Your Questions

Q: Dr. Eppley, I tried to get pics of my face to show my lower third facial deficiency. I live alone so had to use a selfie stick and tried to get different angles. Not too happy with my nose either but maybe it won’t look so prominent if I had a more defined jaw line. 

A: Thank you for sending your pictures. You did a good job with the selfie stick. You are correct in that your very short chin/jawline magnifies the size of your nose. When it comes to chin augmentation, all available options are on the table so to speak, each with a slightly different result. The best one in my opinion, due to the degree of short chin/jaw that you have is a sliding genioplasty with a chin implant overlay. Moving the chin bone out (not the whole lower jaw just the end of the chin bone) helps the neck a lot because it pulls out the attached muscles with it as the chin comes forward. It also serves as a bony foundation for the most of the chin augmentation and lowers the risks of just a large chin implant placed alone. The purpose of the chin implant overlay (small chin implant with long wings) is to primarily add some width to the chin at the back end of the bone cuts, which addresses the aesthetic problem of sliding genioplasties in some patients from making the chin appear more narrow from the front view as it comes forward.  In essence in challenging cases of congenitally short chins, this approach combines the best features of a sliding genioplasty and a chin implant…each of which has their own aesthetic limitations in the very short chin patient.

Attached is some imaging of you as well as an example of what the technique which I have described.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would you need to see x-rays or any other studies to consider doing a chin implant revision?

Have you ever helped anyone in my situation where a larger implant simply needs to be replaced by a smaller one?

Do you have any specialist trained in ultherapy who has experience in treating excessive facial fat?

As I live out of state, do you ever do virtual consultation through Skype, plus photographs I could send so I would not have to travel there twice if I were to be a good candidate for the procedures?

Thanks again for your time and expertise.

A:In answer to your questions:

1) A 3D CT scan of the mandible/chin is always useful to see the position of the indwelling implant on the bone.

2) Chin implant revisions are very commonly done for size, style and/or implant positioning….as many people want their chin augmentation bigger as want it smaller.

3) My medical aesthetician specialist uses Exilis for the treatment of unwanted facial fat with good success..

4) My assistant Camille will contact you to schedule a virtual consultation time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Three years ago, I went to a surgeon who said I needed a facelift, some fat injections in the cheeks and a chin implant for an “inadequate chin“. I told him I wanted some fat injections in the lips as well , but emphasized that I do not want my face to be longer because it was already too long . During the facelift, a medium-size, Medpor button implant was secured in the midline position with a number of 26 mm Stryker screws. It definitely made my face longer. In addition, from the side, the button implant curves out in a funny position, and there is some dimpling of the skin, but that was there before.

My goal is to take it out, and replace it with a much smaller implant that would not be screwed in, be in appropriate shape with the natural projection from the side.

I have frontal, AP , and lateral skull films on CD. The chin problem is definitely a part of the entire facial distortion.

If you have significant experience with revision of excessive cheek fat  injections, would be happy to learn more.

A: Thank you for your detailed surgical history and description of your current facial concerns to which I can answer the following:

1) While your existing chin implant can be replaced with a smaller one of a better shape, it will need to be screwed in as it will otherwise become malpositioned. (smaller implant in a bigger pocket) While an initial chin implant may be capable of maintaining its position due to the created pocket, such is not the case when downsizing a chin implant. (chin implant revision)

2) The best approach to excessive fat removal in challenging facial areas are energy treatments like Exilis or Ultherapy. While that is not the intent of these skin tightening devices, fat absorption is one of their well known adverse effects….which in  your case is a beneficial one. I have seen that successfully done many times.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have attached pics of my torso, I am interested in filling my chest out, attached a dream perfect chest (not expectation) chest filled out, more flat than rounded, more square.  I will not proceed with that if I cannot also do liposuction for abdominal region, normal height, weight is  6’1″, 220 lbs, my current weight is 260 lbs.

GOALS: 

1) A properly proportioned “ripped” looking, filled out chest. (through implants)

2) A Slim waist from size 44 to size 33. 

3) A flat six pack ab stomach, by removing fat from upper and lower abdomen, flanks, back, and small area around pubic bone, 

4) Abdominal line etching if possible.

I am concerned about 1) activities that might cause the implant to shift. 2) activities for best results, food and diet, exercise, 3) activities that impair results, things I should never do, or can no longer do.  4) if i get fat, where would he fat show up? I live a healthy active lifestyle as far as my injuries permit.  I’m concerned about contraindications, (i.e. My blood pressure is 120/80, but controlled with 50 mg daily atenelol), I’m much less mobile than my college football days.  I cannot get the workouts I used to have. I want to properly fit into my clothes and wear designer suits. They do not make designer suits for a man 260 lbs.

