Your Questions
Your Questions
Q: Dr. Eppley, I appreciate that Dr Eppley responded to my RealSelf post and understand that a submentoplasty would be the best option. From some of the research that I’ve done, I worry that because of the location of my hyoid bone, the operation would not be that beneficial to me. I had a genioplasty a couple of years ago and the surgeon told me they removed a small amount of fat under my chin area, as best they could but that there wasn’t much to begin with – therefore, there may only be some loose skin.
I have attached a number of images as requested. Do let me know if you need anything more. The morphed image shows me pulling back the skin to show the potential amount of possible change.
A: As stated in my answer on Real Self the only way to potentially achieve that change, realistic or not, is by directing changing the cervicomental angle as previously described. This is not going to be achieved by removal of excess fat or skin, neither of which you have. Most patients with low hyoid bones have much more obtuse cervicomental angles and less lower jaw projection.
I trust that you realize what you are asking is to take the perfectly normal and make it ‘supernormal’ anatomically. This is not always easy or necessarily attainable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some ways to possibly enhance my cheekbones/zygomatic arch due to them been really flat. I am interested in which options I’d have, custom implants or some kind of fillers?
Also if you can recommend any other procedures for any other parts of the face I’d be open to hear, thank you!
A: Thank you for your inquiry and sending your picture. The only effective and permanent method to enhance the cheek area in young men who seek a high cheekbone look is with custom infraorbital-malar implants. Injectable fillers may offer a bit of a ‘test’ but they can not replicate the definition that an implant design will create.
In terms of their effects and as well as a good assessment of the rest of the face done by computer imaging I would need two additional pictures…a side profile and a three-quarter view.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello sir,I wanted to know whether you can change shape of my forehead?? I want a wider forehand!…Basically I want an oval face ! I have an oblong one now!!….My facial bones are wider than my forehead and it looks quite uneven… I want evenness to my face?? Is that possible? If yes let me know sir.
What are the complications ??
How much am I gonna suffer while treatment??
Any precautions ??
Is it permanent or temporary ??
A: In answer to your forehead widening questions:
1) Forehead widening can be done by a custom implant design that extends the sides down into the temporal area.
2) I would need to see a front view non-smiling picture so I can do some computer imaging to show you its effects.
3) Such a computer designed implant is placed through a small scalp incision. Recovery is largely about swelling that will develop around the eyes but it is not painful. It takes about 10 to 14 days for most of the swelling to subside.
4) The implant results are permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope you both and everyone else in the clinic are okay. When the coast is clear from coronavirus, I plan to come in soon for a procedure. I have a few more questions because I’m still undecided about the cheek implants but am leaning in that direction.
1) How long are the lateral cheek implants are and exactly where they are they placed?
2 ) For instance, do they begin and go up from the angle of the jaw to the bottom end of the temporal implants? ) Do they go up straight creating a square widening to The bottom of the temporal implant, or are they angled out to make more of a “round V shape”, so to speak.
3) If the temporal implant is continuous with the cheek implant is it difficult to make a smooth transition? I want to be able to get a general picture of where they would widening The face.
4) I know that you have done many of these over time. How frequently have you needed to take them out and re-do the procedure , Because there is not enough or too much?
5) Do pictures when I’m younger help? ( You told me that it is not easy to judge what the actual outcome would be during surgery.)
6) Can I return the second day after and begin work?
Thank you kindly!
A: In answer to your zygomatic arch cheek implant questions:
1) and 2) By your own description you call them lateral cheek implants which are anatomically better known as zygomatic arch implants….thus they are placed on the zygomatic arches.
3) The temporal and zygomatic arch implants can not be continuous as their tissue pockets do not merge. That confluence is prevented by where the frontal branch of the facia nerve crosses.
4) Like all facial implants anywhere the never ending question os how much is enough or too little…even patients don’t really know that answer until they ‘wear them’. For this reason as well as asymmetries the global revision rate for these aesthetic concerns on facial implants hovers around the 20% range.
5) Younger preoperative pictures don’t hurt. But the canvas we have to work with now is your current face.
6) Like all facial surgery there will be considerable swelling when all three facial areas are combined. So it is not a question of whether you can physically work but whether you have the facial presentation to be comfortable doing so.
Dr. Barr Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I just saw your post on revising a scalp scar using running w plasty. I have a scar from a hair transplant that runs across the back of my head. It’s mostly thin and straight. The left side of the scar particularly bothers me because I feel it is more indented. Anyway, I was wondering if w plasty is something that would benefit me? I’ve read that a straight line scar attracts attention, while a zig zag w plasty scar is less obvious. I’ve attached images of my scar, please let me know what you think, thank you.
