Your Questions

Q: Dr. Eppley, I have uploaded photos of me and a model for reference in the following link:

To put in words, These are my concerns regarding my forehead/brow ridge:

-I would want my brows to be further apart, straight, slightly lower, and flat. Instead of high, arched, close set, and somewhat rounded.

-I would like the entire sides of my forehead/brows to be built up on. At the moment, I have a rounded (specially to the sides) and somewhat narrow forehead.

– I would like an overall thicker supraorbital rim. 

-Rearding my skull, I have an extremely small skull for a 20 year old male. I would want considerable change here. Basically I would want more on the upper portion of my frontal bone (also towards the sides of it, to reduce the pear shape). and considerable support towards the back of the skull. (to also treat the flat back of head)

A: Thank you for your clarification fo your forehead/brow goals. Forehead/brow augmentation can certainly augment the brow bones (supraorbital ridges) and change the shape of your forehead as you have indicated. You can also increase the shape of your anterior skull as it goes back from the forehead and you would have to do so to have it blend in and look right.

But this augmentation will have no control over the overlying eyebrows and will most certainly to make them go lower…as that is an impossibility….nor make them further apart. Those are not realistic effects from the augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have primary rhinoplasty about 8 months ago. I dislike the result and would like to restore most of my old nose back. My main concern is I want my tip/columella derotated/lengthened so my nose isn’t pointed up. My other major concern is after my surgeon took down my nasal bump my bridge is flatter appearing and my prominent contour dorsal lines are vanished. My bridge is too soft and blends into my face and I don’t like that. No nostril work was done but they changed from tip work.. they are thicker wider and more exposed. I also really dislike how my philtrum look longer because of nose upward rotation. 

What techniques could be used to restore some of my old nose back? Do u do this type of procedure , Pls help?

A: Derotating a nasal tip is a challenge and requires significant cartilage grafting to do so. The first important question is whether your septum has been previously harvested or not. If so this may require rib cartilage grafting to do so. It is also important to realize that while some changes are possible by secondary rhinoplasty surgery you can never return exactly to what your nose was before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had bicep and tricep implants. I am happy with the results apart from the prominent bottom part of the bicep implant I have circled in the attached photos. Just to clarify I’m fine with the rest of the margin been visible just not the bottom part I have circled. 

I have spoken to a couple of surgeons and the following solutions have been suggested:

1) Fat grafting was the initial suggestion but it was deemed I do not have enough fat. 

So use of Hyaluronic acid filler to hide the prominent bottom part of the bicep even if it is only temporary and will need a yearly top up was suggested. 

An amount of 10cc to 20cc using a generic non branded hyaluronic acid filler. 

However when I spoke about this solution to another surgeon he said there would be a risk of “infection” to the implant and so this is not a viable solution. Please could you let me know what your opinion is on this?

2) If I get a tattoo on the inside of the bicep would this be sufficient to create an optical illusion to make it less noticeable? 

Many thanks,

A: The combination of a non-feathered implant edge, an implant that is too long and slightly off axis from the muscle head is why that appears so. It may also appears this way as most of the distal edge of the bicep implant has come through the fascia poking right up against the skin. Filler and fat are a poor treatment options due to the risk of infection and that it will be very difficult to get them between the skin and the implant without entering the implant capsule. Viable options are to either change the implant to one with a better edge or tattoo over the exposed distal edge the implant.

Dr. Barry Eppley

Indianapolis, Indiana

  Q: Dr. Eppley, I write you because I want to ask you some questions about the surgery which I’m really interested: Temporal reduction. I will be so glad if you answer me this questions which are very important to me:

1. Is it safe that after the surgery I will not have problems to chew or another type?

2. All the people who had this surgery didn’t have any problem?

3. How many people approximately have had this surgery? 

4. There is in your plastic surgery center some personal who speaks spanish? I’m from Spain and it would be a lot easier if when I go there I can speak with someome who understands my language. 

Thank you so much!

A:In answer to your temporal reduction questions:

1) There are no after surgery chewing problems with temporal reduction surgery.

2) As stated in #1, no patients have ever had a chewing problem.

3) Over 50 patients have been treated with temporal reduction surgery.

4) Unfortunately no one in my practice speaks fluent Spanish.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to know more about clavicular osteotomy. I’m not happy with the width of my shoulders, i want them to be more masculine/broader. With clavicular osteotomy used for cosmetic purposes, what are the potential effects on functionality? Would it possible to gain back full functionality after the operation? I’m most curious about how safe it is. Also, how much would it cost and who would perform it?

