Your Questions

Q: Dr. Eppley, I am interested in rib removal surgery. The main reason is mostly cosmetic so I would also be looking into liposuction in that area as well. I am of a smaller build 5’2” 118 lbs. The asymmetry in my body and lack of waist has significantly impacted my body image so I have been looking at rib removal for years but always thought it was too dangerous or extreme! 

I am curious about how much greater the risks are in regards to the organs once the ribs are removed and with my scoliosis if the risks are higher?

A: The risk of organ damage in general in rib removal surgery is essentially zero. It is a common misconception that is a concern. I would refer to my website, www.exploreplasticsurgery.com where you search under the term RIB REMOVAL and read what I wrote about Rib Removal surgery and organ damage in an article in more detail. This is particularly relevant in your case where taking rib #12 has no aesthetic benefit. You will understand the relevance of that when you read that article. Your scoliosis creates no added risks to the surgery. Its only relevance is that it has shown on one side why taking rib #12 has no benefit to waist reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m on your page now for the surgical reshaping of a flat back of head? I hate the shape of the back of my head and am willing to travel for this. I also saw your comment on a Real Self question & answer forum saying that this procedure can be done non surgically by injection… could I please learn more? Namely how much would these cost? 

A: To clarify on augmentation of the back of the head, the superior method aesthetically is a custom skull implant. For smaller skull shape defects PMMA bone cement can be used through a very small incision with introduction with a funnel…but that is not a ‘non-surgical method by injection” It is still a surgical procedure that requires the same dissection under general anesthesia as placing a custom skull implant. It also does not produce as good an aesthetic result. You are over interpreting what you have read.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could suggest me what you would do to improve my appearance. I have an asymmetrical jawline, which is more visible when I smile or talk, but at the same time I feel like my face could benefit from other surgeries as well. (my forehead is prominent, my eyes are sunken) I do not know which surgery I would benefit the most from. I am only 26 years old and I feel like I look older, and I would like to go and correct what could cause me to perceive myself that way.

 I would really appreciate your feedback.

A: Thank you for your inquiry and sending your pictures. The one surgery that would benefit you the most is the one that treats the single feature that bothers you the most…which only you can say. You have listed high forehead, sunken eyes and asymmetrical jawline. The reason you look older has to do with your sunken eye appearance with a touch of upper eyelid ptosis. Unfortunately that is also the one facial feature that is the most difficult to improve and even more difficult to try and image the change on your picture. For the sake of discussion I have imaged hairline advancement, rhinoplasty and left chin-jawline augmentation. Then in a second image I added some slight volume to the inferior brow bone/upper eyelid area and even that small amount to ma made a big difference in improving that facial issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached a few photos. Looking to advance the chin a bit, remove some of the fat surrounding the neck and perhaps have implants or filler to give the lower mandible some form. My under eyes are also quite hollow so I would be interested in looking at solutions for that. 

A:Thank you for your inquiry and sending your pictures. I did some initial imaging on the side view one which is the best place to start with an initial assessment from which I can make the following comments:

1) With your thicker facial and neck tissue, and naturally shorter lower jaw, what I would recommend is that you first work on the chin-neck relationship  and gets some positive changes there. With your shorter neck and thicker tissues a sliding genioplasty is a better chin procedure for you as moving the chin bone forward pulls the neck muscle out which is a big help in the thicker neck patient with an obtuse cervicomental angle. This can be combined with a submentoplasty procedure to remove neck fat and tighten the platysma muscle to really help your cervicomental angle. These two combined procedures will do the most for your chin projection and neck reshaping and then you can see about any further work on the rest of the jawline later.

2) Your undereye hollowing could be done with the chin-neck work and is going to require a custom infraorbital-malar implant to give the undereye area the added volume that it needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How much vertical chin reduction can be achieved in my case by the intraoral wedge removal genioplasty?

A:Thank you for sending your chin pictures. While I haven’t yet seen a panorex x-ray to yet determine how much chin bone can be safely removed, I can predict at last 1 cm of vertical bone height would be reduced in the center. (which by definition has to taper out to the sides) But the real limiting factor in how much vertical chin reduction is seen on the outside is the overlying soft tissue which is obviously not removed. It can be compressed somewhat as the chin bone is vertically shortened but not in a 1:1 relationship to that of the bone removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant revision surgery 6 months ago. During the recovery, the nerve reaction on the right side is slightly weaker, causes no problem. I believe there should not be any nerve injury during the procedure. 