A: Thank you for your inquiry and sending your pictures. While geometric scar revisions of the scalp can be beneficial, and I think you would benefit by some form of scar revision, in a very long scalp scar like yours I would be cautious. While a few selected areas may benefit by a non-linear excision pattern, I would do the bulk of the scar with linear excision. (the long part that goes across the back) You want to be certain that whatever you do you don’t make the scar worse or more obvious looking. The linear excision is aesthetically safer because, even in the worse scenario, it could only end up looking the same or just slightly better.
There is a good rule to remember about scar revisions….they are a gamble. There s no assurance that they will always end up looking better. While they usually do it is not a guaranteed outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, May I ask about the ear when plagiocephaly is present. Is it possible to move the ear even a little bit? If the bone behind the ear will be reduced?
A: The answer is no asthe ear is fixed by the external auditory canal so no anteroposterior movement is possible. The protrusion of the cartilage can be setback if it exists but you can’t physically move where the ear is positioned on the side of the head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask you about my smile. I show very little or not enough upper teeth when I smile or talk. You recommended a smile lip reduction. My question is, is it lifetime after surgery? How long is the downtime? Whats the exact procedure called? Thank you and God bless.
A: Thank you for your inquiry. As the name implies (smile line reduction/elevation), it is an excisional procedure which removes a strip of dry vermilion. (very similar to a lip reduction procedure) Thus it raises the lower edge of the upper lip as seen along the teeth behind it. Because it is an excisional procedure it is permanent. Other than some lip swelling it has a minimal recovery time as it relates to work or any physical activity. The sutures used are resorbable and no specific after care is needed other than some care when drinking or eating.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I been looking into your chin reduction procedure and I am a big fan of your work. Here are some pictures of my chin from the front and side view. My chin bone specifically doesn’t need a reduction. I would say I would need a submental soft tissue chin reduction procedure since I have a small chin bone and more soft tissue comes out as I smile. I am looking to get rid of a lot or at least a majority of the soft tissue. Please get back to me when possible if you are capable of working with any of the information I’ve stated. I appreciate your work very much.
A: Thank you for your inquiry and sending all of your pictures. As best as I can tell from your pictures and description of concerns you have a soft tissue chin pad excess when smiling. (dynamic chin ptosis) I would agree at rest that your chin appearance is normal. You are correct in that the only treatment would be a soft tissue chin pad reduction from a submental approach. How successful that procedure would be depends on how pliable or mobile your chin pad is at rest. A tight chin pad is not going to allow much soft tissue removal and/or will result in a wide submental scar. A mobile chin pad (the real sign of chin pad excess even at rest) will permit soft tissue to be excised with a vert acceptable scar outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, good day I wanted to ask if the lower third can be lengthened in a narrow face with a small lower third total height (6.5cm) and if yes by how much. Also can the mandibular region also be supported by an implant for a better result?
And are you familiar with procedures that aim to create a better lower third without making it masculine by making it aggressively looking but just making it look less underdeveloped? (in my opinion a more developed lower third can also be more masculine even if it’s not a very broad chin compared to a overly undeveloped chin, but i think it’s important to get that across well to avoid miscommunication)
thanks and hoping you stay safe
A: If I interpret what you are describing correctly, you are referring to primarily vertical lengthening of the lower jaw. This is not an uncommon design for a custom wraparound jawline implant. The usual amount of vertical lengthening that the tissues will permit is most limited in the chin area in which up to 10mms of vertical lengthening can be achieved. More can be achieved behind the chin but the tight tissues of the soft tissue chin pad will allow stretch so far to be able to get the incision closed over the implant. Attached is a representative example of such an implant design. To provide implant stability on the inferior border of the lower jaw some implant material must come up along the side of the jaw but this adds minimal width.
For patients who require more than 10mms of vertical lengthening in the chin, that is done by an opening wedge sliding genioplasty where 10 to 15mms of vertical opening can be done combined with implant augmentation for the vertical lengthening of the jawline behind it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Following jaw surgery five years ago which corrected an anterior open bite and opened my airway to resolve sleep apnea, I am left with some aesthetic issues, including a deep labiomental crease, slight lip asymmetry, and lip incompetence (see photo).
Is it possible to get an idea of the all-in cost for surgery to reduce my labiomental fold? Would this be an in-office procedure? I realize a more in-depth consultation may be necessary but any general information you can provide would be helpful at this stage. Thank you.
