Your Questions

Q: Dr. Eppley, I’m at 45 year-old male who had Medpor cheek implants for 18 years and had no problems until about 2 years ago. One became infected and wasn’t attached to bone or by screw so it was removed about 3 months later. I’m now at 15 months after having the implant removed and dealing with odd sensations just in my upper lip. Basically everything moves and looks fine but the area on my lip is super sensitive. I feel fine in the morning but as the day goes on and I speak it almost feels like a stretching feeling and I become aware of my upper lip. It’s bothersome but not painful. I’m thinking this is sensory nerve damage but not sure. Will it get better or what are my options for relief?

A: What you are experiencing is infraorbital nerve dysesthesia as an effect from cheek implant removal. Whether it will resolve adequately on its own depends on the linear progression of symptoms over the past year. In other words are the symptoms you are experiencing lessening over time or have they plateaued now for many months. If it is the former you give it another 6 months and see if further improvement is seen. If not then you consider infraorbital nerve decompression (removal of scar tissue around it) with fat graft coverage (a small buccal fat graft) to prevent recurrent adhesions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had surgery for scoliosis in the decades ago. My ribs literally touch my hip bones when I sit or bend. I have a hard time finding pants that sit low enough on my hips in order to keep them from trying to dig in to the very small space that is there. (maybe a finger width). I am looking to help correct this issue which I hope would leave me less boxy looking as well.

A:  What you are describing is known as Costo-Iliac syndrome, a well known ribcage problem in which the lower ribs extend down and impinge on the hip when bending over. Whether this is due to the free floating ribs being too long (rib #12) or being angulated too much downward can be debated. Please send me some pictures of your body/waist for my assessment. By your  very own description the bottom floating ribs could be removed to increase the costal-iliac distance. This may also give you more of a waistline narrowing effect to make you look less boxy. This is most effectively down by removing ribs #10 and #11 as well. Technically this rib removal is subtotal removing the outer half of the rib length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve come across the case study “Derma-Fat Grafting Of Buttock Indentations” from December 4, 2017. I have a very similar case, I have about 3 indentations on my buttocks, it looks like I’m missing part of my butt. My right buttock one is very deep and appears to have a scar/dimple and about 3 inches away from that I have another indentation that’s small. My left buttock side isn’t nearly as bad. I agree with your study on how the indentation happen, I was adopted from Russia when I was a baby, I broke out in chickenpox when I was in the process of getting adopted. I’m sure I was given lots of injections of steroids to cure my chicken pox along with immunizations and etc. I’ve been looking for answers for quite sometime as to why I have these indentations. I want to be able to feel good and confident about my self in a swimsuit along with wearing yoga pants. I’m 21 and will be turning 22 in October. I would like to know if you are able to help me and what an estimate cost would be. Thank you for your time.

A: Thank you for your buttock indentations inquiry. I would need to see pictures of your buttock indentations to provide a qualified answer. But in general fat grafting of some type (fat injections vs dermal-fat grafts) are what is needed to treat the indentations. Dermal-fat grafts do require a harvest site and scar which is fat injection grafting may be more appealing in some cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation and hairline lowering. The problem is that my skull is very small for a man size, around 52 centimeters roughly measured, And I have a very big forehead. I was approaching you to see if I could enlarge my skull, specially the back part and widen the right and left sides. And if it was possible to lower the hairline or decrease the size of the forehead along this procedure. 

A: Thank you for the skull reshaping clarifications to which I can provide the following general statements:

1) Skull augmentation and hairline lowering can not be done together or even separately. One procedure works against the other one. Once one of them is done the other can never be done.

2) Skull augmentation can be done for any part of the head, including the back and both sides using custom made skull implants from the patient’s 3D CT scan. The critical question is what amount of augmentation and whether the natural elasticity of the scalp will permit the placement of an immediate skull implant or whether a first stage scalp expansion procedure is needed to accommodate the implant’s size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been consulting surgeons in my home country to fix cheek sagging that happened after a cheekbone reduction. I hope you can give me advice because I am really stuck and very confused about what exactly I need.I am in my mid 20s and I have received varying responses from different surgeons about what they think I need. I’m not even sure what it is I need anymore.

My major problem areas are deeper nasolabial folds and puffiness around the sides of my mouth. It wasn’t a problem I had before and I would like the most ‘permanent’ solution that I can get.I’ve been suggested temporary fillers, thread lifts, fat grafting, cheeklifts, and more. I’m tossing up between the thread lift and cheeklift.  I was offered a TESS lift which is kind of like a threadlift but using permanent sutures. But I’m worried it will not have as good of an effect as it only tackles the uppermost tissues when I think the deeper tissues need to be moved.