A:Thank you for your inquiry and sending all of your pictures. The first comment that I can make is that we have to be realistic with what its possible. The use of adjectives like ‘dream perfect chest’, ‘ripped chest’, ‘slim waist’, ‘flat six pack abs’….these all end goals that are not going to be achieved with any form of plastic surgery with your current body shape. Those are not achievable goals with your current weight of 260lbs for sure and may not even be if your weight was at 220lbs.

Secondly most of the fat you carry in your abdomen is intraperitoneal not subcutaneous which is very typical for middle aged men. This is fat that can only be reduced by weight loss not liposuction. These are fat collections that are not accessible to liposuction removal around the abdominal organs.

Thirdly I would agree that the chest and abdominal components are linked. There is no aesthetic sense in getting pectoral implants if the abdominal projection is not less than or at least even in profile with that of the enhanced chest projection.

Unfortunately I can not be of any assistance until at the least the intraperitoneal fat component is reduced with substantial weight loss. This not only will create a better result but will also result in the need for less surgery to try and do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking into getting jaw implants and my bottom wisdom teeth extracted. I’ve contacted several surgeons who either say it can be done in one go or I would need to extract the wisdom teeth first before jaw implants. 

What would be your stance on this?

Is a week or a week and a half between wisdom teeth extraction and jaw implants too soon?

A: I will assume you are specifically referring to the lower mandibular third molars or wisdom teeth. As a general rule you should space these two procedures 3 months apart, a week or two is insufficient. Jaw angle implants have the highest infection rate of any facial implant. Why risk doing anything that would increase that risk factor further? It is not a question of whether they can technically done together, as they can. It is a question of the wisdom in doing so. I wouldn’t recommend doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 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 and projected forward horizontally and maybe vertically as well. From the front, I would like my face to look thinner. I feel that my face from the front looks bottom heavy, I have jowls and marionette lines, even though I’m 34 and I am not, nor have I ever been, overweight-  I’m 5′ 8” and weigh 128 lbs.

I’ve have had these issues even when I was in my 20s, so I think it is more an underlying lack of bone, 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, and neck/chin/ jowl  liposuction. 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.

I have attached some current pictures to this e-mail of my face from different angles. Could computer imaging be done to help me understand the possible outcomes and what procedures would best suit my concerns?

A: Thank you for your inquiry and sending your description of your current facial concerns to which I can make the following facial reshaping comments:

1) While jawline augmentation would provide some improved definition, particularly that of chin projection and vertical jaw angle definition, i would have concerns that this may be a contraindication to the goal of also making your face thinner. By definition jawline augmentation adds volume to achieve its effect. While the jaw angle volume would be vertical and the chin volume horizontal, I have some concerns that this may still make our face ‘heavier’ due to your natural tissue thickness anatomy.

2) The real issue that you have with your fuller face is the thickness of your tissues and the jowl sagging that has developed. This is the main component to your face looking heavier. To achieve a more heart-shaped face, which I think is largely what you mean by a thinner face, your really need a jowl tuck procedure (mini lower facelift) with jowl defatting combined with chin augmentation. (which also includes getting rid of the submental crease indication. 

3) I would consider #2 the foundational procedure. I would stay away for now from any jaw angle augmentation as the last thing you need is anything that has a risk of making the lower third of your face heavier.

While on the one hand a lower ‘facelift’ seems incongruous with your relatively young age, it is what the tissues are doing anatomically that matters not their chronological age.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I recently read something you wrote from this website Real Self on recommending an implant for the correction of enophthalmos. I was wondering if you could explain your preference over using an implant instead of fat. I was also wondering if you could clarify whether a risk of filling that area with an excess amount of fat could potentially cause proptosis. Thank you very much in advance.

A: Fat injections are less well uncontrolled in terms of placement and only have a soft push on the structures that need to the lifted. In addition how much volume do you need to correct the problem, over- or undercorrection is as likely as the right amount.  A custom orbital floor-rim implant is made from the patient’s 3D CT scan where the exact anatomic differences between the two sides can be determined down to the 0.2mm level. It is the best method of true skeletal correction if that is the goal.

