Your Questions

Q: Dr. Eppley, I had a chin implant by another surgeon several months ago. My dissatisfaction with it is with the lack of forward and downward projection. I also believe the implant is either crooked or has magnified any natural asymmetry. I am concerned that the shape of the implant is too round. My original chin was more squarish (a slight “butt chin”) and as you can see in the included picture the implant has shifted the soft tissue, making my facial hair off center. I’m not totally opposed to keeping it if this asymmetry can be fixed by the sliding genioplasty procedure, or if the implant itself can be altered.

I am also interested in what my options are for the incision scar on my neck. It is large and raised although I don’t know if the picture shows it well.

I initially raised my concerns with the size of the implant with my surgeon who said that anything more than 5mm would look “cartoonish”, because of this confident dismissal I figured he knew what he was talking about.

I am interested in using 3D imaging/scans to see exactly what my options are.

Please advise next steps.

Again, thank you for your time.

A: By definition most chin implants are round, particularly all Medpor chin implants. So anyone with a naturally more square chin is going to end up with a rounder one. That is an important preoperative discussion about chin implant selection.

All standard chin implants can only produce horizontal augmentation, not any vertical elongation. Only a sliding genioplasty or custom chin implant can increase both horizontal and vertical projection. 

How your chin implant is positioned can not be known completely from viewing the outside. Only a 3D CT scan of the mandible can provide unequivocal clarity in that regard.

The hypertrophic submental scar can be revised to be a finer line.

I will have my assistant Camille contact you to set up a virtual consultation time.

In the interim what you need to get is a CBCT or cone beam scan of your lower jaw which can be done where you live. Search that term in your local area to find a provider of it. It is a common scan used in many dental offices particularly that of oral surgeons, orthodontists and dental implantologists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have a question about jaw enhancement surgery and chin enhancement surgery. If a patient was approved for orthognathic surgery to correct overbite/overjet, could they also while enhancing their jaw later and or at the same time of surgery have jaw implants as well combined with orthognatic surgery as well as genioplasty and chin implants. Thank you.

A: You can not have jaw angle implants or a total jawline implant placed at the same time as orthognathic surgery that involves a mandibular sagittal split ramus osteotomy. This will have to await a healed mandibular osteotomy result. However a sliding genioplasty or chin implants can be done at the same time as any form of orthognathic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a trans male and I’m looking to get some facial implants to really masculinize my face. I am most interested in your custom cheek implants that I saw on your Instagram.

I noticed that you tend to design them differently. You make them much longer such that they extend all the way back close to the ear along the zygomatic arch. 

Do you have to make an incision over by the ear and an incision inside the mouth to insert these?… I see in the pic attached that the man has an incision along his ear 

 Also, I’ve read about some people on Real Self who can’t smile the same after getting cheek implants… Have you seen this ever in your practice? What are the odds of this happening?

A:Thank you for your inquiry. Many patient’s today wants a more contemporary model-like cheek implant result which comes from extended arch style designs. Provided they do not include a significant infraorbital extension they are placed through an intraoral approach. There is NEVER a need for an external ear incision with their placement. What you are seeing in that picture is a patient who also had a facelift procedure which has nothing to do with the insertion of the extended cheek-arch implant.

Like any intraoral approach to the maxilla or cheek there can be some temporary stiffness to the smile from the swelling but this is a self-resolving issue in the recovery process. I have never had a patient who has had any long-term issues in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a couple of questions about wrap around jawline implants: 

1) I’ve read that silicone may not resemble bone very well. This seems to make some sense given how soft and bendable it is. After being inserted, does it look and feel like actual bone? 

2) how predictable is the sizing of the implant relative to the outcome? Can scar tissue severely alter the width of the jawline relative to what is assumed from the implant size? 

Thank you

A :In answer to your custom wrap around jawline implant questions:

1) Implants make of silicone may be bendable but they are not soft., When placed on bone they will feel just like bone. Anyone that says otherwise simply lacks adequate knowledge of bionmaterial properties.

