Your Questions

Q: Dr. Eppley, If we were to impact the maxilla (LeFort 1), I understand the septum would also be trimmed by the corresponding amount. Wouldn’t this result in some shortening at least (perhaps not the full extent of the impacted amount )? Or is this largely variable and dependent mostly on how the soft tissue responds ? Even if post maxillary impaction, there is little or no shortening of the midface (brow to nose tip), if this is followed with rhinoplasty, does this actually increase the amount of shortening the nose can get (frontal view ) since the nasal cavity now is actually a little shorter ? (Septum trimmed by impacted amount and maxilla moved up wards ) 

Many thanks for your time

A: I am not sure I understand your question as it relates to ‘shortening’ whether this means midface shortening or nose shortening. But assuming it is the latter the nose will not shorten in height or length and make even make the nose look larger/longer. This is because no matter what is done wirh the underlying framework you still have the soft tissue coverage which is not changing. While it is tempting to view these concepts of facial change as a mathematical or from an engineering approach, that is not how the face will respond as it is not a 1:1 correlation. The soft tissue coverage must be accounted for and not being a hard structure its responses are not completely predictable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in custom midface implants, infraorbital malar implants, zygomatic arch process… etc. Whichever best suits my face. My midface is flat, cheeks sit low, and my under eye area is droopy. I want a fuller midface, higher cheeks, and support for my under eye area. A more youthful and prettier heart shaped face. 

My questions are: 

What is the estimated cost of custom implants like these? 

Will they help support my cheeks from future sagging? 

How much downtime is needed during recovery? 

My age is 24, and I can provide pictures for reference. 

Thank you.

A: Thank you for your inquiry. By your description it sounds like you need an infraorbital-malar-maxillary implant design to which I can make the following general responses to your questions:

1) My assistant Camille will pass along the cost of the surgery to you later today.

2) Such an implant will provided enhanced soft tissue support that will help decrease cheek sagging that would otherwise occur more severely without such added support.

3) Downtime from almost any facial surgery is primarily related to the postoperative swelling and its impact on your appearance. Most patients needs at least 10 to 14 days if not longer until they may feel more comfortable being in public. But the total resolution of all significant swelling really takes 6 to 8 weeks to occur at a minimum.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Approximately two years ago I had a rhinoplasty surgery at your clinic and the results are amazing. I love the way my nose now looks. However, a few months after the surgery, the skin around my nose (in all of the spots that sinuses are located) started to become inflamed. Every few weeks the skin becomes inflamed and peels off. I’ve been seeing many different doctors repeatedly and it has left them all baffled. They’ve decided it’s not acne or allergies, have tried treating me for bacterial infections and viruses as well as ran blood work and determined I don’t have HSV. Could my nose/body have possibly healed incorrectly and be causing the issue?

 A: Thank you for your long-term followup. Having done many rhinoplasty procedures over the past 25 years, this is a postoperative development that I have never seen or heard of before. Problems in rhinoplasty healing, which is very rare due to the superb blood supply of the nose, affect the nasal skin directly…not off the nose to the sides. The fact that this developed months after the surgery also speaks to that it is not a nose healing issue as such problems would have developed right after surgery and appeared right on the nose. I wish I had a better answer for you that could solve your problem but I am like all the other doctors you have seen….baffled for an explanation as to the cause.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I have 420cc silicone implants. I have had them in for 9 years. Before I had them done I was a B cup, I am now a DD/E cup. I am 27 and 5ft 7inches height, I have had one child breastfed for two months. I hate the size and want to go back to my natural breast but my main worry is will I have enough natural breast tissue and will the skin be extremely loose? I have gone from clothes size 8 to 12 over the years.

