Your Questions

Q: Dr. Eppley, I am interested in information on a chin implant. I have currently have a chin implant However I’m not quite satisfied with the results.  I’m not sure of what kind of implant I have however I can get that information. I feel that my chin appears very “chubby” and I was expecting more of a narrow silhouette. I will attach before and after pics. The first two are before and the second two are now. 

A: Standard chin implants by definition can not make a more narrow chin as the most common type of chin implant used has extended wings…which always makes the chin wider in the front view. I suspect you have an extended anatomic chin implant with long side wings. It would be crucial to know exactly what type of chin implant you have.

Fo your chin implant revision you need a central chin implant with no wings that creates more of a V-shape to the front of the chin. This is what most female chin augmentations need in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you also do Scapula widening surgery? Or even ribcage widening surgery?

A: Scapular widening surgery is not a procedure I have ever heard of nor could I envision from a bone perspective how any such procedure would be done in an aesthetic manner. While I have never done it or heard of it I could envision scapular widening by the placement of an implant.

I have been asked many times about ribcage widening, which similarly would take implants to accomplish not bony osteotomies. But because it would requiters numerous levels of rib implants it has never been surgical yet done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My short midface questions are:

1. I feel that that my horizontal proportions of my face is a weak point. Hence I feel that my mid face between the subnasal area and the glabella region is too short. Hence I was wondering if there was any way of lengthening the mid face region. I am wondering if there is any type of brow lift that will be able to lift the eyebrows as well as the glabella region to increase the length of the middle third of the face. 

2. I was also wondering about how much vertical height chin reduction can be obtained through the chin reduction procedure.

3. I also had the query of procedures that lengthens the forehead and also the maximum possible increase in length of the forehead. To give the appearance of an increased forehead length couldn’t one just wax the present hairline and part of the frontal hairs to vertically lift the hairline up?

4. Are there any loans etc that are available to cover the costs of certain procedures?

A: In answer to your short midface questions:

1) There is no procedure that actually lengthens the midface. Procedures such as a subnasal lip lift and certain rhinoplasties may create the illusion of some midface increased shortness but not increased length..

2) Depending upon the tooth roots locations a 6 to 8mms vertical chin length reduction is possible by an intraoral wedge osteotomy.

3) The only way to lengthen a forehead is to wax the frontal hairline as you have mentioned.

4) Care Credit is the most source of cosmetic surgery financing in the U.S.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year old male and realized in early high school something was wrong with my face when I first took a picture of myself. I always thought I was good looking when I looked in the mirror but when I saw what I truly looked like to everyone else I was very concerned.

From early trauma / sleeping on one side / torticollis, I realize I have plagiocephaly, with my head leaning to the left. This means my right side is elongated in comparison to my left, with my jaw hanging lower and being skewed off center, my right eye is higher, and I also have a flatter right side of the head as well as a forehead protrusion on the right forehead also. Basically my right side is my bad side, and in comparison my left side looks fully developed and frankly very good looking. 

My head naturally tilts into this position I believe to support this deformity, when I force tilt my head to the right I am able to line up my eyes and ears but obviously my jaw stays very asymmetrical (can’t move that so easily.) So I had some questions, I believe I have torticollis, which in my case means the left muscle in my neck is shortened, hence the head tilt.

1. Is the sternocleidomastoid release something you can operate and perform?

2.If you cannot, should I get that operation first before moving on to fixing my face cosmestically?

3. I know skull implants are possible, but is shaving down the protruding bone in the right forehead possible as well, to match the left sides sloped back appearance, which I think looks very good.

4.If I were to get jaw surgery, going off the things I have seen online, what side of the face would you try to match up, my right jaw is very elongated and skewed off center, so I would like to match the left sides more up tight and angular position, not trying to make the left side like the right side, if that makes sense?

You seem to be the only surgeon that specializes in these niche catogories, so I hope to hear back from you, I have heard great things about you!

A: In answer to your questions:

1) Sternocleidomastoid (SCM) release is a procedure typically done in young growing children to avoid many of the symptoms to which you have described. I have done many of them in young children. However the procedure is not known to be effective in adults meaning that the releasing the muscle will not make the head become straight nor improve any of the craniofacial asymmetry appearance issues.

2) Thus, correcting its symptoms of craniofacial asymmetry is all you can do.

