Your Questions
Your Questions
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
Q: Dr. Eppley, I will be visiting you soon for a custom jaw implant. I wanted to ask if it is OK to do a one stitch facelift /mini facelift to pull the skin around the nasolabial folds and cheeks to the ears to eliminate nasolabial creases. Would an Endotine device provide a long term permanent solution by anchoring around the ears to give a permanent results. Of course natural aging will occur but would essentially the surgery and fixation make it impossible for the skin to retract to allow cheeks and nasolabial folds to crease again once a mini face lift is preformed. Also can jaw / chin implant be done post face lift.
A: There is no operation that effectively resolves nasolabial folds including a facelift. Short of direct excision no form of a facelift can solve them beyond the initially swelling period, certainly not any form of a mini facelift. The concept of a more permanent result, particularly at reducing the nasolabial folds is not achievable as you have described it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Upon further consideration, I think the implant I know I will absolutely need is a chin implant. I think that alone will make a significant improvement for. However, I feel that mandibular jaw angle implants may help too, but may not be absolutely necessary.
I think I would like to do a 2 step process where I first get a chin implant and then see how it looks, then maybe in a year after if I feel like I need it (and could afford it) maybe consider getting jaw angle implants.
I guess my question is: If I really wanted to do this in 2 steps (instead of the all in one chin/jawline implant), could I get nice results still? If so, would off-the-shelf implants suffice or do you think custom chin and mandibular implants would be the way to go.
I am very interested in working with you with regards to my chin and jaw improvement. Thank you for your time! Your responses have been appreciated immensely.
A: A chin implant alone is just fine…as long as you realize what it can and can not do. it affects the chin and the chin only. If your definition of a ‘nice result’ is an isolated chin augmentation effect that you will achieve your goals.
Given your potential staged approach to the process, I would go with a standard chin implant first. I would only consider a custom implant approach if you decide to complete the jawline effect later….as many patients ‘learn’ a lot from their initial chin implant and often want to change that later as well. It is then that the whole custom jawline implant approach is taken.
It is very common in my experience that the chin implant, which could well be the end of the process also, serves a ‘toe in the water’ approach where some patients may graduate to the whole jawline augmentation approach later. When you are changing the structure of ones face and its subsequent appearance it is hard to know exactly what one wants until you ‘wear it for awhile’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m an Asian female looking to enhance my midface region, namely frontal cheekbone and paranasal area. I also plan on getting a rhinoplasty either before or after facial implants. I was wondering if getting a midface/paranasal implant would affect rhinoplasty – would lateral osteotomy and alarplasty be affected if I got the implants beforehand? If I got implants after rhinoplasty, would the paranasal implants alter rhinoplasty results? Would you recommend getting facial implants or rhinoplasty first?
Thanks!
A: It would make the most sense to have the rhinoplasty first since paranasal/midface implants may be either in the way of the osteotomies or become secondarily infected by the location of the osteotomy line.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m fully aware that I won’t be able to achieve exactly what I have in mind, but either way, I’d be content with any sort of improvement overall. With buccal lipectomy, it definitely did decrease the “chubby” look to my face. But as you said, the results would have been even better had it been accompanied with perioral mound liposuction. So would it be too late to get it still? Is it usually only done with other procedures as the same time? Also, is it a safe procedure? I noticed that not many doctors tend to conduct this procedure? Or what other procedures can be done to reduce the fat in my cheek area?
A: In answer to your perioral mound liposuction questions:
1) Perioral mound liposuction can be done secondarily and, is often do so, in patients who have had a prior buccal lipectomy.
2) Perioral mound is a perfectly safe and effective procedure that complements the buccal lipectomy.
3) There are np other facial defatting procedures other than buccal lipectomy and perioral mound lipectomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have Lipedema and have had some surgeries with a lipedema doctor and they were very conservative. My biggest concern are the knees and the tops of my thighs, my public area and inter thighs. I have calf concerns but that can be later on down the road.
