Your Questions
Your Questions
Q: Dr. Eppley, I am interested in learning more about I am interested in learning more about revision genioplasty. I had a 6mm silicone chin implant placed under the chin which I had for 18 months. It was uncomfortable and so stiff. I had this removed and replaced by a sliding genioplasty of 8mms. This is also very very tight and all my teeth and gums feel tight and I’m in constant discomfort. There is a heavy feeling in my chin and a real tightness which is made worse when I talk. I have had 3 steroid shots in to the scar and it has helped a bit. Can you add any thoughts as to what’s going on here and any possible treatment? I have attached pictures and x -rays. It’s been 9 months since the genioplasty.
A: Thank you for your inquiry and sending your pictures. Having persistent tightness regardless of whether one has had a chin implant or a bony genioplasty was done may speak to the possibility that any type of chin surgery in you will create the same effect. So it is possible that no revision genioplasty procedure may provide relief.
But the one observation I can make from your x-rays is that your bony genioplasty was positioned very high….much higher than normal. This makes the whole chin tissues vertically shortened and compressed. I think that happened because they wanted to place lag screw fixation and they unintentionally ended up having the downfractured chin segment moved way up to do so. (plate fixation would have avoided that positioning) In effect you have had an unintentional ‘jumping genioplasty’ technique done. I could easily see how that could make you chin tissues tight.
The revision I would see is to move that bony chin segment vertically down to create a more normal bony chin profile and relief the tension on the tissues. (keep most of the advancement but ‘re-lengthen’ the bone) This can be challenging given that lag screw fixation is often not easy to remove but it can be done.
But as I said originally, it is unknown whether any chin surgery will relieve your symptoms. But that is an unusual bone position for a sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 42 years old female and I just had a 3rd Revision Rhinoplasty to remove mersilene mesh implant but the surgeon inserted 12mm diced ear cartilage to have dorsal and bridge augmentation from one ear and made my nose misalignment, huge and high.
Is it true that it is hard to remove all those diced ear cartilages inserted into the nose after one year since I’ve got so many diced ear cartilage pieces and replace them with rib grafts? Will the surgery be somewhat messy and have unpredictable outcome?
Please help, thanks very much
A: I would not envision removing a diced cartilage graft to the nose to be any more difficult than that of mersilene mesh In fact mersilene mesh would be harder to remove. After one one year the diced ear cartilage graft is much more like a composite graft and may be able to even be shaved down. If reduction of the height is the goal I would think that reducing the graft you have would likely be what is needed, not necessarily total removal and replacement with a rib graft….uness there are some major irregularities or contour issues with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about infraorbital rim implants. In addition to having hollow tear troughs, my lower lid is a bit droopy and I have scleral show underneath my pupils. I was wondering if infraorbital rim implants can help elevate my lower eyelids in addition to filling in the hollowness. I was also wondering if there’s an added cost to extend the infraorbital rim implants to the cheek.
Thank you
A: In answer to your orbital rim implant questions:
1) Orbital rim implants along with a lateral canthopexy can help raise up the droopy lower eyelid and decrease scleral show
2) The cost of manufacturing and placing custom orbital rim or custom orbital rim-cheek implants is the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently considering having many procedures done simultaneously:
- Wrap Around Custom Jaw Implant
- Custom bilateral infraorbital-malar implants
- Bilateral Buccal Lipectomies with Perioral Mound Liposuction
- Septorhinoplasty
- Fat Grafting to: Labiomental Fold
- Submentoplasty
- Calf Augmentation Implants: Bilateral
I have questions about other procedures as well:
- Would I be a candidate for bilateral vertical ear reduction? I don’t like the size/shape of my ears and how large the upper half is. I’ve attached a picture.
- Is ear rotation possible? Do you think I’d benefit from rotating my ears forward slightly? I feel I have posteriorly rotated ears.
- Can botox be placed in my mentalis muscle to reduce the bulbous appearance of my chin?
- Are splints placed in my nose after septorhinoplasty? If so, when would these be removed?
- Can all of these procedures be done at the same time?
A: In answer to your questions:
1) You would be a candidate for vertical ear reduction using a scapula flap reduction technique.
2) Ears can not be successfully rotated on his ear canal axis due to the stiffness of the canal cartilage.
