Your Questions

Q: Dr. Eppley, I came across your practice online while researching rib anomaly correction surgery. I have always been self conscious of my rib cage and was hoping to gather some information of surgical options. I saw on your website that you’ve done some rib shaving to reduce the flare. I would like to learn more about the safety of such a procedure, how commonly you perform these procedures, and what would be a realistic expectation for aesthetic improvement. 

A: Thank you for your inquiry and sending your picture. I have done numerous subcostal rib shaving reduction procedures which is the protrusion you are demonstrating in your picture. This is a procedure that is very safe and effective and, in some cases, it is simply better to remove in its entirety rib #8 which is the main cause of the flare. Despite its safety and effectiveness the incision used to do the procedure is in a prominent area. I have always considered the scar a questionable aesthetic tradeoff in a young female in such a visible area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello. Here you can see that by extending my chin down and outward, it corrects 3 key flaws:

1) Lack of lateral chin projection. Before: from side view, the foremost point of the chin is slightly recessed from the foremost point of my lips. After: the foremost point of the chin now extends just *past* the foremost point of my lips.

2) Lack of vertical chin height. Before: from both side and front views, the jawline is weak and undefined, and the lack of height leaves the lower third of my face unbalanced with the rest. After: the jawline is accentuated and the lower third of my face is well-balanced and much more masculine.

3) Deep labiomental fold. Before: from both side and front views, the labiomental fold is excessively deep and concave, giving my lips an overly pouty look. After: the labiomental fold is much straighter vertically and more smooth, thanks to the added vertical chin height and lateral projection.

I understand that moving my entire jaw to simulate the desired look of the chin doesn’t give the most precise representation of a chin surgery result, but it does show that adding vertical height and lateral projection to the chin can significantly enhance the masculinity of the lower third of my face. I’d like to know if you disagree with any of this, and approximately what dimensions in millimeters of added height and projection you think would best achieve the optimum result. Thanks!

A: Thank you for your inquiry and sending your pictures. The jaw thrust is a very good method to determine that vertical chin lengthening is beneficial. What it also illustrates is that the chin movement must be at least a 45 degree type of augmentation, meaning that an equal amount of vertical and horizontal augmentation is needed. I would  estimate that the change you are demonstrating is probably in the range of 7mms horizontal and 7mms vertical, maybe 8 and 8.

Now that these dimensions are known the critical question becomes how best to achieve them. It is important to know that the soft tissue chin pad has limits in which it can be stretched unlike the rest of the jawline. That limit at best is a combined number of 12 to 15mms. (adding the vertical and horizontal augmentation needed) Thus this change can probably not to be done by an implant alone as the soft tissue chin pad will probably not stretch over it. This will requiter a combination of a opening wedge sliding genioplasty (to get all of the vertical length and some of the horizontal) and a chin implant overlay.(to get the rest of the horizontal and to make sure the chin width stays wide as the bone comes down and forward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If you play contact sports like soccer or football, will occipital skull reduction affect your game?(Example: making your skull weak because the outer cortex is being removed and rough contact to the head can injure you badly.) 

A: This is a common question about any form of skull reduction surgery and the answer is no it will not. The skull is composed of two hard cortical layers of which only one of those layers is removed in skull reduction surgery, still leaving a good layer of bone protection intact. It is fair to say like many structures in the human body that the skull is over engineered and provides more bone protection than we typically need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to enquire about your custom cleft chin implant design for male three-piece total jawline augmentation. My question is, is this procedure for men with existing cleft chins, or is it to create a cleft chin. If it is to create a cleft chins, then how does the procedure work. I always wanted a cleft chin as this is a big facial feature in my family and I have lost out on this characteristic/ feature.

I look forward to your response. 

A: The creation of a vertical cleft in the chin is done the same way whether one is getting a chin implant or not. A chin cleft does not occur because there is a cleft in the bone, this is a soft tissue ‘deformity’. Thus just because there is a cleft in a chin implant this alone will not make an externally visible cleft. The soft tissue has to be vertically removed or ‘clefted’ and then sewn down tightly to the bone. When making a cleft in a patient who is getting a chin implant a cleft is put into the implant so that the bone can be reached to tighten down the soft tissues to it. To make a very deep vertical chin cleft this is done by also removing external skin as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you think that there is a significant chance that the vibration from an electric razor, an electric hair clipper, or an electric toothbrush could dislodge the screws that are holding my facial implants in place? If you thought that the vibration might slowly unscrew them over time or cause any other damage, I could just avoid using them.

Thank you, respectfully and humbly, for any thoughts you have. 

A: There would be zero chance that any external vibratory stimuli could ever cause a screw to become loose in any of your facial implants. They are much more rigidly in place than any external stimuli could ever displace them. You should continue to use any electrical facial device that you want without restrictions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would I be a good candidate for head width reduction? I have all my life alway disliked and had insecurities with my bulbous wide shaped head. I cannot wear sunglasses because i look silly being the sides of my head Protrude further out than my sunglasses (especially the left side) and in photos my head always looks odd shape due to my light bulb shaped head. My goal would be to have a more symmetrical straight and less bulbous sides of my head. 

Is this surgery safe and why do more surgeon not offer this procedure? What is the down time for this procedure? 

