Your Questions

Q: Dr. Eppley, I have had upper jaw advancement surgery, and surgeon did not do alar cinch. My nose has remained the same apart from horribly flared nostrils. They flare outwards and upwards so that frontways on – my nostrils are higher either side than the tip, and they look open from the sides. I have since had alar base reduction which has helped a little but the still flare upwards at the sides. If I pull down under each nostril my nostrils look normal again. Therefore I feel I need the cinch to be done as a stand alone procedure. Please can you advise if and how this can be done..and should I approach a jaw surgeon or a nose surgeon? My previous jaw surgeon is not very helpful and states he has only eve done cinch as part of jaw operation. Many thanks

A: An alar cinch procedure is not the correct procedure for dealing with either horizontal or vertical malposition of the nostrils after a LeFort I osteotomy. That is only a preventative procedure done at the closure of a LeFort I osteotomy, Nostril repositioning by sill or nasal base skin excision is the definitive procedure to change nostril position either flaring or vertical malposition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an overbite that I’ve been told (by a couple of orthodontists) can only be fixed with jaw surgery.  And due to the overbite I have a pretty recessed chin and my nose appears bigger.

However, jaw surgery is a major surgery and I don’t have the type of support system needed to help me with the length of recovery required.  Also, it would take a long time before I could even have the surgery because of braces, etc.

So I’ve decided to instead check into improving the cosmetic aspects of my recessed chin for now instead of the underlying problem.  I’m thinking a sliding genioplasty would help a lot.  Maybe I would need an implant too.  But that is what I am contacting you for, to find out what you recommend.  My nose might still be proportionately too big also, even after improving my chin.

When I was younger I found a plastic surgeon and had a chin implant and rhinoplasty.  This was before the internet and I really didn’t know what I was doing. I had never heard of sliding genioplasty. The surgery did result in an improvement, but really not a big change. 

I’ve seen before and after photos from you and other surgeons for sliding genioplasties, and they are amazing!  It wouldn’t address my underlying problem, but it would make my profile look so much better! 

I also don’t like the size of my nose but I don’t know how it would look if my chin looked better.  And I’m noticing my face getting a little saggy around my mouth/chin due to age, but maybe the chin surgery would make that less noticeable?

Anyway, I would love to know what you recommend.  Attached are some pictures I took as well as a x-ray from my more recent orthodontist.

A: Thank you for your inquiry and sending your pictures and x-rays. As you know you have an entire short lower jaw and Class II occlusions for which jaw advancement surgery is ideal…but we know the effort to do that at this point in your life is not acceptable. Thus a sliding genioplasty is the procedure you need for cosmetic camouflage because you have both a horizontally and vertically short chin for which an implant does not do well for those combined movements. (the chin implant you have is very small and is positioned too high to have much of an effect) I have done some imaging looking at bony chin movements of 7mm forward and about 5mm vertical as a starting point. While this will help with some of the loose tissue under the chin , the submental area should be ideally treated with liposuction at the same time for best contouring. By the imaging you can see that the nose looks smaller as the lower face comes into better balance. But I also did some imaging looking at nasal tip reduction as well for you to see the combined effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I do have a few questions.  The first are related to the temples:

a.) If Dr. Eppley were to use filler this time around, would that show me pretty much exactly what an implant would look like?

b.)  What is the price differential?

c.) If I went with the implants, would open me up to the possibility of visible scarring or bruising?  How about the filler?  (I’m thinking about the fact that I have to be back at work four days after surgery.

A: In answer to your temporal augmentation questions:

1) Fillers will have some under approximation of what an implant will do as they are not comparative volumes. A standard temporal implant, for example, is the equivalent of 2.7cc of filler per side. Most patients are not going to invest 5 syringes of filler to ‘see what it looks like’.

2) Temporal implants are gong to cause some swelling which will not be gone by four days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it normal for gluteal implants placed intramuscularly to flip? And is that something that will become less common with larger implants? If not can anything be done to ensure it doesn’t happen?

