Your Questions
Your Questions
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
Q: Dr. Eppley, I have some questions about rib removal surgery and hip implants which are as follows:
Do you think the below change is achievable? (See photos, i would like the area circled in red reduced, not below)
Is there a risk of hitting any organs or key arteries?
Other than bleeding and infection, are there any other risks?
How long after until can work out my upper body and abs?
Would you combine rib removal with any liposuction ?
Hip implants – I have almost no fat on my hip dips – might the implants show through? Might hip implants interfere with my buttock implants? (I intend to augment the buttock implants in 9 months)
How common is hip implant migration?
How soon after rib & hip combined can I fly home?
Cost of rib removal alone, and rib + hip implants?
Thank you!
A: Thank you for sending your rib removal and hip implant questions:
1) I believe the result for rib removal surgery you have shown is exactly what can be accomplished. If I had to image it myself that is exactly what I would have shown.
2) There is no risk of hitting any organs or major arteries. They are nonsuch structures in the path of dissection, Rib removal surgery remains a highly misunderstood surgery.
3) I have never seen any complications from rib removal surgery, including infection and bleeding. Despite how the procedure seems to the uninformed, it is a very low risk surgery.
4) When you return to working out after rib removal or hip implants is going to be in the 3 to 4 week range…and this is more to prevent seroma formation from the hip implants and has nothing really to do with rib removal.
5) Many rib removals do also consist of flank liposuction since one is in the prone position for the surgery and this is a very advantageous position for maximizing flank liposuction.
6) The key to not showing edges in hip implants is a custom design so that hey have very feathered edging. If you just use standard buttock implants for the hips (as some surgeons do) you will see the outline of the implants in thin patients.
7) The pocket locations for hip and buttock implants are quite different and do not overlap or interfere with each other.
8) I have never seen hip implant migration. This is probable because of their custom design and the use of perfusion holes in them…design features which mitigate against that potential issue.
9) Returning home after these combined surgeries is merely a matter of comfort as well as whether you are by yourself or coming alone. But one average it would be 5 to 7 days after surgery.
10) My assistant Camille will pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an Implantech anatomical size small chin implant placed last year. It was placed off center and it is very noticeable. I had a sliding genioplasty more than ten years ago. The doctor blames my crooked implant on the brackets. He injected Juvaderm a few weeks ago on the left to make it look less crooked. It didn’t work. I like the height of the profile and the projection but from a front view it looks really bad. Do you think the vertically lengthening implant will also cover my prejowl sulcus and not look too boxy.
A: Thank you for sending your pictures and x-rays. Trying to place a standard chin implant on a bone based that is irregular is always a recipe for further aesthetic issues. if you look at your x-ray you can see that your original sliding genioplasty has uneven bone cuts on both sides. This combined with the indwelling metal plate and screws makes for an irregular bone surface to place any implant. While a chin implant can still be done it requires removing the existing plate and screws (if not overgrown with bone), shaving the sides of the chin bone to make it even and then placing an implant.
Trying to use an implant to cover up the prejowl sulcus or bony indentation from the sliding genioplasty, by definition, will make your chin wider.
Those comments aside before you do any further surgery you should have a 3D CT scan done on your chin/lower jaw (CBCT scan) so that it is very clear what the bone, metal hardware and current chin implant look like and how they all translate to your outer appearance. One should not guess or eyeball it when the the bony anatomy has been previously altered. You are proof of what seems like a simple chin augmentation procedure can create an ‘unexpected’ asymmetric result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Speaking hypothetically, if one wanted to augment a part of their jawline or even their whole jawline with Mimix hydroxyapatite bone cement, would that be an issue,from a vascular standpoint? Would the blood supply to the bone be jeopardized?
A: Concerns about the blood supply to the bone by performing jawline augmentation with bone cement is irrelevant as it has a rich blood supply from its endosteal intrabony source. What would be a concern, and a 100% probability of problems, would be the irregularities and overall lack of a successful and smooth jawline augmentation result from trying to apply a bone paste through the limited exposure of acceptable extra- and intraoral incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Please note I have breast implants, butt implants (2 months ago, revision operation) and liposuction to the lower back. I want the hourglass shape of small waist and rounded hips, but don’t have enough fat for transfer. Perhaps hip implants could be an option to fill the dips?