A: The most important concept to understand is that removal of breast implants in anyone is not going to return you to the breast shape that you had before they were implanted. Going from a B to DD cup and having a child that you breastfed all means that you will have exactly the problems that you fear….loose skin with less breast tissue that you had before these events. There are unavoidable sequelae of the tissue expansion effect created by the implant and having a pregnancy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 21 years old and I have been losing my hair rather dramatically in the last year or so. This wouldn’t bother me that much as I always knew I would, but my head is asymmetrical. The right side of my head above my ear extends further out than the left side, and the right side of my forehead extends forward more than the left. I was wondering what the cost of a temporal reduction surgery would be for just one side, and what surgery you would recommend for the front. 

Thanks!

A: By your description the temporal reduction procedures sounds appropriate for the right protrusion above your ears. While the forehead can be reduced by bone reduction, the problem is the need for a more visible scalp[ incision to do so. Whether that is a worthy tradeoff would depend on the magnitude of the right frontal protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently read about masseter muscle reattachment after mandibular angle surgery as one of my own patients has presented with masseter muscle disinsertion on the right side after revision of his mandibular angle implants performed in January of this year.  

Recognizing your expertise in jaw implant surgery, I am hoping that you can help me by commenting on whether you are using a similar operative repair technique as what I read in the article and/or or whether you have any additional pearls of wisdom for successfully performing this reconstructive surgery.  

In your experience, how often does masseter muscle retraction occur following mandibular angle implant placement and how can I prevent this from occurring in the future?

Have you generally found it necessary to remove the existing implant at the time of masseter muscle reattachment?

How many (and what type of) sutures do you generally place in order to resecure the masseter muscle to the mandibular bone? 

Do you augment the repair with Alloderm or temporalis fascia?

Is botox treatment of the retracted masseter muscle a possible alternative to surgery?

A: In answer to your questions:

1) I have not found the masseter muscle reattachment procedure particularly effective. When combined with having to place a neck scar to do so, I rarely ever perform it anymore.

2) I treat the soft tissue jaw angle defect today with either the subcutaneous placement of thick Alloderm, perforated ePTFE sheeting or custom made ultrasoft silicone jaw angle implants. This camouflage approach has proven to be far more effective in my hands. This can be done through a less than 1 cm skin incision right over the angle edge.

3) Some patients may merit treatment of the retracted bulge of the muscle with Botox.

4) In terms of prevention, very careful subperiosteal elevation along the inferior border beginning anteriorly at the body of the mandible back around the angle is needed. This technique is far more gentler than the standard stripping done for a sagittal split osteotomy. This will prevent most masseter muscle detachment issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face looks swollen and fatter. How can I achieve a chiseled face look and get better defined facial look. I have attached some pictures of me to review.

A: Thank you for sending your pictures. Compared to many patients with darker skin pigmentation your tissues are not quite as thick as I suspected they would be. What you do have is vertical facial shortening of the lower third of your face with a flat mandibular plane. As a result there are some positive things you can do to your face including vertical chin lengthening and/or total jawline vertical lengthening combined with buccal lipectomies  and possibly cheek augmentation. Stretching out the lower third of the face and adding highlights at the ‘five corners’ (cheeks, chin and jaw angles) is what can make a face more angular.

Many men seek a more chiseled face. But surgically achieving it in the way now may want it is often not possible. The men who get closer to a more chiseled face are those that already have a thin face where skeletal augmentation of the cheeks, chin and jaw angles is best revealed. Defatting a face alone rarely if ever achieve much increased definition. Facial defatting should be looked at as a complementary procedure to changing the shape of the facial bones.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d writing to inquire about a few procedures with Dr. Eppley. I’m wondering if you can tell me the cost of each as well as answer some questions I have. I am transsexual so have to plan these around some other surgeries, both time-wise and financially. I expect I wouldn’t be able to do this probably until early next year, hopefully as my last surgery.

1)Clavicle reduction. How much length can you take off? What is involved with recovery?

2) Rib removal. Can you estimate how much it takes off the circumference of the waist Are there ever issues with soft tissue laxity?

