Your Questions
Your Questions
Q: Dr. Eppley, I’m considering improving my frontal angle of face. I am happy with my jawline but my cheeks lack definition. To add to this I have very unattractive eyes, which are close together and seem sunken in certain lighting especially the inner area – giving me a lion look. I think a cheek implant should be able to improve my eye area, giving me a more attractive look, but to remove the sunken inner eye area would I need a custom that goes all the way around ? If I crop a models lower face and insert it under mine I look a lot more attractive so I think a cheek implant with buccal fat removal will be able to achieve this. Finally I am extremely unhappy with my laugh from my 45 to 90 degree angle (smile is perfect). My cheeks seem very heavy and protrude out whilst my chin seem to move back (I think) will a buccal fat fix this. Thank you.
A: In answer to your facial contouring questions:
1) To get coverage over any or all of the infraorbital rim area a custom infraonital rim implant design is needed.
2) A buccal lipectomy procedure reduces cheek fullness under the cheekbone in a static or non-smiling facial position. It is not intended or can it reduce the cheek fullness that occurs when the face smiles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about mouth widening surgery:
1) How wide can you make a mouth, would it be possible to increase with around 6mm on each side?
2) How natural would it look after the surgery, would it be lop sided or titled by any chance or would it look like a regular mouth.
Thank you
A: In answer to your mouth widening questions:
1) The average mouth widening distance increase done surgically is usually 5 to 7mms per side.
2) The postoperative concerns are not whether it will look natural or have asymmetry but how well do the scars do and whether a scar touchup may eventually be needed. In my experience about 50% of patients who have the surgery need scar revision touchup on at least one side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if hyaluronic acid injectable fillers show up on 3D CT scans? If not, can we work around them? Because I have fillers in place and would really prefer if I don’t dissolve them for the consultation, because of the long wait time between the first consultation and surgery.
A: The only injectable filler seen on 3D CT scan is hydroxyapatite granules (Radiesse) which appears because of the radiographic density due to their calcium phosphate composition. Hyaluronic acid fillers, which are simply sugar molecules, are not dense enough to be seen radiographically.
Even in cases of Radiesse filler being present, the material is digitally removed to do implant designs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Just wanted to check in and Thank You for the Lateral Orbit Rim – Brow Implants, I really enjoy having a broader profile both above and around my eyes!
I also realized I liked having some of the extra swelling on the sides of my eyes that pushed the lateral rim out even further. I wasn’t sure if it was possible to try Fillers on top of the lateral rim implant to try making my appearance even wider around the eyes? (pics below better show my idea)
Is there any concern about infecting the implants when using Injectable Fillers near them? If I did like the temporary Injectable Filler, could Allofill then be used for a semi-permanent effect?
Thank you for any advice!
A: You can have fillers placed above the lateral orbital rim – brow implants in the subcutaneous tissues. Just be sure the injector knows that there are implants underneath and the injector should not try and place the filler down at the ‘bone level’….which is what they would normally do when trying to augment a skeletal structure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffered from a orbital floor / medial wall fracture 6 months ago and had the fracture repaired with a silicon implant. However, the repair has resulted in vertical dystopia. My injured eye (left) is now noticeably higher, 1-2mm by guessing, than my right eye. I wanted to ask if this is something that you confidently feel could be corrected. Or, if this is something I should just live with. Thank you.
A: Whether your iatrogenic vertical dystopia could be improved by further surgery is not a judgment that can be made by guessing. A 3D CT scan of the orbit should be done to determine the location and thickness of the orbital floor implant and how the level of the floor compares to the opposite uninjured side. If the thickness of the orbital floor implant is the cause then you would know reliably that thinning it out should lower the over elevated eye.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I have breast implants that have likely outlived their shelf life. I got them implanted in 2001 and since has had a child, plus gained weight. I am having back issues and cannot exercise like I used to due to the breast weight. I really need to do something to get my life back and I believe this is likely one of the first steps. I would like to get a consultation either virtually or in person to see what i’m looking at regarding options and costs. Thank you.