But the treatment plan for each enophthalmos case must be determined on an individual basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I thought it might be possible to have some form of genioplasty, sliding the chin down slightly to lessen the angle of the chin from the side. I thought moving the chin down slightly might reduce the amount of compression of the lower lip. As for the alignment of the lips I thought I might use a fat transfer or filler  to align the lips. (at a later date)

A: Your concept of moving the bony chin downward (vertical lengthening bony genioplasty) to try and drop the lower lip down with it is one that on the surface makes anatomic sense. In theory one would think there would be some relationship between the bottom position of the chin and the position of the lower lip. However in dong many vertical lengthening chin osteotomies with interpositional grafts, some up to almost 20mms, I have yet to see the lower lip pull down. (which is actually a theoretical concern about vertical chin lengthening) What that is good news for those patients with normally positioned lips, it may not be good news for someone who has your lip positional issues and is trying to change them. However I am quick to add have I ever done this operation in someone with your specific lower lip issues with that being goal.

Such an operation only makes sense for you if there is an aesthetic reason to vertically lengthen the chin. Then even if the lower lip position is not improved there would still be benefit from the surgery. In your face that is already long and narrow, such an aesthetic change would not seem beneficial.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I have three questions regarding the combined sliding genioplasty and neck liposuction procedure.

Would my recovery be much more extensive than with a chin implant?

I’ve gained about 20 lbs over the past few months. If I lost that weight, would I still need the neck liposuction?

And at my age, is it better to do neck liposuction or neck lift?

Thanks again!

A: In  answer to your questions:

1) A sliding genioplasty has some increased ‘recovery’ time from a chin implant but six weeks later that is an irrelevant issue.

 2) Since I don’t know what you looked like 20 lbs ago I can not say. But there is always one way to find out….don’t do the surgery until you lose the weight. That would be the best approach.

3) What you are referring to is the option between neck liposuction alone vs a submentoplasty (neck liposuction + muscle tightening). In fuller necks  a submentoplasty always produces a better result than just liposuction alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have bilateral slipping ribs at 10th level. My 10th rib has been slipping under the ninth and causing considerable pain for eighteen months. I am interested in a qualified plastic surgeon performing this procedure vs.a thoracic surgeon. I have yet to find a surgeon who has ever performed this procedure. Thank you for your time.

A: Thank you for your inquiry. When you refer to slipping of the 10th rib, you are likely referring to the cartilaginous end of the 10th rib where its distal end comes around to attach to the subcostal ribcage. That end of the rib is usually not fused to the ribcage and has some mobility in most people but that his usually asymptomatic. If it is excessively loose or mobile that can a rare source of pain in some people. That portion of the rib can be removed to eliminate the movement of that portion of the rib. I have performed that subtotal rib removal before as well as for other rib pain associated cases like the costo-iliac syndrome patient.

To determine of this or any other type of rib procedure would be beneficial, it would be helpful to see an actual drawing on your ribcage of where the exact location of your pain is so I have a clear anatomic understanding of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What are the reservations of my ethnicity in regards to mouth widening surgery? I am Chinese so would there be any issues? Also would there be scarring? I am very interested in this procedure yet I am quite scared of the risks because I do know it involves cutting the orbicularis muscle. I also do not see this as a popular procedure and it seems like a very rare one. My mouth is very imbalanced with the rest of my face as I have a wider face and my smile looks way too small when I smile.

A: Scars at the corner of the mouth are always a concern in any patients with an form of corner of the mouth surgery. But in Caucasian patients that does not usually turn out to be a problem But in patient with intermediate skin pigments (e.g., Asian patients) those scarring risks are increased since such skin tends to be more reactive and the risk of hypertrophic scarring is increased.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I am interested in jawline enhancement surgery. In fact I already found a surgeon locally and they arranged my surgery for next Wednesday. The reason why I am contacting you is because I accidentally saw a lady who did jawline/chin surgery from the same surgeon as mine, unfortunately she had a really bad experience. Not just her face looks weird but also she had to get implants removed due to infections. After I read her story and saw her pictures i just feel unsafe and scared. Now I am not sure if I should cancel it…. My problem is the angle of the jaw. Eight years ago I did double jaw surgery in Korea and at same time they did “v line” too , my face looks good in front view but profile not good because it is to straight and no angle at all. So my question is if I fly to Indianapolis how long do I have to stay there from first consultation to surgery. Looking forward to hear from you guys . Thank you!!

A:I can not speak to your concerns in regards to your current planned surgical procedure. What I can speak to is what I normally do in the ‘reconstruction’ of the jaw angle area in patients who have had prior V-line jaw contouring surgery. Since the jaw angles have been amputated and the two sides are never symmetric, my preference is to make custom jaw angle implants due to the altered anatomy in which a portion of the implants has to ‘hang’ off the bone so to speak. This is why I have found to be the most effective with the least risks of problems. It is possible to use standard vertical lengthening jaw angle implants also but there is a higher risk of postoperative asymmetry by doing so.