3) Lateral Orbital Rim Reduction. I read on your website this can be done using an intraoral incision. I’ve already had a hairline incision during FFS and one hair transplant with another coming soon so would rather not have a coronal incision on top of it, especially because I would expect shock loss. I’m planning on having fat transferred to my temples soon as they’re very depressed. Do you think this will also reduce the appearance of the lateral orbit? I’ve attached a photo where the light catches it on one side and you can see the silhouette of it on the other.

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

1) In shoulder reduction surgery a 2 cm (one inch) segment is taken fro each clavicle. Recovery is somewhat similar to a broken clavicle with the exception that there is two of them.

2) Patients report a 1 to 3 inch reduction in circumferential waistline measurements. No on has ever indicated that it has caused a soft tissue laxity problem.

3) Lateral orbital rim reduction can not be done using an intraoral incision, that requires a more direct eyelid incision. There is always a chance that temporal augmentation can make the lateral orbital rims either diminished or no longer visible.

4) I will have my assistant Camille pass along the cost of these surgeries to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m trying to gather information and plan out a few procedures to improve my figure. I would like to inquire about shoulder narrowing, custom hip implants and rib removal.

1. What is the recovery like for shoulder narrowing? I read that full recovery takes 6-8 weeks. But how long would I need to wait before traveling? I live in europe, so I have quite a distance to travel.

2. How long do hip implants last? Will they need to be replaced eventually, or are they considered permanent?

3. Can any of these procedures be combined, i.e. done at the same time?

4. What is the price for these three procedures?

Thank you for your time!

A: Thank you for your inquiry on multiple body contouring procedures. In answer to your questions:

1) In regards to shoulder narrowing surgery, you should be able to fly home a week after the surgery.

2) Hip implants are not like breast implants, they are soft solid silicone that will last forever and never need to be replaced due to device failure.

3) The logical staging of these procedure would be a combination of hip implants and rib removal and doing shoulder narrowing surgery as a separate procedure. Which order these two groupings are done in does not matter.

4) My assistant Camille will pass along the cost of these procedures .

Dr. Barry Eppley

Indianapolis, Indana

Q: Dr. Eppley, I have been doing some research into possible solutions for my area of concern, I have very very deep set eyes that appear quite small in comparison to my face. Do you perform oculoplastic surgery? I have heard of something called orbital implants that act to push the eyes into a more forward position, is this something you have any opinion on, or know of any patients who have had this sort of procedure. I am a young woman in her twenties , I don’t have any issues with loose skin around or above the eyes, just very deep set, an almost beady eye appearance. I have looked into plastic surgery for many years seeking to enhance my facial appearance to look more feminine . My eyes are a really big concern for me.

Thank you in advance for reading

A: For the deep set eye there is no procedures that can physically move the eye forward. It is important to remember that the eye is attached by the optic nerve of a certain length that goes  through the apex of the orbit. You can not bring the eye further forward that what the natural given length of the optic nerve is…without risking blindness

The only potential procedure is to reduce the orbital bone that surrounds the eye. Whether this would be of benefit depends on what your periorbital structures looks like ad whether such reduction would make a visible difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had a titanium jaw implant fitted to my left side and v-line surgery including genioplasty. unfortunately I am feeling very remorseful for shortening my chin it was a bad decision which makes my profile too weak with a terrible double chin. I am 38 years old and the surgery was meant to correct asymmetry issues caused from mandibular advancement surgery from 4.5 years ago. 

I have included my before and after X-rays for you to see, please can you tell me if there is a way to reverse the chin via genioplasty, I am not keen on the idea of another implant in my face. I had the plates removed from the advancement surgery which is why there are no plates in the before images I have attached.

I have also included an X-ray of a genioplasty I found on the Internet and one that I have photoshopped my my own chin to ask if this is possible? Another surgeon said this was only possible with a bone graft from my mandible but I am not keen to lose any more bone from my jaw since the recent surgery already removed more than I would of liked. So I am hoping that you might have some ideas. 