A: Certainly removal of the breast implants with a lift is the equivalent of a ‘breast reduction’ effect…which uniformly resolves the musculoskeletal symptoms of larger breasts that have a sag. Removing the implant is the equivalent of removing breast tissue in a traditional breast reduction procedure. And also like a breast reduction a lift will likely need to be incorporated to manage the loose skin that will become greater as the implant volume is removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a custom skull implant. In particular, i’d like occipital augmentation to mitigate the mild flat head appearance that I have. I would like to ask, do you use PEEK as material for this procedure or is it only done with silicone. Also, I am considering getting an FUE hair transplant sometime in the foreseeable future. Would having a skull implant reduce the viability of FUE? Finally, I would like to know rough cost range for custom occiput implants. Thank you in advance.
A: 1) I have no particular preference for the material used in skull implants, But the material chosen will have a major influence on the cost of surgery and how small or large the scalp incision needs to be to get it placed.
2) While having a skull implant does not preclude having an FUE harvest later, given the value and limited supply of donor hair, it can be argued that hair transplantation should be done before skull augmentation. But this was more of an issue when the traditional donor harvest of a strip grafts was done. Today with FUE harvest there is less compelling need for the order of a skull implant and hair transplantation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 27 years old male. One year ago I got 5 mm Medpor jaw angle implants but unfortunately, I think they are not big enough for my face. I talked with my surgeon and he said he could inject fat to provide more projection as a permanent filler. I tried HA filler 3 months ago, while it got absorbed fast in two months, I found the projection it provided to be satisfactory. I got 1.5 ml on each side.
My question is, would fat provide a projection similar to the ones that fillers did? From what I’ve seen, fat seems unable to make contours, but if the volume required is small, wouldn’t they still be a good alternative? If not, replacing the implants seems to be my only option as I seem to absorb fillers fast.
Thanks for taking the time and read my mail. I’m looking forward to your reply. I’m attaching a picture; no 1 is the current me and no 2 is what I’d like to have ( I used software to create).
Best regards.
A: While fat injections would be a logical graduation from injectable fillers, it has two aesthetic issues. First fat injection survival in a young man will likely go just like the fillers…it will be absorbed fast with little to no successful survival. Secondly, even if it survived, it will not create your imaged results. Fat is soft and will not create sharper angles..it will just be rounder with no sharpness. Implants can only create that result because they have an assured firm push on the overlying soft tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young male patient with a brief question regarding facial implant work. I noticed that on your website, you have articles that refer to customized male model-style cheek implants. If a patient wanted to undergo surgery to have these cheek implants placed, would they need to undergo a 3D CT scan of their skull to have the implants designed? Or are they manufactured in an “off-the-shelf” sense?
A:Ideally true custom cheek implants are manufactured from the patient’s 3D CT scan. There is an option for special design implants (using other patient’s custom facial implant designs) with the understanding that they are like all traditional standard performed implants…they are made for someone else (a patient or a skull model) and their fit may not be exact or the aesthetic outcome may not be ideal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would to inquire about a possible sagittal crest reduction. The top most (crown) part of my skull is slightly raised in comparison to the rest of my skull, and there is a slight dip toward the front of my head which accentuates the crests prominence, giving it a more ‘bump’ or ‘bruise-like’ appearance.
My questions are:
1) What are the expected costs associated with this type of procedure?
2) How long am I expected to be in the country should I choose to proceed with this procedure?
3) How is this procedure actually done?
I understand this is a lot of questions, although would appreciate a decent answer to each as it is something I am heavily considering following-through with. The severity between the pictures and real life are fairly contrasting, and it may just be that I notice the severity a great deal more than others, although it makes me uncomfortable having it there.
A :In answer to his sagittal crest reduction questions:
1) My assistant Camille will pass along the cost of the surgery to you.
2) You should be able to return in 48 hours after the surgery.