A: Thank you for sending all of your pictures. Given your slender frame it is certainly true that the only options for further waistline reduction and hip augmentation would be rib removal and implants for the hip dips which could be done at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been treated for facial asymmetry due to hemifacial microsomia with a cheek and eye implant, browlift and a jaw implant and genioplasty for the left side of my face. Despite these efforts, there is still some asymmetry which is not insignificant, particularly around the left brow, forehead, temple and cheek area.
I have spoken to a number of cosmetic and reconstructive surgeons who have said that there is not much that they can do except for soft tissue fillers which I don’t think will address the underlying skeletal asymmetry.
I was hoping to get your opinion and perhaps, given you area of expertise, this would be something you can help with.
A: Thank you for your inquiry and detailing your surgical history. To provide a qualified opinion it would require an assessment of a combination of current facial pictures with a 3D CT scan. No one could say what is possible by merely looking at you on the outside. It requires knowing what your underlying facial skeletal structure looks like, particularly given what has been done previously, and matching that with your external appearance. Then a fully informed recommendation can be given for further facial asymmetry correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 31 year-old mother of 3. I’ve been quite unhappy with my body for awhile now, mainly my butt (or lack-thereof) and have been dreaming of the day that I’d be able to get a procedure done that would make my butt more plump & round… and today’s that day! I’m so excited to make the first step towards happiness! I’m extremely interested in getting a butt augmentation done and would love to meet with you and see what options I have.
Here are some pictures of my buttocks from different angles as well as a picture of my tummy. I’m not sure if I mentioned it but instead of just inquiring about a buttock augmentation, I now would much rather prefer the Mommy Makeover! Although instead of a breast augmentation , I just want to downsize from 36D to 36 full C & would probably need a breast lift as well. But you know best, so I’ll let you make that decision. I have included a front and side picture of those as well. I look forward to getting a consultation date set, as well as hearing your opinion on what procedure you think would work best for my body.
A: Thank you for sending all of your body pictures to which I can make the following body contouring (Mommy Makeover) comments:
1) BREASTS – while you certainly can have a small breast reduction/lift, I would carefully consider whether the scars that would result in doing so. That is your personal decision but I would look carefully at these scars in other patients to be sure the breast shape change is worth that aesthetic tradeoff.
2) BUTTOCKS – you don’t have enough fat to harvest to do a significant or reliable buttock augmentation. Thus you would need to have buttock implants. Whether the size they could achieve would meet your aesthetic expectations remains to be determined and would need further input from you in that regard.
3) ABDOMEN – you would best be served by a mini-abdominoplasty with umbilical float and flank liposuction as your abdominal reshaping procedure.
My assistant Camille will contact you on Monday to schedule an office consultation time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am planning to have zygomatic and chin silicone implants with you very soon. However I have flat moles on those areas of the face that I am planning to remove at some point.
My question is would laser mole removal in any way “damage” or infect an implant underneath (please note I have very thin tissues with not a lot of fat between skin and bones) as I am not sure which procedure to go with first.
A: While I think it would be prudent to separate the mole removal from facial implant placement, that decision has nothing to do with the risk of infection. Removing a superficial skin mole is not going to infect an implant down at the bone level. Rather it is an issue of potential poor scarring. When done at the same time, and provided the mole removal is done over or close to the site of the implant agmentation, the postoperative swelling will stretch the skin closure from the mole excision affecting its final scar appearance. Thus facial mole removal should be done several months before or after facial implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about a custom midface implant:
What are the long term outcomes of this procedure? Are patients generally happy? What kinds of issues have cropped up after the healing period that you’re aware of
A: Every custom midface implant I have ever done has been a favorable aesthetic improvement. In cases where it is larger and extends up over the infraorbital rim and has required an eyelid incision to place it runs the risk of lower eyelid ectropion…but this does not apply to you since it would be an intraoral approach in your case. Some patients, who initially went conservative in size and surface area coverage, have come back for a bigger or modified custom midface implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some septorhinoplasty questions:
a. A desired outcome of this procedure is improved breathing. You’ve mentioned a couple of ways to achieve this through fixing the deviated septum and inferior turbinate reduction. With the CT scan now available, is this still the approach you would take?