I have attached images of my side profile and front face and photoshopped versions to show how I would like my face to look. I had to hold the skin on my chin so that you could see the shape of it.

I would be very grateful to hear from you as I am desperate to restore my face. Please let me know if you think this is something that you would be able to achieve.

A: Thank you for your inquiry and detailing your history and sending your pictures and x-rays.  From what I can interpret from your photoshopped imaging, your goal is to bring your previous genioplasty down and forward which movements that appear to be about 3mm and 3mms respectively. I see no reason that could not be done and, while an autologous bone graft may be ideal, allogeneic bone particulate  or solid graft would also work just fine. The key is the bone fixation used, grafting is of secondary importance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Curious about paranasal or paramaxillary implants. I have poor midface projection and my upper lip doesn’t project as much as I want it to. Would love to discuss this and a chin implant.

A: Thank you for the inquiry and sending your pictures. Based on your pictures you are referring to a paranasal-maxillary augmentation. I don’t think you are referring to a premaxillary augmentation as, besides not being able to project your upper lip any further  (the upper teeth are primarily responsible for lip projection), it will also open up your nasolabial angle and push out the base of your nose across the anterior nasal spine, which with a long upper lip I wouldn’t think you would want that type of midface change.

As for your chin I would predict that you need increased anterior projection but with a decreased vertical height and no increase in width. That type of chin change may be better suited for a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my chin burred down and jaw implants put in ten years ago. Worst decision of my life as my face was asymmetrical and the implants accentuated my asymmetry.

Biggest issue is my Chin Ptosis. I ended up with lip incompetence , severe lower teeth show, flat mentolabial fold and droopy chin.

I am in a desperate situation and I feel aging is making things worse. Been very self conscious about my chin for the past 10 years.

Was currently considering going to South Korea to see a maxillofacial who can help me with my asymmetry and Chin Ptosis until I stumbled upon your name several times . I felt it was a sign to contact you first.

Please take a look at my pics.

A: Thank you for sending your pictures and detailing your surgical history. Any time the chin is burred down for reduction, particularly if done intraorally, chin ptosis will always result. It is not a question of whether chin ptosis will occur but how severe it will be. 

Correction of chin ptosis in the face of lower lip incompetence must resuspend the soft tissue chin pad upward. But this will not be successful unless there is a ‘ledge’ to help hold it up. Whether that is from the placement of an implant or from moving the chin bone forward, the soft tissue chin pad needs support.

While chin ptosis correction can also be done by a submental tuck from below that risk making the lower lip incompetence worse. That approach should only be used when good lower lip position and competence exists.

Given what you have been through and to be more thoughtful in any further efforts, the next step is to get a 3D CT scan of your lower jaw/face. It is time to see what the actual bony anatomy looks like as well as any implants therein.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have large cheek implants in the front of my face. It gave me projection to my mid face which addressed my 1st concern buh didn’t fulfill my 2nd concern to have a wider more angular face. Can i have a 2nd surgery and get extra large implants to put on the sides of my cheek ( and still keep my large midface implants)?

A: That is probably not the best approach to try and place two cheek implants on top of each other. It would be very difficult to get two separate cheek implants close to each other and have then be stable in position. You are asking standard cheek implants to really do what they are not designed to do. You would be far better to have one unified custom cheek implant design which can more effective address your needs and have much lower risk of malposition and asymmetry than four standard cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a square jaw and wide cheekbones which give me an overall square face look.I am right now seeing who’s the best doc for the job. So far all the maxillofacial that can help me seem to be in South Korea, which I have no problem of going to but if I could find something in the US I would prefer that. Here I will attach a photo. Without me telling you what I want, what would you recommend. I am open to everything as long as the risks of complications are kept minimal.