A: The best procedure I have found to correct a really deep inverted-V type labiomental fold is a dermal-fat graft placed through an intraoral approach where the graft is placed directly under the released skin crease but above the muscle. This will also help the lower lip incompetence. This is not an office procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my appointment with my ENT today (virtual consult). He said it seems like a nasal valve collapse. I have to go in physically once the covid-19 lockdown ends. He said there’s an option to have an implant called Lateral or I would need another rhinoplasty to fix it. Is this something that you could fix? He said I’d have to pay out of pocket regardless as insurance doesn’t typically cover it so I wanted to consider my options.
A: When it comes to nasal valve collapse, the first question regardless of the treatment is whether adding internal nasal valve support will help. This can be confirmed if one as a positive response to either Breathe Right strips or the physical Cottle manuever. (pulling out on the cheeks will pulls the nostrils out wider). With nasal valve collapse there are two treatment approaches, cartilage grafting and the Latera resorbable implant. Cartilage grating is the gold standard treatment and involves the placement of cartilage grafts between the septum and the upper lateral cartilage which if done in isolation (which is all you need) can be done through a closed rhinoplasty. The Latera absorbable nasal implant strives to open the internal nasal valve and is placed inside the lateral (side) wall of the nose to lift the nasal cartilages outward. (like an internal Cottle manuever) It is very effective but is made of an absorbable material that will go away over a period of year or so when its effects will be lost as the material is absorbed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi! I just had a quick question. I have a slight maxilla prognathism. As a teen, I had braces that basically moved my upper teeth back in the maxilla, but the excess “bony-ness” remained between the base of nose and top of teeth. Basically, it creates a “monkey mouth” effect. Anyways, my teeth are actually in good position because of the braces, but I was curious if it is possible to shave the gum bone down to give a flatter look between the base of the nose and top of the teeth. Thanks!
A: That is a good question but the answer is no. Right underneath that bone (1 millimeter or two) lies the tooth roots which is what it is called the alveolar bone. Only the bone that lies above the tooth roots can be safely reduced but not the alveolar process. (maxillary alveolar reduction is not possible)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, All right, doctor, congratulations on honesty. In fact, I thought I had a double chin and I needed liposuction under my chin, but now I understand, thanks to you , what I really need.
Forgive me, if I may seem inconvenient with questions, but I am trying to figure out what to do with you , just , we are all free from this quarantine again.
I ask you, in fact, if I need paranasal implants to create that ‘male model effect’ or maybe in that area , is better for me , use something else ?
-Finally , what do you think of implants for my eyebrow crest / brow ridge and temples ?
I noticed and read on your blog, that a prominent brow crest/brow ridge is very masculine and is an attractive feature and for my temples I wouldn’t really know , what would be better to do.
For the paranasals, I’m afraid, of nerve damage or that my nose is raised exposing too much of my nostrils and especially that my smile can change , looking fake .
For the eyebrow crest/brow ridge and temples , I read, that you do, a visible incision in the area of the hairline and that here too, there may be permanent nerve damage , making sure that is little sensitive that area.
I don’t want to seem unnatural or fake, so doc I ask you, if I need these plants in these areas or there are other better and safer solutions.
A: In answer to your questions:
1) I don’t recall ever discussing any need for paranasal implants in your face. I have discussed custom jawline and infraorbital-malar implants only.
2) The third level in facial masculinization is brow bone augmentation. (not temples) When custom brow bone implants are placed they are done endoscopically through a small scalp incision. They are no issues with the potential for permanent motor nerve damage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley: Hi, I am interested in getting a wraparound jaw implant (chin/jaw). I am interested in widening my jaw angles and having a stronger lower half of my face. The first photo attached is of my chin/jaw, and the other photos after are of what I hope to achieve. Please let me know an approximate cost range and what route you recommend taking. I was also looking into chin/jaw osteotomy surgery, but came across a couple comments made by you indicating that this type of surgery does not widen the jaw, despite what I was told by another surgeon. Thank you.
A: Thank you for your inquiry and sending your pictures. You are correct in that no form of mandibular osteotomy (sagittal split advancement, chin wing or sliding genioplasty) can wide the jaw and most certainly not in the way you want it to look.. These are mainly sagittal or anteroposterior bone movements. Jaw widening and/or creating a more defined jawline which has width requires a custom implant to really do it well in a predictable and smooth fashion. While I don’t know what your requirements are in the side view in terms of dimensional change that will await further pictures/analysis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been reading a lot on your blog how you mention that some degree sagging is likely to occur after cheek implant removal because the ligaments do not reattach.
I was hoping I could get some clarification on this.
