Your Questions

Q: Dr. Eppley, I am interested in orbital rim implant removal. Is it possible to remove OMNIPORE Inferior Orbital Rims Implants? Will be an emptiness there after removing which has to be concealed? How to conceal? What is the earliest/best time to remove them after placing?

A: Omnipore facial implants is just a branded name for porous polyethylene. (Medpor) As such they can be removed just like any other Medpor facial implant. The time to remove them is when you have given the result long enough to really see the final result and have adjusted to it. (2 to 3 months after their placement)

You are correct in assuming that the lower eyelid/midfacial tissues may not return exactly to normal given that a subperiosteal elevation and tissue expansion has been done. Thus thinking about tissue management from the deflation caused by the implant removal is appropriate. What one would do depends on what you looked like before and what your original goals were for having the implants in the first place. Tissue resuspension and some volume coverage with allogeneic dermis is one approach.

I will have my assistant Camille contact you on Monday to schedule a virtual consultation time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eye asymmetry correction. I have also always been conscious that my right eye is slightly lower than my left. Looking at the CT scan, I can see that this could be caused by the bottom of my eye socket on the right side being lower than the left.Another thing I noticed on the CT scan is asymmetry of my cheek bones. The right one appears lower than the left, or at least extends lower. 

I did some research and mostly your articles came up. I found examples where you were able to correct all 3 of the above issues using custom implants. Therefore, I was wondering if you could recommend a solution to this? If it’s possible/feasible, I would likely look at getting it done after I recover from my jaw implants.

A: What you are describing for your eye asymmetry is a modest form of vertical orbital dystopia. (VOD) By definition, since the orbito-zygomatic bone complex is a combined unit, if the eye is lower so will be the cheekbone…the two go together since they are connected. Custom orbital floor-orbital rim-malar implants do offer the most effective method of VOD correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Sculptra injection reversal. I had Sculptra injections about 6 months ago and it has given me a square chin and is making me very depressed. The doctor is using an enzyme to dissolve the other fillers I had put into my face but, of course, the Sculptra won’t dissolve. Do you recommend trying to get rid of the dissolvable fillers anyway as there’s quite a large amount too? Would appreciate any help. 

A: As you may know Sculptra is not like the more commonly used hyaluronic-based fillers. It is composed of PLA particles (small bits of resorbable polymers) which create their effect by inducing collagen formation around them. Such PLA particles are not responsive to enzymatic digestion as they are a chain-liked polymer strand. Their resorption will eventually occur through a hydrolytic process (water absorption) but this is a slow process that could take 12 to18 months with the presumption that the reactive scar tissue will fade away as well as the stimulus is removed.

There is no known method to remove the Sculptra filler from soft tissues that would not potentially cause other long-term issues, particularly in the chin area. Steroid injections or liposuction should be avoided due to potential soft tissue deformities from them. 5FU injections are the only injectable strategy that would not cause a potential soft tissue problem but whether they would be effective in this situation is unknown. 

One other potential treatment option, if the Scupltra was injected down at the bone level (your injector would know this), is to remove the material from the bone surface through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in side profile enhancement. I am really insecure about my side profile, I know I want to do something about it, but I’m not sure what the best course of action is! I would like to have a less receding chin and defined jaw line (I’m not overweight). At the moment I’m leaning towards fillers in my jaw/chin and kybella but would it end up being more cost effective as opposed to jaw reconstruction or chin implant? Any advice or personal experience is greatly appreciated! 🙂

A: When it comes to side profile enhancement, you must define your profile goals as either chin or jawline augmentation because they are different. Fillers or a chin implant are the options for chin augmentation. Fat reducing by injection (Kybella) or liposuction can remove submental fat which will be a favorable adjunct to the chin augmentation. Thus the non-surgical approach of fillers and Kybella has a role in subtle to modest chin augmentation efforts. However neither a surgical or non-surgical chin augmentation approach will improve your jawline. That requires different procedures for which fillers, Kybella and even a chin implant will not achieve. To augment the whole jawline more defined (chin and jaw angles) it all must be augmented with implants. Whether this is using standard chin and jaw angle implants, a sliding genioplasty with jaw angle implants or a custom jawline implant requires a more in-depth discussion.

Dr. Barry Eppley

Indianapolis, IndianaSide P

Q: Dr. Eppley, Last year, I went to South Korea for a simple chin narrowing genioplasty. I consulted for a mini-vline surgery, which is what they call chin-narrowing surgery without the jaw bone shaving. 

I don’t know if things got lost in translation or if my surgeon just didn’t understand what I wanted. But my jaw angles did end up getting cut off. I strictly did point out I wanted my jaw angles left alone but when I saw the before/after CT scans, I was absolutely mortified. Only later did I find out, the Korean word for jaw and chin are literally the same.

In fact, a lot of my jaw bone was amputated off. I wanted a slimmer look but I didn’t want that egg-shaped face that Koreans strive for. I think around 2cm or slightly less of vertical bone was amputated. 