3) Botox is not known to be effective for reduction of mentalis muscle fullness.
4) I do not use internal splints or packing for septal surgery. Quilting sutures are used instead to reapproximate the musical lining on both sides of the septum.
5) All face procedures along with calf implants can be done at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know you said that the forehead augmentation surgery is safe. However I do have some questions about brow bone reduction- if you don’t mind giving me some clarity.
- How safe is this procedure? Are there any health risks?
- Would that result in a loss of my ability to control my eyebrows / have facial expressions?
- How much pain is generally associated with this procedure and how long does the pain last?
- I know the sinuses are in the area where the brow bone would be reduced. How often is that an issue? I was reading one of your studies on a patient who underwent a brow bone reduction and forehead augmentation. Due to his sinuses it said something about him needing screws and metal T plate or bracing to undergo the procedure. It was a little hard for me to understand- can you please explain what that did? Also is this commonly a necessity with brow reduction?
Case Study Reference: https://exploreplasticsurgery.com/case-study-combined-male-brow-bone-reduction-and-forehead-augmentation/
Sorry for all the questions. I have never undergone cosmetic surgery so I just want to know what I would be getting myself into.
A: In answer to your brow bone reduction and forehead augmentation surgery questions:
1) Such surgery is perfectly safe and poses no health risks.
2) The surgery does not affect the motor nerves that work the eyebrows and forehead muscles.
3) Actually pain is not that significant with forehead surgery and that is because most of the forehead will have some temporary numbness.
4) By definition a brow bone reduction is a frontal sinus reduction procedure.The bone in front of the frontal sinus cavity is removed and moved back further into the front sinus cavity. That is what makes the projection of the brow bones less. To hold the bone in place as it heals in its new position a small plate is used to do so.
All males that want less projecting brow bones need this type of brow bone reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a nasal implant removed because of an extrusion in skin and was replaced by artificial dermis graft to camouflage the damaged skin in the upper half of my nose while adding diced ear cartilage instead. I’m concerned about the artificial dermis graft that was used specifically for infection or any other complications that may arise from nasal implant removal. Is there any time frame to have free worries about it? Will my skin repair itself and the dermis will disappear within a few months? Thanking you in advance Dr. Eppley for your help
A: Not knowing the exact type of dermal graft, its manufacturer and thickness, I can not provide any specific answer to your questions. But as a general statement most cadaveric or tissue back dermal grafts may eventually be replaced by your own tissue over months to years after nasal implant removal surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I contacted you before about jaw implants. Thank you for doing that morph, but I am wondering how I can get a wider lower jaw, mandible, horizontally, without the use of implants or fillers. You have custom angle implants, but I was wondering if there is a surgery where the bones can be repositioned to achieve a wider jaw, like an osteotomy, which is more natural. I have protruding cheekbones and I also wonder if some bone can be shaved from them and put in, grafted, to both sides of my lower jaw to make it wider and give me a higher facial width. It’s probably not possible but I’m just wondering.
A: In short, there is no other way to achieve jaw widening except by an implant. There is no osteotomy that can widen the lower jaw and bone grafts will just melt away as they have no functional purpose for being there.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering the possibility of getting wrap around jaw-implants. I had a couple of questions.
1) I’m having a hard time finding many before and afters online – especially with people around my age and face structure, do you have more before and after shown in your office that are not online?
2) Approximately how long after the procedure can a person talk and eat as normal? In other words: when can they return to their normal routine and be around others, without it being known they’ve had surgery done.
3) What is the possibility of permanent nerve or muscle damage that the face would not move properly?
Thank you!
A: In answer to your custom jawline implant questions:
1) Due to patient confidentiality and the extreme reluctance of young men to allow their pictures to be shown, few public pictures are available.
2) You are referring to the swelling that occurs after surgery of which it usually takes two to three weeks until one looks fairly ‘non-surgical’ in appearance.
3) There is no risk of the face or jaw not returning to normal function/movement after the swelling has subsided. There is no motor nerves in the pathway of its placenta.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was just wondering if neck implants to give a thicker masculine neck existed. Implants that would be placed in the sternocleidomastoid area to give a wider/thicker neck appearance from the front.
