘safe’/certain.

2) There will be a fine line scar about 4 cms in length but such scalp scars usually heals so well there has yet to be a resultant scar in a primary procedure that a patient felt was problematic. (request for scar revision)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have eye asymmetry. I have had it since i was young. What can be done for it? I have attached pictures for you review.

A: Thank you for your inquiry and sending all of your pictures. Your eye asymmetry is due to a well known condition of VOD. (vertical orbital dystopia) The orbital box (bones that surrounds the eyes) is lower on the one side by 3 to 4mms. This is evidenced not only by the horizontal level of the eyes being different but also by the eyebrows that its lower on that side as well as the slightly flatter cheek in that side as well.

To understand how VOD is surgically treated I would refer you to one of my websites, www.exploreplasticsurgery.com and search under Vertical Orbital Dystopia where you can read and see how that is done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my issue is mainly the posterior part of the temporal muscle. I looked it up and it was stated online that the posterior muscle is responsible for moving the jaw forward and back. I have three questions:

1) Is it possible to remove 50% of the posterior muscle, cut it in half so that it goes from being 7mm to 3.5mm. I don’t want to use the word shave it down, but slice it down the middle. 

2.) Are there any complications at all even from removing a portion of the posterior muscle and not the whole thing? I’m not looking to have a flat side of the hea. I’d still like there to be some curve, I just think there’s a high risk if we go down the Botox route of the units shifting to other parts of the face.

3.) Would I be able to talk to a few other male patients who had this procedure, before I commit to having it. 

My main fear is having something permanent that causes functional problem because muscles do shrink with age. How will my temporal muscle fair up when I turn 80?

A: In answer to your posterior temporal reduction surgery questions:

1) Muscle is not like bone, there is no shaving of it particularly from a remote incisional access. As I said earlier a portion of the muscle can be removed through a release and rotational maneuver to keep some of the muscle thickness.

2) Regardless of what any anatomic textbooks say the entire posterior belly of the temporal muscle can be removed without any functional sequelae on mouth opening and closing. I would know after over 100 posterior temporal muscles removed and no patients has ever even had temporary mouth opening stiffness. That is because 70% of the temporal muscle lines anterior and the posterior part makes up a small percentage of the muscle despite its apparent large surface area coverage.

3) Botox does not shift to other parts of the face. It has a well known intramuscular diffusion range of only 1 to 1.5cms from the injection site.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a board certified plastic surgeon. I recently had a patient requesting an skin excision from her elbow. (elbow lift) I had never heard of that procedure and did not even realize one existed. I saw that you have indeed done this procedure. I was wondering if you have any pics of the scars many months out? I would be so grateful if you could share any advice on this procedure.

A: Like all tissue excisional/tightenng body procedures, and elbow lifts are no exception, it is all about whether the scar is a worthy tradeoff. Forget about whether the scar is good looking as that is the hope but there is no guarantee across a moveable joint. Paint the picture of an adverse scar that will require revision (I have only done one such revision in more than 20 elbow lifts….but that is not the point) and then see if they want to do the procedure. The best candidate for any aesthetic procedure where the scar is unpredictable is when they tell you quickly and upfront after the scar discussion that they would rather have a scar than loose skin. Any wavering about the scar disqualifies them from the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a plastic surgeon that can remove a skin graft that took place due to a car accident where I had a scalp flap rotated forwarded to replace forehead tissue and a skin graft put in place behind the rotated flap. This took place when I was very young. The graft is thin as no tissue underneath so tends to get injured easily if bumped and doesn’t heal well as well as disfiguring now with hair loss. The graft is approximately 6 inches long by 2 inches wide with the 6 inches going left to right on my head and the two inches front to back of head. Do you perhaps a procedure such as the Extended Scalp Reduction or other techniques in place now that were not available when the accident happened? Thanks for the response.

A: The question you are asking is whether a scalp skin graft site can be excised and primarily closed….without a flap and creating a tissue deficient somewhere which requires skin graft coverage. (which is what you have already had done many years ago) If you had not had prior surgery a scalp tissue defect of 6 x 2 inches might be able to be excised and primarily closed. But with prior surgery and loss of 1/2 of the scalp’s ability to stretch due to the previous flap, that is much more in question. Using tissue expansion of half of the scalp that has not previously operated on, it is undoubtably possible. That raises the next question of whether it is possible without tissue expansion. To provide a more qualified answer I would need to see pictures of your scalp and the skin graft site.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I plan to fly out this summer and set up an appointment with you. I’ve read numerous studies and doctors have been able to reduce the temples by 4-5 mm with Botox injections.Yes your right, multiple injection rounds are needed every 3-6 months. But I’m willing to pay and fly out to you every 3-6 months. Is there anyway we can run scans at your office and formulate a plan with Botox. I’m not interested in excision of the muscle under any circumstances. If its impossible to achieve the temporal reduction results as you illustrated with Botox, please tell me up front, but I’d rather fly out every 3-6 months to achieve reversible results. Have you ever reduced the temporal muscle with Botox injections?