A: Thank you for sending your pictures. The critical question becomes in the face of lipedema what happens with liposuction? Will it be effective or overwhelmed by chronic swelling? Will it aggravate the existing lipedema or make it worse? The prior lipedema surgeries may have been ‘conservative’ but may have been done for a good reason…to avoid aggravating the lipedema.
Forgetting the underlying lipedema for a minute, the treatment of your type of lower extremity lipodystrophy requires a very aggressive liposuction approach. With that comes one known and and one unknown risk. The known risk is that the cellulite appearance on the thighs will undoubtable get worse, not better. That is unavoidable. The unknown risk is will it aggravate the lipedema? Just because the conservative treatments did not, that is no guarantee that a more aggressive approach will not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you so much for your reply. The custom implant approach sounds good . My doctor says He will use Goretex implant and craft the implants right there during my surgery. I also want to know is it possible to use Goretex or Medpor because he mentioned these material are more natural than Silicone and it will grow into my bone? Silicone will look more unnatural later on when body starts to form capsule? Now i would like to know how soon can i get surgery done after first consultation?and how long does it take to make a custom jawline implant, I hope one trip can do it all. Thank you.
A: The concept that Goretex or Medpor is more natural than silicone to the body is a completely bogus statement with no basis in scientific fact. Nor are they more natural or create a better facial look. In the end what matters is the shape and dimensions of the implant, that is the key.
The limitations of trying to patch a bunch of different implants together during surgery by hand to create a good result and have the right dimensions of the implant that is needed and symmetric for both sides, speaks for itself.
Biologically all implants produce a capsule (layer of encapsulating scar) around them, Medpor and Goretex are not different. Capsule formation is a normal reaction to any synthetic material placed in the body, and short of actual bone, all compositions of implants form an equal amount of capsular formation. To say that one implant material forms more or less scar than the other one fails to have adequate knowledge about the implantation healing process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 2 weeks post my surgery so I wanted to quickly touch base with you. First things first, I’m so happy with my results! The projection is perfect, surprisingly my lip position has changed too it doesn’t look receded anymore. I also have no loss of sensation- yay! I’m so grateful to you, THANK YOU! Attaching a few pictures for your review.
My only concerns are:
1) I have some muscular/soft tissue asymmetry. My right side drops lower than my left when I smile or open my mouth. Not sure if that’s due to residual swelling or muscular tightness. Although I don’t think there is any swelling left. Is there anything I can do about it?
2) I started working out 10 days after the surgery and have noticed there is generally more swelling and slight pain the next day. Should I continue going to the gym or take a break?
Thanks again,
A: Thank you for the follow up. I would say that your sliding genioplasty went absolutely perfectly. It could not have gone any better. I actually used an 8mm plate and bent it to make for a 4mm vertical lengthening. I thought it replicated your jaw thrusting maneuver fairly closely. Not having any loss of sensation, temporary as it might have been, is always a bonus.
In answer to your questions:
1) It is common and expected that the mentalis muscle function will temporarily work a bit abnormally as its entire attachment to its bony origin was separated and was reconstructed back together. (that has to be done on all sliding genioplasties) The muscle recovery will take the longest time to normal function and that could be up to 3 months after the procedure.
2) I would not hesitate to get back to working out. That may cause some mild increase in swelling, which is expected, but is not of any concern.
Despite how well the first few weeks of surgery have gone, it is important to realize that a complete recovery, and the many nuances of it, takes a full three to four months. So you have a long way to go yet!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had jaw realignment surgery, along with a genioplasty (burring) followed by a revision genioplasty 2.5 years ago. The initial surgery was done because my jaw grew longer on one side. The initial jaw surgery/genioplasty did a great deal to correct the asymmetry, but I still had some nagging asymmetry especially when viewed from below, and I was also interested in a slight narrowing. Following the revision genioplasty (also burring) I have quite a bit of dimpling in the chin and it did nothing to narrow the chin. First, I’m curious for a professional opinion if my desired look was ever actually achievable or realistic (I’ve attached photos). Second, I’m wondering if there’s anything that can be done to improve the dimpling/ scar tissue to gain a better contour. I would like to avoid filler or anything that would make the chin longer/ wider.