Thanks.
A: While there is no such implant made to augment the sternocleidomastoid muscle, as that is a request I have never received before, that does not mean such an implant can not be made. The practical side of placing them lies in the risk of injury to the greater auricular nerve which crosses over the mid portion of the muscle. While this is not a motor nerve that creates any neck movement, it is a sensory nerve that supplies feeling to the lower half of the ear. That would be the only issue to consider in placement of a ‘neck muscle’ implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m currently in consultation with regarding a malar infraorbital osteotomy. But given the risks of the procedure compared to implants, I’d like your opinion on how much augmentation we could achieve, the potential bone loss if using implants, and if the operation can be done intraorally among others
A: Thank you for sending your pictures. In answer to your infra-orbital malar augmentation questions:
1) Give your modest infraorbital recession which is very consistent with your ethnicity the concept of an osteotomy approach to treat it seems like a ‘solution that is bigger than the problem’.
2) How much augmentation that can be achieved and the incisional approach to place it are linked. To provide an accurate answer I would have to know the exact footprint of the implant (the exact outline of its bony coverage) The relevance of that, for example, is of the infraorbital rim needs to he saddled to any significant degree then an eyelid approach may be needed for its placement.
3) The concept of bone loss around facial implants is a fallacious one. More accurately there can be passive bone adaption to a facial implant based on where it sits. This process is completely benign and self-limiting. But even this is not a biologic phenomenon I have seen in the midface across the orbital rims or cheeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to update you on my bicep implants. This may sound strange but what I notice is that since having them it has given my bicep area a “bloated” feeling and look. What I mean by that is that when i assess my pectoral and deltoid implants it feels firmer and it looks quite cut. i noticed the bicep implants are a lot more softer in feel but I’m wondering if the durometer of the implant could be causing my issue? Point being. if I were to change my implants to a harder durometer would it look any different and more like my deltoid and pec implants? i just always assumed muscle implants always just came in a firm feel.
A: Body implants comes in many different durometers (measure of firmness) based on where on the body they are placed. In general the durometer should match the tissue it is designed to augment. (feel like muscle) I do not know what durometer your pectoral and deltoid implants are but I suspect they are firmer than your bicep implants. You specifically requested the use of AART implants which, as a manufacturer, have the softest durometer of any manufacturer. Whether a firmer durometer in your bicep implants would look/feel any better to you I can not say.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about Forehead Augmentation. I have a somewhat sloped forehead and ever since it was pointed out to me I am struggling to unsee it. It is much more noticeable and bothersome from a side profile view. After doing some research on possible solutions I discovered the forehead augmentation surgery. It is something that I am not ready to do just yet however would possibly consider undergoing down the road when I am ready. That being said I do have some questions and concerns about the surgery. My first priority is of course my health and safety. I have done my research about what this surgery entails. The idea of going under anesthesia is very scary to me if something were to go wrong. My other concerns are around blindness, permanent bruising and swelling around the eyes as well as potentially getting an infection. Can you please share with me your honest thoughts about how safe this procedure is? The last thing I want to do is something that could put my life at risk or cause myself to go blind or obtain permanent bruising around my eyes. On the other hand I have extensively studied my forehead and looked into what I think I would like my forehead to be cosmetically changed to. I also have drawn on my face to show what I would like my side profile to look like. If I were to share these pictures and videos with you would you be able to give me a rough idea if what I am looking to do is safe and aesthetically achievable? Also I have questions about the skin on the forehead. By reducing the slope and flattening the forehead, would this make my eyebrows shift around or look different? I like the rest of my face and I don’t want to do anything that would change the positioning of my eyebrows. Also would I lose control of my eyebrows meaning lose the ability to raise or lower them “have facial expressions”? I understand I asked you a ton of questions with out having a consultation however if you could please give me your honest thoughts to my questions and concerns that would give me a better idea of whether this surgery is something I am comfortable undergoing and if the results I am looking to obtain are even achievable.
A: Thank you for your inquiry. In answer to your forehead augmentation questions:
1) Almost all forehead augmentations today are done with a custom forehead implant designed from a 3D CT scan of the patient. This is the most effective procedure that requires the smallest scalp incision to place with the lowest risk of any postoperative aesthetic issues.