I read on your blog that cheek sagging could be helped with an endoscopic scalp/intraoral technique or using a bone suture intraorally. Are these two techniques applicable in my case and do they tackle the deeper tissues as I need? Thank you.

A: Midfacial tissue sagging is a not uncommon aesthetic problem after cheekbone reduction surgery which is a difficult problem to improve. That is why there are so many different treatment options for it, a sure sign that there is no one universally effective treatment technique. 

The fundamental differences in the treatment approaches for postoperative cheek sagging is whether it provides more of a superficial or deeper aesthetic effect. Synthetic and autologous fillers material exert more of a superficial outward pushing effect which adds volume and fills out the tissues but with only a very limited cheek lifting effect. Implants at the bone level add volume and a more effective checklist but seem counterintuitive give the reason you had the surgery in the first place. Cheeklifts, of which there are a variety of techniques, provide a more effective soft tissue lift as the deeper tissues need to be mobilized. I would avoid placing any type of permanent sutures or threads as at your young age the placement of such materials in the facial soft tissues dos not seem like a good long-term strategy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to partially reverse my v-line surgery.My chin was perfectly fine pre-surgery. My chin was narrowed from the front view which was what I wanted, but my chin was also pushed forward 2mm without discussion.

It may seem silly to undergo another major operation just to reverse this small additional projection. But, because my chin was already aligned with my lips and nose tip pre-surgery and my chin was narrowed so much, I feel my chin just draws more attention. It now sticks out that extra length, PLUS all the soft tissue from the chin-narrowing has bunched up at the front and makes my chin all more prominent. 

My surgeon will not perform another sliding genioplasty as he says it’s not worth the very minor reversal, so I’m looking to go somewhere else. But I’m not sure what surgery path would be best. I am of asian descent and don’t scar well so I would like to know what other options I have to reduce my chin prominence. 

Would intraorally burring or cutting off the 2mm tip that it was brought forward create a hanging chin effect? I know that this may not make that huge of a difference but it would bring me peace of mind. I’m not sure what horizontal chin reduction options exist for people of asian descent.

A: Thank you for detailing your surgical history and current goals. I would agree that you are not going to redo your sliding genioplasty for a 2mm reduction of chin projection…..but you also don’t have to. There is nothing wrong with an intraoral burring chin reduction which is such a small amount of horizontal reduction. As long as the tissues are resuspended back up that should not be a problem. The even simpler approach would be a submental approach to the horizontal reduction where there is no risk of tissue sag but in an Asian female i would not put that submental scar no matter how well it usually heals.

Be aware that the soft tissue bunching effect is not going to improve as this is a normal sequelae of the bony narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have scheduled double jaw and midfacial advancement surgery with a surgeon to correct an overbite and to enhance midface projection. My surgeon has proposed two methods of approaching the midface either though a coronal or a subcoronal incision. I wanted to know what approach would you advise for me to take in regards to having a forehead implant done afterwards by you. I’d like to send in pictures for better evaluation, based on the size and shape of what id eventually want my upper 3rd to look like.

Thank you very much for your time.

A: I assume when you mean ‘subcoronal’ you are referring to a hairline or pretrichial incision as opposed to a coronal incision which is further back in the hairline. Without knowing the location of your frontal hairline and the amount of forehead augmentation you would eventually need I can not provide a fully informed answer. But as a general statement I would say the coronal incision would be better for a male who is planning on getting a custom forehead implant after their orthognathic surgery. Being placed back in the hairline it has better camouflage should the frontal hairline location change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have some midface/maxillary hypolasia and I am mostly interested in augmenting my infraorbital rims (having some more forward projection in my lower and lateral rims, maybe some elevation of the rim and some malar projection as well). Right now I only have this pic available, if you need better ones, please let me know. I live overseas and hope that in the near future I can manage to pay a visit to address this problem. Thank you very much for your attention!

A: Thank you for your inquiry. There are a variety of ways to design custom infraorbital rim implants including raising the height and projection of the bone as well as how far out onto the anterior cheek one wants the implant to reach. What is unique about a custom approach to them is that they can be designed like a ‘saddle’ to sit on the infraorbital rim producing a true 3D effect. While there are no true standard infraorbital rim implants, tear trough implants only provide a horizontal augmentation effect to the infraorbital rim.

