Your Questions

Q: Dr. Eppley, I am happy to hear I am a candidate for a sliding genioplasty. I scheduled a consultation for next month to discuss more. Before then, I had two follow-up questions. I understand completely if this is too much for email and would need to be discussed during a consultation. I apologize if this is the case. I just thought I’d ask since the consult is a ways into the future.

1) I was hoping to not have such a scrunched up chin when looking down. I was also hoping to improve support to my lower lip so that it hangs less when my mouth is open (photos attached). Would a genioplasty help with these things?

2) I am nervous about two possibilities from a genioplasty – an overly pointy chin/deep mentolabial fold and a thinned/pulled down lower lip (photos attached). One of the key reasons I was hopeful for a genioplasty and not an implant was that I read on your website that soft-tissue changes were more predictable with a genioplasty. Could the above two results be mostly avoided?

Again, I really appreciate your time and your website as a resource.

A: 1) While in theory a sliding genioplasty could help improve lower lip support in some patients, I don’t think in your case that would probably happen. That tends to occur with large horizontal bony movement in patients with really weak chins who have significant preoperative lower lip incompetence.

2) With the relatively small horizontal bony movement you would be getting, a deeper labiomental fold is not going to occur. This is also aided by the vertical lengthening which often helps prevent a deeper labiomental fold from occurring., You can also hedge against that from occurring by grafting the bony step off of the sliding genioplasty with some demineralized bone granules.

3) I have never seen the lower lip pulled down with either a chin implant or a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am a 32 year-old male and seem to be dealing with progressive hemifacial atrophy on the right side of my face. While signs of the disease first appeared seven year ago, I have seen more significant atrophy over the past 12-24 months. To this point, the disease seems to only be affecting soft tissue with no impact on bone or nerves. I understand your primary treatment option for this is fat injections, and I am interested in understanding more about this treatment as well as other options. 

A: It sounds like you have linear scleroderma as your source of facial atrophy. No one understands why this occurs and there are no known proven or preventative treatments for it. The standard therapy is to wait until the disease has burnt itself out and then fat graft it. Fat injection therapy remains as a front line treatment for a stable disease condition. Whether one should attempt to treat it in its active phase is a matter of debate. But given it is one’s own natural tissue, there is little harm in doing so. Whether it can cease the disease and prevent further progression of it is unknown but theoretically possible.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I contacted you a little while ago regarding chin implants, and you felt that I had a horizontal deficiency of around 10mm.

My first question is whether larger implants like this carry any particular risks or pitfalls compared to the smaller ones. I was also wondering what kind of frontal view change I can expect from a standard/non-custom implant of this size. 

Thanks

A: Good to hear from you again. I doin’t think there are any increased risks with chin implants whether they are small or large. The increased implant load per se does not make them more prone to complications. The more relevant issue is with larger chin augmentations should they be done with an implant or a sliding genioplasty. (move the chin bone) for a more ‘natural’ chin augmentation and one that eliminates the need for an implant at all. That would depend on what type of frontal view change one is looking to achieve. If one wants to make their chin wider or even more square then only an implant can accomplish that frontal view change. If one wants to keep the chin the same width or slightly less wide then only a sliding genioplasty can make that frontal view change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing to you with a question about custom facial implants. Though I am a big fan of your work and admire what you have done for so many people, I am scared to travel out of the country for surgical work.

I have found a reputable craniomaxillofacial surgeon in my home country who also specialises in plastic surgery. He offers custom implants made out of PEEK, titanium or medpor for all areas of facial augmentation. (It is my understanding that PEEK implants for facial augmentation are not yet approved by the US FDA.)

I queried as to why he does not offer silicone implants but he simply stated that the other three materials were his preferences. I did worry about the large incisions that would be required for jaw implants made of solid materials, but with his experience, I feel less worried.

From your medical knowledge, which of these three materials would be the most ideal for my jaw/side of chin augmentation? 

My biggest worry with such a procedure is getting the implants infected. I understand that medpor has a rugged surface that bacteria like to hold onto and is more prone to late infections than a material such as silicone. I am not so sure about PEEK or titanium. 

The initial cost of the surgery and implant is not a worry for me but my worries stem from potentially getting a custom implant infected, having to unzip and zip up my incisions again, and having to fork out the cost for a new implant. 

Which of the three materials should I go for? Which has the smallest likelihood of getting a late infection? It is something that worries me as I don’t want to keep having to go through surgery. I really just want it to be my last.