A: Buttock implants placed in the intramuscular pocket have a much tighter compression against the implant and often have a wider implant base as well. s a result, It would be very rare for a buttock implant to flip in the intramuscular pocket as there is less pocket relaxation that exists than in the subfascial pocket. I have never seen it or heard of it occurring. That is the same regardless of implant size which is often less also because of the tighter pocket. Such flipping is a potential subfascial pocket concern where often lager implant sizes are used that have higher profile to base width ratios. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering how close you could get me to looking like this guy. (link attached)

I’ll attach some photos of myself and explain what I’d want to change to try and match the male model look. 

I want to know about forehead implants and how to go about getting my forehead to look as similar to his as possible. My forehead slopes back so I want it looking flat and a defined eyebrow ridge. 

I also want to know about jaw implants and how to make my jaw as angular as absolutely possible and much wider.

I really want that sucked in cheek look as well so I want high cheekbones but I’ve read that cheekbone implants aren’t very effective, is this true? 

(like this guy in the leather jacket) 

Look forward to hearing your assessment on how I could best go about looking as much like this guy or just a male model that might suit my face better. 

Kind regards

A:Thank you for your inquiry and sending your pictures. While it is good to have goals, all you can do is take the face you have and see how its proportions and shape can be changed. In that regard that means a forehead-brow bone implant, high infraorbital-malar implants with buccal lipectomies and a jawline implant is how you would reshape your face.

Traditional or standard cheek implants will not create the high cheekbone look, that is true. It requires custom infraorbital-malar implants to create it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have four to six ribs removed. I am also planning on extra large breast tissue expanders to reach a goal of 5000cc to 6000cc in each breast. Given that would it be safe to remove four ti six 4-6 floating ribs if I have 6000cc saline in my breasts? I am 1.75 cm tall and weigh 54kg. Thanks.

A: I have done rib removal in numerous women who have had breast implants well in excess of 1000ccs. I have no experience in rib removal in women with breast volumes as you have or are going to get. However, I presume your question is based on that such large breast implants would not be supported by a ribcage that has been modified? I don’t see any correlation between implant/body support and a modified lower ribcage. The strength to support that breast weight/size comes from muscle support not a fully intact ribcage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, several years ago I had a buccal lipectomy. I never liked the result and am searching for a “reversal”. In your blog I have read about the possibility to place a dermal fat graft in the buccal space. This is my preferred option since a dermal fat graft creates more assured volume than fat injections and is a solid graft. I don’t mind having a scar somewhere on the body to harvest the graft. Am I correct in assuming this solid graft would not absorb but replace the lost volume I had pre-buccal fat removal? How many of these procedures have you done in the past to correct buccal fat removal? 

Could you please tell me how much would that approximately cost? Is general anesthesia needed?

I look forward to hearing from you.

A: In answer to your Buccal Lipectomy Reversal questions:

1) It would seem logical that the type of fat graft tor replacement of a previously removed buccal fat pad would be a solid fat graft. As the buccal fat pad is an encapsulated fat pocket of around 3ccs, its replacement could similarly be a solid fat graft of similar volume.

2) While the volume retention of the implantation of a solid fat graft or fat injections can be debated, and never really proven either way on a truly comparative basis, it is more about what the patient wants to go through. Do they prefer having a body harvest site for a likely one time fat grafting procedure (solid fat graft) or do they prefer having less surgery but likely to have to repeat it more than once. (fat injections)

3) My experience in buccal space fat grating has been primarily that of the HIV facial lipoatrophy patient (type 4 and 5) and not a cosmetic buccal lipectomy patient. Although the results should be similar if not better given a more normal ‘fat state’ in a non-HIV patient..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in hairline lowering. Would I need scalp expansion to do so? I can’t tell how loose my scalp is and whether it can move a lot or not. It seems sort of flexible but I am not sure how much looseness is needed.