I will have my assistant Camille contact you on Monday to schedule a virtual consultation time as well as pass along the cost of such surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It was a pleasure meeting you. You made me feel very comfortable and confident in proceeding with the surgery by exhibiting your extensive knowledge of this uncommon procedure.The pictures reflect exactly what I am looking for; a subtle more feminine change. I will be contacting your office this week to schedule an appointment. I must admit, I am very nervous about the intraoral approach after our discussion. Of course I have been researching this procedure for years at this point, and I am continuously running into horror stories about losing feeling in the lower face, and things of that nature with intraoral surgery. I know you mentioned the scar if we were to go with a submental approach, but the scar almost seems more appealing since once you said the submental approach is a direct visual of what you’re able to work with, also that you’re able to tuck in any excess soft issue/skin.

I have just a few questions that I failed to ask at the consultation (possibly due to nervousness): 

– Are there any difference as far as possible risks/complications between intraoral and submental? 

– Any differences with the healing process between the two options?

– Is there a higher chance of nerve damage with the intraoral approach?

– Does the procedure cause premature sagging or complications in the future? Of course I will be happy with a change for now, but being 26, I feel that the future is also very important.

Thank you so much! I truly look forward to working with you, I’ve heard that you are simply the best! 

A: In answer to your chin reduction questions:

1) The fundamental differences between the intraoral and the extraoral submental approach to chin reduction are a modestly higher risk of mental nerve injury (feeling to the lower lip) with the intraoral approach, the skin scar with the submental approach and a more profound bone reduction with the subcentral approach.

2) Neither of these procedures have any long-term skin sagging issues as that is addressed by the excision of extra soft tissue with the subcentral approach and the maintenance of soft tissue attachments with the intraoral osteotomy approach.

Dr. Barry Eppley

Indianapolis, Indianapolis

Q: Dr. Eppley, I have had problems for over ten years with chronically peeling, inflamed lips after taking the acne drug Accutane. I have been extensively assessed by doctors and no ongoing physical cause can be found. My upper lip causes me the most discomfort and when I exhaust all other options, I will be looking into the possibility of surgical treatment.

How feasible is this? I understand that a conservative approach can be taken by taking away a strip of vermilion, but if this failed, is drastically reducing the size of the lip (from relatively full sized to very thin) a realistic option?

A: Thank you for your inquiry. Because your lip symptoms are caused by a medication, this indicates to me that the entire dry vermilion is involved. (unless you can identify focal areas of dryness/peeling) Thus removing a strip of vermilion would seem to provide little improvement. (although it would be a conservative approach) But if that failed then you would to consider removal of all of the dry vermilion (lip resection) with a mucosal advancement flap like is done in cases of lip dysplasia/cancer involvement. The elasticity of wet mucosa allows it to stretch forward towards the vermilion-cutaneous junction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding a prominent ribcage and breast implants. I’m only 4’9 and 90 lbs,my rib cage measures 29 inches which for my frame is quite large and my breasts are about a 34a..My question is would breast implants help balance out my upper body and maybe help to make my rib cage less wide? Thank you.

A: While I have no knowledge as to what your exact body looks like, it would be logical to assume that larger breasts would help to camouflage a more prominent ribcage that lies below them. While the location of the flare of the ribcage lies well below that of the breasts, if the ribcage sticks out more than the projection of the breasts one could easily assume that increasing the size of the breasts would be of benefit.

This is a body contouring question I have heard numerous times before and, having done breast implants in such patients, my and the patient’s observation has been that it has been effective in that regard. It does not completely eliminate the ribcage protrusion, as it obviously does not affect It directly, but does provide a camouflaging effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having my chin reshaped (reduced) in order to correct asymmetry of my chin. I had x rays taken and my chin is 12mm off center. I had a consultation with a doctor and was thinking of having a sliding genioplasty procedure but I read a lot about it online and it seems like so many people have a terrible experience with the genioplasty, long term swelling and numbness, change in shape of their lips and need for revision. Alternatively I could use filler to even out the asymmetry but I think that will make my chin too large (less feminine) and I won’t be happy with it. I was reading instead about the possibility of having the bone reduced instead and I’m wondering if this is a less invasive procedure than the genioplasty with less side effects? To me it seems like it would be a lot less invasive than moving the bone but maybe it is not… Thanks!