A: The question of what facial material is superior is a common one and much thought is given to their biologic tissue interactions. But having done many hundreds of custom facial implants the most important issues are not the material’s biologic properties as the body tolerates all of them equally well and the relevance of tissue adhesion is far overstated. The two factors that matter the most are 1) can the implant material permit it to be placed with minimal scarring and, of greatest importance and often completely overlooked is 2) how easy is the material able to be removed should a revision be necessary. Given that revisions in custom facial implants approximate 20% to 30% (that always surprises patients but it is true nonetheless) that issue takes on extreme precedence. For that reason I don’t prefer any of the materials you have mentioned as they are all more difficult to place and hard to remove and I haver removed a lot of all of them. But the best choice of these less than ideal materials would be Medpor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking your advice on my forehead protrusions. I believe I have two relatively small osteomas above each of my eyebrows and have become increasingly concerned about their appearance. I have looked into treatment for this to try and identify a rough sort of price that I would be paying but can not find one anywhere so I was hoping you’d be able to give me a generic quote. 

A: I suspect that the ‘small osteomas’ to which you refer, which you have also called forehead protrusions, are not osteomas at all but actual protrusions of bone from the underlying the frontal sinus…which are treated quite differently than osteoma removal. The fact that that are paired or bilateral would strongly suggest that brow bone protrusion is the more accurate diagnosis. Please send me some pictures of your forehead for my assessment and recommendations for what is likely going to be brow bone reduction surgery.

Unlike typical forehead osteomas, brow bone reduction is not done by burring but usually by a bone flap technique. This is where the outer table of bone over the frontal sinuses is removed, reshaped and put back.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year-old male and I have untreated plagiocephaly. I am interested in plagiocephaly correction. 

The right side of my skull is pushed forward i.e my back right side of the skull is flat and I have bulge on my forehead and because of that my head looks wide on that side. Also my right ear is pushed forward and my jaw on the right side is also deformed but I don’t know how to name that deformity.

The first thing I would like to know is whether something can be done for the width of the skull?

The second thing, whether something can be done for my jaw, it looks smaller than unaffected jaw side. 

The third thing, whether I can do a forehead reduction. I read that the unaffected side can be augmented , but I really don’t want to touch that side of my face because I think it’s perfect.

I would really appreciate if you provide me with these informations. 🙂 

A: In answer to your plagiocephaly correction questions:

1) The wide of the skull on the wider side can almost always be visibly reduced. This is actually done more by muscle reduction than bone.

2) The smaller jaw can be built up so that it is more symmetric to the opposite side. This is almost always done with a custom jaw implant made from a 3D CT scan.

3) The larger forehead side can likely be reduced to match the smaller side although I would need to confirm that with a 3D CT skull scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about my facelift and laser peel recovery. I am two weeks out from a facelift and full laser peel. I have some residual redness on one side of my face that has a clear demarcation from that of the neck. I wonder if I had been burnt during the procedure. Will this heal and how long will it take for the redness to go away.

A: In answer to your facelift and laser peel recovery question:

1)By definition a laser peel is a burn…a controlled burn but a burn injury nonetheless. So healing is all about recovery from a burn injury.

2) The trickiest part of doing any skin resurfacing in a facelift patient is performing it over where the skin flaps are raised for the facelift. (side of the face in front of the ear and along the jawline) This skin area is treated the least with the peel because it already has a limited blood supply from being undermined from the raising of the skin flaps. Despite being treated with the least amount of peel, it is the most sensitive and will retain redness far longer than any other areas of the face as it is skin that is healing both from below (facelift) as well as on top. (chemical peel) 

3) Complete resolution of the redness can take 6 to 8 weeks or even a bit longer in these areas as the skin responds by an intense erythematous reaction which becomes most apparent by 2 to 3 weeks after surgery…and is part of the normal healing process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an appointment with you about a month ago. I was quoted for breast implants and a lift. I was wondering if he could tell me what it would look like if I just did implants. Thank you for your time. 

A: With breast sagging, where the nipples sits at or below the inframammary folds, a lift always take precedence over an implant. Getting the nipples back up above the fold in a more centered breast position is the foundation of improvement of the sagging breast. When you need a lift, you really don’t have the option of doing implants alone as it will actually make the breast sag look worse and not better. In the sagging breast the basic rule is …while a breast lift can be done without implants, implants can not be done without a lift.