A: Clavicular osteotomies with an interpositional cadaveric bone graft can be used for shoulder widening and they can widen the shoulders by about an inch per side. When fully healed there should be no dysfunction, it is like recovering from a fractured clavicle. However doing both at the same time is a challenge from a recovery standpoint. The alternative to clavicular osteotomies are deltoid or shoulder implants which can also widen the shoulders with a farcquicker recovery and with much less scarring.

Clavicular osteotomies make more sense for wide shoulders for which there is no other treatment options. But when it comes to making wider or broader shoulders, the use of deltoid implants offer an equally effective and far simpler approach than cutting the clavicle and expanding it.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, what do you know about the Vampire Facial? Does your spa offer that service? I’ll jump on the website and check it out. I heard about it from a friend of mine but I’m wondering how much down time is involved and whether I would be a candidate for such. Thanks so much. Hope you’re well.

A: A Vampire facelift is just a branded name for the concept of a liquid facelift. This fundamentally means an injectable facial voluminization procedure using hyaluron-based injectable fillers (e.g., Juvederm or Restylane) mixed with PRP, a platelet extract of your own blood. In the case of a true ‘Vampire Facelift’ the skin is also microneedled and the PRP is applied topically as well for enhanced skin rejuvenation. These are injectable procedures that our master injector Amanda does here in my practice. Whether this would be of aesthetic benefit for you depends on what you are trying to achieve. While I spent most of my time with you at the buttock and knee levels, my recollection of your face is that it is more of a lipodystrophic issue (loss of facial fat with thinning of the face) than it is of a facial skin sag problem. This is the type of facial aging issue for which this treatment approach has merit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been researching aesthetic plastic surgery for quite some time now since I, like many others, would like to improve my appearance. 

But I haven’t been able to find an answer to one question, no matter where I looked. 

And the question is: If someone with volume loss in their face due to aging, or someone with a lack of facial volume simply due to genetics, even in their early 20s, were to have the volume restored/introduced through fillers or implants, would that raise the position of the lips, that is, would it lift the entire mouth vertically towards the nose?

Because this is exactly what happens when I pinch my skin and stretch it outwards, mimicking the volume that I lack. 

Currently, when I rest my mouth slightly open, I can see no upper teeth.

But if I do the same and repeat the little stretching action I described earlier, I can now see my upper teeth. 

My bite is balanced and I don’t have gum show, but nevertheless my upper lip, or entire midface including cheeks for that matter, droops.

I would very much appreciate your opinion on this, as an experienced surgeon with admirable work. 

Thank you in advance.

A: All I can say is that I am not sure that your facial pinch/stretch test really replicates what adding facial volume will do. I have never seen any facial voluminization procedure that lifts the lips up towards the nose and subsequently exposes more teeth..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Is there anything extra that can be done to make the abdominal etching more visible?

I’ve done extensive research into the pec implant procedure – and am still not sure whether the square or oval shape implants would be more appropriate for me. I’m looking for a nice lower pec and medial line of definition, and strong chest fullness throughout.

There are a couple of concerns about the pec implants and gynecomastia excision that I do have as well:

•In many thin patients with mild puffy nipples like me there have been issues of contour dips of the nipples – I’m just wondering if this can be prevented because we are looking at doing pec implants at the same time

•I’m concerned over how natural pec implants feel to the touch, as I don’t want people to see me shirtless, touching my chest that my pecs are fake

•Also – do the pec implants move fluidly with the pectoral muscle – i.e. contracting or moving up when tensing the muscle or, say, moving the arms upwards? I’m basically wondering how naturally pec implants move, as I’m confused if the implant fuses to the chest wall and remains fixed.

•I do have lots of armpit hair, so I’m wondering how percievable the scars from the puffy nipple removal and the pec implant insertation through the armpit would be – as I’ve seen some deep scars that are even visible when viewed straight on. Is it possible for the scars to become visible so no-one would know I’ve had surgery?

As for the ab ethching, I have seen some people where their etching looks very fake, usually in larger men. So I’m wondering how natural we can make my ab etching, otherwise there might be little point in the procedure.

I’ve not, in general, seen many plastic surgeons attempt pec implants, gynecomastia reduction and liposuction in one case  so I was wondering how many cases you’ve dealt with in each of these areas, and how I can optimise my surgery for maximum difference from my form today.

A: In answer to your abdominal etching, pectoral implants and gynecomastia reduction questions:

1) There are no magic methods to make abdominal  etching more visible.

2) There is no question, you and about every male, wants the square/rectangular style….never the oval shape.

3) Contour depressions occur in open areolar excisions because of over resection of tissues…the key is to not take too much tissue.