A: The short answer to your question is that it is more important to select the chin reshaping procedure that fixes the problem the best, not the one that is least invasive. if the two options produced equal results (which I am sure they won’t) then of course you choose the least invasive. The aesthetic outcome of moving the bony chin back to the midline or shaving down the more asymmetric side may not have equivalent results. I would need to see pictures of your chin and x-rays to provide a more qualified answer for your chin reshaping needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know all the options of webbed neck correction. I have a webbed neck, but I don’t have Turner’s Syndrome. I’m 32 years old. I also want to know how people are born with webbed necks without the syndrome. No one in my family, including my children, have this deformity, except me. I am interested in the cost of these procedures, too.

A: Thank you for your inquiry. I have seen webbed necks before in patients that don’t have classic Turner’s syndrome. This is known as mosaic Turner’s syndrome. While Turner’s syndrome involves a completely missing X chromosome, mosaic Turner’s syndrome is where the abnormalities in the X chromosome only occur in some of the body’s cells. In this situation it is possible to have a webbed neck without any or very few of the other signs of Turner’s syndrome. Whether this applies to you I can not say.

I would be interested in seeing pictures of your neck to determine if webbed neck surgery correction would be successful for you.

I will also have my assistant Camille pass along the costs of webbed neck surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the list waiting to my scalp advancement and brow bone reduction and other procedures. My questions are about this 2 i mentionx today only want to reafirm with the first goals: 

– Scalp advancement with the maximun advance as i ask before using the technique one dr name frost (a minimum advance of 3cm at least).

– You tell my the burring technique can get the amoung of reduction of brow bone protusions (i measure the reduction like 4mm)

Thank you soo much!

A: In answer to your hairline advancement and brow bone reduction questions:

1) The goal of almost every frontal hairline advancement is the maximum of whatever the scalp elasticity will allow. It is very hard, and I have never seen it, where the frontal hairline is advanced too much or makes the forehead too short. The technique that is used in every case that I have ever done over the past two decades is what is decribed in the ‘frost’ technique. There is nothing new or novel about that method as that has always been the way it had been done. That being said how much hairline advancement you can get can not be precisely predicted before or guaranteed. In the end the inherent elasticity of your scalp plays as much a role as any technique used to move it.

2) With the burring technique the maximum amount of brow bone reduction is determined by the thickness of the anterior table of bone over the frontal sinus. Whether the thickness of the bone over the frontal sinus will permit a 4mm reduction can only be determined before surgery by an x-ray. This is a pertinent issue over the inner half and central brow bone areas where the frontal sinus exists. It is not an issue over the outer half of the brow bones which are solid bone and without an underlying sinus cavity. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in jaw implant augmentation and am hoping you can point me in the right path. I’m not from the US and love your work but I would feel more comfortable with a surgeon a bit more closer to home.

There’s only 2 surgeons in my country that provide custom implants. One surgeon is on the other side of the country and is trained in oralmaxillofacial surgery as well as plastic surgery. The other surgeon is within 90 minutes of where I live and background is mainly in oral maxillofacial surgery. Their use is for aesthetic purposes after corrective jaw surgeries but can also be used for primary augmentation purposes.

I understand that the experience of the doctor and work examples and having that good connection is key. But would it be safe for someone not trained in plastic surgery and plastic surgery aesthetics to perform augmentations for areas such as the jaw?

A: The direct answer to your question is the surgeon’s specific training (plastic surgery vs. oral maxillofacial surgery) is not as important as their experience in performing this very specialized type of facial surgery. If they do not have extensive experience in the designing and placement of custom facial implants the complication rates are high regardless of their surgical speciality.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am exactly 3 months post-op from a cheekbone reduction. My cheekbones were reduced with an L shaped bone cut which removed 4mm of bone from each body of the zygoma.

I’m not very happy with my current results but I’m not sure whether I am in the right position to be judging yet. A lot of doctors I’ve consulted say that my results now are pretty much the final results with unnoticeable changes to occur in the next 3 to 6 more months. Others say that I will see noticeable difference between now and 6 months post-op. I’m not sure what to believe.

I’m only 22 and I had no wrinkles next to my nose prior to surgery. At 3 months, my cheeks look puffy and slight nasolabial wrinkles have appeared. I think that the excess soft tissue that was suspended outwards fell downwards as the 4mm of bone projection was removed. Nevertheless, it is not an acceptable tradeoff for me. 

Is it too optimistic to hope that this completely resolves in the next 2 or 3 months? Could it possibly be due to residual swelling and may go away with further time and tissue contraction? My soft tissues I think are quite thick and I’m not sure if that made me more prone to soft tissue sagging.