2) Of all the forehead augmentations I have done over the past 30 years with every conceivable material, I have never seen an infection. Most certainly the risks of blindness or any major medical problems are not even on the radar screen for occurrence.
3) The implant is placed in the deep periosteal plane of the forehead which is well below the frontal branch of the facial nerve…so movement of the eyebrows is not affected. Nor will the implant change the eyebrow position.
4) My assistant Camille will pass along the general cost of the surgery to you tomorrow. She can also arrange for a virtual consultation time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some sliding genioplasty and rhinoplasty questions:
1. Will the bone grafts merge with the chin or be replaced later by the body into natural bone? And is it recommended of not using bone grafts over not using them?
2. Can a rhinoplasty on men be made more sharp and straight? I often see on rhinoplasty pictures that it round up near the nasion
How much will rhinoplasty and genioplasty like that would cost and what would be the recovery time to go back to work and how long until I can do intense sports again?
Thanks
A:In answer to your questions:
1) If an autologous bone grafts is used it will; turn into natural bone. If allogeneic bone grafts are used that will become ingrown/overgrown with natural bone. Whether any form of a bone graft is needed in a sliding genioplasty depends on the amount of chin advancement that is done what the size of the step pr bone gap would be.
2) Every rhinoplasty result is going to be different and is highly influenced by what the anatomy of the nose initially is and what type of change the patient is seeking. Having no knowledge of your nose and your nose reshaping objectives are I can not say how this applies to any potential result in you.
3) I will have my assistant Camille pass along some general costs of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We had a consultation in the past and I’ve still been thinking some things over. Would it be possible to have a slight temporal reduction through just bone-burring and not removing the actual posterior muscle? I can feel the bone slightly pointing out within a 1inch strip or so around the sides and was wondering if just that area could be shaved down. Could it be possible that a CAT scan would reveal that portion thicker than the rest of the side of my head?
How many mm of bone could safely be reduced on each side and would it be possible without removing the actual muscle? I really don’t like the idea of removing muscle.
Thank you,
A: Everyone thinks that what they are feeling is bone on the side of the head because it feels so hard. But the reality is that is muscle one is feeling with a backing behind it of bone. The posterior temporal muscle is tremendously thick.
While you can remove some temporal bone, it requires a direct incision on the side of the head to do it and can only remove 2 to 3mms of temporal bone. The temporal bone is thinnest part of the skull. I would not be convinced that any bone removal will make that much of a difference. But I would need to have clear visual understanding of where the area on the side of your head is to provide a more qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am Interested in a lip lift as well as mouth widening. Would there be significant scarring for my lip lift too? Are there any other risks to mouth corner cutting? Or is it just scarring? Can scarring be reduced in any way such as a laser?
A: The risks of adverse scarring from a lip lift is far less than that of mouth widening. This is because the excision and closure for a subnasal lip lift is done along the natural skin crease at the base of the nose-upper lip junction. No such more hidden natural line of structural junction exists at the mouth corners.
Any secondary adverse scarring issues have to be treated by a scar revision approach not a laser.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions regarding the cheek lift:
1) Will it be done through the lower eyelid incision?
2) Are the results permanent? If so, how exactly will the tissue be resuspended?
3) Will my current cheek implants cause any problems when doing the cheek lift?
A: In answer your cheek lifting questions:
1) The most effective cheek lifts are done through a lower eyelid incision as that provides a true vertical cheek lifting vector.
2) No facial lifting procedure is ever permanent as no one beats aging and the effects of gravity. It is only a question of how long any type of facial lifting procedure lasts.
3) Cheeklifts are suspended to the lateral orbital rim through either transosseous holes or microscrew/bone anchor fixation.
4) Indwelling cheek implants do not pose a hindrance for doing a cheek lift, and to some degree, are an asset as they provide a ‘shelf’ onto which the lift tissue can sit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, You had responded to an inquiry of mine a little while ago and I’d like to get more advice. I included a screen shot of the inquiry to remind you. In your response you mentioned that a mucosal roll could help however I’m afraid that rolling the inner upper lip upwards would cause my lip to be even thinner than it already is. Attached is a picture of my resting face to show what I mean. My problem is rather complex as my resting face doesn’t seem to have this problem. I’m wondering if there is some other problem going on. Any advice on the topic you can give would be highly appreciated.