If the scars are a concern then it would be best to not have any surgery at all. Never incur scars unless one is absolutely convinced they are better than the existing sag one has . If cost is the issue then have the breast lift done as implants can always be done later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting closer to finalizing my plans regarding facial implant procedures (hopefully this summer/early fall, depending on school schedule), and I just wanted to ask you a brief question regarding treatment/augmentation goals. Ironically enough, the photo linked below is actually a morph of a person’s face, but in general, is it possible to get (even if to a limited degree) the look you see in the cheeks and chin? More specifically, the fact that the cheeks and chin are not only defined, but also with the lines that run down both sides of the face to create the general “squareness” of the chin.

If it is, in fact, possible to achieve at least some degree of that look (I understand that trying to look like someone else is not realistic/possible), do you think that the combination of the male model-style cheek implants you offer and an off-the-shelf square chin implant would be sufficient to achieve it? 

A: The general answer to your question on that degree of facial definition is…no. Unless you look largely like that from the beginning, no form of surgery is going to create such a defined facial form. Such people have very little subcutaneous fat so they are essentially looking more skeletonized.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, here are some pictures of my current buttock implants. They do not extend to my thighs and I can lift them off my butt by just putting my fingers under the implants. What are your recommendations for my buttock implant revision?

A: Thank you for sending your pictures. What you have are standard buttock implants placed in a subfascial or subcutaneous position. This is why they are so visible as the soft tissue have contracted around the implant perimeters, the rounded edges of the implants are visible and you can physically lift up the underside of the implant.

This is a difficult problem to improve as your options include the following:

1) Reposition implants into the deeper intramuscular place. While this is the best pocket for them as it will eliminate implant show, the implants would end up a lot smaller and there is the uncertainty as to what the overlying skin and subfascial pocket will do. (in other words would there be an overlying soft tissue sag?)

2) Keep the same pocket but have larger custom implants made that have feather edges and will cover a larger buttock area and go more to the sides. While this is a much better implant style to have in a superficial subfascial buttock pocket and will lessen implant show and give a better shape, what will happen long-term to the implants with such thin soft tissue over is unknown. (in other words will they drop over time, will they develop capsular contarcture)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking chin implant replacement surgery. I had a chin implant done in 1989 which I always thought was too small. Mentor is the model but the doctor did not write down the lot number so I do not know the material. After having a midface lift and rhinoplasty the doctor said he did not feel comfortable doing the revision of the chin as he did not know if it was silicone or not. I love my surgeon but he said he needs me to remove my implant, let it heal for 6 months and then do the revision. I trust him completely but since you have so much experience with the custom implants I thought you might have other ideas or techniques. Thank you.

A: In regards to chin implant replacement, if the chin implant was Mentor and placed in 1989, it is undoubtably some form of silicone material so that should not be a confusing issue. I do not see the logic of removing a chin implant and letting it heal for six months before reimplantation….that has no biologic merit. The more pertinent question is what change do you wish to achieve now and whether it is best done by either a standard or custom chin implant approach. I would need to see pictures of your face to determine what type of chin augmentation change you are seeking and how best to achieve it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is in relation to the jaw angle ligaments near the insertion site of jaw angle implants. I saw below that there is a sphenomandibular ligament and a stylomandibular ligament at the back of mandible. I was wondering what happens here since they are directly in the area of insertion/fixation?

A: Only one of the ligaments to which your refer attaches in the region of the jaw angle, the stylomandibular ligament. The sphenomandibular ligament is located on the inner surface of the jaw angle high above the angle and not on the outer surface so it is completely out of the way and is not a factor in jaw angle implants surgery.

In normal jaw angle augmentation cases, the stylomandibular ligament may need to be  stripped off the bone to allow any vertical lengthening jaw angle implant to be properly placed. But in your case with a prior history of aw angle reduction those ligament attachments have already been released since the bony ja angle was removed.

Loss of the styhlomandibuar ligament attachment has no functional or aesthetic significance. It is disruption of the pterygomasseterinc sling that can can cause an unaesthetic relocation of the masseter muscle bulge when clenching or chewing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 52 years old and am interested in a tummy tuck. However I am a kidney transplant patient which was done four years ago. I am taking Prograft, Cellcept and Prednisone. My general doctor and nephrologist have cleared me for the surgery. 