2) While this is a good question, it is actually the wrong question. All implanted materials in the body form a layer of scar tissue around it which has no influence on its external appearance. The real question is what are the dimensional requirements of an implant in any patient that can come closest to achieving their aesthetic goals given their anatomy and thickness of overlying tissue? Since there is no mathematical or computerized method to make that exact determination how are the implant’s dimensions determined? These are estimated decisions made between the patient and the surgeon with the understanding that all one can do is make the best guess possible for all the implant dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would there be a chin implant which would be wider at the sides while still keeping a more V shape? As you can see from the photos attached I have quite a V shaped face but lack definition around my chin and into my jawline. Would an anatomical implant help with that? I did see the pre jowl chin implant but i’m not sure if that would make my face too boxy or would actually help with the definition. I don’t want to change my chin shape too much only want the same shape slightly bigger. I’m probably only wanting 3mm of projection forwards while increasing the width of my face chin slightly to improve my side profile. If a chin implant would not help with this could you recommend what you think would improve it.

A:If the required dimensional chin changes are to maintain a v-shaped chin shape that is wider at the sides, no standard chin implant really accomplishes that type of change. An anatomical chin implant only add projection at the front of the chin and that is a round implant…clearly not the type of change you are seeking.  A prejowl implant adds a little width to the sides but has no projection. The only one that remotely comes close would be a chin-prejowl implant but its basic shape would need to  be modified because it is a round implant not a V-shaped one. Ideally the best approach to addressing those type of chin changes is a custom chin implant which can be made to fulfill those exact dimensional changes and also havhe a design that flows into the jawline naturally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a huge fan of your work and website, and I think I should have come to you in the first place. 

I’ve had a chin implant from outside the mouth done 7 days ago by a doctor in Beverly Hills, and I have problems with my smile. 

I can’t pull down the lip on either side. I can feel everything on both lips and chin, but I simply cannot lower the lip for normal function. (i’ve attached photos of me trying to smile, and of me moving the lip otherwise which is not impaired) 

I’ve seen you have an article on mentalis function. Can I come in and see you for a consult? I’ll gladly pay for the consult. Restoring my normal lip function is my top priority and i’m considering removal of the implant. Whatever is most likely to return normal muscle function!

A: Being only 7 days out from chin implant surgery what you are experiencing does not look uncommon. You have to remember that you put a space-occupying mass right under all of the chin tissues for which the soft tissue cover of the chin was not initially designed to accommodate. Thus it takes time between the swelling and the relaxation of the tissues for the function of the lower lip to work properly. This will be an issue for which time, and the full recovery from chin implant augmentation surgery is a 6 to 8 week one, to fully recover. Short of taking the implant you are not going to expedite the time course of this recovery process. While I can no guarantee your lower lip will fully recover I see no treason it would not and have not seen one that doesn’t.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I spoke with a surgeon who told me this:

“Bone cement cannot be inserted on the sides of the head because there are important muscles named Temporalis which cannot be separated from the bone. 

So, the asymmetry of the occiput can be improved to some degree, but you should consider that there is the limit of correction or asymmetry, especially on the sides of the head and the perfect symmetry cannot be achieved by any kind of surgery. 

The lowest margin for bone cement insertion is situated on the occiput as a parallel line as eyeball level. The neck muscles are attached on the below this line so bone cement cannot be inserted on this portion.”

This made me concerned, since part of my affected area is located on the left side just above the ear. I understand that this is where the temporalis muscle is located? 

What is your opinion on this, and does it also apply to custom made implants?

Also, do you have any before and after pictures of similar cases that you could show me?

A: What you have been told is not completely accurate in terms of the temporal muscle and its release to place bone cement. I have done that many times. What is accurate is that the low end of the occipital bone sits at the same horizontal level of the upper ear…higher than most people realize.

But when it comes to custom implants the muscle on the side of the head is irrelevant as it is placed over the muscle. Another reason for why a custom implant is far superior to the use of bone cements.

To learn more about custom skull implants and their use in plagiocephaly and all forms of occipital asymmetry I refer you to one of my websites, www.exploreplasticsurgery.com  and search under such terms as Custom Skull Implants,, Occipital Asymmetry, and Plagiocephaly. You will find dozens of case examples which so illustrate that good head shape symmetry can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a medium anatomical silicone implant inserted under my chin along with liposuction of my jawline two months ago. I know I’m still healing but I just don’t think there will be enough change to make me happy. My chin feels too long. I can’t tell if it’s placed to low or could it be my anatomy? I feel like I had a really recessed chin so I can’t tell if my feelings are just the fact I’m used to looking at myself with one. It just doesn’t seem to flow with my face and really sticks out now when I smile. I would like a revision but very scared about how it would turn out. This has been a very emotional experience and it’s hard to not recognize your own reflection. I feel like I’ve lost my femininity. I’m not sure what style and size implant would suit me better. I had a very narrow chin before. I now have a more prominent mental crease that’s always visible. I was aware of the crease before the surgery but it was only if I made certain faces and such. I added before and after pics, there is no questioning which is which.