Dr. Barry Eppley

Indianapols, Indiana

Q: Dr. Eppley, I’m interested in changing the appearance of my nose. However, I understand that the typical nose job is a subtractive procedure and that patient’s potential outcomes are limited to some degree by the nose’s original dimension and position.

I’ve always wanted to correct my long philtrum, which in conjunction with my short nose, leaves a large unappealing blank space above my lip. Similar to Stephen King, although not so extreme.

As far as I’ve researched, the only procedures that exist to reduce the philtrum involve altering the upper lip, which I don’t want to do: I like my lips the way they are.

My question is, is it possible to shorten the philtrum by augmenting the nose, not the lip? Is it feasible to create a longer nose that would extend further down into my philtrum, either through use of an implant or other method?

A: The short answer is ….no. You can only change the vertical distance between the base of the nose and the upper lip (along philtrum) by removing skin. Trying to push down the base of the columella or base of the nose by any method will only exaggerate or magnify the the long upper lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I emailed with you approximately a year ago in regards oto facial masculinization, I went through with the jawline augmentation (three pieces of Goertex around my jawline), cheek augmentation and paranasal implants and am now post-op 1 month. Although It looks better than before I still am not happy with the lower/middle part of my face. I am aware that I’m still a few month away from the final result, however I realized now after some more research (which I should have done before) that the problem is my maxilla. Because the maxilla is underdeveloped I don’t get the protrusion that I need which makes my face look flat and mouth/lips sunken in.I feel like the surgeon was a bit to conservative as I wanted it a bit bigger and this might explain why.

I guess I would need both the mandible and maxilla to move forward to get the desired result. From my research there are two ways of doing it, one is bimaxillary augmentation through surgery which is very expensive + higher risks not to mention having to wear braces which adds to the cost and maybe even removing the jawline augmentation which would be a waste.

The second is from the use of braces like “Fixed Anterior Growth Guidance Appliance” (FAGGA) or DNA Appliance and such. Although They might not make as big of a difference as i would like. Which do you think would be the best choice?

Here are pictures of what I think i would look like (i tried my best with Photoshop) postop is how I look now, example 2 and 3 is what I’m guessing i would look like after using FAGGA/DNA or imaxillary augmentation. I’m not sure if the nose gets pushed forward but i implemented that in example 3 anyways (even though I’m not a fan of the nose in 3, i still look a better there than what I do now).
Because I plan to get browbone/forehead augmentation in the future it could make my face look even more “flat” as i want more brow/forehead protrusion.

Are these augmentations unrealistic?

Do you perform Bimaxillary augmentation and if so what is the price range?

Thank you

A: My comments to your facial reshaping questions are as follows:

1) More healing time will only make your results look less significant as all swelling goes away and tissue contraction pulls the elevated tissues inward. In other words your results are only going to become more ‘conservative’.

2) What you lack is overall implant volume in the midface and jawline…which is to be expected when a patchwork approach is using just laying in thin sheets of Goretex. This approach is always bound to create a minimal type result. In essence there has been a mismatch between your aesthetic facial goals and the treatment approach used to try and achieve it. This is why custom implants made from a 3D CT scan is a far more effective treatment approach for increased facial projection.

3) Comparing orthognathic surgery and any type of orthodontic bone protraction is like comparing a bullet to the hydrogen bomb. One is very minimalistic and is never going to create your desired look and the other is far more effective but tremendously invasive.

4) While maxillary profusion may be very effective you are talking about costs that will exceed $35,000 to do.

5) Any forehead/brow bone reduction without further facial change below it, is going to make your lower face look even more retrusive as you have noted.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Attached are the pictures requested. As previously mentioned, I’m interested in getting a chin implant and perioral mound liposuction. I got buccal fat removal done last year, but didn’t obtain the goal I had in mind. I have a round face, and would like to obtain a more heart shaped face, and more of a hollow cheek look as well. Please let me know what you would recommend.

Thank you 

A: Thank you for sending your pictures. To make your chin com both further forward and the more narrow you need a narrowing sliding genioplasty not a chin implant. A chin implant would help in that regard if it was custom made as most standard chin implants wil make you chin wider.

With your buccal lipectomy you should have had perioral liposuction also. A buccal lipectomy alone is an incomplete facial defatting/thinning procedure.