3) Reducing one side of the forehead, within the limits of the thickness of the bone, with augmentation of the opposite side would be the appropriate aesthetic approach to frontal forehead asymmetry.

4) A 3D CT scan and pictures is ultimately needed to first make a diagnostic assessment and establish the proper treatment and its sequencing. While what you are describing for your jaw asymmetry may be the correct aesthetic approach, I can not comment on your exact situation with such information.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was hoping to get more information about the rib removal/modification surgery.  My waist is currently at 27” and I would absolutely love to get it down to 23”. Is that a possibility? How many of these surgeries did Dr. Eppley perform? Were there any cases that had complications arise? If yes, how many? What is the cost of this procedure?

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

1) Whether you can get from 27″ to 23″ with rib removal surgery can to be predicted. Most patents report a 1″ to 3″ reduction in their waistline after the procedure and whether they corset for a short time after surgery. 

I have done dozens of these cases an no postoperative complications have yet been seen…nor would I expect given the nature of the surgery. (it is the removal of tissue rather than the rearrangement of it or he placement of implants)

I will have my assistant Camille pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently underwent double jaw advancement surgery. However my surgery is somewhat overdone and now im left with an extremely full lower third and some irregularities and deficiencies in my middle third.

I read on your blog that its possible to get rid of this fullness through maxillary reshaping of the back end of the maxillary bone. pushing that part back to where it was and thus, restoring the definition that the face had before.

My question is, How effective would this method be? as in, What percentage of the definition that the face had before the surgery could possibly get restored after a large MMA advancement?

Thank you for your time.

A: The determination of effectiveness of maxillary reshaping would depend on seeing the actual shape of the bone as it exists after the maxillary advancement. This would require a 3D CT scan to assess.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The untreated torticollis has left me with a head tilt as I mentioned before, but when I force my head to the right I can line up my eyes and my ears. I would like to model the surgery around my head in this position, not the tilted one, if that makes sense? I was wondering if that was possible, and if there are any treatments to fix the shortened muscle in adults? If there isn’t however I still ultimately rather fix my asymmetric features based on the position in which I tilt my head lining up my eyes and ears. Let me know if you need any clarity on that.

Lastly, would it be possible to do a CT scan, figure out surgeries I need and the cost of the surgeries then come back at a later date to have them performed? I would like to know what the total cost would be and then I could start saving with a direct goal in mind, instead of just guessing.

A: As I mentioned earlier you can not change the head tilt regardless of what is done to the muscle. Besides the fact that the muscle can not be lengthened, even if it were possible the head tilt would remain the same. There are many more anatomic derangements than just the shortened sternocleidomastoid muscle that accounts for the head tilt.

I would agree that any craniofacial changes should be based on a more neutral head position even if that is not your ‘natural’ head position.

It would be essential that a 3D craniofacial CT scan is done for treatment planning purposes. You can not do any facial asymmetry surgery without it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My midface (pupil to lip corner) is a bit too long for my liking.  (aka long midface) I know that shortening the nose could help, but I am wondering if a lip and mouth corner lift could have a significant affect in shortening the midface? Could the mouth corners perhaps be lifted as much as 10mm and the upper lip 5mm if ones philtrum is around 15mm in length ? Could a cheek lift maybe also help with lifting the mouth corners? 

Thank you for your time!

A: In answer to your long midface questions:

1) A subnasal lip lift can have some influence in making the midface looks bit shorter.

2) A corner of the mouth lift can not be done at the 10mm elevation level and would not make the midface look shorter.

3) A cheek lift can never raise the corner of the mouth n any sustained manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just recovering from my rhinoplasty and am very happy with the results so I am starting to plan and save for my wraparound jaw implants and cheek implants with you.

I apologize if I have asked this before, but which material will you be using for the implant and what is the probability of these implants having to be removed down the line? Is it something that happens often?

I remember you mentioned that some photos without my beard would be good to send you. I took some when I shaved my beard for my rhinoplasty. Man oh man, my chin is severely recessed – I realized after shaving my beard.

I really hope that the wraparound jaw implant can give me a result similar to the guy I forwarded you images of in my last email. I have attached to this email a morph of what I hope my jaw will look like as well as several photos of different angles of my face without a beard.

Do you still think, given how recessed my whole mandible is, that a significant deviation and improvement is possible?

Thank you very much for your time.

A: The material for custom facial implants that is easiest to place AND secondarily remove or modify is by far solid silicone. It is also the most economical.