A: Being a kidney transplant patient does not exclude you from undergoing a tummy tuck if it is acceptable to your nephrologist. I would need to see some pictures of your abdomen for my assessment and recommendations as to what type of tummy tuck you need. Given that the typical subcutaneous location for the kidney transplant is in the abdomen, certain aspects of a tummy tuck like muscle tightening can not usually be done. Only excessive skin and some fat can be removed from the abdominal area. There would also be a more limited amount of a lower abdominal skin flap that can be removed to avoid the transplant site. 

The important principle in any aesthetic surgeries is safety first. Thus a more extensive and longer operative time for a traditional full tummy tuck may not be prudent in an organ transplant patient. That does not mean, however, that some substantial improvement can not be obtained. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implant revision. I had Medpor RZ jaw angle implants placed around 1 year ago. They are size large. Overall I think they are a bit too big, and should be replaced with a size medium of the same material of silicone. What do you think? Do you do remove the existing implant or do you carve the existing implant a little? 

A: The problem with your jaw angle implants is not that they are too big but rather the style you have chosen has added too much vertical length. (that is what the Medpor RZ jaw angle implants do…adds primarily vertical length…and if they are not placed as they are designed they will give too much jaw angle width as well) Your jaw angles have been dropped too low which makes your face look heavy.  I think this is an implant stye issue. It would be best to remove and replace them with a different style/size jaw angle implant for your jaw angle implant revisions. It is very difficult to get Medpor implants out as a single piece in may cases. Thus it would be better to have new jaw angle implants placed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a jaw angle implant revision. I am 6 weeks post op from cheek and widening jaw angle implants. I am very pleased with the cheek implants – subtle changes. Now the asymmetry of my jaw angle implants is another matter.  Due to some inherent jaw asymmetry I had a small implant placed on the left and a medium implant placed on the right. The asymmetry now is more noticeable than before. Independently I like each one but I prefer the right one. Plain x-rays does seem to show the left one is well positioned and the right one may be rotated up and forward. The screws seems intact and there are no signs of infection. There has not been any problems with the incisions inside the mouth healing.

My surgeon wants to reposition the right implant and secure it with two screws. Yet I also kind of like the right one better… in which case I would need to displace the correct left which seems counterintuitive.

What would you suggest?

A: You have now discovered the most common and hardest problem to solve with jaw angle implants. It is not as easy as it appears to make an adjustment on one of the implants and have it turn out better. I would not attempt a jaw angle implant revision unless I knew exactly what the 3D position of the implants are. The plain x-ray you have shown does not provide enough information to know what to do or to make an informed decision. You need a 3D image of it using an inexpensive cone beam (CBCT) scan. That information will prove invaluable in making the right decision as to which implant to reposition and on how to 3D reposition the chosen implant. If you just eyeball it I can guarantee you will not turn out better…it will just be a different variation of the asymmetry.

Two screws are always better than one but two screws into an implant than has been moved but is still asymmetric will do you no good.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the following surgeries:

1. High radix rhinoplasty

My nasal bridge/nose-raix is high and little bit wide. The nasal bridge/nose radix is shallow, without an indentation.

I want to make my nasal bridge narrow and located low as possible. I also would like my nasal bridge to have an indentation/a recess.

You wrote what can be done to make the high radix low – 

“Reduction of the high radix can usually not be done by rasping or shaving alone. This only gets the lower end of the radix and will not make a signficant difference. It requires an osteotome to reduce it after an initial osseocartilaginous reduction is done. This may need to be combined with a direct osteotomy done through a punch incision by a small osteotome through the nasal skin from above as well. Guarded rotary drills can also be used to burr the radix down.”

I accept this method of surgery and I want to undergo surgery.

You also wrote “Radix deformities exist in some classic nasal problems. A high radix is often seen in the very overprojecting nose with a large dorsal hump. The nasal and frontal bones are overdeveloped raising radix height with the rest of the dorsum”.

To this I have a question:

Are my frontal bones overly developed (and if so, is it possible to reduce my frontal bones in my case)?

I know that feminization facial surgery deals with the reduction of overdeveloped frontal and nasal bones, and you do facial feminization surgery so if it is possible in your hospital I want to undergo this type of surgery and reduce frontal bones if they are over-developed, and I want to make my nose radix low.