However, intermittent numbness and pain become more severe in the latest month. The implant was perfectly screwed and didn’t shift. I found one possible reason is that one side of the incision (denoted in green color in the attached photo) is close to the mental foramen. As the underlying scar grows, it may compress the mental nerve, which causes the pain and numbness (sometimes an itchy feeling). These feelings become stronger if I pressed the skin above the mental foramen. 

Could this develop into chronic pain? Is that possible to deal with this by nerve decompression surgery someday later? 

I’m looking forward to your reply!

A:It would be impossible to predict how the affected mental nerve may react as its distances itself from the date of the surgery. But at 6 months out from the surgery it would seem not very likely to develop into chronic pain if it has not done so already since the scar tissue has fully formed at this point.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,Hello, a couple of questions. I’m planning on getting perioral mound liposuction, mouth widening surgery, a dermal fat graft into my labiomental crease, and maybe a buccinator myectomy (if needed) I’ve already had around 85% of my buccal fat removed so I dont need anymore removed. A couple questions I workout so I fluctuate in weight by roughly 20 pounds depending if I’m bulking or cutting. I gain slowly (roughly half a pound a week) I was curious would gaining/losing weight effect the perioral mound liposuction? As in would it come back if I gained a bit of weight? As well as would the fat graft in my labiomental crease get smaller/bigger if I gain/lose weight? Also, I’m going to he getting a genioplasty at some point mostly vertical movement and maybe 2 to 3mm forward movement would it be best too get the fat graft in the labiomental crease after that procedure? Also how much would this is all cost? Sorry for so many questions! 

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

1) Since the perioral mound areas is subcutaneous fat and not really a typical fat depot area, it should not be affected by the weight gain that you have described.

2) The injection fat graft is a more relevant one for the concern about it changing with weight gain or weight loss particularly if the abdomen is the donor site. Which is why the inner thigh should be used as this is not a typical fat depot site.

3) Whether you do a labiomental fat graft during or after a primarily vertical lengthening genioplasty is irrelevant from a technical standpoint. It is more relevant from the effects of the genioplasty as vertical lengthening genioplasties tend to lessen the natural depth of the labiomental sulcus. So it is possible you may not need anything done to the labiomental sulcus based on the effects of the lengthening genioplasty. This would be the argument to wait and see.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 1. How would my face look smiling? That was something I forgot to ask during our 10 minute consultation and something the retouched images from your initial e-mail reply didn’t show. Is there any way to predict, or responsibly hypothesize what I’ll look like smiling after implants?

2. This is probably a silly question, but you said custom implant recipients tend to be more prone to wanting revisions. Do we live in such a world that if I’m not satisfied with the end results, costs are waived for revisions or implant removal? If so, what waived costs or discounts are offered?

3. I like to think catastrophically sometimes to try to be as prepared as possible, so bear with me on these next few which get a little dark. What happens if I’m in an accident after surgery and break bones where I have implants? Would I need to have them removed and have you to re-do them after the bone was mended?Are there activities I’ll need to avoid to ensure the implants don’t shift or break?

4. This one gets a little darker so I apologize in advance and hope you see my intent comes from a good place and the desired to think ahead and be prepared: Okay, let’s say we’re halfway through implant design or maybe I’ve gotten the implants and I’m happy with them but something happens and they need to be repaired but you’ve either retired or gotten struck by lightning or, for whatever reason, just aren’t available. Do you have a rolodex of surgeons you trust to do these surgeries just as well or better than you? If so, who are they? Even though it wouldn’t be particularly self-serving, is there anyone who you feel could do these implants just as well or better than you?

Thank you so much for taking the time to help me learn as much as possible before I start this journey with you and your team! I really appreciate it.

A: In answer to your custom facial implant questions:

1) I have not yet had any issues in facial animation with infraorbital-malar (IOM) or jawline implants. The only potential issue with smiling would be with the IOM implants. But because they are in higher position than standard cheek implants they are more out of the way when the cheek tissues bunch up with smiling.

2) This is a very important question and I would ask my staff about that very issue for which there is a revisional surgery policy. It spells out the risks and the patient obligations should that occur. Such revisions are not what I want but when you put implants anywhere the body that risk is very real and not insignificant.

3) The issue of trauma to the implanted site is a common question. The reality is that it has never yet occurred or one in which no patient has ever had an actual scenario as you have described that has been relayed to me. From a trauma standpoint custom IOM and jawline implants are like putting bumpers on the bones. It would be very hard (albeit not impossible) to fracture the bones underneath them. In essence they are like shock absorbers.