b. I’ve been doing research on implant vs cartilage for the dorsum augmentation and based on the long term risks I’d prefer to have a cartilage graft. What is your experience with cartilage graft augmentation rhinoplasty and where is your preferred cartilage source?
c. How long can I expect my nose to be congested for? The reason I ask is that I’ve had issues with severe pressure pain while on previous flights when I have been congested due to allergies. I’m planning on staying in Indianapolis for around 2 weeks after surgery before getting a flight back, will this be sufficient time?
A: In answer to your septorhinoplasty questions:
a. The approach for your breathing improvement remains the same….septoplasty, interior turbinate reductions and possible spreader grafts.
b. The key in nose cartilage grafting is what volume of cartilage is needed to do the job. If modest dorsal augmentation is needed then septal cartilage would be sufficient. Larger amount of dorsal augmentation require a rib graft harvest.
c. Most significant nasal congestion improves by 3 to 4 weeks after internal nasal airway surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some occipital knob reduction questions:
a. With the CT scan available, would you be able to approximate how much bone can be reduced and provide a morph of the image attached so I can get an idea of what the final result might look like?
b. Where will the incision be made, how large is it? I cut my hair short but do not shave my head, I’m guessing as long as this is the case the scar won’t be visible anyway?
c. What are the possible complications and risks of this procedure?
A: The occipital knob can be completely reduced. I have never seen one that can’t. That is because the bone is thicker than normal so maximal reduction is always possible. It is done through a 3.5 cm incision placed just below it. No hair needs to shaved for the procedure. I have never seen any complications with this procedure nor would I expected to given its skull location.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a female interested in custom facial implants and was wondering if you have ever created/installed nasal spine or premaxillary implants. Also, would it be better to get those implants put in before or after a rhinoplasty?
A: When you speak of nasal spine area, you are likely referring to what we call the premaxillary region which is the base of the nose. For that area numerous type of premaxillary implants are available for augmentation. If you are referring to the exact nasal spine to extend it up into the columella to also add to more nasal tip projection, then a cartilage graft is usually done to do so. By your midfacial pictures you could benefit by either premaxillary or direct nasal spine extension grafting.
Regardless of the type of base of nose augmentation used, it would most commonly be done as part of a rhinoplasty as they work in tandem for a better overall aesthetic result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My daughter is 2.5 years old and I have been worried about her head shape since she was 10 weeks old. I brought it up at every wellness check but was dismissed by her pediatrician saying it was fine. Now it’s too late and I live with guilt and regret daily. I was reading on your site about the skull augmentation implants on toddlers. How invasive of a procedure is this and what are the risks? How many cases have you done on toddlers and what is the success rate? I have attached some photos of her head.
A: Skull augmentation is not an appropriate procedure for infants. The skull needs to grow a lot more and the earliest I could consider it is 4 or 5 years of age….but likely even later than that age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have several body contouring questions:
How much actual clavicular bone length be obtained in such shoulder widening surgeries.
Can he ribcage similarly be widened by osteotomies?
Can the scalpel be augmented?
Can the wrists be widened
What is the cost of shoulder widening surgery?
A:In answer to your shoulder widening question by clavicular osteotomy questions:
1) The maximum expansion of the clavicles I have done is 2 cms per side or roughly 1 inch for side.
2) There is no method to widen the ribcage by osteotomies.
3) Scapulas can be augmented.
4) There is no procedure to widen the wrists.
5) My assistant Camille will pass along the cost of the shoulder widening procedure to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m thinking on having a custom jaw implant at your clinic but I’ve been told that jaw implants have a very high rate of infection, specifically of silicone and Porex materials.
What material would you use for my custom jaw implants? I’m very afraid of having a complication and then having to take them off.
Is there a high rate of infection with the material used for the custom jaw implants?