4) Quite frankly an implant in the body is fake….it is not natural and will never feel exactly as soft as the pectoral muscle.

5) Pectoral implants do not interfere with muscle movement as they are in a subpectoral (under the muscle) placement.

6) Axillary incisions generally heal very well, particularly with hair present with regrowth afterward. But no surgeon can make an incision and have no scar, that is not realistic.

7) Abdominal etching in thin people looks more realistic than in thicker abdomens which would not normally have it.

8) It is very common in my experience to do all three procedures at once. There is nothing rare about that combination as that is often what the patients needs. (you being an example)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My overbite is mild and my maxilla and lips are already well positioned, so I’m not really interested in orthognathic surgery since it would only be serving the purpose of chin advancement.

What is the maximum anterior chin advancement one could achieve without a BSSO? Could a double-step genioplasty be combined with either a chin implant or custom wraparound jawline implant to exceed 20 mm of advancement? What factors would determine the patient’s limit?

A: Chin augmentations using a variety of techniques (bone movements with implants can get upon into the range of 15 to 18mm. But even if they could exceed 20mms the depth of the labiomental fold that would ensue as well as other chin shape issues would be the limiting aesthetic factor. Trying to achieve a chin advancement of 20mms or more is not realistic as as single stage operation due to soft tissue restrictions. I woudl focus on getting a chin advancement in the range of 12 to 15mms first using a sliding genioplasty with or without an implant and then see what you think then. Your soft tissues will be more accommodating at that amount of chin advancement. 

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I was looking through some of your before and after pictures for sliding genioplasties, but could not find something I was looking for in particular. I am just wondering if you do sliding genioplasties on patients with a convex chin (moderately deep labiomental fold)? I have a slightly convex chin, which is especially true when I bite down due to a slight overbite. My chin is fairly recessed (15-18 mm), but I don’t intend to make it perfect, an 8mm horizontal projection would be adequate based on some of the morphs I have done. I am just wondering is it even possible to get an 8 mm projection with a slightly convex chin, without acquiring a “witches chin”?

A: An 8mm horizontal projection increase is fairly standard in sliding genioplasties in my experience. Whether that avoid your concerns of a ‘witches chin’ is hard for me to answer because I don’t know your definition of that term. In the medical sense that is a soft term used to describe a sagging soft tissue pad which is not a phenomenon ever seen in a sliding genioplasty due to the enhanced bone support that naturally occurs to the soft tissue chin pad from the procedure. It will, of course, deepen your labiomental fold.

Dr. Barry Eppley

Indianapolis, Indianapolis 

Q: Dr. Eppley, my surgeon had indeed mentioned the possibility of performing my midface lift with a more vertical vector through a combined intraoral and transconjunctival eyelid approach. He did not suggest the transcuteaneous approach due to my young age and the aesthetic scar trade-offs.

What are your thoughts on the transconjunctival eyelid and intraoral approach to midface lifting? 

I rejected this method as I was worried about the risk of ectropion.

I am very happy with my zygoma reduction from a bony standpoint but I really cannot live with the results of the soft tissue.

With the scarred tissues from my zygoma reduction and my intraoral/temporal lift, would my tissues be too scarred and atrophied to attempt a more vertical vectored lift?

Thank you again for your insight.

A:The transconjunctival approach does offer a more vertical midface lift but I would have concerns that the limited access through the inner eyelid and the ability to fix the tissues well to the bone would limit the result as well. Another option that provides a stronger vertical cheeklift is the cranial-based approach coming down from way above, avoiding eyelid incisions at all, and suspending the tissues through a small scalp incision to the bone. (combined with an intraoral approach to place the sutures to the cheek tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting augmentation for my upper midface: infraorbital rims and the area lateral to it (upper part of the zygoma?). I don’t want pre-formed implants if the cheek is involved, because I believe that everybody’s anatomy is different. Especially the cheek area where shape is highly variable. I would be open to pre-formed implants solely for the infraorbitals if the other options aren’t suitable. 

Your blog mentions that there are several ‘custom’ options. 1) Fully customised implant from 3D CT Scan. 2) Implant based off of another patient’s design. 3) Intraoperative hand carving of an implant. 

Ideally I would get a fully customised implant, but I just don’t have the money for it. So I was wondering the prices of your other two options? Would I be correct in saying that the hand carved implant is about the same cost as a standard pre-formed implant? 

Regarding the hand-carved implant, I wanted to ask how reliable it is in terms of creating an aesthetic effect? For instance, if I wanted to project my infraorbital rim, and also have the implant taper around onto the zygomatic arch, would this be possible or would this be asking too much? I have seen hand-carved results that extend out to the very top of the zygoma area (beneath the outside corner of the eye), and they look good. But I’m not sure how much further these hand-carved implants can be taken. If it’s not possible, I would settle for a basic hand carved design involving the infraorbital rim and the top part of the zygoma. 