A: Thank you for your inquiry and sending your pictures. What you have is a classic ‘double’ upper lip caused by a redundant mucosal tissue roll. Contrary to your perception your issue is not complex as everyone that has a similar problem exhibits it the same way….it only appears when smiling and not at rest. The only effective treatment is excision of the mucosal roll which is not known to thin out the upper lip as mucosa is very stretchable. True lip reduction can only occur from dry outer vermilion excision not internal wet mucosal excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions regarding some procedures I am interested in. Right now, I am looking to balance my profile and improve my face shape from the front. The two procedures I am most interested in are the sliding genioplasty and cheek implants. I am hoping the SG can also give me slightly less height to my chin as well as move it forward. Can the SG also reduce my lip protrusion, lip incompetence, and make it easier for me to smile? I also realized I have a slight bimaxillary protrusion and I’d like a reduction in it. (my teeth however doesn’t protrude and I don’t have much of a gummy smile, maybe my gums protrude) I’m hoping I don’t need braces or orthognathic surgery like a double jaw procedure.
For the cheek augmentation, from the front my goal is to have a more V or more heart shaped face based more on Asian aesthetics standards and make my face less elongated. I am also hoping it would further balance out my side profile as my front facing cheeks are rather flat. I am also unsure about paranasal implants; I know it can give me more midface projection so I was wondering if you think its right for me? For the cheeks, do you think a ZSO, a submalar, malar, or combined submalar / malar or even a fat graft (to cheeks and to temples) would be right for me? Also, do you think I would need a custom implant or would a carved one suffice? Finally, I would also like to improve my undereye area and I was wondering if cheek augmentation is sufficient for this (although undereye improvement really isn’t important at all to me). Either way I’m hoping you can answer my questions and suggest treatments you think are right for me. Below I attached unflattering but objective pictures of my face at different angles. I also attached a pic of a cartoon drawing as well as a celebrity whose face shape I find looks ideal (tho obviously I don’t want to look like that I just want a face shape resembling those)
A: Thank you for your inquiry, sending your pictures and detailing your surgical concerns and objectives. In answering your questions:
1) While I can not determine what your bite relationship is, you are not an obvious candidate for orthognathic surgery based on your picture assessment alone. I would agree therefore that a sliding genioplasty to bring your chin forward AND vertically shorten it would be the right procedure. Only a sliding genioplasty can create that exact type of dimensional chin change. In theory bringing the chin forward does improve lower lip incompetence and mentalis muscle strain. This does so in most patients although in some that degree of improvement as no as much as one would like.
2) For cheek augmentation what you are really describing, to no surprise in your case, is Asian cheek augmentation…which can be very different than Caucasian cheek augmentation in terms of dimensional cheek augmentation changes. Given the natural lack of horizontal midface projection that most Asian patients have, what you demonstrating in your examples is a more anterior cheek augmentation rather than a lateral one. (most Asian patients don’t need more lateral cheek or zygomatic arch width)
The real question in the Asian male patient is whether this is best accomplished by the use of standard or custom cheek implants? Given that you don’t want/need an undereye augmentation effect and are ‘soft’ on the need for other midfacial augmentation effects (e.g., paranasal), one can use standard cheek implants. In my experience in some Asian male cheek augmentation patients the use of a standard malar shell cheek implant can work well. But the key is its placement on the bone and its orientation. It needs to be placed more anterior as well as the implant needs to be inverted (turned upside down) to create the desired high anterior cheek augmentation effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am concerned that I will not be particularly happy with the standard, off-the-shelf chin implant. So depending on the price for a custom chin implant alone, I think I would like to go that route. How much do you think a custom chin implant would cost (CT scan, implant design, surgery, and all)?
What is holding me back from getting the entire jawline are two main things: money (I don’t have $12,000-13,000 to spend at the moment for entire jawline) and also I’m a bit anxious about the intra oralsurgery. I don’t like the idea that if an infection develops, I might have to remove my entire jaw line, versus just the chin or one side of my jaw.