Fillers for the rest of my adulthood is not an option for me and a cheeklift seems quite extreme. I have no jowling around the bottom area of my face, it’s just the nose wrinkles that are of concern to me. ‘m scared that my cheeks will look unnaturally pulled upwards and wide if they are pulled towards the temple. 

If I were to get my pre-surgery CT scan and got custom implants to restore my original bone structure, would this lift the tissues back out and resolve my current issue of the nose wrinkles? I am still quite young and I don’t think my tissues are stretchy and loose. Is it possible to resolve this wrinkling issue with just implants?

A: In answer to your soft tissue changes after cheekbone reduction surgery, which I have heard many times, I can provide you with the following two specific guidances:

1) The only way to know whether the soft tissue effects you see now, at 3 months after surgery, are the final result or will improve is…time. Give it a full 9 to 12 months and you will have your definite answer. Any opinion about that issue short of this time period is just that,,,an opinion not a confirmed fact.

2) Whether custom designed cheek implants will completely correct these soft tissue changes caused by cheekbone reduction can not be accurately predicted beforehand. But partially or fully reversing the cause (loss of bone upper) wold be the most anatomically based approach to the problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower facial reshaping surgery. My concerns regarding my chin/ jawline/ lower portion of my face are related to my profile and front views. From the side, I would like my jawline to look more defined, thinner. From the front, I would like my face to look thinner as well. I feel that my face from the front looks bottom heavy, I have jowls and marionette lines, even though I’m 36 and I am not, nor have I ever been, overweight-  I’m 5’6” and weigh 125 lbs.

I’ve have had these issues even when I was young so I think it is more an underlying lack of bone. The chin is possibly too short and/or too recessed than an actual aging issue. I also think I have fatty deposits in my jaw/chin/neck area.  I have looked into chin implants, sliding genioplasty, neck/chin/ jowl  liposuction and buccal fat pad removal. I feel that while the research has helped me to better articulate my concerns, it also has me confused as to what treatments would be most appropriate for my specific case.

A: Thank you for sending all of your pictures for lower facial reshaping. The key determinant in deciding what procedures to do for any facial reshaping is what are the dimensional changes needed from a 3D standpoint. If you want your jawline to have more horizontal projection (side view), be thinner from the front view as well as adds some slight vertical length , you have narrowed it down to the only two procedures that are capable of making that type of dimensional chin change…a sliding genioplasty or a custom made chin implant. Neither chin augmentation method will address the perioral fullness or jowls so microliposuction of these areas would have to be added to it as well. The role of buccal lipectomy is for reducing fullness below the cheekbone as the fat pad does not extend down to the mouth or jawline level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin reduction with bone removal a long time ago. I had a large amount of tissue that ended up causing chin ptosis and I had another surgery to try to lift and remove some of the tissue. Now my chin is not drooping but it is vertically long and uneven with dimpling.With aging and early signs of jowls my lower face looks square and masculine. I’d like my chin to be shorter and more narrow. My face lifted and more oval appearing. My chin is mostly scar tissue so I’m not sure any correcting can be done. I would like to know what could be possible. Thanks!

A: Thank you for your inquiry. I would need to see pictures of your chin and face to determine what can be done. But ti sounds like all of your prior chin eduction efforts were done from an intraoral approach, resulting in chin sagging and the need for soft tissue resuspension procedures. The best approach now, and even then, is an external submental approach where the redundant soft tissue can be more effectively managed. While additional soft tissue can be removed, the chin pad dimpling is probably not improveable.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a mild/moderate case of cutis verticis gyrata on the top of my head consisting of four ridges going from my temples to the rear of my head. Through research i found that you do fat grafting to minimize the grooves. I am begining to lose my hair and would like to have a relatively normal shaped head so that I can shave it without feeling self conscious. Do you have any before and after pictures of this procedure and approximate cost? I live out of state so it would be difficult to be there for a consultation, any info would be greatly appreciated. Thank you.

A: There are no known effective methods that are proven to reverse or partially reverse the effects of cutis verticis gyrata. I am treating such cases with linear groove release and fat injections but the success of that treatment approach, as logical and biologically based as it is, remains to be further evaluated long-term. Short-term results show good improvement, although not complete smoothing of the scalp, but its long-term effects remains to be seen. In particular will secondary fat grafting be needed for further improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had three attempts at chin augmentation with silicone injections; none have worked. Unless silicone oil has been improved and attachment techniques have improved, I need a bone implant. I need consultation to determine the next steps for chin augmentation.