In a 2013 RealSelf answer, I see you wrote the following in reliance to someone who has concerns after his implants were removed:
“ It will likely take at least 6 months or more for all the effects of having had cheek implants to subside. The capules will usually go away completely and the tissues will stick back down to the bone. What effects having had these cheek implants will have on your long-term facial aging is unknown.”
What confuses me is here you mention that the tissue will stick back to the bone. But elsewhere I understood you to say that the tissue does not stick back because the ligament attachments are lost. Maybe I’m misunderstanding. Perhaps I’m confusing the ligaments with the soft tissue (that is to say that the ligaments don’t reattach but the soft tissue does?)
I was also wondering if it’s impossible for the ligaments to reattach, or merely unlikely?
Thank you for the help.
A: While the tissues will eventually stick back and the capsule will be resorbed, this will be longer after the initial tis slide has occurred when the implants are removed. In other words the cheek tissues willfully heal in a LOWER position than where they were initially.
Once ligaments have been released they re not going to reattach. That applies to whether the ligament is big or small.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, does you perform any procedures for adults suffering from untreated brachycephaly that can help reduce the width of the head? I am not sure if reducing the temporal muscle will be enough…
I am this person, my head circumference is quite big (66 cm)… I cannot wear any helmet. If I could somehow reduce the big bulges on the sides of my head, I imagine the circumference would reduce which would then make it possible for me to wear some helmets. I cannot state how much of distress this has caused in my life. I feel like I am the only person in the world suffering from this condition. It has made my personal life very difficult.
A: Thank you for your inquiry and detailing our head shape concerns. In brachycephaly it rally requites a combination of posterior temporal muscle removal and bone reduction of the parietal bones. The parietal bones in posterior brachycephaly are always more flared and represent a significant part of the problem as well. It would be very helpful to see a 2D CT scan and check the slicing through this area to see how much of the bone thickness can be removed. It is not a question of whether this surgery can be done but how effective it would be.
In addition, while it may seem that you are the only one in the world with this problem I have heard your exact story numerous times.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you think it would be possible to transfer a large area of skin (full thickness graft) from a forehead reduction to the cheek that’s about 2 cm in height and 4.5 cm long and then reduce the scars of the borders left behind with lasers (as an alternative to individual punch grafts)? Most of my pits are concentrated in an area that size on my right cheek. If so, or if you think there’s another way to possibly fix my skin I’d like to schedule a consultation with you in person sometime in the next month or two. Please let me know if you think there’s a way to improve my skin, as I mentioned several dermatologists I’ve seen won’t do punch grafts to those areas, because they’ve told me they do not believe that they would heal properly. Thanks for your help!
A: This is definitely the type of skin grafting you don’t want to do. That wold look like a patch sitting on the cheek and would be much much worse in appearance than how your acne scars look like. Punch grafting would still be a much better option than composite excision and all thickness skin grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I like your facial morphs very much.! I agree with you, in fact I wanted to ask you, whether it is better to use fillers or implants with regard to the zygomatic and orbital area? I ask this because, with my friend ,we looked on the web and we think that the implants for the cheekbones are better for women and for men maybe temporary fillers for the cheekbones are good. I repeat it was a supposition made so ‘after a little analysis but maybe you can explain the issue implants vs filler for the cheek bone area (I’m afraid the implant for the cheekbones is too big and that may have damage to the facial nerves )
Other thing I ask you ; Do you use PEEK? or some other even safer material? I read on the internet that PEEK is the one that causes the least infections.
Finally, to get me closer to a celebrity, what else would you do to my face to make me better, without looking unnatural ? I trust your opinion, I hope to meet you soon doc.
A: In answer to your male masculinization questions:
1) Given the degree of severity of your infraorbital-malar hypoplasia, fat grafting would be a far inferior choice of treatment. Besides the fact that fat grafting would never persist in a young thin person like yourself it would also not create the well defined cheek contours that you seek.
2) The reason standard cheek implants don’t look good on men is because they are made for women and not men. But forget about the use of any standard cheek implants as that is not what the morphs are showing. They are showing the use of custom designed infraorbital-malar implants…which is the implant design you need and the one that works best for most men. https://exploreplasticsurgery.com/achieving-the-hi…ek-implant-style/
The male cheek augmentation patient seeks a masculinizing effect on their appearance which is typically described as a ‘higher cheek look’. This term is liberally used but its exact definition has never been clearly explained.
3) All implants carry the same risk of infection, no implant is better in that regard. A foreign body is a foreign body regardless of its material composition. I have never yet seen an infection with infraorbital-malar cheek implants put in through a lower eyelid incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I already have a chin implant in place. But it doesn’t give me the length and definition I was hoping to get. With a custom chin implant can I get a much longer and tighter (square) chin which is protruding.