A: Whether your frontal hairline can be lowered without scalp expansion depends on how much forward movement the hairline needs to come and how much scalp laxity you have. The latter is more difficult to accurately answer by email but the former can be answered by sending me a picture which shows the hairline marked where you would like it to be.

But it is fair to say that scalp expansion makes every hairline lowering better and more effective but removing all doubt about the needed scalp laxity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask you about how to decide the correct size for jaw angle implants. For reference my bigonial width is 9.8cm without soft tissues and 11cm counting them, my bizygomatic width is 13.6cm. Thanks for the help and greetings.

A: The reality is there is no exact science as to how to select jaw angle implant style and size. X-rays and measurements on them are not really helpful anymore than a chest x-ray is helpful in selecting breast implant size for women. What is the most useful thing to do is computer imaging, looking at various changes in jaw angle shape and size and then seeing how you interpret those changes. From that assessment jaw angle implant styles and size is determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been suffering with rib pain for over 2 years now. I can’t walk or do activities without burning pain in my left side. I believe the worst are ribs 11 and 12, possibly 10. I saw that you’ve done surgery for the bottom ribs hitting the iliac crest. I am not sure if thats what happening to mine or not, but I am in a lot of pain. Are all CT scans 3d? I had a CT scan (with contrast) in 2017 when this first started but they did not find anything. I’ve also had a thoracic MRI but nothing found. I am running out of options and not sure wha to do.

A: I obviously can not say for certain whether #11 and #12 rib removals would be the cure for your symptoms.  In costo-iliac syndrome the long lower ribs (or shortened waist on the affected side) can impinge upon the iliac crest. This can be a source of pain that occurs or exacerbated when one bends over onto that side and the ribs actually touch the iliac crest. Otherwise all x-ray studies would usually be negative as they are done in the upright position. This is typical pain that occurs when one bends over but is relieved when one stands straight.

Whether any of this applies to you I can not say. You would certainly not want to got though such rib removals and end up with no relief of your symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two large dents (step-offs) and a large bony bulge (on left jawline) that resulted from a bad sliding genioplasty done in 2009. I just want my straight jawline back but concerns over someone not experienced in bone work, particularly in what I’ve been told is a complicated repair, have resulted in my waiting years. However, it’s time to do something and from what I’ve seen and read of your work you have performed these types of repairs before. I have pictures that will show the deformities and happy to send. Would you be willing to discuss my situation? Thank you very much for your time.

A: A 3D CT scan is needed to have an accurate assessment of both the bony stepoffs and the bony bulge. I suspect the bony bulge is due to a shift of the sliding genioplasty resulting in one wing that sticks out. This also contributes to a larger bony step off on the opposite side than would otherwise exist. This would ned to be burred down. The bony setoffs from a sliding genioplasty can be treated with an overlay implant. For the sake of absolute accuracy I would prefer to make custom implants to fill in the defects which can be designed off of your 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if it was possible to widen or enlarge my head, it is small. That along with a jawline augmentation. Is it possible to do simultaneously. How much would that cost? 

Also are there any long term side effects of placing implant on the skull? Such as headaches, or increased chances of other complications? 

A: In answer to your head widening and jaw widening questions:

1) It is possible to concurrently widen your head (temporal augmentation) at the same time as widening of your lower face.(jawline augmentation)

2) Both head and jaw widening will require custom implants to do so.

3) I have never had a patient who has developed any problems with headaches after any form of skull augmentation. This is an extracranial procedure that has no effect on the brain.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in ear reduction surgery. As you can see from the photo, I already had this surgery done but I would like to achieve better results. 

1. Could you please tell me what would be the total price of the surgery (incl. medication, preparation etc.) 

2. Will you be using dissolvable stitches? 

3. Could you use small bandages (patches) instead of big ones that go around the head? 

I took a measures and it turned out that the reduction should be around 5 mm.

A: In answer to your ear reduction questions:

1) Whomever did your original ear reduction used an inappropriate technique resulting in significant notching of your helical rim in a too high superior position.