A: Thank you for your inquiry. If I understand your history correctly you have had two bony genioplasty surgeries both of which used a burring technique. It was the second chin surgery that has created the chin indentations/dimpling you have now. I am assuming that both burring efforts were done from an intraoral approach since I don’t see a submental scar.
In answer to your secondary chin reshaping questions:
1) Your initial desired chin shape results may have been possible but never with a primary burring technique done from an intraoral approach. That technique completely degloves the soft tissue of the chin, reduces bony support and then often creates chin irregularities due to the mismatch between the same volume soft tissue and the reduced bone size which it envelopes.
2) The better initial approach would have been either intraoral t-shaped osteotomies or a submental shaving technique with some soft tissue reduction. But that is irrelevant now.
3) The more relevant question is what can be done for any further improvement. This is a primary soft tissue problem which can only be done from a submental soft tissue excision/tuck up procedure. How much improvement could be obtained can not be predicted beforehand. When such irregularities occur in the soft tissue chin pad they can be very difficult if not impossible to eradicate.
4) I would agree with you that adding fillers into the indentations will make your chin bigger which is the antithesis of what you are trying to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have two healthy testicles. I’m interested in your envelope implant procedure. (testicular enlargement implants) What are the available sizes (max) and how much volume in milliliters? Are implants oval or ball shapes? How hard or soft is the material? My assumption is as it envelops the testicle that it is a very soft material would feel natural? Do you have pictures of envelope implants a couple of months after surgery? I’m looking forward to your answer. Kind regards
A: In answer to your testicular enlargement implants questions:
1) The maximum external size to date has been 6.5 cms as measured longitudinally along its oval axis.
2) They are made of the softest durometer of which silicone can be made and still be a solid. They are ultrasoft. That softness is enhanced since there is no inner core of material.
3) Since all of my patients are from afar I never see them back again…unless they have a problem which as not occurred to date.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I please also ask for your honest opinion about using Botox for temporal reduction? I read on your website that it’s another remedy, but I was wondering if you think I could expect similar results, and if I could get it at your office?
A: Like the use and effectiveness for reduction of the large masseter muscle, Botox injections will similarly create a reduction in size of the temporal muscles as well. Like all Botox injections its effects will be temporary and how effective it will be is based on dose. (number of units injected) Generally it takes a 100 unit treatment session (50 units per side) to see any appreciable size reduction. Such an effect will last 3 to 4 months.
While Botox can reduce the size of the posterior temporal muscles, it is to not as effective surgery which removes 100% of the muscle and thus has a more profound effect.
The value of Botox injections in the temporal muscles is really a test to determine if one may like the effect. Given that its effects are temporary this not a long-term solution to the problem. But for the unsure patient as to the value of surgery, this is a harmless and completely reversible treatment approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a growing interest in temporal reduction surgery, as I have had life-long issues with my head shape/size during my life.
My number one hesitation, however, is a failure to comprehend how “the posterior portion of the temporalis muscle is removed and the anterior portion shortened” without an effect on function. Did God/evolution put these muscles here for no reason?
I am amazed at the work you have done on others and am in disbelief that this type of procedure even exists, which is something I’ve wished for many times in the past.
If there is anything you can provide in redone to my concern, I would appreciate it.
A: I can not speak for what God intended. But it has been my extensive observation on doing a lot of these surgeries that removal of the entire posterior portion of the temporalis muscle causes not functional changes in jaw opening and closing. This undoubtably occurs because when looking at muscle volume, that section only makes up about 30% of the muscle’s total volume.
While the posterior portion of the temporalis muscle is removed I don’t ever remember writing about ‘shortening the anterior portion of the muscle….as that is not technically possible from an incision behind the ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My facial reconstruction situation may be very complicated, I am just exploring all options to see if this is even viable for me. Just to give some background to my situation, to begin I was diagnosed with a maxillary sinus sarcoma on the right side. I had surgery to remove it, right infrastructure maxillectomy. I then had 30 treatments of radiation therapy, then 18 weeks of chemotherapy. All is clear now and my Dr is discussing reconstruction. The reconstructive surgery poses a lot of risks because of the irradiated tissue. If there were a way to do an implant rather than the microvascular tissue transplant surgery I would be interested to know how or if it could be done.