3) Through a small scalp incision at the back end of the sagittal crest the raised bone height is reduced by high speed burring.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you so much for your response. The imaging is definitely an improvement over what I have now. In the model’s picture, the tip of her nose not only projects outward but also somewhat projects a little bit downward so that her nostrils aren’t exposed. Can we achieve this in my case? I also still think that my nostrils look flared (my nostrils look thick) so I am hoping we can do an alar base reduction as well as a weier resection so that my alar lobules (I think this is what they are called) can be significantly thinned to achieve a further slimming effect. Is there any way we can further slim tip and make it more pointed through removing layers of fibrofatty tissue and then using permanent sutures to retain that refinement? I also think that I’ll require osteotomies for each of the third sections of my nose to bring the bones inward because my bones are so wide I’ll provide a picture. I also think that my columella is both retracted and wide so that the angle between my lip and the tip of my nose is very wide. I believe this causes my nostrils to be overexposed. Is there any way to bring the collumella forward as well as lengthening my nose so that my nostrils are much less exposed? I would also like to reduce the width of my entire nasal base. Do you think my alar base should be lowered or highered since the base of my nostrils are lower than my collumella? My ultimate goal is to not only decrease the size of my nose but to dramatically alter its shape. I am looking for dramatic results and an overall more graceful, feminine, and balanced look.
I apologize for all the questions but this surgery means a great deal to me because my nose is the number one feature that detracts from my face. It’s amorphous and I’ve always dreamed of having a nose like that model’s. Here are pictures of the wide nasal bones in the middle of my nose along the nostrils as well as a picture of the scar on my columella which I hope to be fixed.
A: In answer to your rhinoplasty questions:
1) One of the hardest goals to achieve in rhinoplasty is deprojecting the nose. (making it turn more downward) There are gartfmtung techniques to try and do so but it is still hard to achieve much in that regard.
2) Nostril narrowing/thinning can be done but the results are often more narrowing than thinning.
3) In all revisional secondary surgery I always defat the nasal tip and use an only air closure of surgical with kenalog to try and decrease tip thickening due to scar.
4) The nasal bones are only at the upper third of the nose so osteotomies only affect that region.
5) Your columella is retracted and it will take cartilage grafts to bring it out. That may or may not make it more narrow.
6) There his no good method to reliably raise or lower the alar absence. (attachment of the nostril to the face)
7) As I stated previously, while I can appreciate what your ideal nose reshaping goals are, you have to be realistic with what is possible. Every rhinoplasty maneuver can be done but you are not going to have a ‘model’s thin nose, your natural skin thickness is just not going to allow that to happen. A nose is not like clay where you can just make anything out of it. No matter what is done to the bone and cartilage underneath the eventual result is what the skin that overlies these structures will allow to show through.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested I’m a rhinoplasty.. Please find attached my photographs. What I am interested in is a dorsal hump removal. I am 28 years old, and have no medical conditions. I do not take any medications.
My questions are as follows:
- What is the estimated cost of the procedure?
- Would this be done under local or general anesthesia (I prefer local)
- Would i wear a cast after the procedure?
- How long would the cast stay on for?
A: In answer to your rhinoplasty questions:
1) While dorsal hump removal can be done as the only component of a rhinoplasty, it will make the nose look longer in profile (see attached first image) and can make the tip heavier in appearance. For aesthetic reasons it rarely is ever done by itself as you change one element of the nose it always affects how the rest of the nose looks. A more complete rhinoplasty approach has a better overall aesthetic change. (second set of images)
2) Local anesthesia for most rhinoplasties is not how I usually do the surgery. This turns out to be a painful experience for all involved and usually adversely affects the aesthetic outcome by limiting what the surgeon can do when trying to perform a more complete rhinoplasty surgery.
3) All rhinoplasties due to postoperative swelling and in effort to get the skin to stick back down to the bone/cartilage before scar tissues sets in (and makes the nose thicker) is always used. This can be removed by the patient in 5 to 7 days after surgery.