I was told by local plastic surgeons they would not attempt this and is risky and would not remove temporal muscles being there can be issues later with chewing etc. 

I can feel the sides of my head and I definitely can feel that above the ear it is protruding bone although i do have very thick temporal muscles more towards the upper side part of head on side of forehead. Would you be able to shave some of the bone as well? 

Please provide your professional opinion i would definitely look to get this done if its safe and me being a good candidate.

A: Thank you for your inquiry and sending your picture. Temporal reduction by posterior muscle removal is a very safe and effective procedure. Because the muscle makes up a significant amount of the side of the head, there is almost never a need to remove any bone. And because of the added incision length up along the side of the head to do so, the small amount of bone that can be removed is not worth that scar tradeoff. Removal of the muscle makes dramatic change in the shape of the side of the head alone.

Contrary to what you have heard by other doctors (who have never performed the procedure or know anything about it), removal of this muscle causes no chewing or mouth opening/closing issues.

In looking at your picture, you are a good candidate for the procedure. The amount of potential contour change is seen in the attached prediction image. It is clear that the muscle on one side is nearly twice as thick as that of the other side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about temporal implants, zygomatic arch implants and vertical chin reduction. Are you pretty confident  that you can produce a significant improvement and that you would not have to go in again  and that the result would last several years.

With the temporal implant

With the cheek implant

With the chin

If it’s not enough augmentation, and fillers can make up the difference, then I might as well do fillers. But I believe you said on the net the fat can be used to effectively deal with that.

( I’m confused—-Since you are in there and you see the anatomy and you can custom carve  the implant- I had the clear impression that you can see what you would get before the swelling takes place , and that eliminates the guesswork. ) In the last letter you’re saying that it is tricky to know if it’s too much or too little..

Are most patients happy with a significant difference, (and that maybe you can see it as well). we have agreed that my face is long and that in your opinion the temporal area definitely needs augmentation and I do have a long chin. I realize that I make the ultimate decision but  how you and others experience my visual is important .

Like The experiment with the chin reduction, is there anything I can do to produce some type of visual of what it would look like with the midface implants? Also, and importantly, I want to be able to estimate  the length of the widening in the midface area so I can tell you how much, right? and I wonder that’s since the skin will be somewhat stretched in that area if that would have a secondary effect of slightly pulling out the corners of my lips. 

You have the panorex Of my chin area along with other films that showed all of the screws ——-that I provided on my first consultation. Could you please take a look at that and tell me the amount you can safely take it out? That would make my final decision about the chin area. also the soft tissue swelling that is present underneath the anterior aspect of my chin makes it look long as well and that is not part of the bone. And when I press that then that helps some.

Am I underestimating the noticeable benefit of reducing 7 mm? If you feel fairly confident that you can cut out the soft tissue underneath the anterior aspect of the chain +7 mm, I will do it, 10 mm would be great, but if only 5 mm plus the soft tissue then I would have to think about it. I sent you the pictures of the actor with the width of his face and short length of the chin from the bottom lip. is there a good chance that I could get fairly close to this?

Where is the Incision and scar with midface implants? In front of the year? Is the scar noticeable to the untrained observer?

How many days out before the scars are no longer noticeable or can’t be covered up with make up or skin coloured tape ?

Hoping that this will offer me clarity, and again thanking you for your time.

A: In assure to your temporal implant, zygomatic arch implants and vertical chin reduction questions:

1) All such augmentations of the temples and cheeks are done with implants so we know they will last forever. Their only question is the magnitude of the change…how much is enough, too little, or too much? This is a judgment call to which no one can accurately predict what you will see as too little, enough or too much. In surgery I have to pick an implant size and see what looks goods to me as you are not there to help me with the implant size selection. The biggest fear in implant size selection is in being too big….which is a %100 assurance of a revisional surgery to change.

2) When it comes to a reductive change like that of the vertical chin reduction, the fear is the opposite of that of implant augmentations….there is no risk of doing too much as it more of trying to make sure enough is done to make it worthwhile. This is where the anatomy has more control than that of just making a choice as to how much bone to remove. The limitations of the tooth roots and the mental nerve exit from the bone control where the upper bone cut is made and how much bone can be removed. (you have to stay at least 5mms below them to ensure they are not damaged) This is why I know that at least 7mms can be removed centrally and possibly up to 10mms centrally. A preoperative x-ray measurement will provide more insight which I will do when I am permitted to get back into the office.

3) It is a normal thought and every patient thinks the you can really see what an implant looks like in surgery because significant swelling has not yet occurred….but that is not true. What is overlooked is that in creating the tissue pocket all of the overlying tissues are elevated from their attachments. (that is what making an implant pocket means…creating an open space for the implant underneath the tissues) So when you put in an implant what really occurs is that the released tissues are floating above the implant and are not rigidly stuck down around it…which is what will eventually happen when full healing occurs. So much like having the sheets floating above the mattress on your bed, if you put a small or larger ball on the mattress underneath these floating sheets would you know what size the ball is or even that is was a ball??) This is what makes implant size selection so difficult on the face where a few mllimeters either way can make a big difference to the patient.