Now I find that my face is severely disproportional at the side view and the 45 angle view. And I can pinch a lot of excess skin and fat around the bottom/back area of my jaw. 

I am looking for solutions to remedy my botched surgery of which it appears only custom implants can successfully achieve V-line reversal. 

(1) Would it be ‘dangerous’ to try to restore my original jawline contour with a 2cm vertical implant. Or would I have to compromise and go for a smaller increase such as around 1cm? Ideally I would like to get my original contour but if the risks of complete masseter sling disruption are higher with a larger increase, I would rather opt to compromise. Are the risks of complete disruption high when my masseter muscle is scarred and contracted? My understanding is that the muscle can contract and be shortened, but it cannot be lengthened. 

(2) What would be the risks of using a harder material such as PMMA or PEEK to rebuild my jawline contour? Even if it requires larger incisions, if a person’s jawbone can be taken out, hypothetically, it can also be put back in? 

(3) How long would I have to stay in the US for this procedure to safely rule out the possibility of an infection?  Is it possible to get a delayed infection aside from needle penetration from fillers or dental anaesthetic?

(4) Would it be possible to have the implant extend into the pre-jowl area to give that area width?

I apologize for the long list of questions. I am quite distressed about the situation and really do look forward to your take on my situation

.A: I have heard your jawline surgical story many times. It is not really a language barrier, it is more of a cultural issue. They are simply going to do what they want to do. There is no such thing as customizing or doing an individual treatment approach. Regardless of language issues, it is seemingly hard to confuse a chin procedure with one where the jaw angles are completely removed.

In answer to your V-line reversal surgery questions:

1) Making custom jaw implants to restore your jawline is the only effective treatment approach for it. How much you should attempt to restore it is a matter of personal preference. It is very likely that the massteric muscle sling may already been disrupted as there is no emphasis in its preservation in a bone shortening operation where the muscle needs to contract anyway. That being said it is true that the greater the vertical jaw angle lengthening is after jaw angle reduction that risk is increased. But there is no known actual number of lengthening where the risk substantially changes. I would say that 2 cms is probably too much.

2) When it comes to the material used for custom jaw angle implant restoration, the body doesn’t care what the material is. That will all work the same. And the stiffness of silicone (durometer) can be made to almost match that of Medpor or PEEK. What matters most is whether any of the material can be designed appropriately, placed without trauma and incisional length and can be manufactured at reasonable cost.

3) Infection does not occur until 3 to 6 weeks after implant placement. So no one is going to stay here until that time has passed. The goal is to get home as soon as you can, often between 2 to 4 days after surgery. One does have to be vigilant ab outany injections therapies around the implants. (didn’t inject down into the bone) Such needle tract-induced infections are very rare but they have been known to occur.

4) The implant design can be made to what surface and dimensions one wants including a forward extension out to the prejowl area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, several years ago I had double jaw surgery plus a sliding genioplasty. The jaw surgery itself created what I believe to be alignment issues with my bite, and possibly TMJ and  tinnitus.

My major concern right now is that my lower lip and chin tightness, especially when talking or smiling. With my lips it’s like they were turned inward, and are stretched against my teeth. My chin was moved forward and up, and it feels as if the skin is being pulled taught against the new position of the bone and plate.

My question is, will getting the 7mm bent plate on the chin removed be enough to resolve this or should I get a revision of the chin surgery done? I don’t really care about aesthetics at this point. I just don’t want this tight feeling all the time.

My surgeon is concerned about going in and risking nerve damage. He’s not sure this isn’t nerve damage, but from what I understand nerve damage is typically numbness, not a thinner lip and tightness of the chin. It’s like wearing a chin strap when you talk.

Thanks!

A:  As best as I can tell from your description you had a combined lower jaw osteotomy with a sliding genioplasty advancement. (the maxillary osteotomy is irrelevant for this discussion) While you did not provide the specific numbers of movement for the mandible and the chin was brought  ‘up and forward’ (millimeters of movement?) I will assume that between the two there has been some substantial anterior bony movement and the chin was so done because of the severe retrusion you had where it was sitting down and back so to speak.  Given the tissue tightness symptoms you are describing it is reasonable to assume that the soft tissue chin pad is very tight which will also affect the lower lip position.

Without seeing pictures and the x-rays I can only make a general comment that it is not unreasonable to think that undoing some of the bony movement of the chin may be helpful (down and back a bit) for their relief. But without knowing anything else I am certain that just removing the metal fixation plate is not going to relieve your symptoms. This is not due to the metal plate, it is a soft tissue stretch issue from how the bone underneath has been changed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is that I am a 60 year old male and have had this problem for many years and have now decided that I would like to do something about it. It is not due to weight. I would like to make an appointment but thought I would first ask you what the success percentage is. I realize that must be a vague question and you may not be able to answer it without seeing me in person. I just dont know enough about this. Not sure if the surgery is done if they would grow back or not and do not want to waste money and time if that would be the case. I look forward to hearing back from you. Thank you for your time!