I trust that you do realize that your ideal facial reshaping goals, as you have indicated in the model pictures, is not a realistic goal coming from your natural facial shape. You can get definite improvement but not to level of that degree of a heart shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Before my LeFort and sliding genioplasty operation I had a very bad malocclusion but they only worked on the top jaw. It just seems my mandible is still retruded. If I go through cosmetic chin augmentation I wouldn’t want my face long like it once was. I have been told that my sliding genioplasty was 3 mm and I think it should have been 10 mms.

A: Thank you for sending your pictures and detailing your surgical history. The short version of your current situation is:

1) Your chin is still horizontally short.

2) Only a postoperative cephalometric x-rays can answer how much chin augmentation was actually and how much more can be done.

3) Further chin augmentation should be done by a repeat sliding genioplasty not an implant

4) A sliding genioplasty is far preferred in your case because it is the only chin augmentation procedure that can vertically shorten her chin as well as bring it toward AND it will pull the submental musculature forward helping to thin out the  submental area of the neck a bit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be so thankful if you could help me with a question. 

I lost eyebrows and I decided to take Lumigan. I didn’t have Latisse… but as I know it is the same. I found Lumigan 0.3 which is expired since 2016. But I used it anyway for around 1 week. It was closed and seemed like new.

Unfortunately, i used to many drops… I think it were 10 drops in a small cap in water (bottle top)… I used just a bit of it for each brow.

Later I used Revita Brow for two weeks … 

Now I am just really desperate because I’ve read that bimatoprost (Latisse) could make fat cell loss. 

My question to you:

Can it destroy fat cells around my eyebrows/eyes in just 3 weeks of usage ( + too high dosage of Lumigan and even expired … will the expired Version be stronger or less strong ?? ) 

I would be so thankful for a short answer

I really hope that in this short duration its not destroying fat cells — 

Thank you so much ! 

& 

Warm regards

A: This is not an issue of which I would have any concern with short term usage. This is a potential issue with chronic use which is how it is most commonly used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking through your site and I think I’ve figured out that I would benefit from paranasal implants. I’m confused as to what type of paranasal implant I might need, and how far it should go up the piriform aperture, and what shape it would be. I will send you a picture of me compared to a pic of what I think would be a properly filled out paranasal area. Also, I wanted to ask you about paranasal filler. Before I commit to a full implant, I would like to test filler to see if I like the result. I would like your input on how much filler I would need to approximate the result of the implant. I don’t mind using lots and lots of filler, as it would just be a one-off before I get the implant. 

Thanks!

A: There are volumetric comparisons that can be made between injectable fillers and facial implants. To make such correlations the exact shape and size of the paranasal implant is needed. Since we do not know your exact implant needs yet I would have to use standard paranasal implants as the basis. (which may or may not apply to you) In that case it would be approximately 1.8cc to 2.2cc filler per side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am searching for a surgery of skull reduction and i know that you are able to do surgeries such as reduction as well as implants. My question is will there be side effects like headaches or any other un expected side effects that might come by time  in future like 5 to 10 years as well as the back part of head (occipital) has to do with nerves that can cause serious problems and will a neurosurgeon doctor in surgery … I want to do the surgery but I am really scared because alot of doctors told me that a small mistake can cause death or it can make you never walk again and also doctors keep saying that its a really dangerous procedure and as well that one doctor told me by time like 5 to 10 years you might be mentally disabled and have Alzheimer’s disease … what is really important to me is whether it will affect my nerves or press on my brain in the future. What I really care about is that i want to be normal as I am now with just a better head shape so i can continue following my dreams in sport.

A: Thank you for your inquiry. It is important to realize that aesthetic skull reshaping surgery is an extra cranial procedure, not an intracranial one. Thus none of the adverse side effects to which you or other doctors have mentioned will occur. The biggest challenge with aesthetic skull reshaping surgery is to try and achieve the aesthetic outcomes that the patients seek.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for consulting with me about chin soft tissue reduction. I have attached the Pan X-ray and photos that you requested in order to get a better idea of the type of procedure that I require. 

My main issues with my chin are the long, sagging look from the front and side profile view and the non-smooth, jagged transition from my jaw to the chin. 

Ideally I would like for my chin to look “shorter”, tighter, and less square (more pointed) at the tip with a smooth transition line from jaw to chin. 

Thank you in advance for taking time to review my case. 