A:Thank you for sending all your before and after pictures. I don’t think there is any question that the chin implant result does not fit your face. Your chin has become wider and longer with a 45 degree angulation of chin augmentation. This usually occurs on backward sloping small chins (yours) where the implant is placed where it is supposed to be placed on the bottom edge of the bone. But because the bone is angled downward in chins like yours, such placement ends up losing some of the horizontal effect and inadvertently creates length. (rather than  completely horizontal effect it becomes a combined horizontal and vertical effect…the so called 45 degree chin angulation. (see attached pic) Your chin is also wider because of the anatomical extended wing design. By definition this makes every chin wider, which is great for most men, but not for most women. (see attached pic) The implant has done what it is supposed to do by filling int the prejowl area but this also makes the chin wider. There are a lot of women who need end up the same problem (wider chin) when this chin implant style is chosen. It is a a good chin implant just not a good one for women with small narrow chins. 

Your options at the point are to swap out the implant for a central style that sits a little higher up on the bone (chin implant revision) or a sliding genioplasty which moves the chin forward and up as well as keeps it narrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, As we both know plagiocephaly causes twisted/forward growth of one side of the face. I have this predicament on the right side, where my forehead protrudes out further, and my jaw is more rounder and its lower, also “twisting” towards the left side. I can feel how my zygomatic bone is less developed on this effected side as well.

A few questions

1. Is it easier to treat plagiocephaly by fixing the “pushed out” side or the side that sits normally?

2. My forehead sits protrudes out on the right side, while my left one sits flush and normally. Would it be easier to mirror the left side by shaving down bone on the right side, or mirroing the right side with implants / fillers? The left side sits more sloped and masculine, which I prefer, but if the former is easier I would consider doing it.

3.Unfortunately it seems my entire skull on the right side is flatter as well, from the temple points all the way to the occipital, would it be possible to fix the side of the head projection and the back?

Thank you

A:In answer to your plagiocephaly questions:

1) How ‘easy’ it is to improve the abnormal expanded asymmetric depends on the magnitude of the excess and what exact procedure needs to be done to fix it. That can really only be determined by assessment of a 3D CT scan to assessment how much reduction needs to be done.

2) This answer is the same as #1. The question its how much bone needs to be removed to mirror the left forehead. Only measurements taken from the 3D CT scan can answer if that is surgically possible based on the thickness of the right frontal bone.

3) Adding projection to the entire right side of the head to the back would be done by a custom implant made from the 3D CT scan to match the fullness in the right side.

As you can see in all of the above answers the key is the 3D CT scan from the proper diagnosis and subsequent treatment planning. You can not do so by just looking on the outside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a several questions regarding Lateral Canthopexy : 

1) is it enough to fix sclera show? If not, what additional procedures would be needed? 

2) is there any difference in outcome between Lateral Canthopexy and lateral canthoplasty? I’m aware that the method is different, but what about the outcome? 

3) I read that the results of Lateral Canthopexy can be short lived (sometimes as little as 6 months). Is this accurate? 

4) Is Lateral Canthopexy reversible? I know that canthoplasty isn’t, but because Canthopexy uses sutures, if they’re released will the eyelid revert to its original position? Knowing a procedure is reversible is comforting since one cannot perfectly predict how they’ll look, even with a perfect surgical outcome. 

Thank you for your time.

A: In answer to your lateral canthopexy questions:

1) Lateral canthopexy alone its never enough to correct scleral show. Either the infraorbital rim needs to be build or a lamellar layer of the lower eyelid needs to be grafted raise the lower eyelid up.

2) Lateral canthopexy and canthoplasty are different operations for different problems. They are not comparible or interchangeable procedures.

3) The duration of a lateral canthopexy depends on what it is being used for. If it used to correct scleral show it will be very short-lived.

4) Lateral canthopexy in the short term is reversible since it is a completely suture-based technique that is tightening an existing structure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering doing a simple lateral commissuroplasty where the corners of the mouth are widened about to an ideal nose-width to mouth-width ratio. However, there are a few questions I would appreciate you to answer before I undergo this procedure:

1) What would be the estimated total cost of the procedure, with all factors included?

2) What is the estimated recovery time? Will performing everyday activities be possible during the time of recovery?

3) Will going through the procedure for a second time be possible to achieve greater width?