2) But you are stuck now with using that location for the back cut across the helical rim. Although I believe I can make the helical rom smoother with a secondary ear reduction.

3) I will have my assistant Camille pass along the cost of the procedure to you on Monday. It can be done under local anesthesia.

4) Dissolveable sutures will be used.

5) Only antibiotic ointment is used as a topical dressing.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering what I could do to get a defined, sharper chin that projects downward more. I would like a more heart/diamond shaped face. 

I am content with my jaw definition/angles, but I want to project the chin and make it sharper like the model’s. 

I don’t think i would need an immensely dramatic chin implant, but I’d like to know what you think could achieve the result I desire. 

I’ve reviewed my options of a pre-made chin implant and a custom one, and I’m still not too sure what would suit me the most. 

Could the results I desire be achieve with an off-the-self chin implant? I also wanted to know what a semi-custom chin implant is, and what is the cost of custom and semi-custom chin implants. How many millimeters of projection are ample for this result? 

I’m really eager to hear what would work best for me. I appreciate you taking the time out of your day to respond! 

Thank you

A: In answer to your chin implant questions:

1) The dimensional needs of bringing your chin forward and down with a square shape can only be achieved with a custom implant design. Most likley this is a 45 degree projection of 5mms forward and 5mms down. No standard chin implant style can achieve these type of dimensional chin changes.

2) A semi-custom implant design is using another patient’s custom implant design that may (or may not work) well for someone else.

3) My assistant Camille will pass along the cost of such surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been following for website for years now. I think you are the right person that I should go to. I am looking for forehead implant, more masculine forehead, more brow bone projection, less backward vertical slope of forehead, more typical handsome male model forehead and more deep set eyes. I am an Asian male so I have very little browbone (flat) and small frontal air sinuses. I have sent my pictures.

 I have some questions:

1) How long does the swelling and bruises last? I would like to have this done may be early September so it will give me  6-7 weeks after surgery before my cruise. 

2) How much does it cost for Forehead implant?

 If we can not get this procedure done in early September then it has to be in February 2020.

Thank you and I would love to hear back from you.

 A: In answer to your forehead augmentation questions:

1) Most forehead augmentation patients will have resolution of their bruising and the major part of their swelling by three weeks after surgery.

2) Given that it takes up to a month after receiving the 3D CT scan to have the forehead implant designed and manufactured, the earliest surgery date would be mid to later September.

3) My assistant Camille will pass along the cosy of such surgery to you later today.

4) I have also attached one type of forehead augmentation change that could be achieved in you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in hip implants and rib removal/rib resection surgery for a smaller waist and longer torso done by you. A few questions regarding rib removal surgery. 

1. Can one reproduce after such surgery? 

2. What are the most common risks/long term side effects associated with such surgery? 

3. Can one resume physical activities such as yoga, working out, swimming and rock climbing after they are fully recovered? 

4. Are the organs still protected, are they at more risk of being damaged after such surgery? Can one still breathe properly for the rest of their life after such surgery?

A: Thank you for your inquiry and your very good questions to which I can say the following:

1) Rib removal surgery does not interfere with one’s ability to get pregnant.

2) The most common risks really come down to two issues, 1) acceptance of small back scars to do the surgery and 2) unpredictability of how much waistline reduction can be achieved.

3) There are no physical activity restrictions when one is fully recovered.

4) Since rib removal is subtotal there is no loss of organ protection or risk of organ injury as well as there is no short or long-term pulmonary dysfunction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am still contemplating getting fillers for jawline augmentation. it has been awhile since I contacted you. Is there any new filler that is a injectable solid or implant so I don’t have to worry about migration or accidentally injecting into an artery since it would stay one piece. I read somewhere there was one in development that injects as a liquid but immediately becomes a solid? Is there a bone paste that can be injected also that can be injected along the jawline? Anything else new that is in production I am looking for augmentation in my jaw and chin, perhaps cheeks and nasolabial too? Is the jaw and chin the least likely to have a accidental injection into an artery and you go blind, any reports of this? Is there any type of imaging that can show where the actual arteries are in the face to stay clear of while you are injecting?