4) Like all my geographically distant patients, a virtual consultation is the next step in the process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope this finds you well! I learned that my 3D CT scan copy is received and we will be able to move on to implant design process very soon, which is exciting.
At the same time, I was meaning to find out the following, if you may share your input, that would be great.
1. The following link from your blog shows that this case achieved a 15mm-20mm of augmentation, without a 1st stage augmentation involved. Is this amount of augmentation achievable in my surgery?
 | Case Study: Flat Back of the Head Correction by Augmentation Cranioplasty – Explore Plastic Surgery – Explore Plastic Surgery – Dr. Barry Eppley – Plastic Surgeon Background: The shape of the skull is affected by numerous factors including genetics, in utero skull pressures, post delivery head positioning and growth of the brain. In general, the skull has an oblong shape that is slightly wider in the back than the front. While there is no uniform aesthetic standard for a pleasing skull Read More… exploreplasticsurgery.com |
2. During the design process, how can we figure out what is the maximal augmentation level that is right below unduly tense (too tight) level while it is at a largest viable stretched amount?
3. For augmentation of the areas on which the head is in contact with a pillow while sleeping, e.g. the back of the head, the sides of the head, what are the chances for the implant be moved or loosened, caused by the weight from my head and neck pressuring on the implant approximately 8 hours a night over many years?
If this is a real concern, can we address to this risk during the design stage?
If implant loosening does occur at some point in the future, due to the weight from the head and neck during sleep, how will we handle it?
4. I highly regard your input in the design process of the implant. I replied Dawn’s email on what surgery outcome I would pursue. Please don’t hesitate to share your advice.
5. After surgery, I may choose to have a shaved head style some point in the future. When there is no any hair bearing for camouflage, will the skull shape still look natural and smooth, especially at the edge area where the implant ends and connects to my original skull area?
What makes a smooth and natural transition at the edge of implant possible?
6. Will the implant cause infection many years after the surgery is done?
7. Is an augmentation implant supposed to last all a life-time long?
If not, in what circumstances does the implant require what form of maintenance in the future?
8. After surgery, will it be ok to receive head massage? E.g. finger pressuring on scalp, which is provided by a regular message therapy store.
9. Will I need an additional revisional surgery? If one is needed, how long after the surgery will this happen?
Thanks for your attention Dr. Eppley : )
A: In answer to his custom skull implant questions:
1) No. That was done with a full open coronal incision which allows for some added expansion due to the mobilization of tissues.
2) There is no exact science as to how to know when the implant is too big or the tissues would be too tight to allow it to be placed and the incision safely closed. My design estimates are based on my experience of placing such implants.
3) Zero. While an understandable question it is never been a postoperative concern., I have never seen a custom skull implant move after surgery.
4) I still need to know what skull areas we are going to cover…back only, front only or both?
5) Due to the feather edging in the design there is a smooth transition from implant to bone.
6) No. Infection risks are in the perioperative period. (up two three months after surgery) Once last this time period the infection risk is negligible.
7) Custom skull implants are made of a solid silicone material which will never degrade or breakdown…thus no need for future replacement due to material failure.
8) Head massages are not needed or advised after surgery.
9) Revisional skull implant surgery would only be needed if you determine you want a bigger implant or a different design later. This is not done until six months after the initial surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask you a question about chin implant pricing. I am 54 years old and have a recessed chin and sagging jowls. I want to do a chin implant (referably the one that provides both vertical and horizontal lengths) along with jaw angle implants, and I was wondering if you could give a quote for those 2 procedures separately and together and provide some insight on whether or not that would improve sagging jowl problem.
Thank you!
A: Most forms of chin or jaw augmentation are not an adequate treatment for sagging jowls. These are structural procedures that will enhance the bone but will not provide much if any improvement for sagging jowls. That is best treatment by a jowl tuck up or some form of a neck-jowl lift procedure.