A: Thank you for sending your facial pictures. You have a significant case of lower jaw/chin deficiency for which an injectable filler approach to itsaugmentation was never an option that was going to be effective. It is hard to imagine who would have tried an injection approach on you when your horizontal chin deficiency is at least 15mms if not greater.

Given the magnitude of the deficiency you are much better off with a sliding genioplasty than a chin implant for your chin augmentation. If you combined that with a lower neck-jowl lift the degree of improvement would be substantial. Bringing the chin bone out with its muscle attachment would help your neck significantly as well as that of your profile.

If a chin implant was being considered it wold have to have a design that provided substantial horizontal projection but with no lateral wings to avoid making the chin too wide.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implamts. Here are some photos to give you a general idea of how I look.  All things considered my jawline doesn’t look all to bad in these photos. My main concern is definition, I’d like there to be a more defined separation between my neck and head while at the same time improving the angularity of the jaw, helping to balance the look of my large nose while improving my overall appearance, namely in the area where the ear appears to connect to the jaw.  I’d like this to be a subtle change, one that is additive while not altogether making me look entirely different, rather an improved version of myself. I’m actually very excited to hear what you think of all this and any recommendations are very welcome.

A: Thank you for sending your pictures. By your description and the pictures, it appears that you are referring to jaw angle augmentation….and that appears to be largely about width. Your jaw angles appears to have adequate vertical length. Standard widening jaw angle implants would appear to be sufficient for your aesthetic needs. Although I would point that your result is not going to look like Tom Cruise’s jawline afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wasn’t happy with the results from my jaw reduction surgery and am now looking into jaw implants for restorative purposes. I would like to make it clear that I would like to make improvements on my current physical appearance but not return completely to my facial bone structure pre-surgery.

I am debating between custom silicone jaw implants or using PMMA cement for jaw augmentation. I understand that bone cements are quite hard to shape intraorally, but my case might be the exception as I had my current jaw structure 3D printed in life size on a trip to China I had. 

I read somewhere that PMMA could be pre-formed and I think my 3D printed jaw could be extremely helpful in this case and eliminate the need for custom silicone implants.

I was wondering, is it viable to have my own implants shaped from PMMA cement this way? Using my own 3D printed jaw bone?

Can PMMA bone cement inserted through the mouth have a high chance of presenting infections later in life? (e.g. through trauma and such) I am looking at this surgery as a lifelong restoration and would hate if I had to reopen my incisions over and over due to infections.

Lastly, I am worried about the possibility of masseter muscle disinsertion (through placement of the implants and/or from having to take them out and reinsert them in the case that infection does occur.) Is this a common problem or not-rare occurrence in jaw augmentation surgery? I hear it is a very difficult problem to fix in the case it does happen, but I would still like to length my jaw (not widen) by 7~10mm or so.

A: In answer to your subtotal jaw angle restoration questions:

1) With a 3D CT scan or 3D model, a custom design can be done for either silicone or PMMA.

2) PMMA, otherwise known as plastic bone cement, can not be accurately shaped on an intraoperative basis.

3) There is no value to a PMMA implant either in design or material compoisition. The body is not going to attach or grow tissue into it. It does have a major disadvantage, it has a much higher infectivity risk than solid silicone.

4) Having had a prior jaw angle/line reduction, your risk os massteric muscle is substantially increased for vertical jawline restoration over primary jaw angle implant placement…with a risk probably close to 50%.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Why do I have excess fat on my chin, the chin as in the middle part.It looks like a blob of fat and it’s circular and unpleasant in my opinion. 🙁 Is there anything that can be done to make it smaller?

A: I can not tell you why it is there but I can tell you what it is. What you are describing is the chin soft tissue pad which sits over the end of the chin bone. It is made up of skin, fat and muscle which is stretched out over the bone between the lower lip and the neck. It subcutaneous component varies amongst individuals and some people do have a disproportionate amount of it making it more prominent in some chins.

In large chin soft tissue pad development, reduction in its thickness or prominence may be aesthetically desired. The problem with trying to thin the chin soft tissue pad is that it runs the risk of ending up dimpled and irregular in contour shape, particularly with motion. As a result reduction of the chin soft tissue pad is usually discouraged. This is also true when liposuction is attempted to reduce its thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask a question regarding bony forehead reduction reshaping/reconstruction. My forehead bulges outwardly like that of a beluga whale and I was wondering is there anything that can be done to alter the appearance of it so it’s mess convex and more smoother/flatter. I was reading about scalp advancement and burring of the frontal bone.I’m not sure that will work in my case as my forehead isn’t like a normal one. Please advise.