Can you also give me an estimate of the recovery period?
Thank you!!
A: Thank you for your inquiry and sending your picture. Based on your picture and stated goals, you need a 45 degree type of additional chin augmentation with a very square design. I would estimate that an additional 5mm vertical length and 5mms horizontal projection with a 35mm square width would probably suffice. How much more that is than your current implant achieves I can not say since I don’t know what you have implanted. And there is always the issue of what you see as more significant which is going to require some computer imaging to determine the actual magnitude of change you seek. To do so I would also need a front view picture to at least do two dimensional chin prediction imaging.
The recovery from a chin implant replacement should be identical to your initial chin implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, About 9 years ago I had a chin reduction in which they used a titanium plate and screws to hold it together. These screws and plate were not removed. I’ve had some complications and just don’t want them in my body anymore. I had a few questions for you.
1. Is it possible to remove the hardware after 9 years? And is it possible to remove all of it?
2. If the bone has over grown on the hardware can it be removed to rechieve the hardware?
3. Would you put biodegrable screws in to fill the area or would the bone be strong enough by now even if the hardware is removed?
4. Is this a hard procedure or have you done this before?
5. What is the longest someone has had the hardware in for and were you able to extract all of it?
I am trying to receive my x-rays from my local dentist to show you but hoping you could answer these questions for me. Thank you for your help
A: Thank you for your inquiry. In answer to your questions about chin fixation removal:
1) Whether hardware has been in the chin for 9 months, 9 or19 years, its removal is possible. The ability for it to be completely removed is not dependent on time of implantation. It is actually dependent on whether the screw heads have been stripped during their placement.
2) One can safely assume that bone has overgrown much of the hardware, this is common and predictable. The overlying bone growth can be removed and the hardware exposed.
3) Your bone is well healed and strong enough that it not longer needs the indwelling fixation you have or any need further fixation once it is removed.
4) I have removed fixation hardware all of the craniofacial skeleton many many times over the past 30 years, the chin bone is no exception. When you do a lot of chin osteotomy revisions managing the indwelling hardware is just part of it.
5) I once took a fixation plate out of a 78 year old lady’s lower jaw that was initially placed to fix a fracture in 1972. She has lost enough bone height from not having teeth that the plate became eventually exposed.
Getting an old or recent panorex x-ray would be helpful to see the type of the screw heads that were used. That way one has the right type of screwdriver available that will fit the screws.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffered from severe cystic acne when I was younger that left pitting in concentrated areas on my cheeks. I’ve tried $15,000 of laser surgeries, dermabrasions, retinal products, and punch excision (the punch excision left the pits even bigger) and nothing has worked. The dermatologists won’t try punch grafts, because they do not believe my skin will heal properly with the small punch grafts. This may sound silly, but I know that burn victims have large area skin grafts completed, and I know that I would want a skin graft to my cheeks to match the facial skin as closely as possible. I have quite a large forehead, and I’ve read that during forehead reductions they remove the excess skin. I’ve exhausted all other possibilities, and I was wondering if you think it would even be possible for me to have a forehead reduction and use the extra skin as a graft for my cheeks (all in one procedure). I’m sorry if this question sounds absurd, but it doesn’t sound like there is any technology currently available to replace the dermal layer of the skin to help with ice pick scarring. I’ve attached some pictures of the scars on my cheeks as well as my forehead to show how much extra skin it might have. Please let me know what you think.
A: What you are suggesting for your acne scars is far from absurd, it is actually extremely insightful. It is known as ‘recycling’ in plastic surgery….using the discarded tissue from one area to augment/graft another area. This would certainly be the best tissue to use for punch grafting to the cheeks. Most of the time the punch graft harvest site comes from behind the ear where the skin is actually thinner and lighter. Forehead skin is a bit thicker than cheek skin but at least it is closer in color.
As you have learned through all of your treatments is that it is hard to get a pick scar elevated to the surrounding skin. Every treatment you have done made an effort to lower the surrounding tissue to it, which helps, but can never get it down to the right level. So punch grafting is the most biologic approach at this point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want do get my biceps and triceps enhanced by using fat but I haven’t found very much information about the procedure. Is this something you perform? Thanks
A: I have done fat injections for deltoid, bicep and gastrocnemius muscle augmentations. There are two basic issues with using fat injections for muscle augmentations. The first is a practical one….does one have enough fat to harvest to do the procedure? It takes a lot more harvested fat that one thinks to create a fat concentrate for injection. It is known as the ‘halving principle’ which goes like this….50% of the volume of the harvested fat is reduced by concentration, the remaining volume is then halved because it must be used for each side, and then we can assume that 50% of the injected will not survive. Thus let’s take the number of 1,000ccs or 1 liter can be harvested. (you may have more or less but I will use this number as a simple example) By concentration we are done to 500ccs, split between two sides we are down to 250ccs and then assuming only half will survive that is 125cc split between the biceps and triceps or 60ccs for each muscle belly. (a glass of water for example is 240ccs) Depending upon what your goals are that may be just enough or not enough close to your aesthetic augmentation goal.