While separate standard chin and jaw angle implants can be done they are associated with a relatively high risk of asymmetries given that they are three separate implants. Combined chin and jaw angle augmentation is best done with a custom jawline implant where the risk of asymmetry are less and it has a more powerful influence improving overlying soft tissue sagging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have quite severe chin ptosis following a sliding genioplasty I had. I would like to have this corrected.
I also have a misaligned jawbone following the surgery, my jaw on the left side is clearly broken and not I’m a straight line. I’d like to also have this corrected, although I could possibly have this done with my original surgeon.
It would be good to have an idea of the approximate costs for (1) the chin ptsois correction, and (2) both the ptsois and the jawbone alignment.
I do not need my bone to be altered at all. Already had the sliding Genioplasty and I’m happy with the shape.
A: Chin ptosis after a sliding genioplasty would be very uncommon since the soft tissue chin pad remains attached to the bone and the bone is moved forward. I would need to see pictures of your chin from different angles to determine the extent of the problem.
Fractures after a sliding genioplasty would be very rare. You may be referring to a disruption of the jawline by the backcut of the osteotomy which is very common after a sliding genioplasty. Based on the angle of the bone cut and the amount of horizontal movement this can create a step-off or an inverted V deformity. This is not a fracture but an aesthetic inferior border deformity. It would need to be filled and there are multiple techniques to do so. From bone grafts to implants) I have found ePTFE sheeting the most effective in my hands. But I would need to see they x-ray for a more qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you give a few details about lowering the eyebrow position through brow bone augmentation and tissue expansion?
You have claimed that there is no other way to achieve such change because of the tightness of the forehead’s soft tissues, which is apparently the limiting factor in driving the eyebrows downwards.
1) How would one get started doing this? I suppose the implant placement would follow the initial tissue expansion, correct me if I’m misinformed though.
2) Is the duration of the tissue expansion stage similar to how long it takes to expand e.g. the skull? Is the amount of tissue expansion similar too?
3) Is this a reliable procedure to permanently lower the eyebrows or is there a chance they go up again to the initial position pre-operatively?
Thank you in advance,
A: In answer to your brow bone implant and eyebrow change questions:
1) All brow bone implants will create some eyebrow lowering. But I would not consider it extreme or to the level that you may desire.
2) Due to the tightness and fixed length of the forehead tissue to which the eyebrows are attached at the lower end, there are tissue stretch limits as to how much eyebrow lowering can be achieved regardless of how a brow bone implant is designed.
3) To gain tissue laxity to drop the eyebrows down a significant amount, extra forehead tissue needs to be created. (the concept of tissue expansion.
4) Forehead tissue expansion can be done two different ways, the use of a traditional 1st stage tissue expander or the placement of an initial brow bone implant followed secondarily by a larger one later. Either approach has their advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it true that facelift scars in front of the ears heal better than behind the ear? If this is true, what is the reason for this? have heard this is because blood supply is better closer to the face.
A: As a general statement that is more true than not for a variety of reasons. In facelift surgery the skin on the back of the ear is thinner than the front with less potential blood supply and this area of a facelift is often placed under more tension than the front of the ear. As a result far more hypertrophic scars occur in the postauricular area than in the preauricular region.
Fortunately postauricular facelift scars are more hidden as most of their length remain obscured by the shadow of the overlying ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I was thinking about getting a custom wrap around jaw implant but I have a few questions. I have recessed chin and a deep labiodental fold. I was wondering if the implant could fix the labiodental fold and also fix the recessed chin by moving the lower lip toward too. I thought a genioplasty plus a chin wing by you would be a better option but I wasn’t sure. I can send you more information about me or pictures if needed when you get back to me, Thanks.
A: Whatever is done to the chin by any form of osteotomy or jaw implant can never change the depth of the labiomental fold. The labiomental fold is the origin of the mentalis muscle attachment to the bone. It sits above the chin bone prominence on the concave surface of the bone and thus can never be directly changed by any form of chin augmentation. The projection of the lower lip is controlled by the position of the teeth behind it. Thus only by moving the entire lower jaw forward (sagittal split ramus osteotomy) can the lip be brought forward.