A: Thank you for your ‘older’ gynecomastia reduction inquiry. With gynecomastia reductions in general breast tissue does not grow back, particularly in someone of your age. The more relevant question is what type of gynecomastia reduction do you need as older men often have an excess skin issue/sag and this requires a different gynecomastia technique. I would need to see pictures of your chest to provide a more qualified answer in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in jaw reduction reversal surgery. I’m looking to fix the aesthetics of my face after an over-done jaw reduction surgery. My jaw bone was sliced off up to 1cm below my ear, which gives me a long-chin, long-face and aged appearance that I find difficult to get accustomed to.

My surgeon wants to do custom jaw implants made of PEEK to reconstruct my jaw to the original state or to my liking. In your experience, is surgically going into this site again highly prone to complications?

My surgeon has experience with PEEK implants for craniofacial and maxillofacial use, but not in the context of reversing a badly done v-line surgery (it is a very uncommon surgery here.) I’m worried that having done this surgery will make me more prone to complications.

My biggest worry is the disruption of the sling muscle or tearing of the masseter muscle. Would this complication risk be extremely high? I feel like this nightmare is neverending and I’m extremely weary of having to go through surgery a 3rd time to fix such a problem if it were to occur. 

Also, what is your opinion on the longevity of PEEK implants? I am having difficulty finding any case studies on the material’s longevity or delayed infection risk, which worries me as well.

A: In answer to your jaw reduction reversal surgery questions:

1) A custom implant approach is the only method to reconstruct the previously removed jaw angle/jawline bone. One can have a debate about the implant material and I would submit the body doesn’t care what is used as it will treat it all the same with the same risks. (infection, wound dehisce, asymmetry, over/underdone….all of the standard risks from this type of surgery)

2) The material properties you need to think about is not their biology (which is what most patients and surgeons focus on…which is actually not that important for the reason I have just mentioned) but the mechanics of the implant’s placement and the potential capability of secondary revision should that be needed. (and that risk is much higher in a scarred and anatomically altered area) In other words, how easy is the implant to get in initially and OUT if a revision is needed. A PEEK implant is very rigid which makes it harder to place (bigger incision), requires greater tissue dissection (larger pocket) and is less adaptable. If a surgeon has never used this material in a tight and confined space like the jaw angles and their PEEK experience comes from doing skull implant surgery (a big wide open space) they will likely be in for a surprise during surgery. 

3) When you have a jaw angle/jawline reduction surgery by definition you already have a massteric muscle tear….you just can’t see it because the vertical height of the jaw angle is so reduced and the muscle has shortened around it. There is a very good chance that may become apparent when the vertical height of the ramus is restored. I am not saying that it will absolutely occur but the prior surgery may have already created it. That is unknown that can not be predicted before surgery but the patient needs two be aware of that issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I first heard your name from your TV interview concerning Pixee Fox. I came across you again while googling for information concerning shoulder width reduction by clavicle shortening, and was excited to read your post. I’m very interested in eventually getting this procedure, if it is possible. You mention that it would take an extremely motivated patient to have this surgery – I would like to be that patient, eventually. 

I’ve read a few studies concerning the effects of clavicle shortening on shoulder movement, and my impression (as an layman reader) is that there are very few or no significant changes to shoulder function. Additionally, there are a few pictures online that seem to show some perfectly normal-looking shoulders with shortened clavicles. 

Have you since performed the procedure? Have you learned any further information about it? Is my impression regarding the functional outcome and the effects accurate? Any information is welcome.

Thank you!

A: My limited experience with shoulder width reduction by mid-clavicular ostectomies conforms the following:

1) A motivated patient is one that can accept the incisions over the clavicles to do the procedure and the recovery of having operated on both clavicles at the same time.

2) You are correct in that there are no changes to shoulder function since it is done well medial to the AC joint.

3) With a 2 cm resection of the mid-clavicular bone the shoulder will have a reduction of about 1 inch per side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, A comparatively recent (4 weeks ago) facelift revealed a prominent Adam’s apple and even more prominent larynx. I am a fairly slim woman, and those two bumps stick out visibly and are quite unsightly. Could you please advise on whether anything could be improved?

A: Thank you for sending your after facelift pictures. While tightening the neck and redefining its angles is usually a positive aesthetic outcome, the more rigid structures in the center of the neck can be more evident.  I think what has been revealed from your neck tightening is the hyoid bone (upper) and the Adam’s apple. (lower) An Adam’s apple reduction (tracheal shave)( can be done in the usual fashion with a successful improvement. The hyoid bone is slightly different in that it is a suspensory bone with numerous ligaments and muscles attached rather than a fixed structure like the Adam’s apple. But its prominence can still be reduced somewhat by resecting its central portion.