A: 1) I know of no new injectable fillers that have any of the properties that you describe/desire.

2) Do not confuse so called injectable bone cements with that of injectable fillers. They have very different properties and are not used the same way.

3) There is no type of imaging that exists to avoid arteries doing injections….that only currently exists for veins around the eyes..

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Qn about staging multiple surgeries I intend to have rhinoplasty with another surgeon. In particular issue is the transition between glabella augmentation and brow bone augmentation (deep set eyes effect) 

However I am considering doing the following with you: 

– forehead/brow implants (brow bone augmentation for deep-set eyes effect, more square from front, reduce slope) 

– custom midface implant 

– custom jaw implant 

Questions:

1) Which order should be done from first to last (rhinoplasty/glabella augmentation & 3 implants)? 

(Issue is the transition between glabella augmentation & brow/forehead augmentation) 

2) Can all 3 implants above be done on same day or does it need to be staggered on different days? If so, what is priority order of the 3 implants? 

3) Will brow bone implants change the shape & height of the upper eyelid crease? 

Regards

A: In answer to your custom facial implants questions:

1) All three implants can be done at the same time.

2) I would think the rhinoplasty would be done second as how the nose is set may be influenced by all of the other facial changes.

3) Brow bone augmentation would not typically be thought of as changing the upper eyelid crease…although the short term swelling may make one think so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Some surgeons say pectoral implant on male chest lasts life time while other are saying it will last about 10 years. May I know what you think about the life expectancy of the implant? Thanks!

A: This is a question to which there should not be a mystery or any point of confusion., Pectoral Implants are made of a solid soft silicone material which will last a lifetime barring any unforeseen trauma. They should not be confused with breast implants, which are gel-filled devices, which will not last a lifetime. While there may be some places in the world tat may use gel-filled type pectoral implants, here in the U.S. only solid silicone pectoral emplace devices are manufactured and implanted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When I initially chose to do a genioplasty it was a decision based on genioplasty and rhinoplasties often being two procedures that complement each other. But I think because I never had any real concerns with the chin itself is the reason why I have been left disappointed with the result both from an aesthetic point of view and functional as per our earlier conversations. Moreover when I spoke with a maxillofacial surgeon at my hospital this week he said the horizontal deficiency was so minimal at baseline that a genioplasty should never have been done.

When I think back prior to having any surgeries my concerns with my face were fixated on a hooked nose from the side view and an upper/mid face that looked simultaneously angry/coarse and recessed. I’ve never been able to pin point exactly what it was that I didn’t like and I have never gone into detail about these concerns with any surgeon in the past which is why I think previous surgeries may have been premature and perhaps unnecessary.

The genioplasty was done last yeaer, and I had an open rhinoplasty done the year before. The rhinoplasty itself I think the side view is certainly an improvement from baseline however I also think it does look a bit too feminine while the front looks a bit unappealing and unnatural at the tip area.

I am wondering if we could perhaps have a detailed consultation to discuss if further surgeries are warranted (in addition to reversing the genioplasty) and if so, would this consultation perhaps best be done in person as opposed to over Skype.

My end goal is still to look like me, just a more balanced version that looks natural. I am hoping for a very honest conversation about what is in my best interest as I have worked hard to reach the career point that I am in and am a bit ashamed with myself that my body image issues have suddenly become this big of a problem for me

Attached are my preop photos before any surgeries were done and my current photos taken this week. I would appreciate any honest suggestions you may have.

A: My short comments are:

1) You have very nice results from you rhinoplasty and sliding genioplasty. I think those are very good improvements and almost all patients would be happy to have those changes.

2) The statement that your sliding genioplasty ‘should have never been done’ is completely off base and misinformed. You had a vertically and horizontally short chin for which the sliding genioplasty was a perfect treatment for that type of aesthetic chin deficiency.