A: Thank you for sending your pictures and x-ray. What you have is chin soft tissue pad ptosis with jawline defects from your prior sliding genioplasty. Trying to make a chin that is vertically shorter, tighter and less square is a challenge as some of these dimensional changes contradict others. Such your excess soft tissue chin pad when you reduce the bone to make the chin vertically shorter and then shave the jawline to get rid of the only indents, there is going to be too much soft tissue chin pad. While some chin pad can be excised from underneath the limits of an acceptable submental incision/scar make reducing enough soft tissue chin pad laterally impossible….leading to either keeping the chin width you have now or even making it appear wider. 

While I can see the chin becoming vertical shorter and with a smoother jawline I do not see how the chin can become structurally smaller and then end up being more narrow from the front view with the volume of soft tissue chin pad that you have. This combination of desired chin changes is not surgically possible to create.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, A year ago I had zygomatic reduction in Korea. There was an incision in my sideburn and in my mouth, where they cut the bone and moved it in. I am happy with the reduction, but the part of my cheekbone that is posterior to the sideburn incision (toward the ear) still sticks out, since only the cheekbone anterior to the incision was moved in. Is there a way to reduce the bone behind the incision that is closer toward the ear?

A: That is not an infrequent ‘problem’ that is seen after cheekbone reduction osteotomies. It has to do with the projection of the remaining posterior zygomatic arch which sits behind the osteotomy. This can be reduced by an additional osteotomy further back along the arch or direct burring down of the projection right down to its temporal bone attachment.

Provided that the posterior zygomatic osteotomy was not plated, a useful technique I have found to be help for this aesthetic problem is a percutaneous osteotomy technique. By walking a small 2mm osteotome along the posterior zygomatic arch a series of bone cuts can be made to push the bone further in…without having to reopen the surgical incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, so basically I got jaw and chin implants about three weeks ago and most of the swelling went away and so my doctor told me my jaw implants are in the right place. But I really don’t think so. The bumps on my face are firm and i really think those are the implants but my doctor doesn’t want to admit it. What do you think? I’m really concerned doctor, I don’t like the outcome at all. I was expecting results like this (photoshopped picture) , but I didn’t end up like that. I asked my doctor if he can use the Implantech widening mandibular implants (WMA), so those were the ones we used. Please help, thanks so much!

A: If you really want to know where your implants are positioned, you get a 3D CT scan. That will end all debate about where they are.

At three weeks after surgery, not all the swelling is gone. Only about 2/3s of it at best has resolved. It takes up to 2 months to appreciate the fine details of any facial implant result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just wanted to thank you in advance for reading my e-mail. I have seen some of your work with regards to custom facial implants on your website as well as Real Self and I think your work is absolutely incredible. I have read nothing but good things about you on various cosmetic surgery forums as well.

There is much that I do not like about my appearance that I wish to correct in the future as soon as I am financially able to. I have written down a list of what I think I would benefit from. I am seeing my doctor tomorrow to get a referral for a 3D CT scan. I would like to find out first if I have any growth abnormalities or deficiencies with regards to my upper/lower jaw, chin and maxilla,ect.

I would like to put a detailed e-mail together with some pictures with regards to what I look like, and what I would like to achieve.

If you don’t mind I would like to ask you kind of a quick question in the meantime as my midface area is really bothering me. I have a midface that I feel is too long. The distance between my eyes (pupil to pupil) is a good amount shorter then the distance from my pupil to the middle of my mouth creating a long mid face. Ideally the length or ratio should be 1:1 roughly.

I was wondering is there is any surgical procedure that can be done that can move my mouth further up on my face without messing up other area’s of my face? There was some procedure I was reading about called a CCW Rotation or something along those line that might achieve something like this? When I smile my front 4 teeth do not show any gums but the teeth on both sides beyond that do but not by a huge amount.

I have attached a picture of myself next to a male model who’s features I really like and you can see his midface is a good distance shorter than mine. I would like to do a lip lift in the future to shorten my long philtrum as well as a rhinoplasty as this would help shorten the appearance of my long face but my mouth would still be in the same spot so the liplift would kind of only give the illusion that my midface is shorter.

As far as the whole picture of my appearance my lack of eyebrows  stand out the most in my photo’s and I underwent eyebrow restoration surgery 2 months ago which should help improve my appearance a bit.

I would love to put together a more detailed e-mail with some photo’s for reference and a list of potential procedures/implants that I think may help move me more in the direction I wish to go and would love to get your opinions and maybe do a computer graphic morph is possible.

Thank you VERY much for taking the time to read and reply to my e-mail Dr.Eppley I really appreciate it.