A: Thank you for your inquiry. In the treatment of your wide cheekbones and prominent jawline, you are correct in that bony reduction of both cheeks and jawline is needed. The cheekbones are straightforward as there is only one way to reduce them…anterior and posterior cheekbone reduction osteotomies. The jaw angles/jawline is different in that there are two procedures, 1) lateral corticotomies (thinning) with mild blunting of the actual jaw angles  or 2) jawline angle/jawline amputation for a more radical reduction which eliminates the jaw angle completely. Without seeing a 3D CT scan of your face bones as well as a side and oblique pictures I can not say which may be better in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, First of all it is a great respect and i have to say I admire your facial reshaping surgery work. If one were to do those procedures, what would be the correct order and spacing? 

Rhinoplasty 

Otoplasty 

BSSO and GENIO 

Wrap around jaw implant 

Cheek implant 

Brow ridge and fore head implant 

Eyebrow transplant 

Lip lift and mouth widening? 

And out of those if I were to do the followingwhat will be the cost overall? 

Custom Forhead implant 

Custom Browridge implant 

Custom cheek implant 

Custom wrap around implant 

Lip lift 

Mouth widening 

Rhinoplasty 

Otoplasty

A: Thank you for your inquiry about facial reshaping surgery. Much like building a house you start first with the foundation…in your case the BSSO/genioplasty. Thereafter you build on that foundation six months later with any facial implant augmentations and rhinoplasty. Then the third and final stage would be any lip procedures since all of the other procedures cause too much swelling to make the sensitive lip area amenable to good scarring.

Since it is not yet clear what actual procedures would be done, for now I will have my assistant Camille quote the facial implants and rhinoplasty as done during the proposed stage 2 of the facial reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the head/ temple and jaw widening procedure. I know you have designed some jaw angle and temple implants for mass market use. As I would most likely not want to have another CT scan done do to multiple scans within the past few years from an unrelated accident. My timeline for surgery would most likely be mid next year. My questions are as follows : 

As I do have hollowed temples, would I need both front and side temporal implants or would the sides cover correctly this ? 

What would a ballpark figure be for said surgery with custom vs implantech implants? 

I know this may be a lot to ask but numbers do not have to be precise 

Thanks and kind regards

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

1) Standard temporal implants are for hollowing that exist by the side of the eye in the non-hair bearing area. How that applies to your situation its unknown since I don’t now what you look like.

2) The term ‘jaw widening;’ can mean either just the jaw angle areas only or could be the whole jawline. Like #1 without knowing what you mean exactly I can say whether those goals are achievable with standard or only custom designs.

While my assistant is happy to provide costs of surgery, it is not clear whether standard or custom implants are best in your case. I need more information (pictures and your exact goals) to provide a qualified answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from moderate plagiocephaly.  My biggest concern is the asymmetry of my face as one side seems to bulge out. In my case the flatness of the back isn’t as severe as the front. Is it possible to have reshaping of the front of my head and brow and maybe to contour my cheeks so it doesn’t looks too severe? My eye is also bulging a little bit out but i don’t think it’s fixable.

A: Thank you for your inquiry and detailing your facial asymmetry concerns. The frontal portion of plagiocephaly can be treated as successfully as the posterior portion, it just involves some more complex topographic assessment and treatment than the more uniform back of the skull contour. Please send me some pictures of your face for my assessment and recommendations. A 3D CT scan is always needed in the assessment of facial asymmetries but pictures would be a good start to the assessment process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question about my custom infraorbital-malar implant design. I notice that the back end of the zygomatic arch comes to a blunt end with 2mm thickness Why is it this way as opposed to tapering to a feathered edge? 

A:To refresh your memory as to this very topic we discussed during the custom infraorbital-malar implant design process, the tail end of the zygomatic arch is not usually tapered to a feather edge for two reasons:

1) A fine feathered edge is very prone to flipping up or rolled over during insertion which is never seen during placement…only to appear later when the swelling goes down as a prominent bump. I have learned that lesson more than once.

2) If it is tapered and the design fades from front to back there will be no visual evidence of an arch component at all.