I don’t see anything unrealistic about the imaging you have done with the exception of that of the depth of the labiomental fold which will not forward with the chin as you have imaged. But overall, by my experience, that is not an extreme or large jawline augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cortical jaw reduction done in Asia and unhappy with the results. Do you do custom jaw implants? if so,would Peek or titanium mandible angle implants be better? Thank you. 

A: I have done hundreds of custom jaw implants out of every available material. Whether the more expensive options of PEEK or titanium are viable options for your jaw restoration would depend on what size of implant is needed. Ultimately a 3D CT scan of your jaw is needed to make that determination of implant size and dimensions from which the material  choice for its fabrication could be decided. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask if my head asymmetry where one side of my head is bigger than the other or it looks like it is leaning to one side, would be fixable by any of your surgeries? I am guessing one side should be reduced and the other augmented? If you need pictures from different angles please let me know.

Looking forward to your reply. 

A: For your head asymmetry I would certainly agree that the flatter right wide, from the forehead back to he posterior temporal region, needs to be augmented. I am less certain about the need to reduce the left side which appears more normal in shape. I do see some benefits to left-sided facial surgery reduce the tail of the brow bone protrusion, correct the upper eyelid ptosis and correction of the chin asymmetry.

What you have is an overall craniofacial scoliosis which affects both sides of the skull and face. For further and more definitive treatment planning, a 3D craniofacial CT scan would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you based on a post I saw on realself where Dr. Eppley discussed options for paranasal augmentation with a patient.

I am a 32 year old female with some sinking in the midface area and prominent nasolabial folds for my age. I saw a maxillofacial surgeon to discuss correction and he told me that the sinking is due to bone deficiency in this area and suggested a goretex implant. I believe he is correct in his analysis as I was born premature and have had quite a lot of dental work in my life. I have also been told my orthodontist(s) that my upper jaw is quite small, making much of this dental work a bit complicated. 

I came very close to having the procedure done with goretex but ended up deciding that I was not comfortable with having a plastic implant as infection is possible even many many years after placement and removal is very difficult. I would prefer another material… And after doing alot of research and it seems that coral hydroxylapatite is a good option as it is fairly permanent and typically does not get infected because of vascularization. 

I would like more information regarding the technique used, how permanent it is, how much experience the Dr. has with this procedure, cost and potentially to book a consultation. Would the doctor be using radiesse or is this an actual implant which he would use? Thank you so much 🙂

A: When it comes to paranasal augmentation, any variety of alloplastic materials can be used. While one can have a debate about which material is the best, one thing that is clear is that hydroxyapatite granules are no longer commercially available. This leaves the only option for an hydroxyapatite material as hydroxyapatite cement…which is probably better anyway since it can be formed and allowed to set into place. (granules tend to spread out and become uneven) As a participant in the original development of one of he existing hydroxyapatite cements that is currently commercially available (Mimix from Biomet-Stryker), I have tremendous experience in its handling properties and surgical placement. Such a material is a permanent bone cement into which bone directly attaches. While infection is always possible with any surgical procedure, I have never seen it with hydroxyapatite cement into which antibiotic powders are added in its intraoperative preparation.

I would not confuse the Radiesse injectable material with hydroxyapatite cement. That may seem similar but they are not in many ways. Besides being injectable, Radiesse contains the type of hydroxyapatite particles that end up being absorbed and the injectate only contains 30% hydroxyapatite particles and 70% carrier material…which is why it is injectable. While Radiesse does last longer than most other injectable fillers, and it is a perfectly fine injectable option for paranasal augmentation, it is not a permanent augmentation material.

Besides taking a lot of experience to know how to work with it, particularly in the limited confines of an intraoral application, its cost is another reason it is not commonly used for facial augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 5 months post operation from a temporal midface lift. I had some questions about my recovery as my own surgeon is not being very helpful in answering my enquiries.

On one half of my face, I seem to be having some issues with nerve recovery. My motor function is all intact but my sensory nerves seem to be having some trouble? 

When I blink, I can feel a tiny tickling sensation near the side of my nose. It’s been this way since one or two month post op and I haven’t been aware of any dramatic improvement. It’s not painful and it doesn’t burn, but it’s a very tiny tickling feeling every time I blink. It’s quite bothersome and annoying as I’m always feeling and aware of it, and I always have to aggressively massage it away. (After a few minutes the tickle every time i blink still comes back) Moreso, when I very lightly brush my finger down the bridge of my nose, I can feel the same tiny tickling feeling next to my nose. 