Anatomically the Adam’s apple is the larynx so they are not separate structures. I would advise waiting at least 3 to 4 months after the facelift to give the tissues time to relax and see of these two central neck prominences remain the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a combination problem consisting of a venous malformation over my right ribcage and a prominent frontal bulk, which I assume is rib cartilage, in the front. My questions are; 

1) Where would the scar be for the venous malformation and rib removal? Would it be in the same place (around 10th rib) as the normal method, only slightly longer? And then another incision on the front chest to reduce that bulk? Or would the incision continue in one long line from back to front? I do have partial rib removal already from a failed otoplasty when I was younger and rib graft from my front rib so already have a scar there and a dent. I hope to cut out the remaining area of this out so it isn’t a sharp dent anymore and also on the other side. I can’t wear corsets right now to try and waist train for any longer than a few hours due to the pain of this sharp dent from where the previous rib reconstruction was taken. I included a pic of the rib graft incision. Would it be ok the same place on the front? 

So basically removing the back ribs as much as possible with the venous malformation and muscle and also reducing frontal ones. Would this give me a dramatic change to my waist size? You can see on the pics below how large and disproportional my ribcage looks compared to the rest of my body. I’ve always had this broadness. 

A: To answer your more specific rib removal questions and to clear up some misconceptions:

1) What you refer to as ‘frontal muscle bulk’ is actually the subcostal margin of the union of the cartilaginous ribs # 6,7,8 and 9. This is all cartilage and not muscle.

2) You have had a prior left rib graft harvest in which portion of cartilaginous rib #6 was removed….which was for your otoplasty procedure. This has left you with a blunt cartilage end of #7 and the union of the ends of #8 and #9 exposed lower.

 3) With your very thin body frame with little soft tissue cover over the ribs I would be concerned that any rib removal would show the remaining ends from their removals.

4) Removing the anterior subcostal rib margins creates what is known as ‘vertical waistline  elongation’ as it creates more distance between the bottom of the ribs and the waistline in the front view.

5) #4 should not be confused with horizontal waistline reduction which refers to ribs #10, 11 and 12 and is done  from the back with the goal of bringing in the sides of the waistline at the level of the belly button.

6) The incision for the anterior rib removals would have to be different for each side, using the existing one on the left side but a longer and more posterior one on the right side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had fat injection at lower eyelid three months ago. Now there is lump under one of my eyes. When I touch it I feel something under my skin which is almost lying on my lower eye orbit but I can almost move it a bit up and down with my finger under my skin and it is also almost firm  (not feeling soft like an ordinary fat texture)  I am wondering what is that.

Is that living fat or a  fat necrosis. It is not stuck to my skin, its feeling apart from the skin and my skin is normal. If I use corticosteroid ointment or nitroglycerin ointment on my lower eyelid is it helpful? If i wait more will it dissapear? Can i ask someone to aspirate this for me with needle or its dangerous?

Is mesotherapy or radiofrequency helpful?Is there any way to get rid of it at this early stage?(three months postop)

Please answer me if you are able to help, its really  urgent for me.

I really hope for your help because my own doctor didn’t help me. He said its not important.and didn’t care. But for me it really matters  🙁

A: It is fair to say if you had undereye fat injections three months ago the lump you are feeling is an injected fat lump…which is not uncommon around the lower eye. No topical cream will cause it to go away. Such fat lumps are very unresponsive to injection therapy.  The only assured method of removal is surgical excision through a transpalpebral lower eyelid incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of secondary jaw angle implant surgery. I have had medlar jaw angle implants done twice and both times they had to be removed due to infection. In addition on one side I developed masseter muscle dehiscence. If I go for third jaw angle implants try what can I do to reduce the risk of infection? Can I get the masseter muscle dehiscence fixed at the same time as placement of new jaw angle implants?

A:  My overall assessment of your situation, by just reading it, remains me of the old motto…’past history predicts future behavior’. Jaw angle implants have the highest incidence of infection of any facial implant (about 4% to 5%  in my experience compared to other facial sites of about 1% to 2%) and the Medpor material due to its surface roughness has a higher risk of infection than silicone. I do not know why your implants got infected (placement inoculation vs postop wound dehiscence and implant seeding) but if you have to give a third try silicone jaw angle implants would clearly be the better material choice to lower the infection risk.

In regards to master muscle dehiscence, once that has occurred it is a very difficult problem to try and improve. Muscle repositioning is incredibly difficult and unpredicatable and most certainly would not be performed concomitantly with new implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking eye asymmetry surgery. I added pictures and you can clearly see on it my eyes are not right. Also I know my jaw is not right but will have consultation in August about that. I am not worry about my jaw beacuse I know is possible to fix it but I am worry about my eyes. It is hard to accept. I am always trying avoid any pictures or selfie with my friends, wife etc. Is any help for mm ? Is any chance to fix it ? If yes how much will it cost? Thank you for reply and your help. 