A: Please send me some pictures of your forehead for my assessment and recommendations. I have seen many cases of frontal bossing and I have not yet seen one where improvement in its shape can not be done.

Reduction of a protruding forehead is done by removing the outer table of the skull bone. Whether that would be enough of a reduction to make a difference in your case remains to be seen. Ultimately a lateral skull film x-ray is needed to see the thickness of the outer table and to see how much shape difference its removal would make.

But in most cases of bony forehead reduction the amount of bone removed that can be done is usually enough to make a very visible and satisfying difference in the amount of forehead protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face is quite wide and I am interested in cheekbone reduction. I’ve done quite a bit of research online about the different techniques that exist and have read some studies online so I know exactly what I am getting myself into.

I’ve read that the L osteotomy cheekbone reduction is quite commonly used and involves taking out a wedge of bone up to 8mm wide. I would like to get my head wrapped around one thing however.

When the cheekbones are reduced, logically there is now excess soft tissue whether it’s from reducing 3mm of bone or 8mm. Where do these excess tissues go as I’ve read some people sag, some people don’t.

Do the soft tissues shrink wrap in size and how long does this process take?

Or does the soft tissue just fall downwards and create a sag that is only noticeable in some people?

A: It is important to remember that when any facial bone structure is reduced, there may be soft tissue consequences for the loss of bone support. This is particularly relevant in the chin, jaw angles and cheeks of the face. So your question about whether soft tissue sagging could occur with cbeekbone is relevant. There are numerous factors which can affect whether it occurs or not such as the amount of bone removed, the extent of the subperiosteal tissue dissection, whether soft tissue resuspension is attempted and the patient’s anatomy. It does not always occur and, even if it does, it may or may not be of aesthetic concern to the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor orbital rim implants placed just over a year ago, and my experience with them has not been positive.

The left and right sides of my face were completely numb for 3-4 months, and since then the left side has been very tingly/sensitive to the touch with no improvement. My under eye areas also always feel irritated and “full,” almost as if I always have eyelashes in my eye. Since the operation, when I look straight down I see double, and I have noticed that I now have mild scleral show in my right eye. The muscles in my face/eyes are fully functional and I have feeling everywhere, just not 100% on the left side.

I have read that it is possible that the infraorbital nerves might be being compressed by the implants, and if that is the case, could removing them cause even further damage to the nerves? Also, would removing the implants after more than a year improve the symptoms I am experiencing? 

Thank you so much for your time and consideration.

A: You did not state how your infraorbital rim implants were placed based on the symptoms you are describing. Injury or compression of the infraorbital nerve causes sensory changes such as numbness. Scar tissue and too much volume can cause lower eyelid refraction and other eye symptoms.

Whether removing them will alleviate your symptomatic concerns can not be known beforehand. One piece of information that would be helpful would be a 3D CT scan which can show where the implants sit relative to the infraorbital nerve canal as well as the implant sizee and surface area of bone coverage.

The other factor in whether you should consider implant removal is their aesthetic outcome. If it is good then that should give one pause. But if they have not achieved the desired aesthetic effects and you have these symptoms as well then removal should be more strongly considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will cheek implants cause my eyes to look hollow and sunken in? If they are too big, this might happen. 

I would like to know if I need to wait for the cheek fillers I have in to dissolve. The small shape in my cheeks I do have is because its Voluma.  Do you need my face to look at its original shape or lack thereof?

I cant afford to stay overnight for more than a day or so as well for financial reasons. I have to probably get a hotel for the trip on my there and back as well. 

A: In answer to your cheek implants questions:

1) The placement and size of a combined malar-submalar implant determines how that night affect the eyes. Although hollowing of the eyes is not a typical or expected sequelae from their placement.

2) Whether any fillers in place need to be removed or not prior to Chee implants depends on how much filler is present and how long ago it was placed.

3) There would be no need to stay in town overbite unless you are by yourself and have to drive home.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some brow bone reduction questions. So if I were to undergo brow reduction surgery, would the metal plates in my head prevent me from getting MRI’s?

What are some other things that might result from getting this surgery? I read somewhere that the forehead becomes a bit “loose” because brow reduction decreases surface area. I suppose sort of like the opposite of a brow lift. Is this true?