It is frustrating that the fully custom design is much more expensive, as it would really be the best choice. I have bilateral asymmetry involving the width of my zygomatic arches. It makes my face look narrow on one side. But this is a secondary issue to the infraorbital deficiency, and perhaps I could get the full custom implant some years down the line. I don’t know whether to wait and save up for the full implant, but I’m just not clear on whether it would be significantly better than a semi-custom version. I would appreciate any advice you may have on this matter. For what it’s worth I have thin skin and a lean face. 

Thanks, and great blog by the way! Best resource for plastic surgery on the internet. I wouldn’t have found you without it. 

A: In answer to your questions:

1) I would generally advise doing custom implants for the complex anatomy of the infraorbital-malar areas.

2) In some uncommon cases, I may use what we call ‘special design implants’ which are custom designs from other patients that I think can be modified to work for the patient who can not afford the ideal custom implant. These cost about halfway between regular and custom implants.

3) There are no standard implant styles for the infraorbital areas so that is not an option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orthographic surgery and a sliding genioplasty 5 months ago. I am very happy with the outcome of my jaw but HATE my chin and want to have it undone. Since the surgery I have extreme tightness in my chin, which prevents me from moving it, smiling correctly, and even makes it hard to speak sometimes. I am assuming it is scar tissue. I am wondering how much worse this will be after having another surgery to put my chin back to its original position. I am terrified of being worse off. The tightness has not improved at all since about 1 month post op. Will having the genioplasty reversed make the scar tissue worse? If so, is there anyway to have that fixed after a second surgery? 

A:The answer to your question cannot be predicted beforehand although making it worse seems unlikely. But if you don’t like the look of your chin and the tightness has not improved, it would seem you have little choice but to partially or totally reverse it. (sliding genioplasty reversal) I would seem little risk of making anything worse by doing so and it would be logical to assume that both the appearance and the tightness would be improved by doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to reduce the length of my philtrum, however, I have normal size lips! I am concerned about changing their shape and size. As a male I like the shape and size of my lips as they are and do not want them to look any fuller. But I don’t like the length of my philtrum, so I am getting a lip lift. My question is whether a small lip lift of about 1.5mm in an average person would create any change in the shape of the red upper lip ? If I place my finger where the base of my nose is, and pull the soft tissue upward, it makes my upper lip look ridiculous and triangular shaped, even if I only pull upward a little. Will a lip lift create the same difference to the upper lip as pulling the philtrum upward with my finger does? Please help me stop worrying! 

A: The two comments I can make about your upper lip lift concerns are the following:

1) There is not a 1:1mm correction between the how much skin is removed from under the nose and how much the central upper lip enlarges. It is probably closer to 50% or less from that of the skin removed.

2) Using your finger way over exaggerates the effect of a lip lift and is not representative of it. The wooden end off a Q-tip is more representative to do some lifting under the nose to see the lip lift effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a flat head from the back and it has restricted me from being able to be confident with my hair. I have to tease my hair to reduce the flat look and was wondering what exactly it was that could he done to fix this. 

If implants are required, how dangerous is it to have them next to my skull and will my hair grow less because of it? 

Thank you! 

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

1) Skull implants are as safe as any other cosmetic implant used in the face or body.

2) Skull Implants do not inhibit hair growth. Skull implants aren placed deep on top of the bone while the hair follicles are right under the skin several tissue layers away.

3) The only relevance to hair growth is the incision used to place the skull implant, not the skull implant itself. Great care is taken in both making the incision as well as in closing it to lessen the risk of injury to any hair follicles in the incision’s path. The avoidance of electrocautery and placing dermal sutures are the most important maneuvers in limiting hair follicle damage from the incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having calf and ankle liposuction done. I know treating these areas can be a difficult procedure and I am on the hunt to find a surgeon that specializes in lower leg liposuction. I have attached some pictures of my lower legs so you can see what the ‘assignment’ is.