A: Thank you for your inquiry and detailing your facial reconstruction issues. The key concept to fully grasp is that radiation really adversely affects the tissues when it comes to healing. Getting healthy new vascularized tissue into the defect site is the key to changing the vascular environment now damaged by the radiation. While a microvascular tissue transfer is far from appealing, this is the only type of baseline reconstruction you should have. You have to change the tissues both in volume and vascular quality first. An implant in this situation would be completely contraindicated. The risk of microvascular tissue transfer today are far lower and it is a much more reliable procedure than it was twenty years. Even then when I did such surgery the success rates in the face were every high. (survival of the transplanted tissue)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I tried to get pics of my face to show my lower third facial deficiency. I live alone so had to use a selfie stick and tried to get different angles. Not too happy with my nose either but maybe it won’t look so prominent if I had a more defined jaw line.
A: Thank you for sending your pictures. You did a good job with the selfie stick. You are correct in that your very short chin/jawline magnifies the size of your nose. When it comes to chin augmentation, all available options are on the table so to speak, each with a slightly different result. The best one in my opinion, due to the degree of short chin/jaw that you have is a sliding genioplasty with a chin implant overlay. Moving the chin bone out (not the whole lower jaw just the end of the chin bone) helps the neck a lot because it pulls out the attached muscles with it as the chin comes forward. It also serves as a bony foundation for the most of the chin augmentation and lowers the risks of just a large chin implant placed alone. The purpose of the chin implant overlay (small chin implant with long wings) is to primarily add some width to the chin at the back end of the bone cuts, which addresses the aesthetic problem of sliding genioplasties in some patients from making the chin appear more narrow from the front view as it comes forward. In essence in challenging cases of congenitally short chins, this approach combines the best features of a sliding genioplasty and a chin implant…each of which has their own aesthetic limitations in the very short chin patient.
Attached is some imaging of you as well as an example of what the technique which I have described.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Would you need to see x-rays or any other studies to consider doing a chin implant revision?
Have you ever helped anyone in my situation where a larger implant simply needs to be replaced by a smaller one?
Do you have any specialist trained in ultherapy who has experience in treating excessive facial fat?
As I live out of state, do you ever do virtual consultation through Skype, plus photographs I could send so I would not have to travel there twice if I were to be a good candidate for the procedures?
Thanks again for your time and expertise.
A:In answer to your questions:
1) A 3D CT scan of the mandible/chin is always useful to see the position of the indwelling implant on the bone.
2) Chin implant revisions are very commonly done for size, style and/or implant positioning….as many people want their chin augmentation bigger as want it smaller.
3) My medical aesthetician specialist uses Exilis for the treatment of unwanted facial fat with good success..
4) My assistant Camille will contact you to schedule a virtual consultation time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Three years ago, I went to a surgeon who said I needed a facelift, some fat injections in the cheeks and a chin implant for an “inadequate chin“. I told him I wanted some fat injections in the lips as well , but emphasized that I do not want my face to be longer because it was already too long . During the facelift, a medium-size, Medpor button implant was secured in the midline position with a number of 26 mm Stryker screws. It definitely made my face longer. In addition, from the side, the button implant curves out in a funny position, and there is some dimpling of the skin, but that was there before.
My goal is to take it out, and replace it with a much smaller implant that would not be screwed in, be in appropriate shape with the natural projection from the side.
I have frontal, AP , and lateral skull films on CD. The chin problem is definitely a part of the entire facial distortion.
If you have significant experience with revision of excessive cheek fat injections, would be happy to learn more.