These are the two reasons I don’t taper the ends. Most of the back ends of the arch component are often much thicker in the 3 to 4mm range as a blunt end. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In regards to forehead horns I have three questions: 

1) is it almost always an extra amount of bone, rather than the shaping of the skull? (meaning the skull is shaped rather normally underneath and the excess can be burred off?) 

2) if a “safe” amount is taken off, will integrity be sacrificed at all? If I were to play a contact sport or something after reduction, would skull damage be any more likely? 

3) is there another name for these? Is it just pretty rare? You’re basically the only surgeon who comes up when I try to look in to this.

A: In answer to your forehead horn reduction questions:

1) The exact origin of forehead horns is nor precisely known. But they are a prominence of the upper forehead that can be burred down if that makes for an aesthetic improvement of the shape of the forehead. In some patients that have an overall greater retroclination to the forehead it may be better to build up the bone around the horns as a method for their ‘elimination’.

2) The amount of bone reduced in forehead horn reduction does not compromise the integrity of the frontal bone.

3) The term ‘forehead horns’ is a well known term for these upper forehead prominences that has been in use long before I ever treated them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I was just wondering, If I got 5cm custom hip implants in really soft implants would they have a risk of folding in the healing process? Because I was told that the normal 5cm implants may cause erosion of the underlying tissues, meaning I would have to have “really soft” 5cm ones, but they may fold whilst healing. Is this same risk with your implants? I just want a second opinion because I’m either going to get my hips done with you or the other place I’ve contacted 🙂 thank you so much. 

A: At 5 cm hip implant thickness, even the ultrasoft silicone is going to feel very firm/hard. The thicker an ultra soft solid hip implant is, the more firm it will feel. This is just a function of material thickness. While at 1 cm it will feel very squishy, at 5 cms it will be almost as firm as a brick. Because of this issue and others, I would never place a hip implant that was more than 2.5 or 3 cms thick at most. This is just asking for a complication of some type.  Hip implants are unique because they are not in or under muscle but on top of its fascia. This makes for higher rates of potential complications. By a lot of painful experiences i can only pass along this piece of wisdom….’it is far better to have an uncomplicated result that may be only 50% of your aesthetic goal than it is to have achieved 100% of your aesthetic goal with complications’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,Is there a difference between submental liposuction and submental lipectomy? Do you perform both procedures if this is the case?

A:Technically there is a difference between submental liposuction and submental lipectomy. Submental liposuction, as the name implies, removes fat between the skin and the platysmal muscle by vacuum extraction using a cannula. (like any traditional lipouction only using a smaller cannula) Submental lipectomy is the direct excision of central fat beneath the platysmal muscle. in the midline The combination of submental lipectomy and submental liposuction is always part of the procedure known as a submentoplasty. A submentoplasty is a more aggressive form of neck contouring that also include platysma muscle tightening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Regarding limitations in the size of facial implants, such as chin implants, would the skin not eventually stretch, gradually, to accomodate the implant? That is to say, have you ever had someone get an implant, wait a year, get a larger implant, or is this irrational? Would the tissues simply become too tight regardless of how long was waited? I know, for example, that as people get fat, their skin extends generally regardless of how fat they get. Is there not the same potential for cosmetic implants? Is there any experimental work being done in this area?

A:It is very common that patients unintentionally undergo a first stage tissue expansion procedure (placement of an initial implant) for a second larger facial implant later. They get one implant size today and then may decide later they want it bigger…which is not a problem to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing this email in regards to the query regarding the custom jaw implants. I had a V-line surgery done around 3 years ago in Korea and since then I have almost lost my jawline definition. I am looking to reverse this surgery dr. Probably around in coming 1-2 months or as soon as I get a leave from work.Actually my question is not regarding the custom jawline implant but regarding the possible implications of it on my future surgery. Actually I am scheduled to get a Lefort 1/ Upper jaw surgery. Its ONLY an upper jaw surgery but not a double jaw surgery. Currently I am undergoing orthodontics and it is scheduled for Summer, 2020. My maxillofacial surgeon is very confident that it is only going to be upper jaw surgery with some setback and Clockwise rotation with some posterior impaction. He said that he won’t touch my lower jaw at all. So my questions are:

1.Is it possible that I can get a custom jaw implant to reverse my V-line surgery  and for jawline augmentation in upcoming August/September 2019 and then still in 2020 can go upper jaw surgery only for my maxilla without any compromising effects on my jaw implant. 