Kind regards

A: Thank you for your inquiry and sending your pictures. As you know you have vertical orbital dystopia as part of your overall left facial asymmetry. In appears to be in the range of less than 5mms by your own horizontal line measurement in your pictures. That puts it in the range of being very improvable whose management is based on how it looks in a 3D CT scan. When it comes to eye asymmetry surgery, usually a custom infraorbital floor-rim implant is made to provide optimal skeletal symmetry to the other side. Whether the lower upper eyelid and brow should also be managed is a considerations as you don’t want to lift the eyeball only to have the iris and pupil further buried up under the upper eyelid margin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in zygomatic arch reduction. I am asking this because I have a wide face due to my zygomatic arch flaring out heavily toward the back, giving a somewhat rounded appearance.

Specifically I would like to know a few things:

1) Is a moderate width reduction possible without cutting the anterior portion (which seems too invasive for me)? How much is possible with just a posterior osteotomy? 

2) Is the recovery difficult? I.e. heavy bruising, difficulty chewing, swelling? Would an out of town patient be able to travel home shortly after surgery? How long after the surgery can a person return to work?

3) Are the results subtle or is it possible to tell that the bone was cut, like depressions, protrustions of bone, etc? 

4) Can the skin be affected afterward, as in drooping? 

5) What is average cost for such a procedure? Ballpark range?

Thank your for your time Dr Eppley. I have been considering this for a while.

A: In answer to your posterior zygomatic arch osteotomy questions:

1) It is fair to say that a moderate width reduction is possible just by cutting and moving in the posterior arch. Although the definition of ‘moderate’ is open to interpretation. In some cases optimal reduction is aided by a mid-arch osteotomy as well.

2) Recovery is not difficult at all. You would be able to go home the following day and return to work within a week out less.

3) The results would be subtle and smooth. There are no obvious depressions or irregularities because the overlying soft tissues are very thick.

4) No skin drop will occur for the same reason as in #3.

5) 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 am interested in mouth widening surgery. My questions are:

•Once the procedure is done, how long after it do the stitches come off? I can manage a 2 week trip at most to the US.

•Should any infection or complications arise when i head back home what could be my options?

•What would the expected cost of the procedure be?

•I know there will be scarring. Could the scarring be reduced or removed with laser treatment?

•Will this impact the ability to use my lips normally? Such as drooling or leaking of any liquid items such as water from the sides where the lip is widened? 

•Will you also be making incisions to bring my lips forward as well to make them look fuller or is this a separate procedure? 

A: In answer to your mouth widening surgery questions:

1) For all of my international patients dissolvable sutures are used so they may return home shortly after the procedure. When permanent sututes are used that have to be removed that is done on day 7 after the surgery.

2) This is not a procedure where infection is likely to occur so that is not a complication of concern. The only issue with this procedure is how well do the scars do and that is a an issue not be judged for months later.

3) My assistant Camille will pass along the cost of the procedure to you later this week.

4) If scars turn out to be an adverse issue that is best treated by scar revision not laser treatments.

5) Mouth widening does not cause any functional effects as you have described.

6) Mouth widening moves the corners of the lips outward but does not make the lips fuller….unless something is done separately to do so. (e,g., fat grafting)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  How much would a custom jawline implant cost?

How quickly can it be arranged?

What will my face look like after the surgery?

What complications may arise?

What happens if the result is unlike that which I desire?

A: In answer to your custom jawline implant questions:

1) My assistant Camille will pass along the cost of the surgery to you by tomorrow.

2) It takes four weeks once a 3D CT scan is obtained to do the design and implant manufacture process.

3) Preoperative computer imaging is used to try and determine your facial reshaping goals which helps guide the design of the implant.

4) The most serious complication is an infection, the most common complications are aesthetic in nature. (asymmetry and how close to achieve the patient’s goal did the surgical result achieve)

5) Every surgeon has a revisional surgery policy and forms of which it is mandatory that they have read it and agree to them. No surgery can give guaranteed results eve with custom facial implants

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface augmentation efforts. First of all, thank you for your fast reply. So my first problem is the malar and midface area after my double jaw surgery, which I underwent about a year ago. The skin and soft tissues in this area used to be “tight”, in other words: They sticked to my skull. But after the surgery the skin around my nose became loose, droopy and puffy and it has not improved to this day.

I’ve already asked some doctors on Real Self if there is any proper procedure to tighten the skin. Some of them mentioned fillers and some others talked about facelifts and laser lypolisis. To be honest I’m really desperate because I’m looking for the male model look. I heard about your custom made implants and that’s the main reason I’ve decided to get in contact with you.

My cheekbones are not pronounced they are flat, but I want them to be wider, more prominent, chiseled and high set. Espacially the zygomatic arch is very importnant to me.

Nevertheless as I’ve already mentioned I think the first problem we need to solve to get the best results, is to treat my midface area first. I guess when the skin is too droopy and heavy we won’t get the desired results.

I’ll send you some pictures before and after my double jaw surgery and also some pictures of a few examples so that you can get an idea of what I want.