This should provide clarification that the decision as to how to improve the projection of the chin or shape of the jaw is done with the knowledge that none of these procedures (short of lower jaw orthognathic surgery) will change the depth of the labiomental fold or the position of the lower lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello doctor I got a question, is it possible to shorten the midface by jaw osteotomy (shorten philtrum) about 2-3mms? I guess itis not a big amount and its pretty possible, unluckily in my case standard lip lift isn’t possible because my upper lip is well shaped and lifting it would destroy my look. Second question is if there is possibility to create hollow cheeks effect with some kind of implant (zygos?).
Thank u for attention.
A: In answer to your midface questions:
1) What you are asking about a shortening LeFort Osteotomy will not work for your upper lip shortening goals as it will not work. The overlying soft tissues are not going to shorten because the bone is made shorter, they will stay the same and look worse because the teeth are now more buried under the upper lip. The only way to shorten the upper lip is to actually shorten it by a lip lift which you have correctly stated is not a good aesthetic outcome for you.
2) Part of the solution to getting ‘hollow cheeks’ in the right patient is zygomatic augmentation and often is the most significant part of that effort. But it also usually requires soft tissue (defatting) efforts as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the brow ridge implant. From the website I noticed there are two kinds of implant, one goes with the way to the upper forehead the other do not, which is more suitable for my case? Also, I have frontal bossing because of my lack of a protruding brow bone can implant fix this? I know there are a lot of nerve on the forehead and glabella area, so I am worried what is the chance of blindness if the implant gets infected? Or chances of shifting?
A: In answer to your brow bone augmentation questions:
1) Based on just one side view pictures with your hair obscuring most of your forehead, and no knowing what your aesthetic upper third of the face goals are, I can not tell you what exact style of brow bone implant would be appropriate for you. This will require better pictures, computer imaging and a discussion to provide an informed answer.
2) Contrary to your perception of the neural anatomy of the forehead there are really only one set of sensory nerves that provide the feeling to the forehead which are the supraorbital/supratrochear nerves. Dissection and implant placement is done around them and it is to be expected that there will be some temporary numbness of the forehead after surgery of which feeling eventually returns. These nerves are not responsible for forehead movement nor have any relationship to the optic nerve. Thus there is zero risk of any optic nerve injury or blindness.
3) Unlike implants placed through the mouth, I have never seen infections in any forehead or brow bone implant.
4) I have also never seen such implants shift or would I expect that to occur even when a traumatic injury occurs to the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For the buttock implants, do you use endoscopic technique in order to make sure of the strict intramuscular location of the implant (or do you think it’s unnecessary) ? and do you usually perform one or two incisions?
A: In answer to your buttock implant questions:
1) There is no advantage to an endoscopic technique for pocket development. The key in intramuscular implant pocket development is the muscle transection technique and not the muscle splitting technique.
2) Whether one uses a single midline intragluteal incision or a two paired paramedian infragluteal incisions can be debated. I have done it a lot both ways and even I can not say one is necessary better than the other. Each has their own advantages and disadvantages. But I would lean towards the single midline incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been struggling with my double chin for many years. I had Cool Sculpting done twice to my chin. After the results didn’t work to get rid of my double chin. I went to see a plastic surgeon for chin liposuction. He told me I don’t need chin liposuction and instead need a neck lift or skin tightening treatments. This year I did Venus legacy radiofrequency treatments which didn’t solve the issue. It’s not until I started going to consultations with orthodontists that I found out that I have overbite and overjet with recessed lower jaw and small chin. I was told I’m not a candidate for lower jaw surgery due to extractions I had as a child and has recommended genioplasty. I read up on sliding genioplasty procedures and discussions about it on forums and the thought of such an invasive surgery discourages me. Could my issue be resolved with an extended chin implant? I have attached photos of my lower jaw at rest and then moved forward slightly, approximately 5 mms., If you could kindly provide your professional advice via e-mail I would greatly appreciate it.