My surgeon says to wait it out for another 7 months. But it’s been bothering me for so long and my mind is always thinking about it. 

I’m not sure if I should be worried at 5 months post-op but there just hasn’t been any big improvements in the last two months. I’m worried it’s permanent. What could I possibly be experiencing and what are my options to resolve if?

A: The reality is that all you can do is wait and see how much the sensory nerves recover as there is no operation or treatment for them if they don’t. In addition it can take up to 12 to 18 months for such sensory nerves to exhibit a maximal recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope this email finds you well. Its been a while since I was last in touch as I was busy at work and trying to save for the procedure. I have a few questions if you would be so kind to answer when you have a few minutes to spare from your schedule. Firstly, after the physical structure that is the muscle is removed how does the scalp react in regards to its laxity. Does it sag or how do you achieve for the scalp above the ears to become ‘tent’ and tight to show the straighter profile where the temporal muscle was removed?. Also, does this have to be done under general anesthesia and how long would I have to abstain from work for? I appreciate any feedback you may give me.

A: In answer to your questions:

1) No loose scalp has ever occurred after posterior temporal muscle reduction.

2) Most patients can easily return to work in one week after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Recently I have been researching German maxillofacial surgeon Hermann Sailer’s theories about forward growth being a prime indicator of attraction. My questions along that line are:

1. You have written an article in which you discussed the “male model” face being one comprised of angularity and defined features, which can be achieved by some patients with thinner facial tissue and little bloat through surgery. In your opinion, does forward growth contribute to angularity and is it a part of the “male model” face?

2. Many people seek midface and mandibular osteotemies to improve their forward growth. Do you think that you could create an ante face with just implants? Achieve a result similar to that one?

Thanks for taking the time to help out.

A: You have shown a surgical result That is a well within what custom facial implants can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Last year I had a chin augmentation. It has come to my attention the implant sits crooked/asymmetric. My chin was asymmetric to begin with but I was assured it would not be an issue. Judging by the photo, do you think it’s reasonable to ask for a revision? What surgical methods are available to correct this?

A: I can not tell you whether it is reasonable to ask for a revision, that its between you and your surgeon.

For chin implant asymmetry it would be critically important to know the exact location of the implant on the chin bone as well as the shape of the bone. This is why a 3D CT scan of the mandible is needed. That visual information will provide the corrective approach needed. There is no merit to guessing from its outside appearance how a correction should be done. Obviously the approach of ‘eyeballing’ is not adequate since that didn’t work the first time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw angle implants placed six months ago. Over past few years, I’ve had intermittent sensitivity in bottom left rear molar. About 3 months ago, finally went to see a more experienced dentist who was able to identify a ‘hairline’ crack in the tooth. As luck would have it, the problem is getting worse…suddenly –over past two days.  Before, it would only ‘flare up’ when I brushed w/hard toothbrush vs. Sonicare.

Am traveling out of town Wednesday, but don’t want to do anything stupid in terms of infection. Can I have the root work done? If yes, I have Keflex and Clindamycin. Should I take anything beforehand and afterwards?? 

A: You certainly can have root canal work done. I would inform the dentist that there is a jaw angle implant in there which is relevant to the local anesthetic injections….although the nerve block will likely be done on the inside of the lower jaw (inferior alveolar nerve block) and not the outside of the jaw.

I would also take a preventative approach and take Cindamycin beforehand as well as for two days after the root canal procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am someone who has an extremely long

midface (long nose length) distance between the eyebrow and bottom of the nose, which makes my face extremely long and thin looking.

I also have a severely recessed chin (about 11 mm deficient) 

I have been looking up procedures to give more horizontal projection to my chin and also widen my chin, and give it a more masculine and square look. However, my biggest fear is that a sliding genioplasty of 11-12 mm would elongate my already tremendously long face. 

I am wondering, if someone were to want to completely avoid elongating their face, and wants to add horizontal projection to their chin, and square width to their chin, without adding any vertical height to the chin, should they opt for a genioplasty or a chin implant?

I was initially leaning towards a genioplasty, but fear of elongating the face, caused me to research other options, but I also have heard that chin implants erode the chin bone under the implant etc.