The other consideration is biologic. Beyond what amount of fat may or may not survive, there is how the remaining fat will biologically behave. It will act just like where it came from which for most patients is largely the abdominal area. Thus should you gain or lose weight the size of the injected fat will go up and down in size also.
With that information as the background, how much fat do you have to harvest and how much muscle augmentation are you seeking?
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came across your practice online while researching rib anomaly correction surgery. I have always been self conscious of my rib cage and was hoping to gather some information of surgical options. I saw on your website that you’ve done some rib shaving to reduce the flare. I would like to learn more about the safety of such a procedure, how commonly you perform these procedures, and what would be a realistic expectation for aesthetic improvement.
A: Thank you for your inquiry and sending your picture. I have done numerous subcostal rib shaving reduction procedures which is the protrusion you are demonstrating in your picture. This is a procedure that is very safe and effective and, in some cases, it is simply better to remove in its entirety rib #8 which is the main cause of the flare. Despite its safety and effectiveness the incision used to do the procedure is in a prominent area. I have always considered the scar a questionable aesthetic tradeoff in a young female in such a visible area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello. Here you can see that by extending my chin down and outward, it corrects 3 key flaws:
1) Lack of lateral chin projection. Before: from side view, the foremost point of the chin is slightly recessed from the foremost point of my lips. After: the foremost point of the chin now extends just *past* the foremost point of my lips.
2) Lack of vertical chin height. Before: from both side and front views, the jawline is weak and undefined, and the lack of height leaves the lower third of my face unbalanced with the rest. After: the jawline is accentuated and the lower third of my face is well-balanced and much more masculine.
3) Deep labiomental fold. Before: from both side and front views, the labiomental fold is excessively deep and concave, giving my lips an overly pouty look. After: the labiomental fold is much straighter vertically and more smooth, thanks to the added vertical chin height and lateral projection.
I understand that moving my entire jaw to simulate the desired look of the chin doesn’t give the most precise representation of a chin surgery result, but it does show that adding vertical height and lateral projection to the chin can significantly enhance the masculinity of the lower third of my face. I’d like to know if you disagree with any of this, and approximately what dimensions in millimeters of added height and projection you think would best achieve the optimum result. Thanks!
A: Thank you for your inquiry and sending your pictures. The jaw thrust is a very good method to determine that vertical chin lengthening is beneficial. What it also illustrates is that the chin movement must be at least a 45 degree type of augmentation, meaning that an equal amount of vertical and horizontal augmentation is needed. I would estimate that the change you are demonstrating is probably in the range of 7mms horizontal and 7mms vertical, maybe 8 and 8.
Now that these dimensions are known the critical question becomes how best to achieve them. It is important to know that the soft tissue chin pad has limits in which it can be stretched unlike the rest of the jawline. That limit at best is a combined number of 12 to 15mms. (adding the vertical and horizontal augmentation needed) Thus this change can probably not to be done by an implant alone as the soft tissue chin pad will probably not stretch over it. This will requiter a combination of a opening wedge sliding genioplasty (to get all of the vertical length and some of the horizontal) and a chin implant overlay.(to get the rest of the horizontal and to make sure the chin width stays wide as the bone comes down and forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, If you play contact sports like soccer or football, will occipital skull reduction affect your game?(Example: making your skull weak because the outer cortex is being removed and rough contact to the head can injure you badly.)
A: This is a common question about any form of skull reduction surgery and the answer is no it will not. The skull is composed of two hard cortical layers of which only one of those layers is removed in skull reduction surgery, still leaving a good layer of bone protection intact. It is fair to say like many structures in the human body that the skull is over engineered and provides more bone protection than we typically need.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to enquire about your custom cleft chin implant design for male three-piece total jawline augmentation. My question is, is this procedure for men with existing cleft chins, or is it to create a cleft chin. If it is to create a cleft chins, then how does the procedure work. I always wanted a cleft chin as this is a big facial feature in my family and I have lost out on this characteristic/ feature.
I look forward to your response.