Thank you.
A: Battling a double chin in the face of a skeletally short lower jaw using a soft tissue approach only is always a losing proposition. You have struck upon the key element of the solution to your double chin which is either lower jaw or chin advancement. A chin implant will not improve your neck, only the chin projection. Bringing the chin bone forward is the proper and only solution as that pulls the submental muscles and tissues forward with it. What you have is what I call the ‘accordion’ neck. The tissues are bunched up because the bone that partially supports them needs to be stretched out.
I suspect that a 5mm sliding genioplasty advancement is too little (7 or 8mms would be better) but that is a minor issue compared to the overall concept that you would get the most benefit from a sliding genioplasty procedure. While the providers you have seen to date did not make that diagnosis from the beginning is a mystery to me. This is basic understanding of neck and jaw anatomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to provide an update since last we met. I’ve recently obtained new imaging and found out that my skeletal asymmetry is causing my bite to continue and to worsen and my right condyle is resorbing. Two well respected maxillofacial surgeons have both said my only option is orthognathic surgery. I’ve pushed hard for an orthodontic only option but apparently my asymmetry is too extreme where this wouldn’t solve it.
I’m very concerned of all the variables involved with my case specifically my wrap around implant. I think there are very few cases in existence of a patient who had implants who then got them removed and did jaw surgery. Neither or I, or even surgeons, can frankly give me any indication on how the soft tissue will respond after implant removal and subsequent jaw surgery. The consensus is though that I need to have the implant removed and wait at least 6 months for full healing before I can have surgery.
Since I know you’ve definitely removed your fair share of implants, could you give me an indication on what I’m in for? How will my skin respond? Am I looking at major sagging? Does the capsule stay or does it go away? Soft tissue response? Any major issues to really consider or will it pretty much go back to prior to my implant surgery. Is there an option to potentially do the jaw surgery then have new implants put in later on?
Your advice/input here would be greatly appreciated.
A: Contrary to your supposition that I have removed many jawline implants, that is not true. While placing hundreds of them I have removed less than 1% of them. And that has been done almost exclusively early after surgery due to infection. I do not recall removing a jawline implant that has been in for some time due to any aesthetic issues. Thus I can not speak to whether skin sag would be an issue or not. I suspect that it would not….but that is a conjecture not an opinion based on any clinical observation. The size of the implant would clearly have a role to play in that tissue response.
It is not clear to me why one would not just remove the implant and do the orthgnathic surgery at the same time, as that is what I would do, and I could think of no reason not to do so. This is no different than removing a chin implant and doing an immediate sliding genioplasty which I have done many times.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to let you know, first of all, that I am thrilled with the results of surgery. You have really increased my confidence and I no longer feel that people are looking at my scars, I just can’t express to you enough, how your talent has improved my life!
I have done pulsed dye lasers in the past, along with IPL for redness and discoloring. I have also done C)2 lasering and microneedling to help even out the scars. I was wanting to try a Vi peel I’m wondering when it would be safe to do this peel it is a light peel that ends up being somewhat of a medium peel. I am 3 weeks post surgery should I focus on pulsed dye, or IPL, or is it okay to try a peel and then do these redness treatments later?
A: The early treatment of scars after facial scar revisions can be done by either BBL (what you call IPL) or fractional laser resurfacing depending upon what is trying to be accomplished. BBL is for redness, laser resurfacing is for surface texture.
As for the Vi peel it could be done anytime after the scar revisions IF the healing scars were avoided. Otherwise I would wait 6 weeks after the surgery before having it applied over the scar revisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am greatly interested in the customizable forehead implant you offer. I read that the prominence can be projected upwards to 5-6 mm, but I am more interested in the width, specifically the area at the edge of the eyebrows.