My idea is since I’m really only interested in the projection in the chin at the moment, I was thinking about getting a CT scan, and getting a custom chin implant. And then later down the line, maybe a year or two, if I want to address the mandibular plane angle, I could use the same CT scan to get two custom mandibular angle implants. I don’t think I really need anything for the mid-jaw. I assume that if both the mandibular implants and the chin implants are custom and well tapered, that the gap between the two wouldn’t be noticeable.
I would only consider this approach, however, if the cost for the custom chin implant was considerably less than the entire jawline (maybe $5000-$8000).
What are your thoughts on this?
A: What that is certainly a valid aesthetic approach to your chin/jawline concerns, a custom chin implant most likely does not cost considerably less than a total jawline implant. (for example you may think it would cost half as much for example) And that is because the the manufacturing costs for the implant are the same whether it is just a chin or the entire jawline. But to provide accuracy to that comment since I don’t precisely know that myself, I will have my assistant Camille pass along the costs of a custom chin implant to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For the cheek implants, I was wondering if you carve standard implants a bit to tailor it to the anatomy? I was also wondering if you believe a zygomatic sandwich osteotomy (ZSO) is a possible alternative to cheek implants. I heard with a ZSO or by cutting the cheekbones and moving it, it is hard to get a high anterior augmentation.
A: The Zygomatic Sandwich Osteotomy (ZSO) technique creates lateral cheek width and, by that effect, makes the anterior cheek looks less prominent. (more flat) As indicated in the attachment, it is a vertical osteotomy cut done through the main body of the zygoma from inside the mouth. The outer body of the cheek and zygomatic arch is then pushed outward and held there by an interpositional graft and plate fixation
For those patients who need that type pf dimensional cheek change then this autologous cheek augmentation would be effective. But in the patient who needs any anterior cheek cheek projection this is not the correct procedure. It takes an implant to create that effect as the bone movement of the ZSO doesn’t go in that direction.
I like this operation but there is nothing in your goal pictures that would suggest this is the desired type of cheek augmentation change you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m transgender and am really interested in a brow bone implant because that’s something my face lacks. Mine is barely noticeable and an implant would affirm my gender identity.
A: I am assuming that you are a female to male transgender patient since most facial masculinization procedures are augmentative in nature such as brow bone augmentation. Please send me some pictures of your face for my assessment for this procedure. There are multiple different materials that can be used for brow bone augmentation, and I have used them all. But I have found that the custom brow bone implant approach to be the most effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a mild form of plagiocephaly and have had several fat grafting procedures with good success. However it doesn’t quite work in the bottom section of my skull and therefore am possibly exploring another option…maybe you can advise. I have attached a picture of it as your request.
A: The reason I asked for the picture is that the ‘bottom of the skull’ to most people is actually below the edge of the bottom of the occipital bone which is actually the upper neck muscles…for which this area can not be treated with an implant and an area where fat grafting takes very poorly. I can not tell from the picture your area of concern but my suspicion is that it falls into my above location description. This part of the plagiocephaly can not be successfully augmented.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering about sliding genioplasty. is it possible to get sliding genioplasty that will heal without a stair step? For example this video shows that after the bone heals there is a ‘stair step’ in the chin.
Finally, I am looking to fly in next year for surgeries. Is it possible to get hooded fat grafting, rhinoplasty, and genioplasty all at once?
A: In answer to your questions:
1) Every sliding genioplasty has a bone step deformity whose magnitude depends on how much the chin is advanced. The only way to make that heal so there is not a step is to bone graft it at the same time.
2) It is common to combine upper blepharoplasty, rhinoplasty and sliding genioplasty all during the same surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have pockets of fat around my mouth that have been there since I was a kid. I’m 24 now and I have been self conscious about them for years. Could you help me? I read about Perioral Mound Microliposuction -could you perform this on me?
A: Thank you for your inquiry and sending those pictures. You do have some subcutaneous fat collections around the mouth area for which microcannula liposuction is one treatment option for it. Other non-surgical treatment options are Kybella injections and radiofrequency skin tightening treatments (e.g., Exilis, Ulthera) whose side effects are fat loss. (which in your case is their benefit) No matter which treatment approach is done it is not an easy problem to improve. Having done lots of perioral liposuction surgeries improvements are always seen but some patients (about 50%) may need a second procedure to maximize the result to improve any asymmetries or further reduction that is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from vertical orbital dystopia, my left eye being slightly lower than my right. I have been told bone contouring of the upper left eye orbit would help with the asymmetry, bringing both my upper orbits to to the same level. Also fillers and possibly an implant under the left eye, to bring the eye up slightly to more the same level.