A: From a lower leg standpoint, calf and ankle liposuction is the appropriate and only treatment for them. That being said there are some very distinct caveats that come with doing liposuction on lower legs like yours. First, it is very likely you will not get the ideal desired reduction that you may seek. You can’t take thick legs and make them skinny or ‘normal’ size. They can be reduced but there are anatomic limitations as to how much reduction can occur. Secondly, there is going to be a lot of swelling and it will take months for it to go away. It is just the nature of what happens when extensive trauma is done circumferentially to the calfs and ankles particularly when there is a large tissue reservoir initially. Lastly, almost all such lower legs like yours inevitably will need a second liposuction session to get the best result. It is very hard to get the maximum fat out or have ideal symmetry between two legs particularly given the intraoperative positioning required to perform the procedure. (in the horizontal sleeping position your legs have to be manually held in the air)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Six months ago I had  a PEEK chin and jaw Implant (custom but not wrap-around. Pics of scan attached), while the jaw implants have added a good deal of width and strength, the area around my chin still fails to project enough and does not give the desired strength, thus I am considering a full wrap around implant. Incisions were made via external approach. 2x under jaw angles and one under chin. I prefered this approach due to reduced infection risk. My recovery period was also very easy…almost no swelling and pain.

Have you ever removed PEEK implants before? I believe that unlike Medpor they don’t allow tissue ingrowth so similarly to Silicone should be straightforward.

Are you able to insert a wrap around implant by external incisions only? 

If not, is a custom ‘extended’ chin implant a possibility. One which could almost meet my current jaw implants and could be inserted under the chin?

A: You are correct in that PEEK material does not get the degree of tissue adhesion that Medpor does. I have placed and removed PEEK implants before so I am familiar with their in situ handling properties.

You certainly could place a more complete jawline implant through your current incisions although be aware that it would not to be able to done keeping it as a one piece implant. Depending on its thicknesses it would need to be placed in either a two- or three-piece implant and assembled in situ.

It would also be possible to make an extended chin implant design to meet your current jaw angle implants. Although the arc and the rigidity of the material on that type of chin implant would still make it necessary to have it inserted in a two piece fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a zygoma reduction in January of this year. I’m 22 years old but I had some soft tissue trade offs and it didn’t really achieve the look I was after. I actually saw some tissue sagging 3 weeks post-op, but I had hoped it was swelling. Unfortunately, even now, I can still see the slight sagging. The area above the nasolabial area has become fuller and bulkier, and ages me. I feel older and don’t feel beautiful. 

The body of the zygoma was reduced by 4mm and the back of the arch was cut via a pre-auricular incision. I feel as if my surgeon over-corrected the reduction. When I smile, my side cheekbone area looks flat and my masseter muscle area is bulky and protrudes. I would like to add more volume to the outer portion of the zygoma body so that it isn’t as flat and over-corrected.

As for the sagging, I don’t know what to do? Please can you help?

I’m only 22 and I feel a midface lift is too invasive at this age. But I also hate seeing my sagging cheeks in the mirror and don’t think I can live with this. Will implants be enough to resolve my sagging? How big do I have to make the implants to resolve the sagging? 

I read on your blog that with jaw implants, the soft tissue from the face is stretched out, rather than from the neck. Would the malar implants be able to flatten my surgery-induced nasolabial folds as it stretches the cheekbone prominence back outwards?

A: Thank you for your inquiry. Yours postoperative situation is a common one that I see and your question as to whether zygomatic augmentation will reverse your cheek sagging/nasolabial folds is a valid one and the only recourse to this problem other than a midface lift.

The simple answer is that if the zygomatic augmentation replicates the shape of the zygoma and zygomatic arch before the surgery, this will give it the best chance to have a cheek lifting effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding the “installation” of a custom jawline  implant. Is the implant installed as one complete piece? Or the implant is divided in three pieces? For example. Left Jaw angle piece, center piece and Right Jaw angle piece… In case I only like the angles or in case if the center area only needs revision because infection in the tissue or maybe we need to decrease the size. This way we don’t need to remove it all.

A: Custom jawline implants can be placed either as a single piece, split in the middle and placed as two pieces or sectioned into thirds and placed as three pieces. I have always done it in one or two pieces but have not done it in three pieces although that is a viable method. Whether it is placed as one or two pieces depend on the size of the jaw angles and whether they will safely slide under the mental nerve if placed in a front to back single piece method. If possible this is the preferred method. But if the jaw angles are greater than 9mms and can not be folded to safely fit under the mental nerve, the implant is split in the middle and inserted in back to front method and then reunited in the middle over the chin.

But I have no opposition to the three piece method if it is necessary and that is what you prefer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I previously had jaw implants placed by you and now I’m considering cheek implants.

I am trying to achieve something similar to that model look where the cheeks look sunken in as I have shown here

1. ) I would like to know what (if any) are the benefits of choosing between off the shelf implants vs custom made from a CT scan ? I know with jaw implants you get the full wrap around effect without the breakage, but I don’t really see a benefit like that for cheek implants unless you know something I don’t?