Which would you recommend for a 25 year old male? Really insecure about my recessed thin width chin, but keeping my face as short as possible is definitely a priority.

Thank you!

A: In answer to your long midface treatment questions:

1) Only a sliding genioplasty can bring the chin forward AND vertically shorten it. A chin implant can’t have that dual effect.

2) Chin implants do not cause bone erosion, they are only associated with self-limiting implant settling.

I would need to see pictures of your face to provide a more qualified chin augmentation recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implant replacements. My current cheek implants are a medium combination submalar and malar midface implant. It’s opaque, blue and a rubbery material. The side that is placed on the bone has small tentacle like projections. 

I’m not sure if it caused by improper placement, sizing, implant shape or a combination of both, but my smile is restricted compared to before I had the implants (as in I cannot smile as wide after getting the implants).  My surgeon insists that it’s due to my facial muscles and maybe I’m the small percentage whose facial muscles cannot glide easily over the implant (he’s also blamed it on the fact that I’ve had a child but my smile was completely normal after delivering my daughter), but I’m having difficulty believing that is the case.

In any case, I have attached a few images for you to review. The first two images are pre midface implants. The last two are after implants (one before I delivered my second child and one after). When I am thinner, the implants look to large and I have a hollow under   It in the cheek area.  When I have more weight, I just look completely overdone and the issue with my smile is exacerbated. The other surgeon said the weight from pregnancy would fill in the hollows but either way… to put it plainly… it looks like crap and everyone I know can tell I’ve had work done. Needless to say it’s been an unpleasant experiences and I just want to get it fixed.  

Let me know if any other info is needed on my end! Thanks!! 

A: What you describing is a Conform malar shell style of cheek implant. (a blue implant is the sizer not the actual implant) In reading your concerns the most likely explanation of your symptoms is that of implant size and/or style. It is very easy in the cheek to get implants that are too big. If they were too big when you were thinner that will not change and mag even be exacerbated with more weight in the face. Cheek implants are a great example of less is usually better. Benefits ma y one obtained by either downsizing them or changing to a smaller and different stye. ideally a 3D CT scan should be done to also check their position on the bone which may also be too anterior.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One year ago I had a sliding genioplasty (along with LeFort 1) that horizontally advanced my chin 6mm. Although the projection of my chin improved, I was still unsatisfied by it, so on Friday, I was scheduled to have another 6mm genioplasty (for more horizontal advancement), as well as wisdom teeth extracted. When my surgeon went in, he saw that the plate and screws from the first genioplasty were completely overgrown with bone so he opted to place a 5.5mm implant instead. Naturally I was very upset when I found out upon waking up. I’m 100% I’ll be removing the implant. In a case where the plate and screws are overgrown with bone, is it truly that risky to cut or drill through? Can a 4mm genioplasty at minimum possibly be done at the time of implant removal? 

Thanks!

A: I can only speak from personal experience but I have yet to see a chin plate that could not be removed…and I have seen many with partial or near complete bony overgrowths. I more informed answer would require review of an x-ray that shows your plate and screws. Sometimes the screwheads are stripped and the shaft of the screw(s) can not be removed but the plate can always be with some bone drilling and effort. Once the plate is removed a secondary sliding genoplasty can be performed for an additional 4mm movement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently got Medpor jaw angle implants (1 month ago) 7.5 mm but already I wish I had went larger to the 1cm ones to have more flare. Would it be possible say in a year or so time to place a small custom silicone implant over the polyethylene implant without removal , and if not what would the reasons be.

A: You are referring to the concept of a jaw angle implant overlay. It can be technically done but would require lag screw fixation to they underlying implant to prevent impact migration. The best jaw angle implant to use for that effect would be the vertical lengthening style.

The only potential downside is the risk of massteric muscle disinsertion as it would be necessary to break through the overlying capsule to get the overlay implant down over the existing jaw angle implant. But I have done it more than once successfully.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am curious about custom titanium facial implants. Seeing a lot of fear mongering on the internet regarding bone re-absorption, infection, etc. Can you update me with the latest information on risk? How long do titanium implants last before complications are possible? Possibility of muscle or nerve damage, or large scarring? Is titanium truly the best material for safety and longevity?

I’ve attached front and profile pictures as well as imaging I’ve done on them for how I’d like to look.