4) There is no question you have a long chin and there is no doubt that a diametric widening effect of the temples and zygomatic arches (lateral cheeks) works in concert with the vertical chin reduction to both create a shorter and wider appearing facial shape. Other than computer imaging there really is no other test to preoperatively determine the effects of the temporal or lateral cheek augmentations.

5) For vertical chin reduction I plan on removing both a wedge of bone intraorally as well as a wedge of soft tissue from underneath the chin.

6) Zygomatic or lateral cheek implants are placed through intraoral incisions. But they can also be placed through an external skin incision on the backside of the sideburn over the posterior zygomatic arch.

7) Since the only external scar you would have for all of these procedures is the one you already have (submental), the recovery and outcome for that scar is one you already know.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently read a paper titled “CLAVICLE LENGTHENING BY DISTRACTION OSTEOGENESIS FOR CONGENITAL CLAVICULAR HYPOPLASIA”.

I’ve reached out to the surgeons who conducted the first paper and am waiting for a consultation. 

My question for you is have you ever performed distraction osteogenesis of the clavicle. 

I read your blog post discussing the two options, and how obviously the latter would require a far more dedicated patient. My main concern with the osteotomy and bone graft is that you cannot observe over time A) the aesthetic result that each mm provides the patient and B) the functional health of the glenohumeral joint. For instance if any issues were to arise during the distraction phase then the process could simply be halted and a plate fixation applied at that point.

It seems to me that standard limb lengthening of the legs/arms would be far more invasive and arduous than the clavicle, due to the surrounding musculature and arteries/nerves nearby.

A: Distraction osteogenesis is not quite as simple as you probably think it is. While the concept is straightforward and well known for over 30 years, the rate of distraction is much slower in the axial skeleton than the face and the time period of consolidation much longer. Given that external distraction devices would have to be worn in bilateral fashion for an extended period of time, the practicality of its use for elective shoulder widening is suspect particularly on a bilateral basis. If any ‘issues’ were to occur during the distraction phase, the distracter is not merely removed and plated. It would still require a bone graft for consolidation to occur.

While I have done plenty of mandibular and skull distractions I have never done one for the clavicles. The surgery is straightforward. The issues is the state of development of the distraction devices for a bone that lengthen so very rarely. (as you have found on one case study)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached pictures for your review. My goals are to eliminate/reduce fat around my stomach, back, arms, flanks,  and inner thighs. I am hoping that I’m a candidate for a BBL (Brazilian Butt Lift), but I don’t know if I have enough fat to transfer.  I would also consider a butt implant. I’d like to get your initial thoughts based on my pictures.  

A: Thank you for your inquiry and sending your pictures. While any fat that is removed by liposuction can be injected into the buttocks, the question is how much fat would that be and how does that compare to the patient’s buttock augmentation goals. In just looking at your body pictures it would be fair to say that the volume of fat extracted (after concentration and % survival) would produce only a very modest buttock augmentation result by itself. If the buttock augmentation goal is more substantial the fat removed by liposuction is better served as a concurrent complement to an intramuscular buttock implant placement. (known as composite buttock augmentation)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have positional plagiocephaly on left side, which is not actually that bad but I can feel it and it affects my face, mostly nose and ears because the skull is like rolled on one side and so the bones on cheek and eye bones are more in front on left side. I would like to get my head more symmetrical but it is possible to get my face more symmetrical?

A: Thank you for your inquiry and sending your pictures. Plagiocephaly, otherwise known as cranioscoliosis, can affect the face (front of the skull) just like it affects the back. The displacement on the face is the reverse of what is seen on the back, meaning that the flat side on the back pushes the ear and face on the same side forward. Improvements can be made to the ear if it sticks more but you can/t change the anteroposterior of the ear on the side of the head as that is fixed by the external auditory canal. The more prominent cheek and lateral orbital rim/brow bone can be reduced and it is a question of whether the reduction of the bony protrusion that is possible is worth the surgical effort. To assess that issue a 3D CT scan of your face is needed to look and measure the differences between the two sides.

Lastly, the nose typically deviates away from the more protrusive side of the face of which traditional rhinoplasty surgery can bring the nose back into better symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a middle age male whom found a post you wrote, which is one of the few bits of information I have found online regarding a problem I have and I would be very grateful for some advice as I’m not sure what to do. This is the post I found: 

https://www.eppleyplasticsurgery.com/how-do-i-correct-my-facial-sagging-after-upper-jaw-surgery/ 

I had double jaw surgery almost twenty years ago. My lower jaw was moved forward to correct a large overjet and my upper jaw was impacted to correct a gummy smile. I was warned that I could develop extra lines under the eyes that I didn’t have before. Unfortunately this happened to a much greater extent than I expected. It is very apparent when i smile or make any facial gestures. Even when I talk I get the lines to a lesser extent. It has effected my confidence and i have avoided photos a lot. I also haven’t seen anyone else with a similar problem which makes it more frustrating. 

I have found it very difficult to find much information on this. I’ve tried Botox but it didn’t do much. I tried injectable fillers last year but it didn’t do much. I had a consultation with a dermatologist who told me that I have lost volume and filler would solve it. I also saw an eye surgeon who didn’t think filler would help. He said he couldn’t remove some of the bunched skin when i smile as the skin is taut at rest. 