2. ) How do you decide if someone is a good candidate for these?

3. ) What would you say are the best alternatives to cheek implants for males who want to achieve that hollow model look?

4. ) What are the risks one should consider ( other than asymmetry and infection ) ?

5. ) What are some of the most common complications or complaints that people have after getting these? 

6. ) Are there any long term issues to consider?

7. ) Will they make my smile look weird or anything look unnatural around the eyes if I have very low body fat?

Thank you, looking forward to another potential procedure

A: Good to hear from you again. In answer to your cheek augmentation questions I can provide the following answers:

1) The first thing you have to realize is that ideal cheek augmentation result may not be absolutely possible given that it is a professional picture that has undergone some image manipulation. (lighting etc) But that issue aside,  it is absolutely clear that such a result is never going to come from any standard cheek implant. Standard implants are not made to create that look and don’t have the proper design to do so. Only a custom cheek implant, like the imaged attached, can come close to such a cheek augmentation result.

2) The risks of such implants are like the ones you known and have already been through with your custom jawline implant. The good news is that those risks, and the recovery to o so, are not of magnitude of the bigger total jawline implant.

3) Whether it is a standard or custom cheek implant, neither affects ones smile or facial expressions once the swelling has subsided.

4) I will have my assistant Camille pass along the cost of custom cheek implant surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello,  I am interested in breast augmentations revision.I have an old pair of submuscular saline implants (15 years old) and have had and nursed two babies since. The entire time I’ve had them the right side has felt much tighter and actually uncomfortable. I almost feel like the muscle is permanently flexed. I am very muscular naturally so I get pretty severe deformation even with a little flex and am mostly insecure about that aspect. if i bend over to pick my kid up my implant does not fall forward with me so i am left with wrinkly breast tissue just hanging there. So I am exploring sub glandular. My ideal breast would have almost all the volume in the lower pole. I am under the impression that the sub muscular implants tend to sit higher and then whatever breast tissue I have just hangs off the end of it. I have also read that they can migrate upward over time? I would consider sub muscular if I was convinced I could keep them low and they would not migrate upward through time and as my natural breast age and continue to sag. I am actually pretty satisfied with my left implant placement besides how they move when I flex. I’m looking to minimize the deformation when I pick anything up that is more than 10 pounds. I understand the risks with sub glandular most notably the palpability as I am thin.

Do you do revisions where your patient changes from sub muscular to sub glandular? Is there a method with the sub muscular placement where the pocket can be lower? I am also interested in something called the Dual Plane technique but I don’t totally understand it.

A: Thank you for your inquiry and detailing all of your breast implant history, concerns and objectives to which I can make the following commentary about your possible breast augmentation revision:

1) It sounds like you have 100% submuscular implants, a breast augmentation technique that has not really been in vogue for decades. With 100% submuscular position you would have most if not all of the symptoms you have described.

2) The decision in your case is whether your implant pockets, with new silicone implants, should be adjusted to a partial submuscular (aka dual plane pocket) or switched out to a completely subglandular position. Dual plane implant positioning avoids most of the symptoms that you have described and is how I have done ‘under the muscle’ breast augmentation. for 25 years. It is a combination of submuscular and subglandular pockets. Each implant pocket location as its own advantages and disadvantages….there is not perfect breast implant pocket location.

3) I have changed implants from subglandular to dual plane and vice versa. Implant malposition (implant falling after surgery back into the old pocket) is less likely going from submuscular to subglandular than the other way.

4) I would need to see pictures of your breasts, static as well as with the animation deformity to provide further insight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If possible I wanted to get your opinion on residual swelling post genioplasty reversal. I had the genioplasty reversal almost 3 months ago. I have a little swelling left and it’s been fluctuating- it went down a few weeks ago and then got more swollen this past week. This is only noticeable to me and my boyfriend- it’s not significant swelling but I just want to make sure it’s normal. Would the swelling fluctuations be caused by he increase in heat or using a sauna and hot tub? Will it go away on it’s own? 

Thank you so much for your time.

A:It can take up to six months or more for residual swelling and tissue changes to eventually settle out, particularly in the secondary chin surgery patient. This is particularly so in the geniplasty reversal patient where the soft tissue support from the bone has been reduced. There is more than just swelling involved but the eventual soft tissue contraction (shrink wrap effect) that also must occur.

I would wait a full year after the surgery to not only let all the swelling subside but to make sure you have fully accommodated to the new look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in breast fat transfer to just my left breast. My left breast is like an A Cup and my right is a B cup. Im looking to achieve better symmetry. I’m 28 yrs old in good health. I weigh around 115 and am 5 ft tall. I believe I have enough inner thigh fat to achieve my goal. Is fat transfer or fat grafting a good long lasting procedure? How much would this procedure cost?