A: Having done hundreds of custom jaw implants I would not say that they have a ‘high’ rate of infection, regardless of their material composition. But implants in the bony jaw angle region, due to the remote intraoral access needed to place them and their location to chewing debris, have an increased risk of infection (4%) compared to every other type of facial implant…standard or custom. (1% to 2%)
When it comes to material composition I am not aware that their are absolutely proven differences between them in terms of infectivity. But as a general implant principle, porous or textured implant surfaces have a higher affinity for bacterial adhesions than smooth implant surfaces do. Thus theoretically smooth implants (e.g., silicone) should have a lower infection risk than textured surface do. (e.g., Medpor)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, last year I had zygomatic reduction in Korea. There was an incision in my sideburn and in my mouth, where they cut the bone and moved it in. I am happy with the reduction, but the part of my cheekbone that is posterior to the sideburn incision (toward the ear) still sticks out, since only the cheekbone anterior to the incision was moved in. Is there a way to reduce the remaining cheekbone that is right in front of the ear, posterior to the sideburn incision?
A: To determine what is possible, I would need to see a 3D CT scan of your face to determine what the altered anatomy now looks like. But in most cases either an additional osteotomy behind the old one or a burring reduction of the protrusive tail of the zygomatic arch attachment to the temporal bone can be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is there a treatment for upper eyelid exposure? I have moderate eyelid expsure and I want my eyes to be completely hooded, this normally occurs in men due a low set orbital bone and brow ridge. But my upper-orbitals are high-set which makes my upper eyelids exposed which are giving my eyes a tired and somewhat feminine look
Fillers usually work quite well for that, but they don’t cover up the upper eyelids to 100%. They also make the eyes look more Asian since Asians generally only have more fat in their upper eyelids, but i want hooded eyes due a low set brow/orbital bone.
Is it possible to place a implant on the upper orbitals/brow ridge?
A: While an implant can be placed in the brow bones, it is never going to have the effect of covering up 100% of the eyelids. You simply can’t drive down the eyebrows and upper eyelids to the major degree to which you seek. A brow bone implant primarily achieves an increased brows bone prominence which may have some slight influence on upper eyelid exposure but not to the degree that you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am just curious about the custom jawline implant option vs a standard chin and jaw angle implants. I feel I have a very weak chin and would like to enhance that and the jawline. Im curious how long this procedure takes? Cost? Cost if performed with a septoplasty? Are there any issues with having a wrap around implant vs the more widely done jaw and chin pieces? Materials?
A: The question you are fundamentally asking is which would be better….standard chin and jaw angle implants or a one-piece custom made jawline implant. The answer to that question is the same for everybody…. a custom jawline implant is always superior because it is made specifically for the patient from their 3D CT scan and it is all connected as one piece. This allows for more controlled aesthetic outcomes and less risks of implant asymmetry. The only reason to ever do three separate standard chin and jaw angle implants is cost. If the patient can not afford the custom implant approach then they have no choice but to use standard implants.
Either jawline augmentation approach can be with a septoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 26 years old male and I am interested in undergoing the clavicle lengthening procedure for aesthetic purposes. Do you perform this? In this regard I have a couple of questions. What would be the orthopedic implications of such a surgery? Would I loose shoulder mobility? I am asking this as I am quite into sports and I do practice bodybuilding and rugby. Moreover, I have a condition to my right shoulder. A couple of years ago I broke my AC joint ligament. How would this interfere with the surgery? Would it still be effective? What would be an approximate cost of the operation?
I really look forward to hearing from you. Thank you for your time.
A: Thank you for your inquiry. Clavicular lengthening for increased shoulder width is a procedure that I perform. It is a mid-clavicular osteotomy with interpositional graft so it does not involve the AC joint which is at the lateral end of the clavicular bone. As a result it does not affect shoulder mobility since this primarily relates to the AC joint. It does require a sufficient healing time, much like that of a clavicular fracture, and since it involves both sides it would take three months before one can fully return to strenuous sporting activities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am now three months after placement of my custom forehead/brow bone implant. I have a weird tingling sensation on the left side of my brow and I’m wondering if ithe implant is getting infected…When I press on it it goes numb.