It feels to me that there is too much force pushing the skin under the eyes when i smile and it is causing it to bunch and crumple. It feels to me that I have too much tissue under the cheek bone area that is pushing the skin and I have hardly anything under the eye area to resist the push! Not sure I had much under the eyes to begin with as I had a long thin face prior to surgery. But I feel like I’m just guessing. 

Any help would be much appreciated! 

A: Thank you for your inquiry and sending your pictures. Unfortunately more pictures than just a frontal smiling one are needed for a more comprehensive assessment. (non-smiling and smiling front and side views) But based on your surgical history and description of symptoms I would initially speculate that what you have is ‘too much tissue’ for the vertical midface bone height. Thus it bunches up a lot because there is a mismatch between the amount of soft tissue (which hasn’t been changed) and the vertical midface bone height (LeFort I impaction) which has. This would suggest that this isn’t a volume issue (which is why filler will not work) but an excess tissue one. It may be appropriate for a lower blepharoplasty-midface lift…but I would need to see what your undereye-midface looks like when you are not smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about the three operations I will be having. What are the downsides of any of these three procedures (temporal implants, lateral cheek implants, chin reduction)? And percentage frequency of the downsides? Is there any chance the implants would not look natural? Do they look as good as fillers?

I heard once, and it may not make any sense, that injections of saline can give a good idea about how fillers or implants might look, and then a person can make a decision about implants. Is that true? Is there anything else that might work this way to give an idea that might last only several hours or a day?

Are you confident that you can obtain at least 7 mm reduction in chin length (hopefully more)If you are not certain of this then I don’t believe I would go forward unless would be certain that with five or 6 mm  it would make a significant difference ——I am not interested in just a little better or slightly noticeable in its effect on the entire face. I definitely would want 10 millimeters or 1 cm, which is only 2/5 of an inch. In real life, when this is done, is this a lot? Does it usually make a noticeable difference? Will this change the shape of the chin? Do you grind it down with a machine?

Will the scar necessary for the temporal implant be noticeable? If it is behind the hairline, will it change the hairline or be a noticeable scar underneath?Same question for cheek implant.

What are the chances of the implants moving, or shifting, or getting bumpy to where they would have to be replaced?

You may have answered this question, and I apologize if you already have, but is it possible that the temporal implant will erode the muscle or the bone?

How long will the implants last?

Would you have to do any filler around it?

Regarding the possibility of the lateral cheek implant to widen the face, does that look natural or a little strange or different?

Will that significantly widen the face or just a little bit?

When I am very pleased and confident with my face when I change to a wide mirror, obviously, the entire face is widened, including the area from where the jawline begins to the chin. Of course we don’t want to widen this, but I wonder if that will be problematic in terms of the overall look of the wider face I am seeking.

If I go forward with the lateral cheek implant and that fails, and there is some redundant skin, can filler be used as a backup that would look good if needed?

If I hold off on doing the lateral check implant and want to do some injections 1st to see, can the lateral cheek implants be done under local? that really helps with the cost.

Can I go back the next day? Any particular work restrictions as long as I’m okay with the swelling? Any big bandages on the chin?

How many of each of these three procedures have you done over the last year, and since your career? I would suspect because you are board-certified in both maxillofacial and plastic surgery, that you have done many.

Thanks very much and hopefully no more, not too many more questions

A: Like all procedures there are downsides/risks…which is what I think you are asking. Having done a lot of all three procedures I would say that the only real major aesthetic downsides are as follows:

1) Temporal implants –   least risky of them all and completely reversible. The question is how much is enough and what is too much augmentation?

2) Zygomatic Arch Implants – effective but can be tricky to get perfect symmetry…but still reversible.

3) Vertical Chin Reduction – I think the question here is given the amount of bone that can be reduced, is this enough

The only solace I take from #3 is that #1 and #2 help with the overall appearance change. In other words, widening the temples/midface works in concert with the chin reduction to help make the face appear vertically shorter.(diametric movements)

I think with the implants there if very little risk of looking overdone. I worry more about not enough than overdone. As a general rule, implants usually look better than fillers and have a more pronounced effect.

You can try saline injections, and they don’t really create the effect of the implants, but they will at least do something. (a thin liquid can never create the same tissue push as a more firm implant)

Most vertical chin reduction by intraoral wedge osteotomy remove in the 7mm range of vertical bone height. A panorex x-ray is needed to measure how much bone can be safely removed based on the location of the tooth roots and the mental nerve exit.

While the chin shape will change if someone has a more pointy chin (will get more flat or square) yours is already so…so in your case I don’t envision any significant chin shape change.

The temporal implant is put in with an incision behind the ear so it is scarless.

I have never seen temporal or zygomatic arch implants move/migrate. They are very smooth so they will not cause an irregular outer contour. Again symmetry is the issue here.

The temporal implant is a muscular implant which is unique amongst facial implants. It sits on top the muscle underneath the fascia. Muscle erosion is not an issue of concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if head width reduction can only be done by the removal of the temporal muscle, or is it possible after removing the muscle to also apply some bone burring to reduce the width even further?