A: In answering your thoughtful questions about what can be done about the high radix in rhinoplasty, I have done some imaging looking at the combination of a combined rhinoplasty and brow bone-forehead reduction (shaving reduction) for the most change that is possible at the fronto-nasal junction. This is what is possible with a radix reduction combined with a frontal reduction as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my ears are pointy. Can you reshape them and make them rounder? They don’t look as pointy from profile view and one ear looks sort of different from the other.  

A: Thank you for sending your ear pictures. While your ears are pointy they are not a classic Stahl’s ear deformity as there is no abnormal or third crus. Both the superior and inferior crus are present and in the correct locations although the superior crus is a bit wider or thicker. The ears appear primarily pointy because there appears to be a deficiency along the superior helical rim.

For your pointy ear correction you have several options:

1) Cartilage graft the helical rim defect to fill it out to the surrounding helical rim, which will keep the ear the same size.

2) Reduce the ‘high’ areas above and below the helical rim defect which will make the ear a bit smaller.

It is also possible that a combination of both (defect augmentation and supero-inferior reduction) may also be effective.

The graft source would be a conchal harvest from the sane ear as it has a curved shape that will work sufficiently for the helical rim. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead asymmetry correction. My forehead on the right side is about 3 or 4mm flatter than the left side. My temporal hairlinesare different on each side making me look slightly plagiocephalic and I can spot this quickly in a mirror. “I think” this is due to sleeping on a pillow at night on that side for years and it has flattened one side of my face very slightly. I need a little bone cement to make my forehead more symmetrical. If I was to get bone cement injections I would need 2.5inches square with a thickness of 3.5mm over a portion of the right side of my forehead This is all rough estimations, but this is all I would approximately need. I hope you can help? 

A: The proper treatment for your forehead asymmetry correction is probably not bone cement injections, they have a high risk of irregularities. In addition they can not be used to lay on soft tissues of which some of your correction would need to be because the apparent transition of the forehead defect into the temporal region. Bone cements have been largely replaced by custom skull implants made from a 3D CT scan which are far more reliable in terms of contour and smoothness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have brow bone protrusion.I would like my forehead to be flatter and this obvious dent disappears. Plus, my eyebrows are asymmetric. I have two surgical methods in my mind. 

1) An eyebrow lift with subsequent filler

2) an eyebrow lift and forehead contouring

In this case, however, it is out of the question for me that the incision is made on my scalp. it would have to be made under the hairline. Is that even possible?

Please tell me about the advantages and disadvantages. Of course, you’re welcome to say what you would recommend. I just want my eyebrows to be more symmetrical and my forehead flatter I always look very angry because of my forehead.

A: Thank you for your inquiry. What you have is brow bone protrusion which is often accompanied by a central indentation between the medial brow bone protrusions. While an endoscopic brow lift can be done through limited scalp incisions, any reduction of the brow bones will requite more of s scalp incision of which you have stated is unacceptable. There is no method for coming from below due to the location of the supraorbital cranial nerves as they exit from the lower end of the brow bones. This leaves you with the only option for forehead contouring of filling in the central forehead indentation with a small custom made forehead implant from a 3D CT scan which can be done through the same small incisions as that of the endoscopic brow lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a subnasal  lip lift two months ago only to reduce the distance between the nose and the lip. I didn’t want a lot of skin taken off and I didn’t want larger size or Cupid bow lips. I’m left with a triangle shape upper lip and my mouth doesn’t close all the way. My two front teeth show when I talk and I have really huge smile now like a horse. The scar is raised and terrible looking. A lot of skin was taken off and sutured to the muscle. Can anything be done to help. I am so embarrassed. Can more skin be put in to lengthen the area? Can anything be done?

A: An overdone subnasal lip lift is a difficult problem to improve. Time will help the lip to lengthen by about 10% to 20% over the next six months due to tissue and scar relaxation and it can also help to stretch (pull down) on the upper lip on a regular basis to create some stretch as well. If the muscle has been sutured down it may help to release it. But skin grafting is not an aesthetic option since it will create a patchy look under the nose which would just be trading off one aesthetic problem for another.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two questions about temporal reduction surgery.

1. How long time does it take removing the posterior temporalis muscle? If you already have made an coronal incision and the only thing that is to be done is removing the muscle?

2. How is it with scar tissue after skull reduction? I have had it done by a European Doctor and I now have 5 mm of scar tissue beneath my scalp. Does this happen when you do skull reduction? Is it possible to remove this scar tissue? 