A: The creation of a vertical cleft in the chin is done the same way whether one is getting a chin implant or not. A chin cleft does not occur because there is a cleft in the bone, this is a soft tissue ‘deformity’. Thus just because there is a cleft in a chin implant this alone will not make an externally visible cleft. The soft tissue has to be vertically removed or ‘clefted’ and then sewn down tightly to the bone. When making a cleft in a patient who is getting a chin implant a cleft is put into the implant so that the bone can be reached to tighten down the soft tissues to it. To make a very deep vertical chin cleft this is done by also removing external skin as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you think that there is a significant chance that the vibration from an electric razor, an electric hair clipper, or an electric toothbrush could dislodge the screws that are holding my facial implants in place? If you thought that the vibration might slowly unscrew them over time or cause any other damage, I could just avoid using them.
Thank you, respectfully and humbly, for any thoughts you have.
A: There would be zero chance that any external vibratory stimuli could ever cause a screw to become loose in any of your facial implants. They are much more rigidly in place than any external stimuli could ever displace them. You should continue to use any electrical facial device that you want without restrictions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Would I be a good candidate for head width reduction? I have all my life alway disliked and had insecurities with my bulbous wide shaped head. I cannot wear sunglasses because i look silly being the sides of my head Protrude further out than my sunglasses (especially the left side) and in photos my head always looks odd shape due to my light bulb shaped head. My goal would be to have a more symmetrical straight and less bulbous sides of my head.
Is this surgery safe and why do more surgeon not offer this procedure? What is the down time for this procedure?
I was told by local plastic surgeons they would not attempt this and is risky and would not remove temporal muscles being there can be issues later with chewing etc.
I can feel the sides of my head and I definitely can feel that above the ear it is protruding bone although i do have very thick temporal muscles more towards the upper side part of head on side of forehead. Would you be able to shave some of the bone as well?
Please provide your professional opinion i would definitely look to get this done if its safe and me being a good candidate.
A: Thank you for your inquiry and sending your picture. Temporal reduction by posterior muscle removal is a very safe and effective procedure. Because the muscle makes up a significant amount of the side of the head, there is almost never a need to remove any bone. And because of the added incision length up along the side of the head to do so, the small amount of bone that can be removed is not worth that scar tradeoff. Removal of the muscle makes dramatic change in the shape of the side of the head alone.
Contrary to what you have heard by other doctors (who have never performed the procedure or know anything about it), removal of this muscle causes no chewing or mouth opening/closing issues.
In looking at your picture, you are a good candidate for the procedure. The amount of potential contour change is seen in the attached prediction image. It is clear that the muscle on one side is nearly twice as thick as that of the other side.
Dr. Barry Eppley
Indianapolis, Indiana
Can Temporal Implants, Zygomatic Arch Implants and Vertical Chin Reduction Be Done At The Same Time?
Q: Dr. Eppley, I have questions about temporal implants, zygomatic arch implants and vertical chin reduction. Are you pretty confident that you can produce a significant improvement and that you would not have to go in again and that the result would last several years.
With the temporal implant
With the cheek implant
With the chin
If it’s not enough augmentation, and fillers can make up the difference, then I might as well do fillers. But I believe you said on the net the fat can be used to effectively deal with that.
( I’m confused—-Since you are in there and you see the anatomy and you can custom carve the implant- I had the clear impression that you can see what you would get before the swelling takes place , and that eliminates the guesswork. ) In the last letter you’re saying that it is tricky to know if it’s too much or too little..
Are most patients happy with a significant difference, (and that maybe you can see it as well). we have agreed that my face is long and that in your opinion the temporal area definitely needs augmentation and I do have a long chin. I realize that I make the ultimate decision but how you and others experience my visual is important .
Like The experiment with the chin reduction, is there anything I can do to produce some type of visual of what it would look like with the midface implants? Also, and importantly, I want to be able to estimate the length of the widening in the midface area so I can tell you how much, right? and I wonder that’s since the skin will be somewhat stretched in that area if that would have a secondary effect of slightly pulling out the corners of my lips.
You have the panorex Of my chin area along with other films that showed all of the screws ——-that I provided on my first consultation. Could you please take a look at that and tell me the amount you can safely take it out? That would make my final decision about the chin area. also the soft tissue swelling that is present underneath the anterior aspect of my chin makes it look long as well and that is not part of the bone. And when I press that then that helps some.
Am I underestimating the noticeable benefit of reducing 7 mm? If you feel fairly confident that you can cut out the soft tissue underneath the anterior aspect of the chain +7 mm, I will do it, 10 mm would be great, but if only 5 mm plus the soft tissue then I would have to think about it. I sent you the pictures of the actor with the width of his face and short length of the chin from the bottom lip. is there a good chance that I could get fairly close to this?