A: There is no question that Botox can shrink a masticatory muscle. But like all drugs its effect is dose dependent. And the temporalis is an enormous muscle that would require very high doses (in comparison for example to the masseter muscle) to see a substantive effect.(of which 4 to 5mms would count as substantive) What dose that is per side can not be fully predicted beforehand and the dose:effect ratio per patient can only be learned by doing it. (pick a dose, see the effect and adjust accordingly next time) There is no scan or imaging that is going to be helpful when injecting Botox into any muscle as long as the target muscle location is known.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Looking through the internet about “chin ptosis” (I just find out this is the medical name) I found a blog in which you provided some valid points and and your views on patients with the same “issue” that I have. I had no idea that I was not alone about this, usually I always hear about “chin enhancements” such as implants or fillers to make it prominent but never to make it smaller or “reduction”, so I was very happy when I read about it and find out about you. Im still not sure what procedure would be best for my unique case because it seems that the bone in my chin is way short, and the “pointy” or “prominence” comes from a “fatty ball” that is seating on the bone, I am aware that I need probably an x-ray, but what kind of x-ray should I request? Do I need a prescription? Or this is something that its include on the examination? Or maybe a referral? I have many questions,  concerns and doubts that I’m sure it could resolve with an initial  consultation. Please I will be so happy to hear from you soon. 

A: Thank you for your inquiry and sending your pictures. The one simple x-ray that shows best the relationship of the chin bone to the overlying soft tissues is a lateral cephalometric x-ray. This is a very common x-ray done in any orthodontists office. Whether the bone has any contribution to the appearance of your chin and the thickness of the overlying soft tissue pad of the chin will be revealed in this classic lateral facial x-ray. That piece of information will be critical for our virtual consultation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you perform hip implant and butt implant surgery at the same time?

A: It is technically possible to perform buttock and hip implants at the same time…but that makes for a difficult recovery. I have had numerous patients go through this combo body contouring/augmentation surgery but they will tell you it was rough and it comes with increased risks of complications. (four implants and notes two) The other caveat is that the buttock implants have to be intramuscular if hip implants are concurrently performed or eyen in the future to keep the tissue pockets from merging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had posterior temporal reduction surgery by muscle removal three months ago and am very pleased with the result. My question now is what can be done for the anterior temporal muscle closer to my eye. 

A: Based on your email previously and the current one, I assume the remaining issue is the front part of the side of the head, the anterior temporal region. The anterior temporal region is different from the posterior in that the muscle can not just be removed like the posterior temporal region. That would cause contour deformities as well as potential jaw opening/closing problems. Thus the anterior temporal fullness must be treated differently. Options include non-surgical (Botox injections…very effective but not assured of permanency)) and open electrocautery surgery which causes permanent muscle shrinkage due to the thermal injury of the outer muscle fibers. Botox injections take weeks to see their effects while electocautery can take up to three months after the surgery to see the full effects of muscle thickness reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had 300ccs of Aaquafil injection into my hips last year. I am interested now in getting hip implants for more volume. Is it safe to do so after these injections?

A: Aquafil is an injectable filler that is composed of 97% saline and 3% polyamidized hydrophilic gel. (It is not FDA-approved in the US) It is a filler that is allegedly absorbed but can take up to five years or more to do so. While a 300cc injection is really about 30 cc of the actual gel material (or less) the actual amount of material there is relatively small. But it primarily works by inducing  a lot of scar tissue reaction around it. BUT with the high rate of seromas (fluid collections) in hip implants anything that could increase that risk gives one pause.

It is hard to say for certain that it would or would not be a problem knowing the total volume injected. But given that this is elective surgery is always wise to limit risks when possible. Certainly the safest course is to not proceed with the hip implants for now and await one day when one is more certain that the filler has gone away….or at least there s less of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom pectoral implants.I’m 6’ 3” and anywhere from 220 to 250lbs  so the 900cc custom pectoral implants would work. Is my silicone that was injected in my chest an issue? I am also planning on having shoulder surgery soon, is that an issue? Ideally I’d like to get the surgery not so far after the shoulder surgery so that I’m not going through tons of “down time” but I don’t know if that’s a possibility. 

Thank you

A: In answer to your custom pectoral implants questions:

1) I assume that the silicone injections were either placed into the chest soft tissues above the muscle or into the muscle itself. Pectoral implants are placed under the muscle which presumably is out of the zone of the silicone injections….with the operative word ‘presumably’. Do you know what volume of silicone was injected, how many injections and how long ago?

2) Pectoral implants can be done after shoulder surgery. (or before) The critical question is how long after the shoulder surgery. That would depend on what your shoulder surgeon says is advisable as we have to put your arms out to 60 degrees from your body during surgery. Whenever he/she says it is safe to do so would be the guiding principle for the timing of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am concerned about long term infection with a Medpor chin implant. I had a medpor chin implant placed one year ago and I’m worried about the infection possibility of the implant. Is it beneficial to switch this into a silicone implant now?

A: By your description you have an existing Medpor chin implant but without any previous or current signs of infection. If it has been one year since its placement and you have never yet had an infection, I would just leave to alone if it is aesthetically satisfying. The risk of any implant infection is almost exclusively in the perioperative period. (first three months) Once past that time period the risk of infection is so low that it is not worth removing and switching it to any other implant material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My son is 5 years old and was born with scalp aplasia cutis congenita. Around 3 x3 xm on the scalp. The dermatologists does not wish to help us correct this until my son has a say on this when he is older which I think is ridiculous as a parent. 

A: Thank you for your inquiry. Congenital scalp cutis aplasia areas can be excised at any age. The real question is not whether it can be excised but whether it can be primarily closed without undue tension or excessively long incisions from scalp rotational flaps. Scalp surgery in a growing head is interesting in that scars do expand with growth so many of these scalp surgeries require further surgery in the future for scar widening from the expansion of skull growth. But certainly it can be substantially reduced. I would need to see some pictures of it for further assessment.

Some cutis aplasias have either very thin skull bone underneath them or rarely I have seen them with areas of missing skull bone underneath them. But I assume that the latter is not evident in your son’s case.

Dr. Barry Eppley

Indianapolis, Indiana