A: In answer to your temporal reduction questions:

1) Whether one has en existing coronal incision or not (a coronal incision is never used for temporal reduction) the time it takes to do the surgery is the same. The presence of a corona scar only make sit possible to do a more direct approach to muscle removal but it does not shorten the operative time.

2) Sealing the bleeding bone and using a postoperative drain in my experience leads to minimal scar tissue formation under the scalp and minimal to no bone regeneration. If you have scar tissue present from a prior skull reduction procedure, it can be subsequently removed during another skull procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle reduction along with chin implant surgery two weeks ago. My lower lip is crooked when I’m smiling or trying to pull down my lower lip. The muscle under left side seems to be stronger than the right side. I don’t know if it is the trauma to marginal mandibular nerve or improper bone attachment of mentalis muscle. How can I fix this?

A: I will assume you have addressed this issue with your surgeon and have received guidance. That being said your description could be some weakness of the marginal mandibular branch of the facial nerve which controls the depressor action of the lower lip. The recovery of function of this monofascicular motor nerve branch is one of time only. There is no way to expedite axonal recovery within the nerve. It must do so on its own over a course of weeks or months. In most cases the nerve does recover by three months or so after surgery if not sooner.

While there may be some mentalis muscle tightness after intraoral chin implant placement, it does not usually present as lower lip asymmetry with movement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know the biggest risk of brow bone reduction. Is blindness a risk?And if you could tell me if osteotomies above the brow area have similar (small) risks as brow bone reduction.

A: There is no risk of blindness with brow bone reduction. The osteotomies used in an osteoblastic bone flap setback technique are done outside of the orbital contents and the orbital ape lies well below and behind this level of bone manipulation.

Having done lots of primary and secondary brow bone reduction procedures, it is an operation that has few medical risks that I have ever seen. Other than a few cases of temporary and elf-solving air leaks in bone flap techniques, I have not seen infections or any problems with the healing of the bone segments. There are aesthetic risks such as asymmetries, palpable irregularities and whether the brow bone has been adequately reduced particularly at the frontonasal junction. Like many other craniofacial surgery procedures, it looks dramatic and seems to be a high risk procedure but the superb blood supply of the head and face allow for these major operations to do well with few complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What type of implant is movable, shave-able, and low risk of infection? I am planning in getting a custom forehead implant, 12mms thick on top of my forehead. And also can a brow bone be shaved once the implant is placed?

A: Custom made silicone forehead and other skull implants have proven to be the most adaptable with the lowest risk of infection in my experience. I have yet to see an infection with silicone skull implants. (unlike PMMA and other bone cements) They are made from the patient’s 3D skull CT scan. Whether a forehead augmentation could be as much as 12mm depends on whether the overlying forehead tissue and scalp can safely stretch to accommodate it.

If the brow bone is reduced at the same time or even later by an osteoblastic bone flap technique, it would be important to seal all the opening along the osteotomy lines with hydroxyapatite cements to ensure there is no risk of an air leak up into the implant space. This is not important in brow bone reduction by shaving as there is no exposure to the underlying frontal sinus. (at least there should not be)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old male interested in jaw augmentation surgery, and from reading your very informative blog posts I believe what would best suit me is a custom jaw implant. In broadly qualitative terms, what I want to achieve is an overall squaring of my jaw, an improved definition of my jawline and a strengthening of my chin, increasing the size and ‘strength’ of my lower third. 

In more specific terms, I think this will include: 

-Chin: Broadening my chin; projecting it forward; and increasing its vertical length. 

-Jaw: Widening my jaw laterally, decreasing the gonial angle, and adding horizontal and vertical length to the jaw. 

I don’t believe I’m able to attach pictures via this online form – obviously they are the best way for you to make an initial assessment on how I might achieve those aims, and I’d be very happy to attach them in further emails for your expert opinion. 

Regarding initial questions about jaw augmentation. surgery more generally, could you advise me on the following: 

1) Does the above sound like it would be feasibly achievable through a custom jaw implant? 

2) Could you sketch out the broad timelines that you would expect going from initial consultations to designing an implant to the surgery itself? 

3) I live outside the U.S. – would this present any problems as an overseas patient, and how long would I need to spend in the US pre- and post- operatively? Would I need to travel to Indianapolis before surgery for a face to face consultation, or can all of these be done virtually? 

4) What is the likelihood of infection in custom jaw implants? Typically how often after surgery would any infection become apparent, and what implications would that have post-surgery (i.e. could it likely just be treated with antibiotics, would the implant have to be removed, could it be replaced, etc) 

5) Beyond infection, what are the other main causes of complication in custom jaw implants? How likely are these? 