4) Will a palate  expansion be necessary to fill the empty space on the sides of the smile?

4) Finally, is there anything else I should know before undergoing this procedure?

A :In answer to your mouth widening surgery questions:

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

2) There is not an real physical recovery. This is just externally corner of the mouth surgery.

3) I have never done a ‘two stage’ approach for maximal mouth widening so I can not answer that question accurately. But it would seem theoretically so

4) No. This procedure moves the outside of the mouth corners not the inside.

5) The biggest thing to know with this procedure, and I have done many, is that there is a near 100% risk of the need for scar revision. The corner of the mouth is very sensitive area to manipulation and almost always there is one side that just doesn’t scar as well as the other. This risk is magnified in patients with intermediate skin pigments, such as Asian ethnicities, who are more prone to a higher risk of hypertrophic scarring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a couple of questions regarding infraorbital rim implants.

1) Considering they’re placed via an eyelid incision, is there a risk for a scar? 

2) Can they be placed in the corner right near the nose and right below the eye? From photos I’ve seen it seems they don’t usually extent that far, but that’s where my hollowness is worst.

A:In answer to your infraorbital rim implants questions:

1) All incisions make scars. The only question is how significant that scar will be. Subciliary lower eyelid incisions heal very well with minimal scarring.

2) With custom designed infraorbital rim implants they can be designed to cover whatever area needs to be covered. Each individual design will be different.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about under eye fillers. I tried it once but was not very happy with the results. Even though my under eye hollows did slightly improve, I got the Tyndall effect, which overall made my under eyes look worse (despite the decreased hollowness). I’m not sure if this is a result of lack of skill of the injector or just my anatomy. However, I’ve read that Belotero has not been associated with the Tyndall effect. Is this accurate, and should I give fillers another try? Or should I look into other options such as fat transfer or even an implant? Thank you for your time.

A: Treating the undereye hollows can be done by synthetic fillers, fat injections and implants. Each has their own advantages and disadvantages. For some patients they take the progressive ladder approach (try fillers first then fat and then an implant based on success of each along the way) Other jump into whichever one first sounds most appealing. You have tried fillers first and now have seen one of their downsides. All hyaluron-based fillers can have the Tyndall effect. Whether you want to try another injectable filler probably has merit. If it aesthetically unsuccessful then it is time to move one up the ladder.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your website because I have the exact bony chin asymmetry featured on your site. The right side of my chin is very slightly longer. I can feel it easily– the two little bony bits at the bottom of my chin don’t line up and the right side extends a few millimeters further. 

I have uploaded a photo and I have a few questions: 

1. Would the “inferior border shaving” be an option in my case? 

2. If so, what is the recovery time like? Could I potentially drive up for the procedure and drive back the same day? 

3. What would be the estimated cost (or range) for the procedure? 

Thank you for your time,

A: Thank you for your inquiry. In correcting your bony chin asymmetry the only question is whether the incisional approach should be submental (from below) or intraoral. (from above) There are advantages and disadvantages with either approach. To determine the exact amount of reduction needed, preoperative measurements should be done on a panorex x-rays which lays out the two sides of the chin and jawline in a comparative manner. It can also be done on a 3D CT scan as well.

Otherwise this is a one hour outpatient procedure done using dissolve sutures for closure so no suture removal is needed later.

I will have my assistant Camille pass along the cost of such surgery to you by tomorrow. She can also arrange for a virtual consultation time as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old. I have recently discovered that I had plagiocephaly when I was a baby and unfortunately, it did not get fully treated. This has made my head pointy and a little asymmetrical at the top. I was wondering if it is possible to shave the bone at the top of the skull down enough to achieve a more rounded and less high look of the skull. If this is possible, how much would it cost and would it leave me with any complications. I play soccer and intend on playing it in the future, so would this surgery allow me to continue playing sports after wards? Anyways, thanks for reading this and I hope to hear back from you on this, thanks again. 

A:Without knowing exactly what your head looks like and evaluating it with a 3D CT scan, I can not tell where enough skull reduction at the top could achieve a more better head shape or even whether that would be the correct approach to treat it. Until the exact treatment is known the cost of such surgery can not be accurately given. But for the sake of basic information I will have my assistant Camille pass along the cost of skull reduction surgery even though we do not know whether that is the best approach in your case. But regardless of what skull reshaping procedure is done, it will not affect your ability to participate in any sporting activity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The birth mark next to my nipple has given me trouble for years. I have been denied by just about every plastic surgeon I’ve been to because they have said the scar is not worth it. I have also had several Sciton IPL treatments that lightened the birthmark but did not completely get rid of it. Please let me know if the skin graft may be a possible answer for my birthmark. Thank you for your time. 