3) If these type of changes are largely unsatisfactory I would be very concerned that any revision of them will end up any better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you again for you prompt response, and please find the previously mentioned photos attached below.

*Please note I’ve included the frontal photo me smiling that is when I feel my area of concern is most pronounced

The green on Area of Concern photo indicates bone that I would like brought ‘in’ to reduce width of face. This is on the sides of my face starting parallel to the corner of my eye and goes down for 4cm.

The purple/pink indicates the area starting under my eye sockets and going down 3cm to the bottom of my nose where I would like to reduce the extent to which the bone comes forward from my face.

A:Thank you for sending all of your pictures and a good description of your concerns and objectives to which I can say the following:

1) The cheek area you have highlighted in green can be reduced in width and is done so by anterior and posterior cheekbone osteotomies…which moves the zygomatic arch width inward which is the primary source of facial width increase in that area.

2) The area you have highlighted in purple, however, is not going to be reduced by any form of bone reduction. This anterior cheek area thickness is comprised of soft tissue which becomes exacerbated (bunches up ) when you smile. (This is a very common facial concern in smiling) The underlying bone is actually concave in contour (not convex like the zygomatic arches) and this is not a bony protrusion that can be reduced. Any further bone reduction in this area, besides not having the eternal desired effect, will expose the maxillary sinus which lies immediately beneath it.

3) The purple cheek area is a facial region for which no effective soft tissue reduction is possible. Cutting out the soft tissue is not an option as permanent injury to branches of the facial nerve will occur. Liposuction of this fibrofatty tissue in this area is ineffective. I have tried its many times and it never produces any improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have viewed your custom facial implant results and you have mentioned that attractive results depend on the soft tissue. I’m not sure if mine is thick or thick but is there a way to thin or reduce the soft tissue to make my face looked more defined with the implant. Also say if I have thick soft tissue would PEEK material give me more angularity and stretch than silicone? Thank you

A: In answer to your facial reshaping and custom facial implants questions:

1) There are a limited number of fat reduction procedures of the face (buccal lipectomy, perioral liposuction) that can be performed. Thus the results of trying to reduce the soft tissue thickness of the face are very limited.

2) It is a fallacy that one type of biomaterial over another offers superior show of a facial implant through the tissues. This makes no biomaterial property sense despite the it is a common misconception that is frequently stated. This might be true if the silicone material as like a breast implant (soft) but it is solid silicone which is quite firm.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in abdominal panniculectomy surgery. I have a question about what is the best way to cut into the groin region so a female person having this procedure does not end up with a femoral nerve being cut? I do no want a numb thigh or leg if I have a panniculectomy done. I wish I could get an answer from a great surgeon such as you. Please email me a response and explain it this can be done with no nerve damage to my leg. Thank You it would be much appreciated. 

A: An abdominal panniculectomy does not enter the femoral triangle which is a subfascial space in the upper thigh. Thus femoral nerve injury is not a concern with this procedure. The nerves that are at risk is the lateral and anterior cutaneous branches of the iliohypogastric, the lateral femoral cutaneous and the ilioinguinal. While their risk of injury or entrapment is low, they can still be responsible for chronic pain and numbness. But this does not entail a risk of ‘nerve damage to the leg’. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a deformed forehead. My brow bones are sticking out and the bulge is very prominent.I am hereby sharing the photographs 

I would like to know if it is possible to shave the brow bone partially through incision below the brows as I don’t want to go for scalp incision due to receding hair line and possible scar formation post surgery

My expectation from this surgery is reduction in the deformity and not to get a perfect look. Also, the bulge above left brow is more prominent  than right which looks even worse. I would like to know if that can be shaved off to bring down to the size of right bone.