6) While all elective surgery obviously carries risk, how risky are custom jaw implants in the grand scheme of elective surgery? (apologies if this is too obtuse or vague a question!) 

7) How long lasting are custom implants? Are they designed to last a lifetime, or is it likely I would need a replacement at some point in the future? 

Thanks you very much for any initial information you can provide, and I look forward to talking further. 

A: Thank you for your inquiry. In answer to your jaw augmentation by custom jawline implant questions:

1) Every dimensional jawline change you have mentioned are very typical for most young males.

2)It takes about 4 to 6 weeks, after receiving a 3D CT scan, to design, manufacture and be available for surgery.

3) Most patients in my practice are from afar so your situation is common. The consult and any subsequent discussions are done in a virtual fashion. There is no reason to come here for a consultation first…unless you want to do so.

4) The risk of infection in jawline implants is about 5%. They are always initially treated with antibiotics and most, but not all, can be successfully treated without further surgery. I have a very specific postoperative care protocol to lessen the likelihood of such occurrences as much as possible.

5) Beyond infection all other custom jawline implant complications are aesthetic in nature. (size and symmetry)

6) A custom jawline implant is not risker than other type of standard facial implant…it is just a bigger implant and to some degree has less aesthetic risks than using standard implants.

7) A custom jawline implant is designed to be lifelong device. The material never degrades or breaks down.

I will have my assistant Camille contact you to schedule a virtual consultation time. In the interim please send me some pictures of your face for my assessment and computer imaging for jawline augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering cheekbone reduction reversal. In your expert opinion, would it be risky for me to try and attempt to flip the cheekbones back out after cheekbone reduction? Would flipping it back in place close the gap as well?

A: Based on your 3D CT scans to move the anterior end of your prior cheekbone osteotomies out you would need an interpositional graft and plate and screw fixation. This can certainly be done as in your case they actually removed a vertical wedge of bone through the whole body of the zygoma. 

While that can be done the more important question is what are your trying to accomplish by doing so? If the goal is to provide a cheek lifting effect that is a possible outcome from expanding the cheek back out but such a result can not be assured. The cause of the cheek sagging is that the tissues have been stripped off the bone to do the surgery. Returning the bone to its original position may not elevate scarred and now shortened cheek tissues back to where they originally were as bone expansion creates a lateral soft tissue push not a vertical one. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am starting to prepare for the custom infraorbital rim-midface implant.This is because even tho the result is okay the off shelf orbital rim implant makes the two sides of my face a bit assymmetric and its not fixed with screws either, which I believe it should.

I would like to ask since I have now been through three surgeries in my under eye and midface area…first custom Medpor midface implants, then removal and now the off shelf orbital rim implants. I wonder, do you think I would have enough tissue left under the skin so the result of a custom infraorbital-midface implant still will be looking good?I believe I have read something you have written before that states every time a surgery is being done, some of the tissue dissolve, due to the swelling or something?

I just want to check in on your thoughts around this.

A: My general thoughts are your situation is that every surgery has risks and no surgery ever turns out perfect no matter how many revisions are done. Thus if you have an ‘okay’ result in the more precarious tissues of the lower eyelid and cheek this would give me pause as to considering further surgery. It is all about how much benefit is their to gain vs the risk in doing so.

That being said, each surgery creates scar but that does not necessary mean the tissues become thinner. So I don’t see this as a limiting factor for considering a custom infraorbital-midface implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am ten days after my custom jawline implant and, while all has gone well and it looks good, I desire just a little more vertical chin lengthening. I think now would be the time to do it while I am still healing. My gut feeling before surgery was that it was not vertically long enough in the design and my feeling now is that it is just a bit short. What are your thoughts on an early custom jawline implant revision?

A: When considering an early custom jawline implant revision, let me pass along my thoughts based on an enormous experience with facial implants, particularly larger ones that are often done in young men:

1) it is critically important to wait for the true final aesthetic result to be seen and appreciated, which takes a full three months, before judging the final result from which one can make accurate and well thought decisions as to what to do next, if anything. Sitting in a hotel room alone in a different country thousands of miles from home at ten days after surgery does not really qualify as a reasoned perspective on which to make sound surgical judgments. Just because it may be convenient to consider improving an early perceived result does not make it a sound medical decision to do so. 