Please feel free to judge and give me your honest opinion about my situation and also tell me if it is achievable in my case or not.

Thank you very much Dr. Eppley for any type of help

A: Thank you for sending your picture and detailing your surgical history. When the entire midfacial tissues are degloved to perform a maxillary osteotomy there will be some permanent soft tissue changes induced by the surgical swelling and the disruption of the ostecutaneous attachments. There is no form of soft tissue tightening or surgical lift that is going to solve that aesthetic concern. 

You are correct that midface augmentation is the only effective method to fill out the loose midface tissues. You are also correct in that custom designed implants are the only implant design to try and accomplish the type of facial reshaping change you seek. However you may not be correct in that the final facial result will look like the male model picture you have shown as that is not a realistic outcome with any form of facial augmentation. You have to have a ultrathin face with little facial fat to achieve that type of result…which is not your natural facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have sone questions about zygomatic arch implants. 1.I am wondering if this patients results are a normal outcome of this procedure? 2. Where is this type of implant usually inserted? 3. Did he augment his malar area as well 4. Is buccal fat removal a good procedure to combine with the zygomatic arch implant with to get better results Thank you

https://www.realself.com/review/indianapolis-custom-infraorbital-rim-malar-zygomatic-arch-implant-dr-eppley

A: In answer to your zygomatic arch implants questions:

1) Since I can not see the case to which you refer I can not answer your questions specifically about whether such outcomes are normal or not. But if your question is whether one can achieve a more well defined and sculpted midfacoal appearance as a result depends on the natural shape of one’s face. Thinner faces always get more defined results than fuller ones.

2) The case study has the title of ‘custom infraorbital-malar-zygomatic arch implant’ indicating that it did cover the malar area as well. Such custom implants are usually placed through lower eyelid incisions. Isolated zygomatic arch implants are placed through an incision inside the mouth.

3) Buccal lipectomies are commonly done along with many types of midface implants to create a bit of more defined facial result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal artery ligations. I’ve found you while searching for a problem I have which is swollen superficial temporal arteries. I believe weight lifting caused this.

So it is possible to remove these arteries or at least the offending parts? If so, can weight lifting be resumed?

If I don’t have a procedure done, will further weight lifting make the already swollen arteries even worse or branch out?

A: While prominent temporal arteries typically develops almost exclusively in males, weight lifting or any type of physical activity would not be the cause of it. Such activity certainly aggravates it but is not the cause of it.

The treatment of prominent temporal arteries is done by an approach known as multi-level temporal artery ligations from the bottom of the superficial temporal artery by the ear up to the top of the forehead. With this approach I have not seen recurrences. It s possible that some ‘new vessels may appear afterwards if undetected feeder vessels are not seen and treated during the initial procedure. Weight lifting can be resumed after the procedure.

No one can say whether the prominence of your temporal arteries will become worse if they are not treated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m a 32 year–old female interested in secondary chin reshaping. A year ago I underwent a sliding genioplasty which I deeply regret as it has affected my work and self-esteem. My chin prior to surgery was very pretty, just horizontally deficient. 

My chin was advanced 5mm and vertically shortened 5mm. However, it appears that it was also widened somewhat, against my wishes (there was no computer imaging done, just tracing). I have a natural V-line jaw and the new segment of chin does not blend into the narrower jawline. To make matters worse, the cut was asymmetrical so that one side veers out more than the other and at a greater distance. 

I have since used HA fillers to improve the chin and these have helped immensely. However, I have a very delicate bone structure and so rather than building up the volume to disguise the problem, I would prefer to have the width of the chin narrowed ever so slightly (at most 4-5mms). I came across this article of yours: http://exploreplasticsurgery.com/case-study-submental-chin-reduction/ and would like to have this procedure done. Would you be able to assist? 

A: From a structural standpoint when you bring the chin forward and up by definition it is going to make the chin wider due to the position of the posterior ends of the osteotomy. This was most likely not a deliberate effort on the part of the surgeon but one that was inevitable by the way the bone was moved. Narrowing of the wider chin can be done from an intraoral or submental approach although it is more effective when done from below for maximal narrowing along the chin/jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My current pre-consultation questions are as follows:

1. Will a combination of custom chin and mandibular angle implant be able to expand the width of my entire jawline from chin to mandible? I am concerned about the possibility of seams and bumps between the separate implants. Would a single-piece wraparound implant be a better choice? How much more expensive would that single-piece implant be?

2. How accurately can we predict the final result? What tools does your office use to predict the result?

3. I am also concerned that my cheekbones are very flat and will look out-of-place with a larger jawline. If cheek implants are out of the budget or not feasible at this point for some reason, would fillers be able to accomplish the same result as cheek implants to complement the finished jawline?

4. What would a ballpark estimate be for this procedure’s cost?

Obviously these questions are all subject to change depending on what is seen and recommended during a consultation. But from my current knowledge, I’d like to hear your opinions and answers at the current moment.