A:Thank you for your inquiry and sending your pictures. Given the one cup size difference between your breasts and only wanting to improve the asymmetry, breast fat transfer over an implant is a logical choice. The advisability of that treatment option depends on two key factors: 1) how much fat you have to harvest (aka is there enough to do the job) and 2) the patient’s understanding that injectable fat grafting is not completely predictable in terms of survival. It takes a lot more fat to do injection treatments than all patients think and I would question whether someone at 115lbs and using the inner thighs as the donor source would have enough fat to do so. But that determination awaits an assessment of the smaller breast’s volume needs and the generosity of your inner thigh fat.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I am a 35 year old female, 5’5 160 lbs (have lost about 70 and plan to lose 50 lbs more). I am having chin/jaw liposuction done in September but do not want a chin implant until after I have healed from the liposuction. Do you believe that I can still get good results by doing the chin implant after I am healed? Also do you think that the implant and liposuction alone will fix the issue of my face blending in to my neck (no jawline even in elementary school and very thin). My face is also very flat and I am wondering what you could do about that as well. Also I do have sleep apnea and I do believe I have had it even from a young age/low bmi but I am not sure if jaw surgery would be an appropriate alternative. Thank you.

A: While I think that liposuction of your neck will provide some good improvement, it is not the optimal treatment for the congenitally full neck that has a short chin and low hyoid bone. More ideally a submentoplasty which combines liposuction above the platysma muscle, central neck defatting below the platysma muscle and then midline platysmal muscle plication creates the best neck reshaping with the most well defined cervicomental angle. Because of the low hyoid bone and the benefit of anterior muscle pull and the need for some slight vertical chin lengthening, a sliding genioplasty in your case is preferred. Together with the submentoplasty a clear separation of the lower face and neck will result.

For the upper face, the combination of central face defatting (buccal lipectomies and perioral liposuction) combined with infraorbital-malar augmentation is the best approach to make an inversion of the facial shape below the eyes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley: Over the last few years I’ve been intrigued with the idea of customizing implants to fit an individual’s face and I’m looking into getting a customized implant for my cheekbones. My cheekbones are quite flat but also quite low down my face. Meaning the main part of my cheekbones seem to sit well below my lower eyelid. My first question is whether this can be addressed with a customized implant? Can my cheekbones be brought higher???? 

The other question that I have is whether it’s possible to order a layered-segmented implant from the implant company. I’m scared about getting an implant too big, but also too small. So I had this idea: could we order a single implant that can be ‘layered’, meaning can we order a single segmented implant where the implant is essentially in two similar layers, one over the top of the other. My thoughts were that I could have the lower layer implanted and then reassess whether I want more, and if so I would get the second layer implanted over the top of the first, thus avoiding the need to order two separate implants from the company. 

Look forward to hearing from you 🙂

A:When it comes to custom cheek implants they can be made just about any way we want. One of the most common reasons for custom cheek implants is to get the higher cheek look which standard cheek implants either can’t do or do very well. Attached are a few examples of the many types of custom cheek implant designs that I have done.

As for making a layered custom cheek implant, that can be done. They concept of secondary placement of the second layer if needed, however, is the reverse of what you have mentioned. It is far easier surgically to slide a second implant layer under the first one than it is to secondarily place it on top of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How soon post op can patients return to corseting and does corseting after rib removal surgery increase the permanent waist reduction results. (actually permanent rather than the temporary results achieved from corseting under regular use).

A: Patients resume wearing their corset the day after surgery if that is the most comfortable garment for them to wear. It probably provides the best support due to its snugness and conformity of the garment to your body.

It would be logical to assume that corseting after rib removal further enhances the waistline reduction results as well as creates a permanent change vs the temporary one that corseting does. (although if used daily over many years it has been shown that it does create some permanent waistline changes…but this is for only the most dedicated and motivated of users)

It is actually not uncommon that women that present for rib removal surgery are using a corset beforehand. This is not only a good preoperative test for the surgery but a great postoperative garment afterwards as well. Most patients typically resume weaning their corset days to a week after the procedure.

I would point out, that while wearing a corset is a benefit after surgery, it is not a requirement as it is not what is responsible for the eventual waistline reduction result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I first wanted to thank you for the detail that you’ve provided in each of your case studies. They are extremely informative. 

I had a few questions regarding the Occipital Skull Reduction case study (https://exploreplasticsurgery.com/case-study-occipital-skull-reduction-2/) 

I am in a very similar situation as the subject of the case study, except that the sides (more like, upper corners) protrude as well, and my overall head size is probably larger. 