I know that the determining factor is the orbital shape and length which cannot be currently altered, but I wanted to know if it will be possible to use implants to “stretch” the eyebrows horizontally. If it is possible, by how much can the width be increased?
A: While the lateral brow bone and orbital rim area can be augmented, I can not say that such augmentations necessarily produce significant eyebrow stretch as a result. Quite frankly it is just not an issue that patients have ever asked for before nor have I ever actually looked or measured that type of overlying soft tissue change. Whether it occurs or not in the way you would like I can not precisely say.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had 1.7 mL of Radiesse fillers placed onto my cheekbones in the last 2 weeks. Do I have to wait the full 12 tp18 months for them to fully dissolve before proceeding with surgery for custom infraorbital-malar implants?Or, would you be able to remove/workaround the filler during the surgery.
A: That is a good question since the Radiesse filler is going to add some volume that will affect to some degree how the custom infraorbital-malar implants are designed. With a 3D CT scan, however, Radiesse injections will be seen in the scan, volume location and amount measured and then it can be determined whether they can be worked around or accounted for in the implant designs. Having seen Radiesse injectable material many times in 3D CT scans and in designing custom facial implants, it usually is not an issue in the design and is never an issue in implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to find out if my cheek augmentation goals are achievable. I have a photo album describing my issues and my desired look.
My thinking is that weight loss (80-90 lbs), fat removal, cheek implants and a LeFort I osteotomy can achieve my goal look. I’m probably wrong, so can you give me some idea of how close I can come to achieving it?
A: I can not speak to the merits of a LeFort 1 osteotomy in your case as that operation does have any effect on the cheeks. Like many cheek reshaping patients that have fuller faces, the real challenge is in getting the area under the cheekbones more concave or flatter. Cheek implant augmentation certainly is an essential part of trying to achieve that goal as well as defatting beneath the cheek bones. But even then many patients with fuller faces can simply not achieve that look. But if you factor in am 80 to 90 lbs weight loss, that would certainly add an element into the treatment approach that would make achieving such a midface look more possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an uneven brow ridge with uneven eyebrows (one is flat while one is pexed, makes me look constantly expressive). I want to know if it’s possible to correct the asymmetry of my brows and adjust their position so that they are both closer to my eyes, giving more hooding if possible. I have produced a (poorly edited) morph of the look I would like to achieve. How realistic are my goals? Can it be done with implants/ a solution other than fillers and Botox? Thanks.
A: I find that your eyebrow shape goals are only partially realistic. The first question is about the asymmetry…why does it exist? If it is bone based, as the eyebrows often follow the shape of the bone, then a custom brow bone implant for brow bone reshaping can be done which may also help lower them a bit. If the eyebrow asymmetry is soft tissue based this is more problematic as then only temporary Botox injections can be done. Bit either way it is to possible to move the eyebrows inward or any closer as there is not treatment, non-surgical to surgical that can do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask a question regarding jaw and cheek implant. Are facial implants such as these visible in dental x-rays? I am strongly considering this procedure but feel somewhat insecure about someone seeing them in x-rays. Is there anywhere I can see how the look on an x=ray?
A: Non-metallic implants are not seen in a dental x-ray which would be that of a panorex. However any screws used for the implant’s fixation would be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a prior sliding genioplasty but want more of a result with further horizontal augmentation. But I’d like to avoid a revision genioplasty. I was wondering if you think it would be possible/advisable to get advancement of the chin and labiomental fold area with a combination of chin implant (I think wraparound would make sense if I’m already having the jaw implants) and some soft tissue procedure to reduce the fold (filler possibly?). I attached a morph of my goal and a superimposition.
A: The amount of horizontal chin advancement you have shown is achievable with an implant. However filling in the labiomental fold can not be done with any form of an implant as that area reflects the attachment of the mentalis muscle which sits above where any implant can be extended. That is an area which can only be augmented by fat grafting. But that part of your imaging is not achievable in the magnitude you have shown.
Dr. Barry Eppley
Indianapolis, Indiana