Is this a realistic expectation? The skin around my jaw is rather loose so I believe it could accommodate the size of the implant without over-stretching.

My under-eye area is a minor concern but I’m open to suggestions. It will probably get worse as I age.. runs in the family. I’m 25 now. Filler should work fine there but I haven’t tried fillers before.

Overall I want bigger zygos, a more pronounced, wider and straighter jaw line, and a more pronounced chin that closer lines up to my lips. I feel these changes would improve the harmony of my facial features such as my somewhat over-projected nose.

How close can you get me to the imaging and what is a ballpark price range I should expect to pay?

Thanks for your time. Looking forward to working with you.

A: The reality is that titanium as a custom facial implant material in the U.S. is not a viable option due to:

a) It’s tremendous cost (it would cost about $20,000 just to have the implants made) and

2) surgical placement. This is relevant to the jawline were the rigidity of the material will require it to be sectioned into four pieces and the need for larger incisions for placement

The risks of placing titanium implant in the face are identical to any other material from which custom facial implants are made. The material does not change those risk factors.

I see nothing unrealistic about the facial imaging you have done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m emailing you regarding coral hydroxyapatite/Interpore. 

It is a porous, non-degradable granular mixture of hydroxyapatite from coral in the sea. It is perfect for facial augmentation, I believe. 

Do you use this material or happen to have any of it on the shelf? I don’t like the idea of a traditional implant in my face so if you know anything or anyone who has this material it would be great if I were notified.

A: I am very familiar with hydroxyapatite (HA) granlules for facial augmentation and have used it many times in the past. While it still has a useful role in small areas of facial augmentation it has issues with contour irregularities since it is applied as a paste/gel and rarely heals in a smooth and linear fashion. Due to this contour unpredictability it is an inferior facial contouring material compared to the smooth and predictable contours of preformed facial implants.

Hydroxyapatite granules are becoming increasingly hard to find as the number of manufacturers has become limited.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had mandibular body implants, placed bilaterally without complication, around 20 years ago. The projection of my chin was also reduced at that same time. There  were no screws, the mandibular body implants were the largest size available. 

At  that time it was very uncommon to lower the mandibular jaw angle , so I only enhanced the mandibular body without  lowering  the height of the jaw angle. I am interested in utilizing the better technology which exists today, in order to  possibly replace the jaw implants.  

I’d hope to focus specifically on lowering the mandibular angle, and give the jaw angle a more defined  square jaw appearanc , instead of the high angle tapered appearance . 

I’m sending some pictures in the hopes that you might be able to tell me if the  current results can potentially be safely improved on.  My impression is that the left jaw has always been comparably weaker.

I should add that I had a neck lift and fillers over the past several years, also without any complications.

Thank you in advance for any opinions you may have. 

A: I would need to see a 3D CT scan of the current position of your long-standing jaw angle implants. In the face of well encapsulated implants I would be cautious about trying to open the capsule and drop the implant borders down with a vertically lengthening implant. That is not a complication free procedure which can result in masseteric muscle dehiscence with indwelling jaw angle implants. But seeing the scan would help me determine as to the advisability of this procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 22-year old male. My temporalis muscles bulge at the sides which makes me look like an alien. Because of the my protruding posterior temporalis, my hat size is 58cm, and even that feels a little tight. 

I heard that you’re one of the few surgeons that can surgically excise the muscle. You’ve mentioned in your blogs that a 7-9mm width reduction each side can be expected from the surgery.

However, I’d like to try out botox first to see if I’d like the final look. However, since botox only shrinks the muscles and doesn’t remove it:

1. How much width reduction per side can I expect from botox? Will it be considerably lesser than the 7-9mm through surgery? Is 4-5mm reduction per side through botox possible?

2. How many units do you recommend per side? I’ve seen doctors quote a range from 25 units to even above 50 units per side.

Thank you!

A: In answer to your questions:

1) The effects of Botox compared to surgery would be less than 20%.

2) You would likely need 100units per side to get a really noticeable muscle temporal reduction effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just would like to know if you can help me with a procedure. So, I would like to have a silicone implant in my head to grow 2.5 cm for my job and my career. My career requires me to have at least 166, but my size is a 163.5 . I know that this procedure is common in Spain. People do it to grow taller. Please let me know if you can help me. Thank you very much.