A: Thank you for your inquiry and sending your picture. Your dilemma is that neither excision or a skin graft will produce a marked improvement or elimination of its appearance. Of the two choices, however, excision is the better option as a skin graft will just look like a patch of a different color than the surrounding skin albeit of a lighter color. One excisional option that may not have been presented to you is a staged approach. First cut out the central 2/3s of the birthmark, let it heal for three months and then do a second stage completion excision. This is the best way to reduce the risk of hypertrophic scarring as this allows the surrounding tissues to stretch out in stages as opposed to cutting it out all at once…which has a much higher risk of hypertrophic scarring.

But the reality is that no plastic surgeon probably wants to operate on the birthmark because they fear, and perhaps rightfully so, that unless the resultant scar becomes almost invisible you will be an unhappy patient. That is where the risk of the surgery lies in your case. Your aesthetic requirements, based on the effort you have put into making you body look like it does, makes any scar a high risk proposition.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I was hoping to schedule an appointment with you soon for undereye filler. I’ve had this done several times before. I attached a photo, if that’s helpful. I don’t have considerable hollows or wrinkles, but I’ve noticed some flatness since the product has worn off. Is this something you’d recommend correcting with filler? I don’t envision needing a ton of volume, just a little extra plump-ness! It’s been over a year since I’ve had any filler. (Before I had surgery with you, actually!) 

I’m considering fat transfer in the future for more permanency, and I was hoping for your opinion on this? 

A: Good to hear from you. Almost all injectable filler treatments done in my practice are done by my master injector Amanda who has done it full time for 15 years.

If you have had successful filler injections to the undereye area in the past then there would not reason not to have more with the unfortunate understanding that they are not permanent. 

Fat transfer is the other injectable option and some good permanent results can potentially be obtained. However fat transfer is not predictable in terms of survival in thin young patients and is also very prone to irregularities which can be a hard problem to solve. The only assured smooth and permanent results obtainable for infraorbital hollows are custom made implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding wrap around jaw implants. I’m one who always likes to play things safe and I ideally only do procedures that are reversible. With regard to wrap around jaw implants, are they completely reversible? Google searches have not yielded much results for me. While many sites claim such procedures are reversible, I’ve only seen some say that the soft tissue changes, as well as possibly bone changes, after implants may cause permanent changes even if the implants are removed. Is this accurate? And if so, does getting the implant removed early on (day after a couple of months) mitigate it? Of course I would not get implants with the intention of removing them, but I recognize that no result is perfectly predictable, so I’d like to play it safe. 

Thank you.

A: In answer to your questions about custom jawline implants:

1) All such implants are completely reversible, meaning the implant can be removed. But I don’t think that is what you meant by reversible.

2) I believe you are referring to whether you face would completely return to normal shape if the implant were subsequently removed. The answer to that question would depend on how big the implant was and how long it had been in place. While I suspect that for the most part the tissues would shrink back down and return to normal or very close to it, the ‘safest’ answer is don’t have the surgery. That is the most assured method of having he identical face shape you have now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope this message finds you well. I understand that you’re very busy, so I apologize if I’m asking too many questions. If answering all of them is too extensive that’s totally understandable. I’m potentially interested in three procedures—head width reduction, tear trough implants, and jaw implants. I’ll address each separately: 

Head width reduction: The area of concern is above my ears until the top of my head. My head is just quite wide and always has been. From reading your blog, my understanding is that the area right above my ears can be reduced by extracting muscle. However, what about the uppermost area on the side of the head? My understanding is that area is made up of bone. Would bone burring and muscle extraction have to be done to narrow the entire sides of my head? Also, if burring were necessary, would the incision have to be made on the side of the head, or can it be made on top? The reason I ask is because a scar or hair loss on top of my head would be easy for me to hide, but not so with a scar on the side. 

Tear trough implants: This is pretty straightforward. My tear troughs are pretty hollow. I’ve tried fillers, but they don’t seem to give me the result I’m looking for. I’m wondering if it can be corrected with custom implants, especially because I have asymmetry where my left under eye hollow is deeper than my right. From my research on RealSelf, it seems some surgeons are not big fans of this approach. Some claim there are complications and that nowadays there are better methods. I guess my question is, do you believe there is any validity to those claims? 