A: Thank you for your inquiry and sending your pictures. You have major brow bone protrusion. An effective reduction can not be done by just shaving the bone (it is too thin), it will require bone flap removal and setback. The more pertinent question,  however, is the surgical access to it if any scalp incision is eliminated as an option. An incision would to be made at the eyebrow level. Whether that is made just at the hairline at the bottom or top edge of the brow bone can be debated but I would prefer the bottom edge of the eyebrow hairs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have differences in the shape of my buttocks with the left being lower than the right. I was told that a buttock lift would be need to improve the asymmetry at the bottom.

How familiar are you with the procedure? I’ve read that trying to fix something like my case is 85% more likely to make the problem worse due to fat distribution. I would just like your professional reassurance as to how you would avoid making the problem worse. Thank you.

A: Your right buttock has a lower infragluteal fold than that of the left. Thus a left infragluteal or lower buttock lift is needed to raise the lower side to match better with the higher right side. 

I have performed lower buttock lift surgery for almost 30 years. In so doing I have never seen or would understand how it is likely to create an ‘85% risk of making the problem worse’. That is not a pertinent question or a relevant likely outcome. The real question is whether the fine line scar along the new raised infragluteal crease is a worthy tradeoff in the correction of your buttock asymmetry. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know you’re one of the top surgeons in the USA for revision. I had my nose job (primary) about 1.5 years ago. I’m satisfied however I notice a bump – ball lump like feeling on the side of my nose tip. I do not know if this is common. I read that it isn’t cartilage coming out as usually does shows after 3-6 weeks post op and not 1 year post up and plus. Do your patients usually get these or have these and is it due to maybe an acne or thick pore build up? What’s the resolution that you would do for this. If I took a photo you wouldn’t see it as when I put my finger on the side of my nose tip I can feel like a small ball. I attached a photo to show the area. 

However I’m thinking it could be a epidermoid cyst tip of nose. How do you remove these without any scarring?

A: Just based on this one picture it is more likely that you are seeing the cartilage underneath the skin. It can 1 or 2 years sometimes for the fine details of the shrink wrap effect of the the tissues to reveal the underlying osteocartilaginous anatomy particularly in the tip area. It would be very unlikely that a dermoid cyst could occur from an open rhinoplasty….not impossible but I have never seen it or heard of it occurring. Undermining the skin would not be a mechanism for its occurrence. Until proven otherwise I would assume this is due to the same of the underlying lower alar cartilage.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Thank you for the quick turnaround and spending the time to morph my pictures, much appreciated. Some feedback and follow-up questions:

1) I agree with the chin, I definitely wanted more projection both vertically and horizontally, and your initial morph there I think is very close to what I would like (I might have to play with it myself a bit to allow my mind to adjust to the drastic change haha). My questions here:

     a) Do you know about how many millimeters of a movement that would predicted to be?

     b) Is the width of the chin also changing here or just a chin movement? This questions is mostly to understand if the body of the chin needs to be change as I know I have some asymmetry there.

2) I think the cheekbones are a little trickier. I would like them a slimmer, but I also would like to maintain the current natural “curve” of the zygomatic body and arch I currently have. I am not intimately familiar with all the various cheekbone osteotomy procedures, but I know the ones popularized in Korea are the L and U shaped oseoteomies. I have also attached photos of people I think who have gotten such reductions that reflect the results I would like to achieve. I think my overarching goal there being to maintain the natural “curve” and protrusion of the cheekbones despite the reduction. My questions here:

    a) Which variation of cheekbone osteotomy (name in the literature) would you recommend so I can do more research? Pointers to any publications would be appreciated!

    b) Would your recommended procedure also affect my anterior cheekbone projection?

    c) Is there imaging and preplanning here to plan the cuts as to  protect the facial nerve?