A: When it comes to head width narrowing by temporal reduction, it is important to appreciate the muscle:bone ratio of the width reduction that is possible. Since all of the muscle can be removed but only a portion of the bone, the bulk of a head narrowing effect comes from the muscle removal. The thin temporal bone underneath can be reduced a bit but it takes a longer incision along the side of the head to do so. Because if this aesthetic tradeoff and the minimal contribution the bone removal creates, most patients opt to go with the muscle removal only with a completely hidden scar. So it is not a question of whether it can be done but whether it is worth it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m thinking about scheduling a consultation with you guys, but before I fly all the way to Indiana I have a few questions. 

With your custom chin implants how many mm will the jaw be extended? I need about a 20 mm extension. I know that’s not common, but I was also thinking doing a sliding genioplasty procedure for more extension. Is it possible to get to get the projection I want with those two procedures? 

A: Thank you for your inquiry. To get to 20mms of horizontal chin lengthening the backbone of that procedure would be a horizontal sliding genioplasty done first of 12 to 14mms, followed by either a second sliding genioplasty or a custom chin implant. The stretch of the soft tissues will not permit an immediate 20mm of horizontal chin lengthening. The custom chin implant would be the preferred secondary chin procedure as it could address the narrowing effect of the large sliding genioplasty movement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After having my cheek implants removed, I feel like my mid-face is looser and less smooth. I think as thinking about getting co2 ablative laser to tighten it and hopefully help the tissues settle to how they were before. I think there is some sagging and my lower cheeks appear fuller, but I’m only two weeks after removal, so I assume I have to wait a few months to make a final judgement. I also want to get cheek and under eye fillers. 

1) how long do I have to wait to get ablative co2 and do you think it can help with tightening/settling the soft tissue? 

2) how long do I have to wait to get filler in the area? 

3) if I get filler and co2, should the co2 come first? 

Thank you

A: In removing cheek implants it is important to recognze that the tissues are very unlikely to ever return to exactly what they were before. If you recognize that cheek sagging is evident now aye this early point after their removal, now further healing time is not going to make sagging tissues snap back into place…those ligamentous attachments have been lost. While treating the outer skin by any form of laser will not hurt, that can not address the deeper cause of the sagging nor will a minor skin tightening effect make any change. Volumetric addition by injectable fillers  may provide some temporary lifting effect. Fillers should always be diet after laser treatments so the heat from the laser does not prematurely cause breakdown of the filler that lies underneath.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think I have cutis vertices gyrata (CVG) of the scalp. I have not consulted with a dermatologist so I’m not sure what CVG type it is. Ideally, I would like to have a scan CT/MRI to identify the disorder and plan treatment moving forward. If your facility provides all these services then I would like to schedule a consult.

A: CVG is a scalp disorder not a bone one. Thus MRIs or CT scans are not helpful in making the diagnosis or for treatment planning purposes. There is no method to diagnosis it over than by its appearance and clinical examination. The cause of CVG is unknown. It can only be treated by either  excision (cutting it out) or by fat grafting. (release and fill with injectable fat grafting) Each treatment method has its advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long chin and I know you said that the correct treatment for it was a vertical chin reduction done from inside the mouth.The computer imaging you sent looked like a good improvement. But I wanted to know one more thing. If you could make the chin this it would be perfect. My other question is can I also get a rhinoplasty to go with it. On the side it just all sort of needs to come down a little and be straightened. I have a lot of cartilage around the sides. When I smile there’s a pretty good bump. Thats all for now thanks alot. 

A: In answer to your vertical chin reduction and rhinoplasty questions. 1) If I understand the purpose of the two pictures properly, I believe you would like to achieve that degree of vertical chin shortening in the frontal view. While that is an admirable goal, the limitation in vertical chin reduction is how much bone can be removed given where the tooth roots and the mental nerve exist are located. As a general rule 8 to 10mms of bone be removed which I suspect will not exactly achieve your ideal vertical chin shortening goal.

2) It is common to perform rhinoplasty with any other facial procedures particularly that of chin surgery. What you are fundamentally describing is the straightening of the dorsal lines of the nose as the fundamental goal of your nose reshaping objectives. This is a common and achievable goal for many rhinoplasty patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a wide and asymmetric forehead. I have asked people if the right side of my forehead was larger than the left side but they said they didn’t really notice. But my forehead is definitely bigger than the rest of my face. What would be the options for making the forehead more in proportion with the rest of my face?

A: Thank you for sending your pictures and inquiring about forehead reduction surgery. From the frontal view I see two issues that make your forehead appear wide. 1) The posterior temporal area at the side of the forehead (marked in black) and wide bony temporal lines of the more anterior forehead. (marked in yellow) The temporal widening is treated by a temporal reduction procedure done from an incision behind the ear. (scarless)  While the bony temporal lines can be reduced to make the forehead more narrow, this requires a scalp incision which is more aesthetically challenging in a male. Forehead reduction in a male requires a thoughtful approach to the decision for incision placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Since I live out of town I assume that the creation of a custom chin implant is a process which would probably (?) necessitate my traveling to Indiana more than once. It would take a lot of effort for me to travel for the actual surgery. Therefore, I was hoping that the Implantech off-the shelf VLC chin implant would work for me. Your last email seems to indicate that this type of standard chin implant might not work for me.