2.Will the custom jaw implant create any hindrance if my maxilla is impacted/rotated or setback or if it has to be removed during my maxilla surgery.

3.Can I get a custom jaw implant now on my mandible but still in future can undergo ONLY upper jaw surgery without any problem.

Thank you so very much for your time Dr. I am really looking forward to get my custom jaw implant with you. My basis of this query is just that as I can get leave now from work and I would like to get my custom jaw implant with you now as I really dislike my un-defined jawline. Looking forward to hear from you soon.

A:Thank you for your inquiry and detailing your issues and upcoming maxillary surgery in 2020. I think all of your three questions revolve around the same issue…can a jawline implant interfere with any aspect of a subsequent LeFort 1 osteotomy? And the answer to that would be no. As long as you know that you are not going to need bimaxillary orthognathic surgery, then placing a custom jawline implant will be just fine.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is a direct temple lift the same or different than an endoscopic browlift? Or I assume the direct temple lift pulls the tail vertically while the endoscopic browlift pulls the whole brow up to the hairline.

A: There are differences between a direct temple lift and an endoscopic browlift. An endoscopic browlift uses 4 scalp incisions  (2 parasagittal and 2 temporal) to create a total brow lifting effect. Conversely a direct temple lift uses an incision either at the tail of the eyebrow hairline, at the edge of the temporal hairline or back in the temporal hairline to create a tail of the brow lift. Most commonly the incision is placed at the edge of the superior temporal hairline which lifts the tail of the brow in a 45 to 60 degree angulation upward. 

The combination of a lateral cantoplasty and a direct temple lift is the most powerful technique for creating an upward sweep or angulation to the outer eye area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, this is about mouth widening surgery, I saw online about a question about how mouth widening surgery can improve the length of the mouth and Dr. Eppley answered about 5mm on both sides of mouth, Is that right? I don’t see how wider the mouth can get without cutting too far into the muscle which can be dangerous.

A: All mouth widening surgery involves removing a wedge of orbicularis oris muscle as that this is a necessity to help prevent relapse. There is nothing dangerous about such muscle manipulation/removal. This is a small wedge of the lateral aspect of the muscle which has no functional significance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eyelid surgery to correct negative canthal tilt. I know lateral canthopexy can be done to raise the lateral canthus but i also need the medial canthus to be lowered in both eyes. I talked to one doctor who told me it is impossible to do. I started researching this and found many articles on the topic that have been published throughout the years. All of them describe methods and techniques for reattaching the medial canthal tendon. When i sent one of those articles to the surgeon he told me those techniques do work but they’re only for “medical problems”. I even saw a video of of the procedure being done. I e-mailed another surgeon asking him if it is possible to do and i suggested cutting the bone to which the tendon is attached and moving it down then fixing it in that position. I asked him if that would work and he said that it would and that he’s done things like that before. I just don’t see any reason why this can be done for people who have severe skull fractures/shattered orbitals but not people who are perfectly normal? Is it possible to do or is it impossible? I’m confused and just looking for a real explanation.

A: Medial canthoplasty is a far more challenging procedure than lateral canthoplasty due to the more limited access of the inner eye and the very thin bones to which the tendon is attached. It is also a procedure that is far less successful as a result. While attempting to do it for reconstructive purposes has merit, manipulation of the medial canthal tendon for aesthetic purposes must be considered far more carefully. I would doubt that moving the inner corner of the eye down will be successful if attempted by trying to move the medial canthal tendon downward. The bones of the medial orbital wall are very thin due to the sinus cavity that lies on the other side. This makes secure fixation very difficult. If the goal is to move the inner corner of the eye downward boy a few millimeters it would far more sense to do so by skin manipulation such as a small z-plasty. It would be more effective and incur none of the risks of destabilizing the medial canthal tendon attachments.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in jawline custom implants but what material does the you use? 