Thanks.
A: You are undoubtably referring to the supraorbital nerves that exist the brow bone area and supply feeling to the forehead. These sensory nerves lie right up against the implant as you can see in the attached picture of your forehead implant on your brow bones. (arrows) You can see that the implant design was adjusted to account for where the nerve comes out of the bone at the supraorbital notch. On the symptomatic left side the implant and nerve must be directly touching and this is why you can make it go numb if you press on the skin which pushes the nerve down onto the implant. This is not a sign of infection but speaks to the proximity of the implant and nerve which is unavoidable when the brow bones are augmented. Interestingly there is the exact same situation of the right side side and you have no such symptoms.
Whether this will completely resolve I can not say. But for now I would just give it time and see what it does.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 25 years old and my natural facial bone structure is lacking. I’m interested in getting chin and jaw implants, or possibly a wraparound implant if it is called for. I would appreciate if you could answer some general questions about the procedure, as you seem most experienced when it comes to facial augmentation with implants.
(1) When lowering the mandible angle, how many millimeters would you say is needed to be able to appreciate any sort of difference? If I were to get non-widening jaw implants that drop my angle down by say 5mm, would I be able to see a noticeable difference? While 5mm seems like quite a lot when it comes to chin implant projections or nasal implants, I’m not sure how 5mm would work for the angle.
(2) What % of patients or what % chance exists of getting a post-op infection? If the implant was to be inoculated with bacteria from the surgery itself, what time period post-op would it be most common to get an infection? I’m not very fond of the idea of having to pluck the implant back out if it were to happen.
(3) After surfing through RealSelf, I’ve learned that no branches of the facial nerve are affected by chin or jaw implants. The main nerve at risk of permanent or temporary damage seems to be the one that provides sensation to the lips and chin. Would you be able to expand on why some chin implant patients experience lip paralysis or their bottom lip moves strangely post surgery? If motor nerves are not affected, why does this happen?
(4) Have you ever had a patient experience permanent nerve damage from chin and jaw augmentations?
Thank you for your time. I hope you continue to help people surgically and with this blog as it has been a great educational tool for me and undoubtedly others as well.
A: In answer to your jawline augmentation questions:
- Whether a 5mm drop in your jaw angles would be aesthetically significant I can not say since I do not know what you look like or what your aesthetic jawline augmentation goals are.
- The chance of infection in any type of jawline augmentation procedure is in the 2% to 3% range. They typically do not appear until 3 weeks after the surgery. The initial treatment of such facial implant infections is an extended course of oral antibiotics of which about 50% resolve without the need for further surgery.
- It is not true that the only nerves at risk in any chin or jawline implant are the sensory mental nerves. There is also the marginal mandibular branch of the facial nerve that crosses over the inferior border of the lateral chin which supplies movement to the lower lip.(depressor anguli oris muscle) It is possible in some cases that this tiny nerve branch gets stretched and the affected lip side may take some time to recovert. I have never seen any cases permanent paralysis of the lower lip from traction injury to his nerve in jawline implants. That issues aside you are more likely referring to the initial changes of lower lip and chin movement from the swelling and initial expansion of the tissues…which filly resolves in most cases as full healing takes place weeks to months after the surgery.
- As noted above I have not yet seen any patient with permanent damage to either the aforementioned sensory and motor nerves branches around the chin from any form of bone or implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, As for my chin, I’m not so worried about the profile aspect of my face, so bring my chin forward isn’t so important to me. It’s more of the front view of my face. I’m not really interested in getting a sliding genioplasty. I’ve done a lot of research on it, and it just seems too invasive and adds many more complications than what chin implants do. I’ve spoken to other surgeons, and some recommended a older type of implant called a “button” implant. Since it tends to produce a more pointy chin. Or a custom cheek implant to produce more definition in my face, would have narrow my face a bit more.
A: In answer to your chin augmentation questions:
1) Implant options are either a custom chin implant or a hand carved v-shaped anatomic implant.