A: In answer to your chin implant questions>

1) A custom implant approach is all done remotely, meaning you never have to come here to get the scan or design the implant. You only come here for the surgery.

2) But for the sake of further discussion on the less than ideal approach of trying to make a standard chin implant work, the VLC provides an equal amount of horizontal projection as well as vertical so the implant would have to be significantly modified in surgery to try and create the pure vertical lengthening effect. You simply can not use the VLC implant as it was designed in your case of vertical chin elongation.

3) And for the sake of thoroughness on the topic of vertical chin lengthening, the intraoral vertical lengthening bony genioplasty is the traditional approach to accomplishing that and it works well when the lengthening needed is 7mms or more….which an implant does not do well beyond that length requirement due to the need for the soft tissue chin pad to stretch over the implant.

4) As an overview you have three options for your vertical chin elongation which would be in the ideal order of:  vertical lengthening bony genioplasty, custom chin implant and modified VLC standard implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, About six months ago I had jaw implants. Three days ago I had unbearable pain from a toothache. The next day I went to a dentist and was prescribed Clindamacyn 300mg 3 times daily to treat a tooth infection. A day later I had the tooth drained, and next week it’ll be treated with a root canal. I’m concerned that the infection may have/will spread to the implant. The infection was around my upper molar. It led to severe left cheek/jaw swelling that I still have two days after beginning antibiotics. I wouldn’t say I have sharp pain at the implant site, but definitely some tenderness. 

I guess my questions are: 

1) is it likely that the infection could have spread to the implant? 

2) is there any way I can verify definitively whether the infection spread? Would x-rays be able to determine that? 

3) is 300mg 3x daily clindamycin the only thing I can do about it for now regardless? 

Thank you

A: In answer to your questions about potential jaw angle implant infection:

1) Generally an upper tooth infection does not spread to the jaw angle area as that is in a different tissue plane. There may be overall swelling in that side of the face but that does not necessarily mean the jaw angle implant is infected.

2) Infection can not be ruled in or by out by a CT scan unless there is a large fluid collection present.

3) Clindamycin is one of the first line drugs of use for oral-based infections. But like any infection the primary and most effective treatment is to eradicate the source.

4) These questions are more appropriately directed to the surgeon who placed your jaw angle implants. He/she would want to know about these concerns and followup up accordingly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long chin and I know you said that the correct treatment for it was a vertical chin reduction done from inside the mouth.The computer imaging you sent looked like a good improvement. But I wanted to know one more thing. If you could make the chin this it would be perfect. My other question is can I also get a rhinoplasty to go with it. On the side it just all sort of needs to come down a little and be straightened. I have a lot of cartilage around the sides. When I smile there’s a pretty good bump. Thats all for now thanks alot.

A: In answer to your vertical chin reduction and rhinoplasty questions. 1) If I understand the purpose of the two pictures properly, I believe you would like to achieve that degree of vertical chin shortening in the frontal view. While that is an admirable goal, the limitation in vertical chin reduction is how much bone can be removed given where the tooth roots and the mental nerve exist are located. As a general rule 8 to 10mms of bone be removed which I suspect will not exactly achieve your ideal vertical chin shortening goal.

2) It is common to perform rhinoplasty with any other facial procedures particularly that of chin surgery. What you are fundamentally describing is the straightening of the dorsal lines of the nose as the fundamental goal of your nose reshaping objectives. This is a common and achievable goal for many rhinoplasty patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think it might be best just to ask a few questions along with a few photos for you to view. I understand a chin implant or a sliding genioplasty would highly benefit myself, although being 26 years of age, I am leaning toward a sliding genioplasty.

If I’m deemed a suitable candidate, my main concerns are: 

1) The “step off” created from moving my chin forward creating a narrow profile (sliding genioplasty), being a male with an already narrower jaw/chin a smooth tapered jaw/chin is ideal. Some surgeons use materials like Goretex to place along the chin/jaw for a nice look. What would likely be recommended in my case?

2) A unnatural labiomental fold is, this is a big concern and reason I’m looking to avoid an implant. Based on a quick assessment of my photos provided, would grafting to my labiomental fold be necessary to avoid an unnatural look? If so, what type of grafts are used?

My goal is a well balanced natural looking face with a stronger chin and jaw. 

Here are two patients of a sliding genioplasty along with my facial profiles to get a quick assessment of myself

A: Thank you for your inquiry about sliding genioplasty and sending all of your pictures to which I can say the following:

1) The deepening of the labiomental fold occurs in both implants and the sliding genioplasty. There is no difference between the two in terms of having that effect as the labiomental fold is a fixed anatomic point due to the origin of the mentalis muscle. That is not a good reason by itself to choose a sliding genioplasty.

2) The sliding genioplasty does offer the ability to manage the depth of the labiomental fold better by placing something into the anterior step-off which is either a graft or an implant. The anterior step-off is better managed by some form of a bone graft.

3) Every sliding genioplasty, by definition, creates lateral or posterior stepoffs which will narrow the chin or create indentations. That can be managed by implants of which ePTFE (what is historically known as Goretex) is one option.

4) A sliding genioplasty provides aesthetic enhancement to the chin not the jawline that is behind it. It is not a jaw enhancing procedure by the anatomic definition of the jawline.