A: A custom jawline implant can be made by a variety or materials from solid silicone, Medpor, PEEK or titanium. I am not married to any of them, ultimately that is the patient’s choice. However they are not all equal, meaning there are major differences in cost, how they would be placed (one piece or sectioned into multiple pieces) as well as the size of the incisions to place them. The reason solid silicone is chosen by most patients is its lower cost, ability be placed as a single unified implant and the smaller incisions used to place it. But I have had lots of patients who have chosen other more expensive materials and had equally satisfactory results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for the detailed reply and the options therein. When considering the submentoplasty procedure for neck sagging problem, my questions/concerns are as follows:

Putting aside (for the mpment) the expense of the work needed, there is, for me, the more difficult or challenging elements of having the work done without it being readily identifiable as someone who’s ‘had some work done’.

Can the procedure described be done in stages so as to minimize its obviousness? In the closing paragraph of your last email it appears that you are alluding to a sequence of steps, could those steps be the thresholds for a series of successive procedures or are they too intrinsically woven to be approached separately ?

It’s important to me that my friends and family think I’ve just had a vacation, fallen in love, or gotten laid properly (or all three) when they first see me after the operation.

Additionally, I’d like to know what the pain management path is; would I be put out for the operation,  is the time envelope for the work an hour or two, or significantly more? In terms of pain management history,  I have had some oral surgery and dental implants over the course of a few decades and have always insisted on anesthesia – not the local variety, but rather being put out by an attendant Anesthesiologist.

Logistical speaking, do I need to be swaddled in bandages fo a day, or three, or a week or more ? Travel considerations ?Time of year ?

A: In answer to your submentoplasty questions:

1) The concept of someone wanting to have facial work down and not looking like work has been done is not an issue you should be concerned with given the type of procedure you are considering. By definition a submentoplasty procedure simply can not look overdone. Its real issue is whether it can fully address your neck concerns. So the potential issue is really the opposite of what you think….not looking overdone but can it do enough to satisfactorily improve the problem. If you remember my discussion of your options, the ideal treatment for your neck concerns is a lower facelift. You just may not be ready to undergo that effort at this time.

2) The submentoplasty includes all three components that I discussed which have to be done at the same time. There is no benefit to staging them from a result or recovery standpoint. 

3) Changes in the neck are not really noticeable to other people as a specific identifiable change as people are not that perceptive. They may only ‘notice’ as some type of overlay beneficial change.

4) This is not an operation that is associated with much pain as most facial/neck procedures have low levels of discomfort.

5) Such procedures are done under general anesthesia.

6) There is a chin/neck strap applied for one day after surgery. Thereafter its use is optional.

7) You could return home 1 to 2 days after surgery.

8) The best time to is such surgery is when it suits your schedule the best. Time of year and weather make no difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My paranasal-premaxillary area is very recessed. I was wondering If is it possible to do paranasal-premaxillary augmentation with fat grafting. I know that peri-pyriform implants exist, but I want to know If fat grafting can achieve 4mm or more augmentation. Thank you Dr.

 A:Thank you for your inquiry. Can fat grafting be done to the midface and can an initial 4mm paranasal-premaxillary augmentation be achieved….the answer would be yes. The question is not whether fat grafting can be done to the midface but whether it would be successful. (i.e., survive) My experience and the observation from patients who had it done by other doctors is that the survival rates are low. There is also the issue that, even if it survives with some reasonable volume, the look is often more of a bloated/full one and not that of a skeletal augmentation effect which is the source of the problem. Once fat grafts are in there should the look be undesired there is no good way to remove the fat.

Dr. Barry Eppley

Indianapolis, Indiana