2) A button or central style of chin implant can used but it would have to be hand carved into almost a v-shape as it is otherwise a round implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your answer about the helix being out of view in an otoplasty that is overdone or pulled back too far.. I would like to know if I come to you for a reverse otoplasty, how long would it take for the surgery and do I need someone with me? I would rather keep the procedure to myself. Right now a simple rolled up double sided piece of tape stuck in the crease between the head and ear makes me very satisfied and no one has noticed it that I know of for over a year doing so. It makes me self conscious that someone might see it though and I would rather have something permanent that will make it more comfortable as after several hours it pinches the skin.
A: Thank you for your inquiry. The success of a reverse otoplasty depends on the placement of an interpositional cartilage graft…which may come close to replicating the effect of a roll of tape that you put behind your ear. This is a procedure done under local anesthesia so there is no problem with you coming by yourself.
I will have my assistant Camille pass along the cost of the surgery to you on Monday. In the interim please send me some pictures of your ears for my assessment for this procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In regards to a vertical lengthening chin implant. I’ve read a lot of conflicting things in regards to the labiomental fold., I have a deep one. I don’t mind that it deep and I am not looking to correct it. I just want to know if I could still have this type of implant while maintaining a natural look and not making the fold worse. I am reaching out to you guys because I’ve done a lot of research and know that you designed this implant. I need vertical length and am not interested in a more invasive surgery.
A: The best way to avoid making the labiomental fold deeper and look natural is to do a vertical lengthening bony genioplasty. Otherwise a custom chin implant would need to be designed to achieve a similar effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I emailed with you approximately a year ago in regards to facial masculinization, I went through with the jawline augmentation (three pieces of Goretex around my jawline), cheek augmentation and paranasal implants and am now post-op 1 month. Although It looks better than before I still am not happy with the lower/middle part of my face. I am aware that I’m still a few months away from the final result, however I realized now after some more research (which I should have done before) that the problem is my maxilla. Because the maxilla is underdeveloped I don’t get the protrusion that I need which makes my face look flat and mouth/lips sunken in. I feel like the surgeon was a bit to conservative as I wanted it a bit bigger and this might explain why.
I guess I would need both the mandible and maxilla to move forward to get the desired result. From my research there are two ways of doing it, one is bimaxillary augmentation through surgery which is very expensive + higher risks not to mention having to wear braces which adds to the cost and maybe even removing the jawline augmentation which would be a waste.
The second is from the use of braces like “Fixed Anterior Growth Guidance Appliance” (FAGGA) or DNA Appliance and such. Although They might not make as big of a difference as i would like. Which do you think would be the best choice?
Here are pictures of what I think i would look like (i tried my best with Photoshop) postop is how I look now, example 2 and 3 is what I’m guessing i would look like after using FAGGA/DNA or imaxillary augmentation. I’m not sure if the nose gets pushed forward but i implemented that in example 3 anyways (even though I’m not a fan of the nose in 3, i still look a better there than what I do now).
Because I plan to get browbone/forehead augmentation in the future it could make my face look even more “flat” as i want more brow/forehead protrusion.
Are these augmentations unrealistic?
Do you perform Bimaxillary augmentation and if so what is the price range?
Thank you
A: My comments are as follows:
1) More healing time will only make your results look less significant as all swelling goes away and tissue contraction pulls the elevated tissues inward. In other words your results are only going to become more ‘conservative’.
2) What you lack is overall implant volume in the midface and jawline…which is to be expected when a patchwork approach is using just laying in thin sheets of Goretex. This approach is always bound to create a minimal type result. In essence there has been a mismatch between your aesthetic facial goals and the treatment approach used to try and achieve it. This is why custom implants made from a 3D CT scan is a far more effective treatment approach for increased facial projection.
3) Comparing orthognathic surgery and any type of orthodontic bone protraction is like comparing a bullet to the hydrogen bomb. One is very minimalistic and is never going to create your desired look and the other is far more effective but tremendously invasive.
4) While maxillary advancement surgery may be very effective you are talking about costs that will exceed $35,000 to do so.
5) Any forehead/brow bone reduction without further facial change below it, is going to make your lower face look even more retrusive as you have correctly noted.
Dr. Barry Eppley
Indianapolis, Indiana