This is an issue that has destroyed my whole life, please would it be possible to help. It is insane how no oculoplastic surgeons seem to offer the treatment you do and seem completely ignorant about it.
A: Thank you for your inquiry and sending your picture. With what appears to be about a 5mm vertical orbital dystopia, that is within the range of being treatable by orbital floor-rim implant augmentation as well as supraorbital rim bone reshaping. To determine the exact treatment plan you would need to get a 3D CT scan of your orbits which will provide the accurate information as to how to exactly proceed down to the millimeter level.
Having treated numerous cases just like yours, good improvement is possible. You may never get the eyes perfectly level (there are limits as to how much the eye can be safely raised) but visible improvement is possible nonetheless.
I will have my assistant pass along a document which will describe how to find a place locally to have the 3D CT scan for which we can then provide the order to the chosen facility for you to get the scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having rhinoplasty and am wondering if my goals for the procedure are achievable.
1 – My nose looks better when I flare my nostrils vs when they are at rest. When flared, my nostrils are lifted and take on more of a “v” shape than an “m” shape. I would like my nose to look like it does when flared but at rest. Aside from that, i would also like to have my nose made smaller while avoiding the typical things that can be seen in ethnic rhinoplasty, such as: triangular nostrils, a “pinched” tip, nostrils that are far bigger than the tip etc. In other words, i just want to look natural. I’m fine with just a modest size reduction, I’m more concerned with shape than size.
2 – I’d also like for the columella/bottom of the nose to be made fuller/longer and for the nose itself to be lengthened by a few millimeters. I’ve included one picture to illustrate the “ideal” nose and how the bottom part of it is fuller than mine. There is one more picture that shows a perfection mask based on the golden ratio placed over my nose. This is just to highlight the imperfections.
Are any of these things achievable through surgery? Would you mind creating a morph that illustrates how close my nose could be made to what I have described here?
Thank you for reading.
A: Thank you for your inquiry and sending your pictures. In terms of your aesthetic goals, some of them are incongruent with others. With your thick nasal skin the goals of making your nostrils more flared and the tip longer does not mesh with an overall goal of making the nose also smaller. You may be able to give it a better shape but not truly accomplish much of a size reduction. With your thick nasal skin there would never be a concern about having a pinched tip or sharp triangular shape to it..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, As far as calf implants are concerned, is it going to be OK to walk in the airport to go home eight days after surgery? Just want to make sure? Is it OK to walk on calf implants 8 days later?
A: The key in calf implant augmentation recovery is early mobilization and rehabilitation. Calf implants are just like breast or buttock implants….it is a surgery that causes muscle trauma/injury. Stretching the muscle out is how one recovers sooner rather than later. You can’t hurt the implant, it is just sitting on top of the muscle. It takes a few days after surgery before one starts the stretching when it becomes more comfortable to do so. So walking on them is started long before the one week after surgery time.
Knowing your physical condition I would say this would probably not be a big problem even when combined with hip implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In doing some research on chin reduction, I discovered you are an expert and I’m hoping to get a second opinion on a chin reduction surgery. I had jaw realignment surgery and chin burring done over 10 years ago to address a problem with my bite, as well as the fact that my chin grew longer on one side. I’m very happy with the surgery and it did a lot to improve the asymmetry. However, there was still some leftover asymmetry in the chin, especially when viewed from underneath that continued to bother me. For that reason, about three years ago, I had a revision. The surgeon reviewed my case and recommended additional burring. I also asked him if it would be possible to narrow the chin slightly at the same time, as this was something I had also wanted for cosmetic reasons. However, since having the revision, I haven’t noticed an improvement in the asymmetry and my chin is now dimpled in areas (even when relaxed). I’ve been told to get filler as a correction, but since a reduction and narrowing was my initial goal, I’m reluctant to consider filler long term.