A: Thank you for your inquiry and sending your pictures. In short, and it is a very common concern and question, there is no non-surgical or surgical procedure that can substantially shorten the midface. (i.e.,decrease the distance between the eyebrows the base of the nose) The only procedure that is a bit helpful in that regard is a a subnasal lip lift or a vermilion advancement…procedures that shorten the distance between the lip and the base of the nose. A procedure that your picture shows would be beneficial in your case as you have a long upper distance between the base of the your nose and your upper lip. Like your eyebrow hair transplants, that is a procedure that can be performed under local anesthesia with minimal recovery and an immediate impact.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a transgender woman and am looking into possible feminisation surgery. I have heard you come highly recommend among the transgender community, I’m curious to know if my insurance with my employer would cover it? Could you give me some info on that? I appreciate any thing you can do.

A: Like all plastic surgery procedures that potentially may be covered by insurance, an insurance predetermination process needs to be done. This is where a letter is written from the surgeon with pictures and coding for the carrier to make that determination. Only by going through this process can the patient ever really know before surgery. It is not something the patient can find out by reading their policies or calling the insurance company themselves.

Even if coverage is approved for some or all of the facial feminization procedures, all expenses of surgery may not be covered. Because I do not perform these procedures in a hospital but in a surgery center, any implant items that may the used during surgery (e.g., plates and screws etc) will not be covered by insurance. This is more relevant for the brow bone reduction part of facial feminization surgery.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I had a surgery to correct my inverted nipples ten years ago and it did not work. It just left me with scarring. I read some reviews on your success with the surgery and wanted to get more information about how I go about scheduling a surgery living out of state.

A: I have found the best method for inverted nipple correction is to do a release and simultaneous placement of an interpositional graft. (e.g., stacked Alloderm wafers, dermal-fat graft) Whether that would be effective now for scarred down inverted nipples of long duration after a prior effort can not be predicted before surgery. It could only really be known by doing it. A prior procedure and scarring makes it more difficult than it would otherwise be. One test that could be help is whether you can manually make the nipple come out by gently squeeing on it. If so that is a very positive sign whether you have had prior surgery or not. I suspect, however, that yours does not even your prior surgery. That does not mean, however, that subsequent surgery may not be more successful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two questions for you:

1. I will be getting jaw surgery in order to advance both my maxilla and mandible. Would it be a good idea to let my surgeon know that I plan to see you afterwards for both custom jaw as well as midface (orbital and zygos) implants? Or would it not matter? I planned on telling him to give me the best aesthetic result he can from jaw surgery before I came to you with implants. 

2. How much forward growth can be obtained from custom midface implants (orbitals and zygomas)?

A: It is irrelevant what you are going to do with your face after orthognathic surgery, custom facial implants not withstanding. That has no influence on how the orthognathic surgery is planned or done,

The amount of forward midface augmentation (not growth) that can be done with custom facial implants is in excess of whatever anyone’s aesthetic needs are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to ask in general if it is okay to do a chin implant and cheek implant prior to jaw implant if I am considering a jaw implant as well. Or rather would it be better if all 3 implants are done at once (cheek + chin + jaw implant). Last question if a drill hole canthoplasty is done say 10 to 20 years later I wanted to do a revision are drill hole canthoplasties can it be done again does the orbital bone that’s drilled initially heal over time where another drill hole can be done again or would the previous drill hole still be used for future canthoplasty revisions. Thank you 

A: Presuming we are talking about three separate implants (chin, jaw angle and cheeks), I don’t think the order matters. It is all a personal preference as well as which procedures have the highest aesthetic priority. When they are separate implants they can be placed at any time.

Most drill home lateral canthoplasties are done as high up on the lateral orbital rim as possible. So once it is done it can never be moved higher as there is nowhere else to go.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering having a large skull augmentation. And am considering no where or no one else in the world to do it other than you and your brilliant team!

I have uploaded the photos of the shape of my head to WeTransfer.I have taken a shot from each angle, to give a thorough idea of what my head shape is like, to give the best possible idea of what I may need. I have a long birthmark running along the top of it, and asymmetric ears which might make it hard to tell the true shape. I also have quite a few asymmetries over my whole head in different areas which I would like to be corrected with whatever method I choose for a perfectly smooth outcome from all angles. 

I have also attached a few photos where I have outlined the areas I want volume to be added to. I have also attached photos of the look I am going for which is one similar to the shape of Amber Rose’s and ideally Jorja Smith’s head.

I have quite prominent facial features, and adding more volume to my head area, wether its through hair or the use of a hat, always takes the focus away from that, and balances it all out.

I have a few questions to ask before, so that I know I am clear on as much as possible before I move forward with important decision making. And also so that I can reference back to the answers whenever I need to. 