A: Thank you for your detailed surgical history and description of your current facial concerns to which I can answer the following:
1) While your existing chin implant can be replaced with a smaller one of a better shape, it will need to be screwed in as it will otherwise become malpositioned. (smaller implant in a bigger pocket) While an initial chin implant may be capable of maintaining its position due to the created pocket, such is not the case when downsizing a chin implant. (chin implant revision)
2) The best approach to excessive fat removal in challenging facial areas are energy treatments like Exilis or Ultherapy. While that is not the intent of these skin tightening devices, fat absorption is one of their well known adverse effects….which in your case is a beneficial one. I have seen that successfully done many times.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have attached pics of my torso, I am interested in filling my chest out, attached a dream perfect chest (not expectation) chest filled out, more flat than rounded, more square. I will not proceed with that if I cannot also do liposuction for abdominal region, normal height, weight is 6’1″, 220 lbs, my current weight is 260 lbs.
GOALS:
1) A properly proportioned “ripped” looking, filled out chest. (through implants)
2) A Slim waist from size 44 to size 33.
3) A flat six pack ab stomach, by removing fat from upper and lower abdomen, flanks, back, and small area around pubic bone,
4) Abdominal line etching if possible.
I am concerned about 1) activities that might cause the implant to shift. 2) activities for best results, food and diet, exercise, 3) activities that impair results, things I should never do, or can no longer do. 4) if i get fat, where would he fat show up? I live a healthy active lifestyle as far as my injuries permit. I’m concerned about contraindications, (i.e. My blood pressure is 120/80, but controlled with 50 mg daily atenelol), I’m much less mobile than my college football days. I cannot get the workouts I used to have. I want to properly fit into my clothes and wear designer suits. They do not make designer suits for a man 260 lbs.
A:Thank you for your inquiry and sending all of your pictures. The first comment that I can make is that we have to be realistic with what its possible. The use of adjectives like ‘dream perfect chest’, ‘ripped chest’, ‘slim waist’, ‘flat six pack abs’….these all end goals that are not going to be achieved with any form of plastic surgery with your current body shape. Those are not achievable goals with your current weight of 260lbs for sure and may not even be if your weight was at 220lbs.
Secondly most of the fat you carry in your abdomen is intraperitoneal not subcutaneous which is very typical for middle aged men. This is fat that can only be reduced by weight loss not liposuction. These are fat collections that are not accessible to liposuction removal around the abdominal organs.
Thirdly I would agree that the chest and abdominal components are linked. There is no aesthetic sense in getting pectoral implants if the abdominal projection is not less than or at least even in profile with that of the enhanced chest projection.
Unfortunately I can not be of any assistance until at the least the intraperitoneal fat component is reduced with substantial weight loss. This not only will create a better result but will also result in the need for less surgery to try and do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking into getting jaw implants and my bottom wisdom teeth extracted. I’ve contacted several surgeons who either say it can be done in one go or I would need to extract the wisdom teeth first before jaw implants.
What would be your stance on this?
Is a week or a week and a half between wisdom teeth extraction and jaw implants too soon?
A: I will assume you are specifically referring to the lower mandibular third molars or wisdom teeth. As a general rule you should space these two procedures 3 months apart, a week or two is insufficient. Jaw angle implants have the highest infection rate of any facial implant. Why risk doing anything that would increase that risk factor further? It is not a question of whether they can technically done together, as they can. It is a question of the wisdom in doing so. I wouldn’t recommend doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my concerns regarding my chin/ jawline/ lower portion of my face are related to my profile and front views. From the side, I would like my jawline to look more defined, thinner and projected forward horizontally and maybe vertically as well. From the front, I would like my face to look thinner. I feel that my face from the front looks bottom heavy, I have jowls and marionette lines, even though I’m 34 and I am not, nor have I ever been, overweight- I’m 5′ 8” and weigh 128 lbs.
I’ve have had these issues even when I was in my 20s, so I think it is more an underlying lack of bone, chin is possibly too short and/or too recessed, than an actual aging issue. I also think I have fatty deposits in my jaw/chin/neck area. I have looked into chin implants, sliding genioplasty, and neck/chin/ jowl liposuction. I feel that while the research has helped me to better articulate my concerns, it also has me confused as to what treatments would be most appropriate for my specific case.