At this stage, I’m wondering two things. First, I’m wondering if my desired “after” goal was realistic (I’ve attached a photo of the before/desired and actual result). Perhaps the goal was never truly achievable, which would help me manage my expectations.
And second, I’m wondering if there’s anything apart from fillers that could help the dimpling at this stage.
I’m attaching photos because I had filler done about 8 months ago, that has masked the problem area, so I’m not sure to the extent a skype consultation would be helpful at this point. The filler is dissipating, but I’m unhappy with continuing it, as I my original goal was a smaller, narrower chin, rather than a larger one.
I really appreciate your help, and look forwarding to hearing from you.
A: Thank you for your inquiry, detailing your history and sending your pictures. In answer to your chin reduction revision questions:
1) Your original aesthetic goal was never achievable, at least by burring. That was the worst choice of all available chin reduction/reshaping techniques. They detaching of the soft tissues and the lost of support volume creates the soft tissue contraction….which you see as dimpling.
2) Other than fat grafting, which will make your chin bigger/wider, there is no permanent and effective cure for your chin dimpling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year-old female and have been struggling very hard from scarring after a too-harsh dermatologic treatment many, many years ago. As a red-blonde I was treated with TCA peeling 30% and prescribed Vitamin A creme. This must have been too much for my thin and sensitive skin. I ended up with scarring on my chin. The upper layer of skin has changed structurally. Really tough to treat and after having sought out help from renowned dermatologists, there is really nothing more we can do.
As the scarring is only in the lower third of chin I came up with an idea: couldn’t we first remove the scarred skin while performing a sort of chin reduction procedure and afterwards elongate it back to its former shape or even a bit longer (which would suit my round face shape)?
Is that even possible? I really don’t want to make things worse.
A: Thank you for your inquiry and detailed history on your chin scarring. What you are describing would be very ill-advised. The scarring that would result from excising the scarred skin segment would be far worse than whatever the chin looks like now. In addition, if that segment of chin pad was excised you could never re-establish the lost chin length.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had multiple custom PEEK facial implants with another surgeonI have soft tissue problems now. Attached are videos showing face now and implants used. My problems now are:
- chin ptosis/lip incompetence after implant removal
- masseter not attached to mandible border
- temple hollowing
- lateral canthus hollowing
Can you tell me what can you do to correct these problems?
A: In answer to your custom facial implant revision questions:
Besides the chin and lower lip incompetence issue, what you have in all three other areas is the almost expected sequelae of placing larger implants made out of a very stiff material that lacks feather edging…as the material does not permit it. It requires feather edging int the designs to not show the outline of the implants where they transition into the natural bone in the thinner tissues of the face above the jawline. Some of your issues are also a matter of implant design as they all look very bulky and lack a natural transition into the surrounding bone…a common design flaw. As a result you have the following:
1) Masseter Muscle Dehiscence – this is the result of over stripping of the soft tissue attachments which often needs to be done to place larger stiffer material jaw angle implants. This is also a risk when the implant design extends beyond the natural posterolateral jaw angle border. I ave seen it many times and trying to reposition the muscle back over the implant has a very low change of success and involves a neck scar. I have found it more productive to place a soft tissue jaw angle implant over the deficiency muscle area right under the skin in the subcutaneous plane.
2) Temporal Hollowing – This has occurred because there is now a mismatch between the ends of the brow bone implants and the temples and may also have occurred as a result of some stripping of the termporalis fascia and muscle along the anterior temporal lines near the brows. To improve that the brow-temporal disproportion a combination of feathering of the tail of the brow bone implant with adjacent temporal augmentation is needed.
3) Infraorbital Hollows – This is a design flaw with lack of bringing the implant design further up along the lateral orbital rim. When you augment the infraorbital and cheek area that much, the implant design must go up into the lateral orbital rims to create a natural transition. Otherwise this will create an infraorbital hollows as you now have. That can be treated by adding a lateral orbital rim implant to fill in the ‘defect.
4) Lower Lip Incompetence – I am presuming you had = a chin implant removed and now have this problem. When the chin loses structural support, the vestibule and lower lip will contract down lower than its normal position. This may or may not be associated with actual chin pad ptosis.. Beyond replacing the chin implant, soft tissue treatment options include mentalis muscle resuspension and/or fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