1) Ideally, I would prefer to use a material such as PMMA instead of a custom fit implant, due to my assumption that it will require smaller incisions. 

However if an implant is more suitable, will it be necessary to fly out to design the implant, and then back again for the date of the surgery? Or is it possible to design the implant without me being present, by sending over some sort of scan of my skull? 

And if not would it be possible to make the implant within days or the same week as the date of surgery?

2) From the pictures, the shape of my skull and my desire for it to be, as an estimate how much can I expect this to cost?

3) How long after the surgery date would I be able to fly back home? And then resume casual non strenuous work?

4) What solutions for reducing the visibility of scars are there? Are there any good creams or treatments?

5) How long after (and if at all), before I can return to dancing how I usually do, which is very fast, energetic and involves a lot of head banging and sudden head and neck movement?

Thank you Dr. Eppley for taking the time to read this email, and answer my questions, I really do appreciate it. 

You are the best! And I look forward to moving through with all of this!

A: Thank you for your skull augmentation inquiry and sending all of your pictures.  To answer your questions:

1) Only a custom skull implant can provide such a large area of skull augmentation in a smooth manner with a smaller scalp incision. PMMA bone cements require a full coronal scalp incision for placement and such material can not be placed over any muscular skull areas…which much of your desired skull augmentation does. PMMA bone cement is not a skull augmentation options for you.

2) Based in the total amount of skull augmentation it most likely would require a first stage scalp expansion procedure.

3) Such custom skull implants are designed are from a 3D CT scan of he patient which can be done in a remote or virtual manner.

4) It takes an average of 30 days from the receipt of the 3D CT scan to got though the design and manufacturing process to have to ready for surgery.

5) My assistant Camille will pass along the cost of the surgery to you in a day or two.

6) Most patients fly home in one to two days after other surgery.

7) Scalp incisions can heal remarkably well and the most important component in how well they heal is in how they are surgically made and closed. The use of scar creams after surgery never hurt but they are not magical.

8) They are no physical restrictions after surgery, patients return to any physical activity as they feel fit to do. I suspect it will be a few weeks, however, before any ‘head banging’ sounds or feels appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in shoulder widening surgery by lengthening the clavicle bone. How does the scapula move after the procedure and how much change can there be in shoulder width. 

About the widening, does the scapula widen in conjunction with the clavicle ? Does the bi-deltoid width increase and by how much? Also why is there such little research on this topic across the internet.

A: The scapula moves normally since the AC joint is not involved in the clavicular bony lengthening.

A 2 cm mid-clavicular osteotomy and interpositoinal bone graft is done roughy increasing shoulder width almost 1 inch per side.

The scapula bone does not widen per se, its angulation changes slightly to accommodate the change in the lateral clavicular and AC joint positions.

There is an an approximate 80% correlation between the linear lengthening of the clavicle and the increase in the outer contour of the deltoid soft tissues. Thus about 2 cms per side.

Clavicular lengthening surgery is a rare aesthetic treatment for shoulder widening given that there are already two other treatments methods which are less invasive. (fat injections and deltoid implants) Thus it is rarely requested and is done by very few surgeons around the world leading to a paucity of any information about it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope you’re well. I am loving my rib removal results. I would like to know if complete buttock hip augmentation can be done if my current buttock implants are intramuscular? Can the size of my buttock implants be increased at the same time? How common is hip implant shifting and malposition? How much hip Augmentation can be achieved with custom implants?  And my last question is have you done thigh augmentation with quadricep muscle implants? 

A: Good to hear from you and I am glad to hear that the rib removal surgery has been successful. In answer to your questions:

1) I am not completely sure what you mean by complete buttock-hip augmentation but I assume you mean a confluent augmentation as the buttocks cross into the hip area. Having hip and buttock implants in the same tissue plane is really only most relevant to very thin individuals with little subcutaneous tissue for implant camouflage. Thus I think you are alright in that regard and a hip implant that extends back over the lateral buttock area, even with intramuscular buttock implants, will work just fine.

2) Secondary buttock implant enlargement can always be done as the first implant acts like a tissue expander. As a general rule up to 50% volume increase can secondarily be done.

3) For hip augmentation a maximal thickness over the defined central projection point can be 2.5 to 3 cms per side. But don’t let that number fool you as the surface area hip implants cover is much greater than buttock implants and thus their effects are more impactful than that linear number alone would suggest.

4) I have done thigh augmentation numerous times and have a specific thigh implant design to do so.

Dr. Barry Eppley

Indianapolis, Indiana