I have attached some current pictures to this e-mail of my face from different angles. Could computer imaging be done to help me understand the possible outcomes and what procedures would best suit my concerns?
A: Thank you for your inquiry and sending your description of your current facial concerns to which I can make the following facial reshaping comments:
1) While jawline augmentation would provide some improved definition, particularly that of chin projection and vertical jaw angle definition, i would have concerns that this may be a contraindication to the goal of also making your face thinner. By definition jawline augmentation adds volume to achieve its effect. While the jaw angle volume would be vertical and the chin volume horizontal, I have some concerns that this may still make our face ‘heavier’ due to your natural tissue thickness anatomy.
2) The real issue that you have with your fuller face is the thickness of your tissues and the jowl sagging that has developed. This is the main component to your face looking heavier. To achieve a more heart-shaped face, which I think is largely what you mean by a thinner face, your really need a jowl tuck procedure (mini lower facelift) with jowl defatting combined with chin augmentation. (which also includes getting rid of the submental crease indication.
3) I would consider #2 the foundational procedure. I would stay away for now from any jaw angle augmentation as the last thing you need is anything that has a risk of making the lower third of your face heavier.
While on the one hand a lower ‘facelift’ seems incongruous with your relatively young age, it is what the tissues are doing anatomically that matters not their chronological age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently read something you wrote from this website Real Self on recommending an implant for the correction of enophthalmos. I was wondering if you could explain your preference over using an implant instead of fat. I was also wondering if you could clarify whether a risk of filling that area with an excess amount of fat could potentially cause proptosis. Thank you very much in advance.
A: Fat injections are less well uncontrolled in terms of placement and only have a soft push on the structures that need to the lifted. In addition how much volume do you need to correct the problem, over- or undercorrection is as likely as the right amount. A custom orbital floor-rim implant is made from the patient’s 3D CT scan where the exact anatomic differences between the two sides can be determined down to the 0.2mm level. It is the best method of true skeletal correction if that is the goal.
But the treatment plan for each enophthalmos case must be determined on an individual basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I thought it might be possible to have some form of genioplasty, sliding the chin down slightly to lessen the angle of the chin from the side. I thought moving the chin down slightly might reduce the amount of compression of the lower lip. As for the alignment of the lips I thought I might use a fat transfer or filler to align the lips. (at a later date)
A: Your concept of moving the bony chin downward (vertical lengthening bony genioplasty) to try and drop the lower lip down with it is one that on the surface makes anatomic sense. In theory one would think there would be some relationship between the bottom position of the chin and the position of the lower lip. However in dong many vertical lengthening chin osteotomies with interpositional grafts, some up to almost 20mms, I have yet to see the lower lip pull down. (which is actually a theoretical concern about vertical chin lengthening) What that is good news for those patients with normally positioned lips, it may not be good news for someone who has your lip positional issues and is trying to change them. However I am quick to add have I ever done this operation in someone with your specific lower lip issues with that being goal.
Such an operation only makes sense for you if there is an aesthetic reason to vertically lengthen the chin. Then even if the lower lip position is not improved there would still be benefit from the surgery. In your face that is already long and narrow, such an aesthetic change would not seem beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have three questions regarding the combined sliding genioplasty and neck liposuction procedure.
Would my recovery be much more extensive than with a chin implant?
I’ve gained about 20 lbs over the past few months. If I lost that weight, would I still need the neck liposuction?
And at my age, is it better to do neck liposuction or neck lift?
Thanks again!
A: In answer to your questions:
1) A sliding genioplasty has some increased ‘recovery’ time from a chin implant but six weeks later that is an irrelevant issue.
2) Since I don’t know what you looked like 20 lbs ago I can not say. But there is always one way to find out….don’t do the surgery until you lose the weight. That would be the best approach.