I have an album of pictures from various angles available if you would like to see them for yourself. Please let me know.

A: Thank you for your custom chin and mandibular angle implant inquiry. In answer to your questions:

1) A custom one-piece jawline implant is always the superior jawline augmentation method as it creates the most complete volumetric augmentation, is a single seamless linear implant from front to back, and has the less risk of asymmetry and malposition as opposed to three separate chin and jaw angle implants.

2) No surgeon or design software today can accurately predict the external facial effect of what any implant shape and size will create. Surgical experience helps guide the process but it is not an exact science.

3) Fillers are a frequently used option for cheek augmentation either as a trial or an ongoing treatment. They do not create the same exact aesthetic effect as implants but they can be helpful nonetheless.

4) My assistant will pass along the cost of the surgery to you by tomorrow.

You may feel free to send me any pictures for my assessment and computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For several years I have been interested in pursuing jumping genioplasty to correct my elongated chin. I have seen a couple of oral surgeons and to my surprise have became aware this is not a common procedure- I finally found one willing but he lacked confidence and told me the end result would be “subtle.” so… I am not interested in spending thousands of dollars and going through pain for only weak results. I want to have an altered appearance.. that is the point. is this not possible. please advise. 

A: While a sliding genioplasty bone surgery for chin advancement is common, its variant of a jumping geniplasty is not. While the jumping geioiplasty provides maximum horizontal chin increase it also has several other aesthetic sequelae….which may or may not be favorable for a patient. First, it will cause a significant vertical shortening of the chin which may be favorable in your case by your description. Second it is prone to making the chin appear wider because the thickness of the sides of the chin has been doubled. Lastly it is prone to bony stepoffs between the jumped bone segment and the natural underlying jawline. 

It may be that a jumping genioplasty is the right procedure for you but I would at the least need to see pictures to make that determination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an old scar on my shoulder that is about 3”x1.5” and I’ve been wanting to get rid of it for some time now. I saw your post about using Acell products after searching for info about Recell. I was interested in Recell after doing some research but if Acell can provide similar results then that would be something I would be very interested in. I guess what I am wondering is, if you do use Acell products are you essentially performing a skin graft and using the Acell product in the place of grafted skin? 

A: Thank you for your inquiry. To provide clarification about scar revision in general:

1) Scar revisions are performed by cutting out the scar and reclosing the wound. Skin grafts are never used for scar revisions.

2) The goal of scar revision is to improve the appearance of the scar….but there will always be a scar but hopefully one that is more normal. But its length will always remain. There is no such outcome as ‘getting rid of the scar’ or complete scar removal.

3) The use of accelerated wound healing agents in scar revision or wound healing in general, while highly marketed by their manufacturers, remains theoretical in its benefits. They are not magic powders that can just make wounds or scars disappear.

4) Scar revisions across moveable joints, like the shoulders, are challenging to improve no matter what is done because of the motion across the scar revision site.

Dr. Barry Eppley

Indiaapoliss, Indiana

Q: Dr. Eppley, I have a question about elbow lifts and what can be done after the surgery in terms of physical activity. I was wondering how long before a patient would be able to bend her arm fully after having had elbow lifts? Thank you

A: What you are referring is when can the patient after an elbow lift bend their arm beyond 90 to 110 degrees without risk of creating a wound separation of the incision line which is placed perpendicular to the extension-flexion movement of the arm. That answer is around 3 weeks after the surgery. Fortunately most activities of normal daily living do not require such full arm flexion movements.

Being well aware of the need to protect the incisions after surgery, elbow lifts are performed with the arm bent at 90 degrees. This ensures that over resection of skin is not done preventing undesirable scarring and the risk of wound separation if one should accidentally bend their arm over 90 degrees in the first few weeks after surgery.

Careful preoperative marking with the arm both straight and bent at 90 degrees is paramount in deciding on how big the crescent of tissue excision should be.  But following the principle of ‘less is more’ is a good approach with elbow lifts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can the subnasal lip lift be done as an upper lip lift with a no scar suspension as an in-office procedure? The upper lip is shortened via an intranasal incision and suspension suture that elevates the upper lip and anchors it to the anterior nasal spine. I would like this technique if possible. 

A: That technique you have described for a subnasal lip lift is not a good one for two reasons. First, putting the incisions inside the nose eliminates the natural nasal sill, making it look abnormal. Once the nasal sill is lost it can not be reconstructed. Secondly anchoring it to the nasal spine or any deeper tissues will affect your smile, making it stiff and abnormal. Such suturing interferes with the normal sphincteric movement of the orbicularis muscle as well as may interfere with the excursion of the upper lip in smiling.