5) Attached imaging is one flavor or degree of chin augmentation, you may prefer more for less….yet to be determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, when it comes to my eye area i suffer from extremely ” big “/ puffy and swollen upper eyelids which have gotten even ” bulkier” since my usage of oral minoxidil ( a medication which cause water retention that i can’t unfortunately stop) So I would like to know if there is a way to actually reduce the size of my upper eyelid in itself especially if i’m still using medication that cause water retention or with people suffering from congenitally ” bulkier” upper eyelid than average 

That’s a question I’ve had in mind for quite some time now and I would to have an answer from a skilled surgeon like you. Most surgeons in my country when it comes to an enlarged upper eyelid due to water retention / allergy or congenitally bigger than the norm seem to work by skirting the issue using upper eyelid fillers or fat graft but won’t touch to the upper eyelid in itself. 

Here is a picture (which is not of my eyes but with a problem similar to mine when it comes to upper eyelid minus the droopy upper eyelid skin ) to illustrate my case. 

A: Thank you for your inquiry and sending your picture. The use of fillers or fat grafting to the upper eyelid would be counterproductive in terms of decreasing the upper eyelid above the level of the crease. Your assumption is correct in that a surgical procedure is needed which may consist of fat, muscle and skin removal based on what the preoperative exam shows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am an older female who had a small chin implant placed many years which I have never been happy with. It provided a small amount of increased chin projection but it still looks short. I think it needs a vertical increase which I think would be best done by a vertical lengthening chin implant. Does this sound right to you? 

A: Thank you for your inquiry and sending your pictures. While I think the attached imaging is clear that vertical chin lengthening is of aesthetic benefit, there are other dimensional issues to consider that go behind just that of the vertical dimension. In particular in the front view your perception of the width of your chin (do you want it wider as that is what a standard vertical lengthening can implant will do) and also in your case the prominent prejowl indentations which will not be eliminated by the use of a standard implant. (see attached image) It becomes important to know before surgery what the limitations of any implant style and size will do and not do so you don’t end up where you are now…improved but still with some missing improvements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a small anatomical chin implant five years ago and am seeking a revision. I want additional height and projection to the chin without looking too boxy along the jaw. Can you tell me which would work better? The flowers mandibular glove chin implant or the vertical chin lengthening chin implant?

A: Thank you for your inquiry and sending your pictures. If your description of a small anatomic chin implant is accurate this means you have a central chin style (no wings) implant of 6mms horizontal projection. Your pictures show no compelling need for any significant vertical chin lengthening. While it is not clear how much more horizontal projection you desire, the large or x-large mandibular glove chin implant should suffice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a recovery question after my perioral liposuction surgery. My healing process is going great and I feel great too! I was just wondering if I need to be massaging the liposuctioned area at all as it feels a bit hard? Perhaps that is normal but I wanted to ask, in case I just need to leave it alone…

Thanks for your help! Talk to you soon! 🙂 

A: Any area of the face or body that undergo liposuction area will feel very hard up to 6 to 8 weeks after surgery, perioral mound liposuction is no exception.tThis is normal and will resolve naturally on its own over time. But the process can certainly be expedited by massage which helps break up the scar tissue and get the lymphatic drainage in the area returning to normal sooner. Within reason you can’t overdo the massage manipulation of the perioral area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, With my surgery approaching, I wanted to reach out with a couple of very specific questions. On the phone we discussed that I would still be about to practice martial arts (specifically Brazilian jiu jitsu) following rib removal surgery. You explained that the ribs removed really aren’t shielding anything and so it’s totally safe to resume all activities after healing. Now that I’ve decided to have the operation, I just wanted to confirm this and explain a little more about the sport. It’s basically wrestling with submissions, and it can get pretty rough. Along with striking, its the main martial art used in the UFC and training often involves people far heavier than me putting maximum pressure on my abdomen, crashing into me, taking me down hard, etc. While there is no striking, human beings lifting each other and hurling their bodies through the air can create a lot of impact and the sport can get a little extreme. At my gym, we try to be as safe as possible in training but not everyone has a high level of body awareness and this can lead to injuries. I also wanted to share that prior to scheduling my surgery. I talked to another surgeon about rib removal and he seemed nervous/hesitant when I asked if I’d be able to train Brazilian Jiu Jitsu afterwards. He explained that he trains the sport himself and said he was nervous I’d get hit in the kidneys. I forgot to share this with you at the time of our consult so I am trying to understand why he might have that hesitation–whether it’s overly cautious or warranted due to his knowledge of the sport. Martial arts is my passion, and I wouldn’t want to lose the thing I love to do most. At the same time, if it’s safe, then I absolutely want to do it—but since the operation is not reversible, I am feeling the need to clarify and explain in depth. 

Secondly, I wanted to ask about child birth. Is it possible to have a child after this operation? I don’t even know if I plan to have kids, but I read that the model Sophia Vegas suffered complications after having the child and having the rib surgery. From what I read, it sounds like her organs shifted and she required an operation. I was wondering if you heard about this story and if you think it is a risk factor as long as the operation is done correctly. 