Will I be able to function normally after I heal (head the soccer ball with my forehead, dive underwater, sneeze, blow my nose, etc)?

Also, may I see some pictures of what the scar may look like post surgery? I know the scar will be somewhere within my hairline, but I’d like to know if it’ll be noticeable.

A: In answer to your brow bone reduction questions:

1) The metal plate used injections brow bone reduction is made of a titanium,  a non-ferromagnetic metal. It will not interfere with getting an MRI or any other x-ray study.

2) There is no truth to the statement that the forehead becomes ‘loose’ after brow one reduction surgery.

3) You should be able to perform all physical activities without restriction after surgery. But I would wait a full 6 months after the surgery before having your head hit by a soccer ball.

4) There are two location for the incision for brow bone reduction surgery, at the hairline (pretrichial) or within the hairline. (coronal) Each incision has its own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I do however still have some questions with regards to the lower blepharoplasty procedure.  My surgery is tomorrow and I’m flying out late tonight.  I hope I get to address these with you.  I really appreciate it.

After searching the limited info online about Alloderm, I read that alloderm is not permanent?  (If true, I don’t see the benefit of going with alloderm and assuming the risk of rejection and higher risk of infection).   Therefore, in the OR can we correct my hollowness by trans-positioning my fat pad and if I don’t have abundant fat pads what are other options (but not fat injections cause I dont want lumping)   Is there any permanent solution for the hollowing that would look natural?  Would that be a tear trough implant?

Another question is that my lower eye skin is crepey like ,very thin and  not tight.  Can I expect the lower blepharoplasty to address this? or Can CO2 laser be an alternative to the lower blepharoplasty?  I read online that worse crepy appearance can occur after the swelling of the lower blepharo procedure goes down. (is that true?) Is it important for you to assess the quality of my under eye skin to determine which is best for me?

Also with regards to the cheek lift  I found this picture on your website with the following description of a 47 year old female that had a cheeklift done through lower eyelid incision.  The cheek tissues were lifted up and sutured high up onto the cheekbones to a reabsorbable screw.  Would this be the technique you would use for me for my cheek lift?

A: Let me address/answer your lower blepharoplasty quesrions:

1) I have never seen Allodem resorb in the lower eyelids.

2) You probably do not have enough lower eyelid fat for transposition without running the potential risk of increasing lower eyelid hollowness. But that determination can not be made except during the procedure.

3) A tear trough implant is not appropriate for a thin-skinned hollowed lower eyelid as it will not look natural. The role of Alloderm is to serve as a method to address the lower eyelid hollowness that will not have the same risk of that of an implant.

3) While the lower blepharoplasty will improve some of the lower eyelid loose skin/wrinkles, it is not going to get rid of of all of them. My concern for you is that I don’t think you may have a realistic expectation for your lower eyelids. You can’t improve all of the aging concerns without the risk of other complications. (lower eyelid retraction, irregularities) While one can be aggressive on the upper eyelid, you must be more conservative on the lower eyelid to avoid problems. And being more conservative means you have ti settle for subtotal improvement.

4) The type of midface lift you have highlighted is as direct midface lift with fixation to the orbital rim. I just don’t use a resorbable srcrew anymore because it is very palpable for months.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in paranasal implant revision. I had Medpor paranasal implants placed one year ago. My surgeon told me that it is an implat on each side of the nose.I also had an open rhinoplasty at the same time.

Here are comparison pictures I took around 2 weeks after my surgery last year in June (I was extremely happy with the results) and around a month ago. The lighting is different and I put on around 5 pounds but I feel like since the swelling went down, I actually find the results less optimal (especially the fact that my nose still looks a bit droopy like before surgery and the nasolabial folds came back more than I would have liked)

A: Thank you for sending your pictures and detailing your surgical history. It is not rare that the facial fullness caused by midface implants early after surgery is very appealing due to its wider overall effect. But when the swelling goes down the effect is much less. I don’t know the premise for why you had paranasal implants but the treatment for nasolabial folds would not be one of them. Their primary purpose is to bring out the base of the nose which can have some slight improvement of the triangular fossa at the top of the fold next to the nose. But that effect will usually be very modest. Whether a more profound midface effect could be obtained by paranasal implant revision with a different implant design or size depends on knowing the exact paranasal implants you have in now. If they are Medpor paranasal implants they only come in one size although they may have been modified in surgery.

Dr. Barry Eppley

Indianapolis, Indiana