Jaw implants: Although I wouldn’t say my jaw is particularly weak, I’m looking to get a more chiseled, masculine jawline. My own intuition makes me feel that wrap around implants would produce the most natural and best outcome. However, I’m not looking for much of a change to my chin, as I believe the main issue is with my jaw. I may want to advance my chin a mm or two, but that would be about it. Is it possible for a wrap around implant to be designed to mostly augment the jawline but mostly keep the chin the same? I know that implants for only the jaw exist, but based on my own intuition I feel wrap around implants produce the most natural result, as there is a smooth transition around the entire jawline. With just jaw implants I feel that may create a bit of a step off that may not transition smoothly to the chin. Obviously I’m not an expert, so I don’t know if there’s any validity to this. Second, I’m only looking for a slight enhancement of my jawline, but not to completely change it. From my research it seems that patients who are unhappy with jawline implants generally feel they were too wide. To play it safe, I’d look to augment my jaw by only a few mm, may 3 to 5. From your experience, will 3-5 mm have a noticeable effect? Lastly, my jaw is asymmetrical in that it is tilted towards one side and my right side is rounder than my left side. I think this may in part be due to my right cheek being wider than my left cheek. Is this jaw asymmetry something that can be predictably corrected with custom implants? 

A: In answer to your questions:

1) To reduce the very top of the sides of the head, known as the anterior temporal line, an incision would have to be placed somewhere near it. Perhaps closer to the top of the head than the side.

2) Having put in many custom infraorbital rims implants (which work far better than standard tear trough implants) I have observed that this is the far superior method. I would put little stock in any surgeon that has no knowledge or experience in the complete gamut of infraorbital rim augmentation methods.

3) Like all custom implants designs they are based off of the patient’s 3D CT scan. With that skeletal information one can learn a lot about the patient’s natural anatomy, what asymmetries and proportionate relationships exists and now to design the implants to account for those issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to let you know that I have fillers in both cheeks. They are about a year old and about 1 syringe of Voluma was used.  I do like the fillers and would like to replicate their effects with implants. As for my chin, I would like more projection and length to help add more balance to my face. I also mostly wanted the profile of my cheeks to taper down towards my chin. I would also like my chin to be more symmetrical.

My first major concern is about the longevity of the cheek and chin implants. I was wondering what techniques you use to make sure the implant does not shift at any point after the surgery. 

I have also heard that cheek implants have a high infection rate. I was wondering what techniques you use to ensure the implants do not get infected at any point after the surgery.

Another concern of mine is how symmetrical my face will look after the surgery. I understand that there will still be some asymmetry no matter what. However, I was wondering how you ensure the implants will suit my face and look as proportionate as possible after the surgery. 

Lastly, I was wondering if you can give me a price estimate for both surgeries done at the same time, including surgery fees and implant prices. Do you have any travel or hotel accommodations, as well?

Thank you again for getting back to me. I look forward to hearing from you.

A: Thank you for sending your pictures. In answer to your questions:

1) In addressing your aesthetic chin goals, a chin that needs both horizontal an vertical elongation is best done with a sliding genioplasty not an implant in most cases. (implants do not provide any significant vertical elongation effect) Although in looking at your pictures I do not see the need for much vertical elongation of your chin.

2) In addressing your aesthetic cheek goals, 1cc of filler per side is equal to a small or medium sized cheek implant. Since I don’t know what you looked like before, I can not say what style of cheek implant that filler is creating. 

3) Any type of facial implant is composed of a permanent material that does not degrade, break down or ever need to be replaced due to loss of material integrity. Thus they have a lifetime duration.

4) I am not aware that cheek implants have a ‘high infection’ rate. That source of information is inaccurate. Their infection risk is no higher than any other facial implant.

5) Numerous intra- and postoperative strategies are done to reduce the risk of any facial implant infection. But no strategy can completely eliminate that risk…short of not having the surgery.

6) If you have known facial asymmetry then one can be assured that they will have facial asymmetry after the surgery. Placing implants that have the same size and shape on asymmetric facial bones is guaranteed to create ongoing postoperative facial asymmetry. The only question is how significant will that be. To answer that question it is best to get a 3D facial CT scan before surgery to assess how different the two sides of the face are and whether the use of standard or custom implants offers the best aesthetic outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Unfortunately almost two years ago  I incurred damage similar to that of laser but from retinoids. Then my cat scratched me to make matters worse. Since then I’ve been exploring avenues to repair my compromised deflated skin. I’m looking to do full stem cell face fat grafting, face lift, brow lift and PRP treatments. I’m hoping you can help me get my life back. Thanks for your time. 