A subnasal lip lift is a delicate technique that requires prevision in its execution to avoid asymmetry, poor scarring and smile alterations. It is important to not over resect skin as it can not be put back. My general rule is to not remove skin in the range of 25% to 33% of the natural philtral length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently researching for a possible revision rhinoplasty. To provide some background, I had a prior rhinoplasty procedure that included an alar base reduction to narrow the nostrils. Unfortunately there is asymmetry, and I believe it is a bit too narrow. I am aware that these types of procedures are difficult to revise, but I wanted to know if there are any possible solutions. 

For one, I have have researched PDO threads used in temporary nonsurgical face-lifting. Is it possible to use PDO threads to slightly widen the alars by pulling the skin outwards? Similarly, is it possible to do a surgical procedure using permanent sutures to widen the nostril base? If it is feasible, I would definitely be interested in consulting on possible solutions.

Thank you 

A: Nostril narrowing achieves its effect by removing tissue to do so. As a result to reverse their effects is not going to happen by any form of tissue suspension to suturing. Such excisions-based procedures can only be changes by adding tissue back in. And while this can be done, the placement of such a graft will create a mismatch in skin color which is why it is rarely ever done.

That being said an intraoral vestibular subperiosteal release (like is used in the surgical access for a LeFort osteotomy) is well known to widen the nostrils and is one of that procedures acknowledged adverse aesthetic effects. Numerous closer techniques have been advocated in that type of midfacial surgery to prevent nostril widening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m seriously considering reversing my sliding genioplasty. 

Here are two questions:

1) I read your post about genioplasty reversal on Real-Self. You said: “resuspend/tighten the mentalis muscles at the same time so you do not get a soft tissue ptosis (witch’s chin) as a result of the loss of bony projection/support”

In my case, do you think we would need to resuspend the mentalis muscles? (I’m almost one year from the original genioplasty and the movement was 4mm forward and 2 downward) Is it a technique used in every genioplasty case or only in reversal ones?

2) Is that possible for the muscle and tissue to go back to where they were before the surgery?(not 100%, but mostly) I’m worried about skin sagging and facial deformity. (I’m 32 and my skin is good).

Thank you so much!

A: In answer to you sliding genioplasty reversal questions:

1) By definition every closure of a sliding genioplasty, regardless of the direction of movement, entails resuspending the mentalis muscle since you have to release it during incisional access to do the procedure. How tightly you may reattach the muscle is what varies on an individual patient basis.

2) It is safe to assume in the reversal of any enlargement procedure of the body, albeit a sliding genioplasty, breast implant removal or pregnancy, that the tissues will never return to what they were before the enlargement procedure. All surgery causes some irreversible changes. So the question is not whether one will return 100% to normal, as you won’t, but how close to normal would it be. Given that your original sliding genioplasty was relatively modest, your chances are better than a sliding genioplasty in which much bigger movements were done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking through your patient pictures and found a 43-year old male who had surgery to correct his vertical dystopia. He opted for cheek augmentation with an implant, but even in the after-picture I can see his vertical dystopia is still there, although very much improved. The inner corner of the affected eye (medial canthus) is slightly lower than the opposite side. This is also the case with me. I have slight vertical dystopia (left eye higher than right with the medial canthus being lower on right eye as well) but is there any disadvantages/advantages by going for orbital box osteotomy rather than cheek augmentation? I know it’s a highly delicate surgery with certain risks but I imagine the result being better. Do you have any experience in this type of surgery? 

A: The key in treating a vertical orbital dystopia (VOD), in which there is no perfect result obtainable, is to get appearance improvement WITHOUT causing any other aesthetic issues. This is why in smaller or more aesthetic VOD patients (6mms or less of horizontal pupillary discrepancy, building up the bone deficiencies and adjusting the soft tissues around it is the aesheticaily safer approach. 

Orbital box osteotomies are reserved for more severe cases of VOD where the aesthetic tradeoffs to do so (risks of adverse scalp scar, bony irregularities, palpable hardware, lower eyelid retraction, numbness and even frontal nerve weakness) may be worth it for the degree of bony change.

But the most assured way to trade off into numerous new aesthetic problems is to apply a big operation( orbital box osteotomy) for a much smaller problem. (vertical orbital dystopia < 6mms)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle augmentation done with hydroxyapatite granules at the end of last year. While the outcome produced some improvement, I have a very short lower jaw and I am looking for anbetter solution to vertically lengthening my jaw angles.

The question is in the case if I would like to have an operation with you shall I remove the hydroxyapatite granules which might be difficult or you can put implants on top of the hydroxyapatitite? I should mention that the maximum projection on the jaw angle is just 2.0mm.

A: You would need to augment your jaw angles with implants on top of the hydroxyapatite granules as they are very difficult to remove and have bone growth throughout them at this point. Given what is probably some asymmetry induced by the granules this raises the question of whether standard vs custom jaw angle implants would be needed. One approach is t burr down any irregular jaw angle surfaces and place standard vertically lengthening jaw angle implants, The other option is to have custom jaw angle implants made to account for any asymmetry and irregular bine surfaces caused by the hydroxyapatite granules. 

Dr. Barry Eppley

Indianapolis, Indiana