I am currently in my early 30s. I have very slight thinning on the crown, but my hairline has receded a decent amount. I plan on getting a hair transplant (FUE not a strip, so there will be no strip scar) for the hair line within the next year, perhaps prior to undergoing skull reduction surgery. 

I believe I may have communicated with several years ago. At the time, you were very straightforward that there would be a very noticeable scar resulting from a reduction surgery, and compared it to a strip surgery / hair transplant scar. Is that still the case? I read a case study you posted on March 25, 2018 (https://exploreplasticsurgery.com/making-pleasing-scalp-scars-aesthetic-skull-reshaping-surgery/) regarding scars, and it seemed very promising. Have there been new developments, or are the scars still expected to be very noticeable? 

For instance, how noticeable is the subject’s scar in the Occipital Skull Reduction case study? I would wear my hair around the same length. 

Also, if I were to just flatten the top without doing anything to the back or sides, were would the incision need to be? 

Lastly, what would pricing be for a similar operation as the one in the case study? Thank you in advance.

A: Good to hear from you again. In answer  to your occipital skull reduction questions:

1) Any type of skull shaping surgery should be done before hair transplantation procedures.

2) The incision used for many occipital reduction procedures are far shorter in length and lower on the back of the head than the traditional strip harvest scars for hair transplantation. The length of the scar is related to how much skull reduction  needs to be done in terms of location and surface area treated. Without knowing this exact details int your case I can not comment on what your scalp incision would be in terms of length.

3) 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’d like to do a brow bone augmentation surgery. I want to add some depth to my eyes and make my eyebrow bones more prominent 

But I just want to do the parts in the middle where they connect to my nose… Is it possible? Or do I have to do the whole thing…? Also I assume implants will be used? What options am I looking at here when it comes to implant materials…? 

Thank you very much for your time! 

A: Thank you for your inquiry. You can make a custom implant that just augments the central glabellar and medial brow area from a 3D CT scan. This is best done with a solid silicone material which allows it to be placed through the smallest scalp incision. (endoscopic technique) All other materials (Medpor or PEKK implant materials or bone cements) would require a more open semi-coronal or full coronal scalp approach for placement but they can be used as well if one can accept a longer scalp scar)

The brow bone area you want to augment is the Y-area and would largely look like that in the final implant design. (probably closer to a more flattened Y)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read about your wrap around jaw implants and I am very pleased with what I have seen so far. 

My lower jaw is small in comparison to the rest of my face, but the bite is good. I think a wrap around implant would improve the appearance of my jaw drastically and have a positive effect on my life, as it can lengthen the ramus, reduce the gonial angle and create a more masculine chin while still looking natural. 

My main concern is whether the implant will manage to to widen my jaw angle substantially. As my lower jaw is very narrow, i wonder if it is possible to widen each side of it about 1.5-2cm or to use smaller implants for the sake of long term stability of the implant and then widen the jaw angle a bit more with the help of masseter hypertrophy or dermal fillers. 

A: Thank you for your inquiry in regards to wrap around jaw implants. A custom jaw angle can substantially widen the jawline and jaw angles. But I am fairly certainly you would not need 15mm to 20mms of additional width per side as that would by extreme and an amount I have not seen done in hundreds of custom jaw angle and total jawline implants. Understandably as a patient you would not grasp the significance of that number on an actual human face. But suffice it to say that your interest is in the most lower facial width that can be achieved.,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about plastic surgery, in particular, slimmer face surgery.

 On both sides the proportion of the bone between the eye’s outer edge until the head’s edges (hairline, ear) is too broad… as broad as the eye itself, whilst ideally it should have had maximum 2/3s of the eye’s width. I’d like to have a throughout slimmer face through:

1) temporal muscle reduction, together with bone shaving 

2) cheekbone reduction

3) bone shaving on the left and the right of the jaw (V shape)

What can be done for it? I read on your website about the temporal muscle reduction, but can it all be done together? 

And how many millimeters will the face become slimmer? I need 1.5 cm in total, or 2 × 0.75 at least.

Thanks in advance! 

A: The procedures of temporal reduction, zygomatic arch reduction and jaw angle/jawline shaving can all be done during the same procedure in an effort to achieve less head and facial width. (slimmer face surgery) I think it is realistic per side to have 7.5mm or a total of 1.5mc of bifacial width reduction achieved. This collection of head and facial procedures is the cost that can be done to reduce bitemporal and bifacial width.

Dr. Barry Eppley

Indianapolis, Indiana