2) Every new surgical procedure around an implant involves additional infection risks, particularly when an intraoral incision is used. You are not even beyond the initial set of infection risks from the first surgery. (6 to 8 weeks) Having additional surgery within this time frame essentially doubles the infection risks from the first surgery.

3) I have seen patients in face and body implants who had a ‘90%’ result, and in the pursuit of a more perfect result, incurred complications that ended up with an outcome that was far less than had they just left the 90% result alone.

4) It is important to remember that when it comes to placing implants in the body, we are creating an  unnatural situation. Implants are not meant to be there and it is a marvel of the human body that they tolerate them as well as they do most of the time with a relatively low rate of complications. But every time you manipulate an implant, particularly one that seems to be doing well, you risk tipping the delicate balance between tolerance and intolerance. 

May this experienced perspective add some additional insight to your early surgical recovery,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am quite stuck and I hope you could provide some surgeon’s insight on my situation. After my cheekbone reduction, I noticed slightly deeper tear troughs lines and minor deepening of the nasolabial sulcus. The sagging was minor, but of course I was hoping for none. I’ve been consulting for cheek resuspension surgery. 

Every surgeon I’ve been to, I’ve explained my surgical history thoroughly as well as my surgical goals – which in my opinion are very reasonable. I know the hollower eyes most likely won’t be helped without an eyelid incision, which is something I am not ready for. I’ve accepted it and it doesn’t bother me too much. 

What does bother me is the nasolabial grooves and cheek puffiness towards the front of my face. I think a temporal and intraoral incision cheeklift procedure would help me solve this aesthetic issue. When I push the front of my cheeks outwards towards where the temporal incision would be, I like what I see.

However, the few surgeons I’ve visited have made me start to lose hope. Even with the surgically induced drooping, they state I am too young for a cheeklift and should stick to fillers. I really don’t want to keep going back to the office every 6 months or so until I age enough to actually get my desired surgery done. Financially and time-wise, it would be hard on me to keep getting fillers, year after year after year, as I am only in my 20s. Even if the resuspension surgery would cause major swelling, I would rather just deal with the whole ordeal once and then move on with my life. 

Is age really the only reason why I am being rejected for cheek resuspension surgery, do you think, or is there something more to it? Is there such a big risk for looking unnatural or ‘wind-swept’ if I were to pursue correcting minor sagging of the cheeks after cheekbone reduction. 

I’m really at a loss. I don’t think the end result that I want is unrealistic and since the sagging was instigated surgically, I don’t see why resuspending tissues that dropped would be ‘too much for my age.’ 

I really can’t understand if it’s me or if it’s the surgeons I’m consulting with.

A: While pushing up the cheek tissues towards the temporal region creates the desired effect, it is surgically not that predictable or simple. Lifting of any facial tissues is based on the concept that the tissues are loose and minimally elastic, as in older patients due to aging. In younger tissues they do not move the same way or stay as well even when repositioned. So to a large degree your young age is the reason surgeons are not very enthusiastic about doing any cheek lift on you. It is not a question of whether your goals are unrealistic it is really whether they are possible or worthy of the effort.

Of course there is one way to answer that question..have the cheeklift procedure done as it will either be successful or it won’t. But then you will know for sure. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am happy with results of my custom jawline implant and am now ready to tackle the masseter muscle detachment issue. It appears to me that there are three options available:

1) Muscle reattachment surgery,

2) AlloDerm or similar regenerative tissue matrix,

3) Permanent/ semi-permanent filler ( Bellafill). Each option obviously comes with its own set of pros and cons. Which approach would you recommend?

A: The one option you have left off the list, which would be under #3, is fat injections. I would not use so called permanent filler.

You are correct, each has their own advantages and disadvantages which are as follows:

1) While trying to relocate the masseter muscle is the most biologic of the treatment options, it has a low rate of success and requires the placement of neck incisions to do so.

2) Placing a layer of Alloderm (cadaveric dermis) over the missing muscle area will increase soft tissue thickeness of the implant and requires only a very small incision right at the angle to do so. Alloderm has proven to be non-resorbable.

3) Fat injections requires no incision to place and provide unlimited volume for coverage if one has enough fat to harvest somewhere. Its issues is its unpredictability of survival. This is often the first option to pursue because there is no risk of any aesthetic tradeoff.

Dr. Barry Eppley

Indianapolis, Indiana