4) Admittedly a bit darker but not a completely impractical question. There are other surgeons in the US who do perform these surgeries. It is a very small number but they exist. Most are not going to have my experience in designing or perform these surgeries. I can not tell you whether any of them are poorer, as good or better than me at it, regardless of their experience since there is no assessment method to make that comparison.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was curious generally speaking what percentage of people have the type of skull shape which would accommodate a 1 inch implant for cosmetic stature gain in an aesthetically pleasing manner, and what that ideal skull shape is. 

To be candid I was surprised to find that this is even done, because my first instinct was to assume that such an implant would look unnatural, like something from Star Trek or Coneheads or something. Is it the case that average skull height is variable enough throughout the population that such a change is easily concealable? Does the size of one’s forehead or their hair type or any other factors significantly affect one’s suitability for the height increasing procedure with respect to concealment? 

I feel like there are two bifurcated philosophical schools when it comes to cosmetic surgery patients – those who don’t mind a slightly (or significantly) unnatural look, which perhaps represents the vanguard of cosmetic augmentation, and those who want as close to a natural appearance as humanly possible. I would definitely place myself in the latter group and wouldn’t want anyone to wonder “what’s up with your head”? 

I was also curious what your opinion is regarding surgery on the scalp for patients with a history of keloids developing in common keloid forming areas. For example I have several keloids in my sternum area as well as my right shoulder, which apparently are two common areas, however I thankfully do not have any on my face. Could a small “test incision” be done on the scalp to make sure the area responds to trauma well before an actual procedure? 

Thank you for reading

A: Thank you for your inquiry. The key to all skull implants is that their design has to look like they belong there as a natural extension of the convex shape of the skull.  As a result they cover a much larger surface area than one would initially think to do so. And usually most patient’s way over estimate the thickness of the augmentation they need because they focus on a simple linear measurement rather than the volumetric effect of large surface area coverage. The limiting factor in any skull augmentation is the ability of the scalp to stretch to accommodate what is placed underneath it. In general most people can tolerate a 100 to 150cc implant without a first stage scalp expansion.

When it comes to what patients want, very few patients want anything but a natural looking result. One’s interpretation of what looks natural will vary as what one person deems natural may be unnatural to another. But in skull augmentation everyone wants a natural head shape result.

Trying to correlate how a scar looks on the body to what may occur on the face or scalp is not comparable. Most likely you have hypertrophic scars, not true keloids, which are common in many people particularly in the sternum (which is a terrible area for a scar) as well as the shoulder which is a high motion area with thick reactive skin. Making a test incision in the scalp is not replicative of the situation when an implant is placed underneath it with the incision subsequently closed under tension.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your reply to my son regarding further head width reduction treatment He is extremely happy that you are able to carryout further treatments to enable him to look and feel better about himself and therefore more confident.

There are a few areas I am unsure about and so would like clarification on please. Previously you mentioned two options 1. Botox and 2. electrocautery surgery.The advisory treatment offered to him is ‘Temporal Reduction Bilateral, Anterior, is this the electrocautery surgery? 

Is this the preferred treatment for Nic as opposed to Botox injections? I assume this option has been chosen as he would prefer a more permanent result.

As he has already had posterior temporal reduction and now planning anterior surgery will there be any possible adverse long-term side effects?

How long will the immediate recovery period be before he will be able to leave your care and carry on with his journey?

I look forward to hearing from you

A: While Botox will likely create improvement in the fullness of the anterior temporal muscle, it will not be permanent. The thermal treatment of the muscle results in eventual partial muscle shrinking/atrophy which is permanent. I have done such anterior reductions on patients who have had prior posterior temporal muscle removals and there have been mo adverse functional effects from doing so. Like the last surgery he will be able head home on a similar time frame. While the immediate postoperative swelling is very similar the effects of muscle atrophy take much longer to see than muscle removal. The muscle shrinks down over a period of months after the surgery so getting to the final outcome requires more patience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve wanted to get skull augmentation surgery done for a while, probably 3 procedures if not all together, the frontal, temporal and back of the head procedures and i was wondering what the cost would be. I don’t want an extreme change but to make my forehead a bit more round in shape and more prominent i guess and possibly near my brow bones or cheekbones too if possible. I was wondering if they’d have to be done all at once or not, what the cost would be etc.

A: Thank you for your inquiry. You are referring to skull augmentation in which you reference the forehead, temporal and back. Since the scalp will only permit so much augmentation to occur (unless one does a first stage scalp expansion), it is important to prioritize the areas of concern. Based on your description of your forehead /temporal objectives I would assume that is a priority area as it is also the most visible. That would be done as a combined implant in one surgery.