3) What you are referring to is the option between neck liposuction alone vs a submentoplasty (neck liposuction + muscle tightening). In fuller necks a submentoplasty always produces a better result than just liposuction alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have bilateral slipping ribs at 10th level. My 10th rib has been slipping under the ninth and causing considerable pain for eighteen months. I am interested in a qualified plastic surgeon performing this procedure vs.a thoracic surgeon. I have yet to find a surgeon who has ever performed this procedure. Thank you for your time.
A: Thank you for your inquiry. When you refer to slipping of the 10th rib, you are likely referring to the cartilaginous end of the 10th rib where its distal end comes around to attach to the subcostal ribcage. That end of the rib is usually not fused to the ribcage and has some mobility in most people but that his usually asymptomatic. If it is excessively loose or mobile that can a rare source of pain in some people. That portion of the rib can be removed to eliminate the movement of that portion of the rib. I have performed that subtotal rib removal before as well as for other rib pain associated cases like the costo-iliac syndrome patient.
To determine of this or any other type of rib procedure would be beneficial, it would be helpful to see an actual drawing on your ribcage of where the exact location of your pain is so I have a clear anatomic understanding of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What are the reservations of my ethnicity in regards to mouth widening surgery? I am Chinese so would there be any issues? Also would there be scarring? I am very interested in this procedure yet I am quite scared of the risks because I do know it involves cutting the orbicularis muscle. I also do not see this as a popular procedure and it seems like a very rare one. My mouth is very imbalanced with the rest of my face as I have a wider face and my smile looks way too small when I smile.
A: Scars at the corner of the mouth are always a concern in any patients with an form of corner of the mouth surgery. But in Caucasian patients that does not usually turn out to be a problem But in patient with intermediate skin pigments (e.g., Asian patients) those scarring risks are increased since such skin tends to be more reactive and the risk of hypertrophic scarring is increased.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in jawline enhancement surgery. In fact I already found a surgeon locally and they arranged my surgery for next Wednesday. The reason why I am contacting you is because I accidentally saw a lady who did jawline/chin surgery from the same surgeon as mine, unfortunately she had a really bad experience. Not just her face looks weird but also she had to get implants removed due to infections. After I read her story and saw her pictures i just feel unsafe and scared. Now I am not sure if I should cancel it…. My problem is the angle of the jaw. Eight years ago I did double jaw surgery in Korea and at same time they did “v line” too , my face looks good in front view but profile not good because it is to straight and no angle at all. So my question is if I fly to Indianapolis how long do I have to stay there from first consultation to surgery. Looking forward to hear from you guys . Thank you!!
A:I can not speak to your concerns in regards to your current planned surgical procedure. What I can speak to is what I normally do in the ‘reconstruction’ of the jaw angle area in patients who have had prior V-line jaw contouring surgery. Since the jaw angles have been amputated and the two sides are never symmetric, my preference is to make custom jaw angle implants due to the altered anatomy in which a portion of the implants has to ‘hang’ off the bone so to speak. This is why I have found to be the most effective with the least risks of problems. It is possible to use standard vertical lengthening jaw angle implants also but there is a higher risk of postoperative asymmetry by doing so.
Dr. Barry Eppley
Indianapols, Indiana
Q: Dr. Eppley, I’m interested in changing the appearance of my nose. However, I understand that the typical nose job is a subtractive procedure and that patient’s potential outcomes are limited to some degree by the nose’s original dimension and position.
I’ve always wanted to correct my long philtrum, which in conjunction with my short nose, leaves a large unappealing blank space above my lip. Similar to Stephen King, although not so extreme.
As far as I’ve researched, the only procedures that exist to reduce the philtrum involve altering the upper lip, which I don’t want to do: I like my lips the way they are.
My question is, is it possible to shorten the philtrum by augmenting the nose, not the lip? Is it feasible to create a longer nose that would extend further down into my philtrum, either through use of an implant or other method?
A: The short answer is ….no. You can only change the vertical distance between the base of the nose and the upper lip (along philtrum) by removing skin. Trying to push down the base of the columella or base of the nose by any method will only exaggerate or magnify the the long upper lip.
Dr. Barry Eppley
Indianapolis, Indiana