A:Thank you for your inquiry. For facial skin rejuvenation/restoration there are a variety of agents that can be mixed in with fat injections including PRP (platelet-rich plasma) and Bioburst rejuv which theoretically may work synergistically with the cells in the fat graft for a stimulatory effect on the skin including the stem cells that naturally reside within the fat graft. Processes stem cells, however, are illegal in the U.S. and are forbidden to use by the FDA. So any so called ‘stem cell’ procedures in plastic surgery really means injectable fat grafting. Otherwise these are marketing terms for procedures which are either approved for clinical use or don’t really represent stem cells at all.

I would need to see some pictures of your face to determine if you might be a candidate for this type of therapy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it a very short sighted decision to get hip implants when in say 20 years they may look terrible or need taking out? My skin now is very good and quite thick, I worry that as I age the implants will start to show?

Thank you.

A: Your question is a good one and I am afraid no one knows that answer because such procedures have not been done with decades of experience. So that risk is really not known. But in speculating about it I would not predict that would be an issue for you because the implant size (load to the tissues) is relatively small and the edges would be very feathered. With the perfusion holes in it is also merges with the tissues rather than just be an unattached object in a smooth tissue pocket. But I would think that might be an issue in patients with much bigger implants, just like large breast implants do in women with little skin coverage/thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently undergone orthognathic surgery and see the need to progress with jaw implants to address bony irregularities which have occurred from the operation.

Would the titanium plates in place after orthognathic surgery need to be removed to obtain a CT scan for planning and design of the implants?

If so, should the plates in the upper jaw region be removed as well?

I have heard that any metal in the head would distort the CT scan. Therefore, the plates need to be removed beforehand .

Thank you for your time.

A: There is no need to remove any hardware before getting a 3D CT scan and designing implants off of that scan. Such titanium hardware does not interfere or distort the 3D CT scan. So what you have heard is not accurate. That may have been true twenty years ago but not today. It is very common to design implants after orthognathic surgery of which there is hardware over the chin, jaw angles and maxilla. Should there be metal plates and screws which will lie underneath the implant, the design incorporates their negative image on its undersurface.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a genioplasty with you last summer. Since then I have had tightness in the right side of my chin. The tightness was mild and was progressively getting better each month.

A few weeks ago, the tightness was the worse it had been since I got the procedure. And almost every day it gets worse. Today is one of the worse days and the scarring is also more prominent. I also feel dryness in my lips as if I need to moisturize it.

This started the day I did a hard workout for the first time since the surgery. I don’t understand how a cardio workout would cause this so I don’t know if the two are related.

Is there any cause to be concerned?

A: Thank for what is now an eight  month followup. Your description of symptoms (tightness) this delayed after surgery is not one I have heard before nor the correlation with a typical workout. Thus I can not say why you have it and whether it will persist. But what I do know is that much healing has occurred since your sliding geniopaosty surgery including bone healing and I would not have any concerns about any problems with the surgical site in terms of infection or some impairment of the complete healing process. I suspect this tightness will become a self-resolving problem in a matter of a few more weeks or months. If not let me know and we can always check an x-ray to see what it looks like on the inside. It is also possible to inject some steroid intraorally see if it will make it better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did more research and noticed that sometimes you use an incision under the eye instead for cheek implants. Myquestions are: 

1) Which approach is more likely to get a symmetrical result?

2) What are the biggest risks of going through the eye lid?

3) Lastly, what is the recovery like when going through the eyelid? 

Sorry for all the questions, but I’m very interested in the eyelid approach in order to virtually eradicate the chance of infection. 

A: The incisions used for surgical placement depend on the actual design of the implant. But if the implant has a significant infraorbital component that saddles the bony rim then a lower eyelid incision is used for its placement. This is also helpful if the zygomatic arch component is very long and extends back to the zygmatico-temporal suture line.

The biggest risk in going through the lower eyelid, like any lower eyelid surgery for any reason, is ectropion or see slight malposition of the corner of the eyelid. But this is very uncommon in young patients who are not having an excisional procedure and the incision is used only for access.

Like all facial implant surgeries the initial swelling will be significant and will take a few weeks to become less disturbing…although the complete facial recovery is a 6 to 8 week process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some eyebrow asymmetry that I wanted fixed by a browlift. Can this be done through a incision from the eyelid? Also what can eh done permanently remove the deep vertical wrinkles between my eyebrows? I have attached some pictures to provide a clearer understanding of my concerns.