Sorry for the long winded email. Because there isn’t a lot of information online about this surgery, it’s hard to look things up and do the level of research I normally would. The martial arts question is my main one, and I basically just want to make sure I’m emphasizing how rough it is, so you can advise whether that activity would still be absolutely safe post op–of course once I am healed. 

Thank you so much for your time.

A: In rib removal surgery the portions of the ribs that are removed do not affect the medial portion of #12 which is what is covering/protecting the kidney. So in theory this should not be an issue from an anatomic perspective. That being said I have never performed this surgery in someone who is exposed to this degree of physical activity or trauma. And since this physical activity is your passion, and rib removal surgery is purely elective, the absolute safest choice is to not do the surgery. If, however, one wants to take a ‘riskier’ or unknown outcome choice, do the surgery and leave #12 rib alone which has the least impact on the outcome due to being the shortest of all ribs.

As for child delivery after rib removal, I have never heard the story to which you refer nor do I believe it. Subtotal rib removal of the lower ribcage would have no bearing on pregnancy or delivering a child either vaginally or by C-section.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgery for a full custom wrap around jaw/chin implant. The desired outcome is to augment the chin both horizontally (widen) and vertically (elongate) whilst creating a more ‘square’ shape. The desired outcome is also to widen and create definition in the 

lower mandible border and vertical elongation of the mandibular angles – again to create a more ‘square’ shape. I also have some asymmetry in the chin/jaw which I would be looking to improve with the implant. 

I am based in the UK and willing to travel internationally for surgery. Is this something which can be accommodated? Are my desired outcomes something that could be achieved via a custom wrap around jaw/chin implant? 

A: Thank you for your inquiry and detailing your facial reshaping objectives. It is fair to say that only a custom wrap around jawline implant can accomplish the complex 3D changes in the shape of the lower jaw. I will have need to get some pictures of your face to do some computer imaging to determine the exact magnitude of these jawline changes. I have many international patients so your request is a common one in my practice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question regarding cheek sagging/puffiness after cheek implant removal. I had my cheek implants removed after 2.5 months because I wasn’t happy with the look. I felt my soft tissue didn’t look chisled, and the implants didn’t look natural. Even when they were in, I noticed that my lower cheeks seemed fuller, despite there being no implant there. After getting them taken out I still feel that my lower cheeks, particularly near my nose, look fuller and bloated. It’s not so much that they’re sagging; it’s more that it’s just not tight and thin like it was before. 

I feel the reason for this is after the soft tissue was detached from the bone, it’s simply not reattaching the way it was before. So even though it may not be sagging, the area is still bloated. When I push down on it I feel like I can push down half an inch. Is there anything I can do about this? I’m basically just looking to tighten the skin to the way it was before. The whole thing is just extremely depressing for me, as I lost thousands of dollars and feel like I was permanently disfigured. Had I have known that it wasn’t a reversible procedure I don’t think would have ever done it. 

Are my concerns valid? Essentially, does it make sense for the soft tissues to be bloated as a result of them not reattaching to the bone? And will they ever reattach? And is there anything I can do to tighten it up again so my face is not so bottom heavy/bloated. Would soemthing like laser work? 

Furthermore, if there is a solution is it risky? I’ve gone though enough emotional and financial trauma that I don’t want to do it unless it’s a relatively straightforward fix.

A: Thank you for your inquiry and detailing your surgical history and postop cheek implant removal concerns to which I can say the following:

1) By definition placing cheek implants requires the disinsertion of the osteocutaneous ligaments to the cheeks. The implant then acts as a spacer lifting up the released tissues. (soft tissue float) If the implant is removed these ligaments do not reattach. In a facial structure like the cheeks, which is like being on the side of a cliff, the released and floated soft issues fall down. Thus your supposition of what you are feeling is anatomically correct.

2) If a male gets standard cheek implants, they are more likely than not to created that bloated facial look and not achieve a more chiseled look. That is because such standard cheek implant create anterior submalar fullness and are not design to create the high cheek bone look that many men desire. This requites custom implant designs to do so. The standard cheek implant styles are largely made for women not men.

3) While there are techniques to try and reattach the cheek soft tissues up higher and back into place, they are neither straightforward or have an assured outcome of doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, if I’m going to vertical chin reduction done as part of my facial widening I want it to be substantial and not an improvement by just a little bit, it seems as though you’re suggesting that the shaving approach is much more involved and actually I thought that’s what we were going to be doing. You would mention 5 mm to a maximum of seven for the vertical chin reduction. If we were to do the 7 mm, plus temporal implants, do you think that would significantly widen my face and do the trick?

A:In reference to the vertical chin reduction there are two approaches to it, an intraoral wedge reduction bony genioplasty and a submental shave technique. (technically using a saw) In both approaches the maximum of 7m ms of vertical bone reduction can be achieved. Since you have an existing submental incision that would seem to be the logical approach. To really know if 7mms vertical chin reduction would reach your desired aesthetic change, I would take a 3 x 5 card or piece of paper and place it at the horizontal level of the chin up from the bottom that looks like the amount you see as being effective and then mark it. Take the vertical measurement then from the bottom of the chin. That number will tell us where 7mms is in the ballpark of being aesthetically effective for you.

Dr. Barry Eppley

Indianapolis, Indiana