3) As for risk factors: I know genioplasty is a relatively more common and well-practiced/studied procedure. It is also performed rarely, especially here in the states, as the procedure seems more nuanced. In my research, the main complications seem to be facial sagging and bone integrity issues (non-union) after cheekbone osteotomy. So my questions here are:

    a) As compared to genioplasty, how often do you perform of cheekbone osteotomies? 

    b) What is the relative complication/satisfaction rate for each?

    c) Has the technique for cheekbone osteotomy been changing recently or has it been the same technique used for a number of years? Based on the literature, it seems cheekbone osteotomy is a relatively recent technique that’s constantly undergoing new innovations, which makes me concerned about the stability of the outcomes.

Sorry for all the questions, and thanks again for the time!

A: In answer to your questions:

1) I would estimate the chin movements as 7mm horizontal and 5mms vertical.

2) Chin width never increases with sliding genioplasty. If anything it may  become slightly more narrow.

3) In cheekbone reduction osteotomies you never lose the natural curve of the zygomatic arch as the osteotomies are done in front of and behind the curve of the arch.

4) The L-shaped anterior cheek bone reduction osteotomy is the most common osteotomy pattern used.

5) I have performed many cheekbone reduction osteotomy surgeries in both Asian and Non-Asian patients. But by comparison chin osteotomies are more commonly requested and performed.

6) While there are many subtle variations in technique whose clinical relevance can be debated, the fundamental concepts of anterior zygomatic body and posterior arch osteotomies with plate fixation has remained the same.

7) A preoperative 3D CT scan is required before any form of facial bone surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First off, thank you for all your posts and answers which have put out for free on the web. I have found them to be an invaluable source of information. 

I am a 25-year-old male looking for some advice. I am grateful to have been blessed with a decent facial bone structure but I am looking to take things to the next level aesthetically. While my jaw is quite strong and wide, I feel I have a relatively flat mid-face. I would like to augment and strengthen this feature, particularly my zygomatic arches, for that hollow, chiseled male model look you have written about so extensively. As I understand it, this would also serve as a preventative measure against mid-face sagging as I age, while also providing under-eye support. 

What do you think of this plan? And if possible, could you also provide a rough estimate of the anterior and lateral projection that would suit my particular case?

In addition, to achieve a significant outcome in my case, would fillers be sufficient? Or would I need to go with customized silicone cheek implants? Finally, would you recommend any augmentation to the lower third, such as the chin to balance everything out?

Thank you for time. 

A: Thank you for your inquiry. In answer to your questions:

1) In looking at your pictures, you do have a lean/thin face which is always the most favorable to create definition from any form of facial implant augmentation…which is particularly important in trying to achieve the type of midface look you have described.

2) I can not provide numerical estimates for infraorbital-malar implies just based on pictures and an email response.

3) You can certainly try fillers but they an not create the same effect. Fillers are like injecting jello which is adequate to create indistinct volume but is not the same as putting a firmer material that pushes off of the bone. The latter can create an angular skeletal look was opposed to the former which creates an indistinct mass effect.

4) I could see the benefits of chin augmentation in the spirit of some additional facial masculinization effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to ask if can enhance and get sharp, well defined jaw while I have some asymmetry there? I mean if its possible with custom implants or something else would be needed? 

Best wishes.

A: A custom jawline implant is always the best approach for maximizing the effect and improving any bony asymmetries of the lower third of your face. Whether you would be able to see the type of result you desire is affected by one other factor…the overlying soft tissue and its thickness. Patients who get the best results have the thinnest tissues and leaner faces which enables whatever is put beneath them to show through the best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the maximum scalp expansion possible? I think I would like to spend at least 4 months and maximum of 5 months in the first stage scalp expansion. This is because i would need a pretty big augmentation, and my case is a bit of an outlier. Perhaps something similar to this photo. Is it possible? I have the time to spare.

A: Based on the picture you are showing no form of skull augmentation would require a scalp expansion to that degree. That is from a reconstruction case due to scalp loss and the scalp flap would be covering normal vascularized tissue one the tissue expander was removed not an implant.

But I am all for a nice slow scalp expansion in which more could be achieved than in the typical six week period commonly used in most two-stage skull augmentations.

Dr. Barry Eppley

Indianapolis, Indiana