Dr. Barry Eppley

Indianapols, Indiana

Q: Dr. Eppley, I would like a forehead reduction procedure. My questions are:

1) is it possible to reduce the advance and the width of my forehead?

2) what is the waiting time to be operated?

3) how long do i have to stay during the operation in the USA?

I also know that a scar is visible after the operation.I was thinking of doing a FUE hair transplant procedure to hide this one and advance my front line. 

Do you think this is possible?

Best regards.

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

1) It is not a question as to whether your bony forehead can be reduced in both width and forward projection…but by how much. Bony foreheads can be reduced by removing the outer cortical layer of the skull down to the diploic space. How thick that layer is is what determines the magnitude of change. A preoperative CT is needed to make that determination.

2) if you want to undergo a hairline advancement this is best done at the time of the forehead reduction as the best place to put the incision is at the frontal hairline. That would achieve two goals at the same time.

3) You wouldn’t do a hairline advancement and FUE hair transplants at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have prominent temporals major muscles which are very strong. It bothers me in two ways: 

1) I get incredible tension headaches from clenching in the night and even eating chewy food. 

2) I dislike the look. 

I’ve had three Botox courses into the muscle to try and reduce it and whilst it provides some temporary relief it’s short lived. 

I’m interested in the surgery and wanted to understand more about it.

Thanks in advance.

A: Thank you for your inquiry and detailing your temporal muscle concerns. The critical question is which part of the temporal muscle is involved.  (posterior, anterior to both) That knowledge determines the extent of the surgery and time/cost to do so. Please send some pictures that show the event/location of your temporal muscle hypertrophy. Based on your description I suspect it is a combination of both posterior and anterior area temporal reductions which, although can be surgically treated at the same time, are done by different methods.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Im wondering on the cost of getting bone cement in my forehead to fill in the sunken in curves for a beautifully shaped forehead. Thank you!

A: Thank you for your inquiry. There are three materials in which to perform forehead augmentation including two types of bone cements (PMMA and hydroxyapatite) and a custom forehead implant. With each technique comes different costs and potential outcomes. You mentioned ‘bone cement’ but I don’t know if that is what you are interested in exclusively or that is the only technique in which you are familiar. Custom forehead implants always produce the best aesthetic results and are done through the smallest scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley: I have a Medpor chin implant. At three months post-op, I went to dentist for regular cleaning. However, my soft tissues are not fully healed with the Medpor chin implant at that time, and when the dentist presses my lips, I felt a sharp pain in my chin. I lost the sensation of my chin immediately. 

Now it’s about 4 month after the dentist visit, one side of my lip still feel kind of numbness. I guess my mental nerves are over-stretched by the dentist. Will the sensation of lip gets back to normal? How long will it take. Is it possible to have a permanent mental nerve damage by regular dental cleaning? Thanks a lot!

A:  I do not think it is possible that permanent nerve damage to a chin implant can occur from a dental cleaning.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about a breast augmentation and possible lift. I have sagging due to two children breastfeeding. I was told having a lift would make the sagging worse from a previous surgeon. How can we ensure this would not happen if I only did the augmentation?

A: Thank you for your inquiry. I have never heard of or can understand how a lift could make sagging worse if done with breast implants. It is the opposite which is certainly true….in the presence of sagging (nipples below the inframammary fold) the use of breast implants alone can make sagging worse. Perhaps you have pseudoptosis (nipples at the level of the inframammary fold but with breast tissue hanging below) in which breast implants alone would be adequate.

As you can see the type of breast sagging determines where a lift is needed with breast implants.

To determine what this means for you I would need to see some pictures of your breasts from the front and side for a more informed recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is tip reduction possible in this very thick skinned big bulbous nose tip?

A: Thank you for your inquiry and sending your picture. The question is not whether tip reduction rhinoplasty surgery can be done in your nose but whether the amount of improvement obtained would justify the effort. That answer would never really be known until the surgery was done and the outcome eventually seen. But the way to choose whether surgery is worth it up front, in a procedure where the outcome can not be accurately predicted beforehand, is the attitude one walks into surgery taking. If one says to themselves any improvement is better than what I have have…then surgery will be worth it But if one has a very specific goal (e.g., 50% reduction and a substantially thinner nose) and one feels surgery would not be worth it unless that was obtained than one shouldn’t do it.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I came across an article written by you about fat grafting to the chin for a deep labiomental fold. It is something I struggle with and was hoping to get more information about the procedure. Thank you.