A: Skull augmentation with a custom implant can be done to increase your height by 2.5 cms. But this will require a first scalp expansion as no one’s scalp has enough flexibility to permit such a large implant to be placed without it being stretched first.

With the immediate insertion of a custom skull implant one’s height can be increased by about 12mms or 1/2 inch due to the limits of scalp stretch. With a first stage tissue expander the thickness of the implant can be extended to 25 to 30mms (one inch) due to the scalp stretch obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long face, it’s actually long through out and while i am looking into hairline lowering/hair transplant , and have already had a chin reduction , the mid face and the part of the lower face that is between the lips and the nose appear to be harder to address. Can a Lefort 1/maxillary impaction help to reduce the vertical length of that part of the face between the lips and nose? Also, I am thinking the impact to the mid face (brows to the tip of nose) would be minimal, but some doctors says optically the surgery has the potential to make the mid face look shorter, what are your thoughts? 

Also, will shortening the maxilla actually shorten the vertical length of the nose on the frontal view? Or is there any surgical maneuver at all that can reduce the length of the nose (frontal view) when the tip is already at a good position and not drooping? I think we are constrained by the nasal cavity here. 

Thanks for your time. 

A: In short, there is no effective procedure for reducing the middle third of the face unlike the forehead and chin. No bone shortening procedure shortens the visible midface, it only affects the amount of upper tooth show. A lip lift, which shortens the distance between the base of the nose and the upper lip is the only procedure that provides some vertical midface reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had decent results from Botox to correct temporal hypertrophy, but the results are always temporary unfortunately, so I’m looking for something more permanent. I have a few questions please .. .1) I think the muscle is thickened in both anterior and posterior aspects, but I think in my case its more an anterior problem, it actually aches in that area at times. I see Dr Eppley’s approach for Anterior is “high temporal release”. Could you please give me a ballpark idea of total cost of that procedure alone. Cost is unfortunately a fairly big issue. So that’s probably a good place to start. 2) Could you please also give idea of cost for posterior approach? 3) The last time I had general anesthesia I had a bad experience from the anesthesia and I swore to never have general again, at most conscious sedation. So, is it at all possible for Dr Eppley to do any of the procedures with local anesthesia/conscious sedation?

A:Thank you for your inquiry. Unfortunately I can not be of assistance in your case. I do not have a reliable way to reduce the anterior temporalis muscle like I do for the posterior temporalis muscle. Furthermore even if I did this is not a procedure that I would do under anything less than general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am searching for a doctor well experienced in sliding genioplasty revision. I had a sliding genioplasty reduction 6 months ago as I wanted to reduce the protrusion of my chin when I smiled. I am happy w the results, the problem is the dynamic ptosis my chin manifests every time I smile. My chin also looks flat and without form when I smile on top of having the tissue/muscle pulled down. I am wonder if this is a matter of mentalis muscle resuspencion or if I can simply have my original surgeon move my chin more forward? Will that fix the hanging tissue or do I truly need a resuspension? 

A: Thank you for your inquiry. As expected when you slide the chin bone back for horizontal reduction you are going to develop dynamic chin pad ptosis. (and in some cases submental fullness as well) This occurs because a purely bone-based procedure does not account for the soft tissue excess that is also present. This problem is not going to be solved any any form of muscle suspension as it is a tissue excess probpenm. Your options are to either slide your chin back out to pick up the loose tissue or have a submental chin pad excision/tuck done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been following a lot of your work and you seem to know a lot about computer imaging. I think I will have to go with you for my next procedure because my current doctor doesn’t seem as informed as you.

I had off the shelf cheek implants inserted by a surgeon who put them in asymmetrically ( everyone makes mistakes, not a huge deal ). He wanted to see the asymmetry so he can better know how to fix it during revision, so he ordered an X ray for me, but the X rays only showed us the screws and not the implant. 

What type of imaging should we order so we can see the silicone implants and not just the screws? Would a CT scan work? I see in your writing here https://exploreplasticsurgery.com/category/custom-facial-implants/page/11/ that a CT scan works, but do we just order a regular CT scan or do we need to ask for some special CT scan that shows silicone?

Thank you very much for your time.

A: The short answer is that the implant images are in the CT scan, which I assume is a 3D CT scan which is the type of scan to accurately assess facial implant positioning. But if you don’t have special software to pull them out of the data, you will not be able to see them.

Dr. Barry Eppley

Indianapolis, Indiana