Where is the Incision and scar with midface implants? In front of the year? Is the scar noticeable to the untrained observer?
How many days out before the scars are no longer noticeable or can’t be covered up with make up or skin coloured tape ?
Hoping that this will offer me clarity, and again thanking you for your time.
A: In assure to your temporal implant, zygomatic arch implants and vertical chin reduction questions:
1) All such augmentations of the temples and cheeks are done with implants so we know they will last forever. Their only question is the magnitude of the change…how much is enough, too little, or too much? This is a judgment call to which no one can accurately predict what you will see as too little, enough or too much. In surgery I have to pick an implant size and see what looks goods to me as you are not there to help me with the implant size selection. The biggest fear in implant size selection is in being too big….which is a %100 assurance of a revisional surgery to change.
2) When it comes to a reductive change like that of the vertical chin reduction, the fear is the opposite of that of implant augmentations….there is no risk of doing too much as it more of trying to make sure enough is done to make it worthwhile. This is where the anatomy has more control than that of just making a choice as to how much bone to remove. The limitations of the tooth roots and the mental nerve exit from the bone control where the upper bone cut is made and how much bone can be removed. (you have to stay at least 5mms below them to ensure they are not damaged) This is why I know that at least 7mms can be removed centrally and possibly up to 10mms centrally. A preoperative x-ray measurement will provide more insight which I will do when I am permitted to get back into the office.
3) It is a normal thought and every patient thinks the you can really see what an implant looks like in surgery because significant swelling has not yet occurred….but that is not true. What is overlooked is that in creating the tissue pocket all of the overlying tissues are elevated from their attachments. (that is what making an implant pocket means…creating an open space for the implant underneath the tissues) So when you put in an implant what really occurs is that the released tissues are floating above the implant and are not rigidly stuck down around it…which is what will eventually happen when full healing occurs. So much like having the sheets floating above the mattress on your bed, if you put a small or larger ball on the mattress underneath these floating sheets would you know what size the ball is or even that is was a ball??) This is what makes implant size selection so difficult on the face where a few mllimeters either way can make a big difference to the patient.
4) There is no question you have a long chin and there is no doubt that a diametric widening effect of the temples and zygomatic arches (lateral cheeks) works in concert with the vertical chin reduction to both create a shorter and wider appearing facial shape. Other than computer imaging there really is no other test to preoperatively determine the effects of the temporal or lateral cheek augmentations.
5) For vertical chin reduction I plan on removing both a wedge of bone intraorally as well as a wedge of soft tissue from underneath the chin.
6) Zygomatic or lateral cheek implants are placed through intraoral incisions. But they can also be placed through an external skin incision on the backside of the sideburn over the posterior zygomatic arch.
7) Since the only external scar you would have for all of these procedures is the one you already have (submental), the recovery and outcome for that scar is one you already know.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently read a paper titled “CLAVICLE LENGTHENING BY DISTRACTION OSTEOGENESIS FOR CONGENITAL CLAVICULAR HYPOPLASIA”.
I’ve reached out to the surgeons who conducted the first paper and am waiting for a consultation.
My question for you is have you ever performed distraction osteogenesis of the clavicle.
I read your blog post discussing the two options, and how obviously the latter would require a far more dedicated patient. My main concern with the osteotomy and bone graft is that you cannot observe over time A) the aesthetic result that each mm provides the patient and B) the functional health of the glenohumeral joint. For instance if any issues were to arise during the distraction phase then the process could simply be halted and a plate fixation applied at that point.
It seems to me that standard limb lengthening of the legs/arms would be far more invasive and arduous than the clavicle, due to the surrounding musculature and arteries/nerves nearby.
A: Distraction osteogenesis is not quite as simple as you probably think it is. While the concept is straightforward and well known for over 30 years, the rate of distraction is much slower in the axial skeleton than the face and the time period of consolidation much longer. Given that external distraction devices would have to be worn in bilateral fashion for an extended period of time, the practicality of its use for elective shoulder widening is suspect particularly on a bilateral basis. If any ‘issues’ were to occur during the distraction phase, the distracter is not merely removed and plated. It would still require a bone graft for consolidation to occur.
While I have done plenty of mandibular and skull distractions I have never done one for the clavicles. The surgery is straightforward. The issues is the state of development of the distraction devices for a bone that lengthen so very rarely. (as you have found on one case study)
Dr. Barry Eppley
Indianapolis, Indiana