A: Thank you for your inquiry and sending your pictures. You have a moderately deep labiomental fold for which fat grafting would be an appropriate choice to treat it. The debate is whether that is injectable fat grafting or the intraoral open placement of a dermal-fat graft. That question is best answered by how the fold responds to injectable fillers. If injectable fillers pushes it out nicely then fat injections would work. If it doesn’t push it out well due to tissue adherence then the release and open placement of a solid fat graft is best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am unsatisfied with how high my eyebrows are, and I feel like they make me look slightly feminine. When I furrow my eyebrows, they move downwards, closer towards my eyes, and become straighter, which gives me a more masculine appearance, as you will see in the image I’ve attached. Additionally, my eyes become slightly hooded as well, as the excess skin over my eyelids moves down. Overall, I am extremely pleased with this appearance, however, it is inconvenient for me to go around with my eyebrows constantly furrowed! 

That being said, I am wondering if there exists any procedure(s) (surgical or nonsurgical) that will give me the look I desire when I furrow my brow. I am currently considering a reverse brow lift, but I am unsure if it will produce the result I desire. Botox is also an option, but I am uncertain how far my brow will be able to move down. Will injections give me the look I desire? 

Also, please let me know if there are any other procedures I could undergo to achieve the desired look, no matter how expensive or unique. 

Thank you in advance!

A :The lowering of the eyebrows is a difficult tissue change to accomplish in a young person because of their tight forehead skin. Enough Botox may have a temporary effect  (3 months) but that is obviously not a long term solution. A reverse browlift is not going to work for the reasons previously described. (tissue tightness) The only way to lower the brows is with a supplemented reverse browlift using forehead tissue expansion. You must create the tissue stretch closest to where you want the effect. This is done with a specially shaped type of tissue expander

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about testicle enlargement. I have normally functioning albeit small testicles. I am curious if you have noticed any atrophy of the existing testicles with the implants? Any problems with sperm count after the surgery? 

Finally, would you let me know if you have any pictures of the implants and the cost of the procedure? 

Thanks.

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

1) I can not speak to whether implants have any adverse effects on the existing testicles as no such tests have ever been done (e.g., sperm counts) nor has any patient ever mentioned any issues. I would assume it does not since the vascular supply to the existing testicles remains intact. Most of the men who get this procedure are often older where any concerns about sperm counts are largely irrelevant.

2) To see pictures of the implants I would go to www.exploreplasticsurgery.com and search under Testicle Implants where you will find many articles with implant pictures on this subject.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Are you put to sleep while the occipital bone reduction procedure is being done? & how long do you have to be out of work after the procedure is done.

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

1) You are put to sleep for almost all forms of skull reshaping surgery. These are not procedures to be done under local anesthesia or IV sedation.

2) Physical recovery is very quick from skull eduction surgery and you would be out of work at most one week after the surgery. The actual results, however, takes much longer to finally see.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young African-American. man. I am looking into augmentation rhinoplasty. The concerns I have with my nose are its wide nostrils, bulbous tip, and low bridge, in order from most distressing to least. The internal structure of my nose is in great condition. I have no trouble breathing. My septum is in pristine shape, full of cartilage with no deviation. Cartilage grafting and an alar base reduction seem to be the best course of action. I am looking for a surgeon who can reasonably achieve what I’m looking for and do it affordably. I’ve attached pictures of myself below. I am asking that you provide me with a quote for the rhinoplasty procedure. I completely understand that without a physical examination you cannot give an exact quote, but I’m certain that the doctor or director can give a reasonable price range based on the information I have provided.

A:Thank you for your inquiry and sending your pictures. You have clearly outlined your rhinoplasty needs/goals of which augmentations of the dorsum, tip narrowing and elevation and nostril reduction are the cornerstones of it. The key issue in any augmentation rhinoplasty is what type of material does one want to use to do for the building and how much of a build does the patient want or need. For the tip of the nose septal cartilage is always used for the columellar strut and onlay tip grafting, there is not any debate at this augmentation area. It is the bridge (dorsum) where the discussion lies.

The bridge can be built up using three types of materials, septal and rib cartilage and an implant. Each has their own advantages and disadvantages and the results are not always similar. When using septal grafts this supply is limited and given that some of that is used for the tip there is not as much available for the bridge as one would think. Thus using septal cartilage for the bridge will only create 2mms or so of augmentation. (see attached 1st rhinoplasty prediction) More substantial cartilage augmentations require rib grating where the amount of buildup is more substantial because there is more material to use. (see 2nd rhinoplasty prediction) Thirdly the use of an implant (hand carved ePTFE not silicone) works really well in isolated bridge augmentations and produces maximal augmentation results like rib grafts but without the donor site and less operative time to perform.