A: Thank you for sending your pictures. When you mention the left eye, I assume the pictures are mirrored images since that is the eyebrow that is lower than the other side.

If that is the case, that degree of brow ptosis can not be well corrected by a transpalpebral approach as that browlift approach only affects the outer half of the eyebrow. All other methods of browifting, which are superiorly based, are more effective. Technically the direct browlift method with an incision at the top of the eyebrow is the most effective but the fine line scar is always a potential aesthetic concern.

Treating frown lines is one thing but they can never be permanently eradicated particularly when they are as deep as the two glabellar furrows that you have. They are so deep that direct excision of them with a broken line closure and dermal graft placement would be need to provide the best and most sustained improvement in their appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of a chin reduction. My chin is fine at rest but when I smile it sticks out and looks very unflattering. What do you recommend?

A: Thank you for your inquiry and sending your pictures. I assume your concern is the chin protrusion that occurs when you smile. The chin at rest or non-smiling position shows a normal chin. That is what is known as a hyperdynamic chin ptosis problem. It is an ‘excess’ of soft tissue chin pad that protrudes downward as the chin tissues pull back across the end of the chin bone.

This is a very challenging chin protrusion problem to improve as almost all chin reduction surgeries are designed to treat a static problem and not a dynamic problem. That means that trying to improve a dynamic problem may cause an adverse effect in the static position.

Having treated hyperdynamic chin ptosis cases before, the only effective approach is a submental approach where the end of the chin bine is reduced and some soft tissue chin pad is removed and tucked to decrease the dynamic protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been 5 years using cocaine mainly through the left wide of the nose and that area of my face it is a little bit sunken and the part of the maxilla that makes the lateral shape of the nose it is more retracted than on the other side. Also the right alar sidewall is more elevated compared with the left side. I would like to know if its is possible to make a custom implant to reestablish the shape of my face and nose in a natural way. 

THANKS! 

A: By description it sounds like building up the bone would be helpful in the improvement of your nasal base asymmetry. I would need to see some pictures of your face that show this nasal/midface asymmetry to provide a more qualified answer as to what may be able to be done. But by description you are referring to the medial maxilla or the paranasal region. This can certainly be built up by a customized paranasal implant. While a a custom implant made from your 3D CT scan would be ideal, even a hand carved one made from ePTFE could be done at the time of the surgery and would be of good aesthetic benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For my cheekbone implants, I would like them to be placed high on the cheek and to stretch around the length of my zygomatic (like the implant on the right in the first picture attached) and to create an ‘ogge line’. One thing I’m kind of nervous about though is the possibility of having my cheeks augmented too much and looking very weird as a result. I see a lot of women on the streets who have fillers which make them look ridiculously bloated around the zygomas.

A: The key to having a natural looking cheek augmentation result, regardless of the style of implant used, is to not overdo it in terms of size. The cheek is a very sensitive area in terms of volume and a little bit does go along way particularly in small female faces. But this is an issue I am well aware of and I will know during surgery if such is the case and can make the necessary implant adjustments if needed to avoid that exact problem.

In addition injectable fillers notoriously can make the face look bloated because they are placed in the soft tissues and being a soft material they can make the cheeks look puffy and full. Fillers can not create a well defined cheek in most cases. Bone-based implants are different because they push the soft tissue away from the bone in a defined manner based on the shape of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a setback otoplasty seven years ago and have been bothered by how far back they were set. My surgeon released the sutures and scar tissue several months after surgery but it did no good. Can a reverse otoplasty help bring my ears partially back out and by his much? Could it be as much as 1 or 1.5 cms?

A: I would estimate you can move the ears back out by 5 to 7mms with a reverse otoplasty.

While it is true you can place any amount of cartilage grafting behind the ear to push them out quite far, large cartilage grafts will result in not being able to close the skin incisions behind the ear used to place them. An often overlooked part of a setback otoplasty, when done in the traditional manner, is that a large segment of skin is removed from behind the ear. This has been an historic part of otoplasty for the past 100 years. It has been proven to be unnecessary, as it does not help create or maintain the setback ear position, but it is still commonly done today. As a result a skin ‘deficiency’ now exists on the back of your ear and this prohibits the amount of cartilage ideally need to be placed to push the ears back to their initial preoperative position.

Dr. Barry Eppley

Indianapolis, Indiana