Knowing how you want to do your augmentation rhinoplasty will allow a proper cost of surgery to be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want my forehead lowering, my chin is too small and my forehead is big and it is asymmetrical.

A: Thank you for your inquiry and sending your pictures. The forehead lowering appears straightforward and the only issue there is how much hairline lowering you think you need and whether it can be achieved. The way to answer that question is for you to draw on yourself the ideal hairline position and take a picture of it so I can determine what is possible. For the chin the debate is not whether you would benefit by increased horizontal projection but how best to address the chin/jawline asymmetry for which there are two options. A sliding genioplasty is the historic approach as it can bring the chin forward as well as slide it over to the midline. While that is good from the centering of the midline chin point, that does not really address the jawline behind it and leaves bony stepoffs along the jawline as well. Ideally a custom chin implant addresses all aesthetic needs more completely but costs more to do so and involves an implant. In short both methods are valid approaches but each has their unique set of disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in getting a custom jaw implant and sliding genioplasty (don’t know if I am a right candidate for genioplasty or chin implant, please see my pics). I want to get a shape like Brad Pitt. I know I won’t look exactly like him after this procedure but I wanted to give you an idea of what kind of shape I’m looking for. Also, in my picture you can clearly see my forehead is gone in a little bit. So please advice me on that, if I should get a implant for that. Lastly, do I need cheekbone implant?

A: Thanks for sending your pictures in this additional email. I have done some imaging for you looking at jawline augmentation alone as well as with infraornital-malar and forehead augmentations from which I can make the following comments:

1) I believe you are correct in that a bony genioplasty with custom jawline implants is best for you because you have a vertically short chin which needs an 8 to 10mm lengthening. This is best done with an opening wedge intraoral bony genioplasty to which the jawline behind is matched with custom implants. When you get into vertical chin lengthening at 8mms and above the soft tissue chin pad will not stretch over an implant. When you drop down the bone, however, the soft tissue chin pad comes with it. That will also help the depth of your labiomental fold as the soft tissue is stretched/lengthened down as well.

2) I added on infraorbital-forehead augmentations in a second set of imaging with the jaw augmentation predictions. As would be expected these help your overall face as they continue the reshaping effect to the next two levels above the jawline. (jaw-cheek-forehead facial architecture) Whether you do one, two for all three levels in a single surgery is a personal choice.

3) Imaging is provided and it is important to understand its role in facial reshaping surgery. These are examples of one degree of change for any facial structure altered, this does not mean it is the only type of change possible. Imaging creates a dialogue to help better determine what degree of facial change a patient is seeking.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you would have time to pop a quick email response back to me with some advice and quotes. I have a heavy lower 3rd of my face. I have seen a variety of ways to address this (jaw reduction, buccal fat removal, perioral mound lipo, facelift) and I’m wondering what he would recommend. My goal is to have cheeks that are round and full in the front and a vline, slimmer jaw shape that is not so bottom heavy and long. When I lift the tissue around my jaw towards my cheeks/ears it helps me get more of the look I desire. I will attach some photos! Thank you. 

A: Thank you for your inquiry, sending your pictures and detailing your facial concerns/objectives. Your facial reshaping question is a common one to which I can make the following comments:

1) While pushing/pulling the tissues back along your jawline in front of the ear creates the desired lower facial reshaping change, that does not mean that a lower facelift will end up with the same result in a young person without significant tissue laxity. In other words, the ‘facelift’ maneuver over estimates the effect it can create and sustain. And this should not in a young person be the go to first procedure for lower facial slimming. That doesn’t mean it should never be done but it should be either the procedure of last resort or a complementary procedure to others being done

2) For you the procedures of bony jaw angle reduction (width only), masseter muscle reduction and perioral/lower facial liposuction would be the foundational procedures.

3) You have good cheekbone structure but to enhance that further buccal lipectomies with anterior cheek augmentation using either the buccal fat as pedicled transfers or converted to fat injections or a small malar shell implant would be the approaches to achieve cheeks that are rounder and fuller.

Dr. Barry Eppley

Indianapolis Indiana

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

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

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

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

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

Any information would be appreciated.

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

1) Can the implant be kept for a lifetime ?

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

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

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

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

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

Best regards,

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana