Your Questions

Q: Dr. Eppley, I’d like to ask 2 questions to Dr. Eppley regarding my future procedures I’m going to get from him 

1) If I get a custom jawline implant and infra-orbital-malar implant, will they always look “sharp / chiselled” or does that depend on bodyfat percentage, and if someone stores a lot of fat on his face then the implant will look “bulky” instead of “sharp/defined/chiselled” (especially the jaw and zygos)? 

2) Why do fillers (Juvederm Voluma in the jaw and chin) lose their sharpness in the first month and instead become “bulky”? Is there a scientific explanation for this? 

Thank you.

A: In answer two your custom facial implants questions:

1) The creation and persistent of any facial angularity done by custom implants depends highly on facial fat content…both initially and long-term.

2) Injectable fillers are soft gels int which the tissues pull back quickly and distort their shape to relieve the pressure they exert. The firmness of implants prevents that effect from happening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how would orbital decompression effect palpebral fissure length? I have rather wide set eyes, albeit shallow set ones, and anything that would make my eyes seem horizontally shorter would be sub optimal.

A: The orbital decompression procedure is not known to necessarily affect horizontal palpebral length. Theoretically it may as the eye settles back in but that is not an assured aesthetic effect and most likely would not do so. This aesthetic issue is not a reason to do the procedure or avoid it either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just wanted to ask a couple more questions about hip implants if that’s okay. 

I understand the pricing, the pain level, the scar, and that I need about 3cm per side custom hip implants… but I was wondering if it would feel somewhat real and soft at 3cm and won’t be noticeably fake to touch? Also if you would be able to see the implants edges, outline or sticking out in certain movements such as at the gym? The feel and look .. whether it will be noticeable that they’re implants is the only thing stopping me from getting it done. 

Thanks so much 🙂 

A: No implant anywhere on the body will ever feel perfectly natural…as it is not a natural substance in the body. Hip implants are no exception in that regard.

Edging is usually not an issue due to the feathered edges of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a deep mental crease. Some time ago I underwent a bilateral sagittal split, which I am told was successful and to date, have had no issues. I have regular checkups at the dentist and have been told that my bite is fine, after years of feeling that it wasn’t. For the deep crease the dentist did suggest fillers to me however, I understand this is only a temporary measure and I would prefer a more permanent solution if at all possible.

I did not have my chin altered during the surgery, although I was led to believe this was going to happen and was offered to have it done at a later date, but I declined their offer.

To me my chin has had such an impact on my self confidence over the years and I am wondering if you would be able to help me please 

I am based in the UK and have been unable to find anyone who does this kind of surgery.

Picture of my face taken this week and my chin this week.

Kind Regards

A: If I interpret your inquiry correctly your goal is to have the labiomental crease made less deep. Otherwise the structural shape of your chin is acceptable. While injectable fillers are one treatment option you have correctly assumed that they would be temporary Fat grafting is a more assured option for softening the deep labiomental crease and this could be done by either a percutaneous injection technique or the placement of an intraoral dermal-fat graft….each has their own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,“I am looking to enhance jaw and chin area. Attached are six photos-

1. Front- full bite/molar teeth touching

2. Front- relaxed face

3. Front- advancing chin vertically and slightly anteriorly

4. Side- full bite/molar touching

5. Side- relaxed face

6. Side- advancing chin vertically and slightly anteriorly.

#6 shows the type of chinb/jawline change I am seeking.

Thank you. 

A: Thank you for sending your pictures and demonstrating your goals. You have an overall vertically deficient chin/jawline which is most evident in the chin area with a short lower third of the face and a deep labiomental fold. Undoubtably you probably have a deep bite as well. What you are demonstrating by jutting your lower jaw forward and down is an overall vertical lengthening effect which is greatest in the chin area. This exact effect is only obtainable in a pure bone technique by doing a CHIN WING OSTEOTOMY which is an extended version of a sliding genioplasty. The alternative approach is a VERTICAL OPENING BONY GENIOPLASTY with CUSTOM JAWLINE IMPLANTS. There are advantage and disadvantage ago either approach. It really comes down to what type of change, if any, you want at the back in the jaw angle area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an orbital floor injury and subsequently had an orbital floor implant added but I may need another metal implant or simply silicone on top of it. Can that be done?

A:You can place either a custom metal or silicone implant on an existing titanium orbital floor implant. This is not a problem to do and is not uncommon as getting the exact orbital volume restored from a primary fracture repair is difficult to do. It is best done in a custom fusion using a 3D CT scan to design the add on implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is a revision genioplasty more risky than the original genioplasty? How soon can a genioplasty be revised? My surgery was two months ago and the lower part of my chin (below the fold) is still out further horizontally than my lips. I value your opinion. Thank you.

.A: In answer to your revisional genioplasty questions:

1) A secondary bony genioplasty has no ore risk than the original procedure…and in some ways may actually be less.

2) You revise a sliding genipalsty as soon as you have assurance that what is being seen is the actual result and not just swelling and lack of complete tissue adaptation yet.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a previous Custom Chin Implant that provided me with horizontal projection of my chin. However, I would like to have my chin augmented vertically with a sliding genioplasty. I am just curious if the chin implant would be needed to be removed in order for a sliding genioplasty to be performed in order to vertically lengthen my chin around 3mm.

A:Usually there is not problem with doing a bony genioplasty cut just above the chin implant and moving the chin either further forward or for vertical lengthening. But I would have to see images of the custom chin implant design to confirm that a vertical lengthening bony genioplasty can be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had upper jaw advancement surgery, and surgeon did not do alar cinch. My nose has remained the same apart from horribly flared nostrils. They flare outwards and upwards so that frontways on – my nostrils are higher either side than the tip, and they look open from the sides. I have since had alar base reduction which has helped a little but the still flare upwards at the sides. If I pull down under each nostril my nostrils look normal again. Therefore I feel I need the cinch to be done as a stand alone procedure. Please can you advise if and how this can be done..and should I approach a jaw surgeon or a nose surgeon? My previous jaw surgeon is not very helpful and states he has only eve done cinch as part of jaw operation. Many thanks

A: An alar cinch procedure is not the correct procedure for dealing with either horizontal or vertical malposition of the nostrils after a LeFort I osteotomy. That is only a preventative procedure done at the closure of a LeFort I osteotomy, Nostril repositioning by sill or nasal base skin excision is the definitive procedure to change nostril position either flaring or vertical malposition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an overbite that I’ve been told (by a couple of orthodontists) can only be fixed with jaw surgery.  And due to the overbite I have a pretty recessed chin and my nose appears bigger.

However, jaw surgery is a major surgery and I don’t have the type of support system needed to help me with the length of recovery required.  Also, it would take a long time before I could even have the surgery because of braces, etc.

So I’ve decided to instead check into improving the cosmetic aspects of my recessed chin for now instead of the underlying problem.  I’m thinking a sliding genioplasty would help a lot.  Maybe I would need an implant too.  But that is what I am contacting you for, to find out what you recommend.  My nose might still be proportionately too big also, even after improving my chin.

When I was younger I found a plastic surgeon and had a chin implant and rhinoplasty.  This was before the internet and I really didn’t know what I was doing. I had never heard of sliding genioplasty. The surgery did result in an improvement, but really not a big change. 

I’ve seen before and after photos from you and other surgeons for sliding genioplasties, and they are amazing!  It wouldn’t address my underlying problem, but it would make my profile look so much better! 

I also don’t like the size of my nose but I don’t know how it would look if my chin looked better.  And I’m noticing my face getting a little saggy around my mouth/chin due to age, but maybe the chin surgery would make that less noticeable?

Anyway, I would love to know what you recommend.  Attached are some pictures I took as well as a x-ray from my more recent orthodontist.

A: Thank you for your inquiry and sending your pictures and x-rays. As you know you have an entire short lower jaw and Class II occlusions for which jaw advancement surgery is ideal…but we know the effort to do that at this point in your life is not acceptable. Thus a sliding genioplasty is the procedure you need for cosmetic camouflage because you have both a horizontally and vertically short chin for which an implant does not do well for those combined movements. (the chin implant you have is very small and is positioned too high to have much of an effect) I have done some imaging looking at bony chin movements of 7mm forward and about 5mm vertical as a starting point. While this will help with some of the loose tissue under the chin , the submental area should be ideally treated with liposuction at the same time for best contouring. By the imaging you can see that the nose looks smaller as the lower face comes into better balance. But I also did some imaging looking at nasal tip reduction as well for you to see the combined effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I do have a few questions.  The first are related to the temples:

a.) If Dr. Eppley were to use filler this time around, would that show me pretty much exactly what an implant would look like?

b.)  What is the price differential?

c.) If I went with the implants, would open me up to the possibility of visible scarring or bruising?  How about the filler?  (I’m thinking about the fact that I have to be back at work four days after surgery.

A: In answer to your temporal augmentation questions:

1) Fillers will have some under approximation of what an implant will do as they are not comparative volumes. A standard temporal implant, for example, is the equivalent of 2.7cc of filler per side. Most patients are not going to invest 5 syringes of filler to ‘see what it looks like’.

2) Temporal implants are gong to cause some swelling which will not be gone by four days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it normal for gluteal implants placed intramuscularly to flip? And is that something that will become less common with larger implants? If not can anything be done to ensure it doesn’t happen?

A: Buttock implants placed in the intramuscular pocket have a much tighter compression against the implant and often have a wider implant base as well. s a result, It would be very rare for a buttock implant to flip in the intramuscular pocket as there is less pocket relaxation that exists than in the subfascial pocket. I have never seen it or heard of it occurring. That is the same regardless of implant size which is often less also because of the tighter pocket. Such flipping is a potential subfascial pocket concern where often lager implant sizes are used that have higher profile to base width ratios. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering how close you could get me to looking like this guy. (link attached)

I’ll attach some photos of myself and explain what I’d want to change to try and match the male model look. 

I want to know about forehead implants and how to go about getting my forehead to look as similar to his as possible. My forehead slopes back so I want it looking flat and a defined eyebrow ridge. 

I also want to know about jaw implants and how to make my jaw as angular as absolutely possible and much wider.

I really want that sucked in cheek look as well so I want high cheekbones but I’ve read that cheekbone implants aren’t very effective, is this true? 

(like this guy in the leather jacket) 

Look forward to hearing your assessment on how I could best go about looking as much like this guy or just a male model that might suit my face better. 

Kind regards

A:Thank you for your inquiry and sending your pictures. While it is good to have goals, all you can do is take the face you have and see how its proportions and shape can be changed. In that regard that means a forehead-brow bone implant, high infraorbital-malar implants with buccal lipectomies and a jawline implant is how you would reshape your face.

Traditional or standard cheek implants will not create the high cheekbone look, that is true. It requires custom infraorbital-malar implants to create it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have four to six ribs removed. I am also planning on extra large breast tissue expanders to reach a goal of 5000cc to 6000cc in each breast. Given that would it be safe to remove four ti six 4-6 floating ribs if I have 6000cc saline in my breasts? I am 1.75 cm tall and weigh 54kg. Thanks.

A: I have done rib removal in numerous women who have had breast implants well in excess of 1000ccs. I have no experience in rib removal in women with breast volumes as you have or are going to get. However, I presume your question is based on that such large breast implants would not be supported by a ribcage that has been modified? I don’t see any correlation between implant/body support and a modified lower ribcage. The strength to support that breast weight/size comes from muscle support not a fully intact ribcage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, several years ago I had a buccal lipectomy. I never liked the result and am searching for a “reversal”. In your blog I have read about the possibility to place a dermal fat graft in the buccal space. This is my preferred option since a dermal fat graft creates more assured volume than fat injections and is a solid graft. I don’t mind having a scar somewhere on the body to harvest the graft. Am I correct in assuming this solid graft would not absorb but replace the lost volume I had pre-buccal fat removal? How many of these procedures have you done in the past to correct buccal fat removal? 

Could you please tell me how much would that approximately cost? Is general anesthesia needed?

I look forward to hearing from you.

A: In answer to your Buccal Lipectomy Reversal questions:

1) It would seem logical that the type of fat graft tor replacement of a previously removed buccal fat pad would be a solid fat graft. As the buccal fat pad is an encapsulated fat pocket of around 3ccs, its replacement could similarly be a solid fat graft of similar volume.

2) While the volume retention of the implantation of a solid fat graft or fat injections can be debated, and never really proven either way on a truly comparative basis, it is more about what the patient wants to go through. Do they prefer having a body harvest site for a likely one time fat grafting procedure (solid fat graft) or do they prefer having less surgery but likely to have to repeat it more than once. (fat injections)

3) My experience in buccal space fat grating has been primarily that of the HIV facial lipoatrophy patient (type 4 and 5) and not a cosmetic buccal lipectomy patient. Although the results should be similar if not better given a more normal ‘fat state’ in a non-HIV patient..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in hairline lowering. Would I need scalp expansion to do so? I can’t tell how loose my scalp is and whether it can move a lot or not. It seems sort of flexible but I am not sure how much looseness is needed.

A: Whether your frontal hairline can be lowered without scalp expansion depends on how much forward movement the hairline needs to come and how much scalp laxity you have. The latter is more difficult to accurately answer by email but the former can be answered by sending me a picture which shows the hairline marked where you would like it to be.

But it is fair to say that scalp expansion makes every hairline lowering better and more effective but removing all doubt about the needed scalp laxity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask you about how to decide the correct size for jaw angle implants. For reference my bigonial width is 9.8cm without soft tissues and 11cm counting them, my bizygomatic width is 13.6cm. Thanks for the help and greetings.

A: The reality is there is no exact science as to how to select jaw angle implant style and size. X-rays and measurements on them are not really helpful anymore than a chest x-ray is helpful in selecting breast implant size for women. What is the most useful thing to do is computer imaging, looking at various changes in jaw angle shape and size and then seeing how you interpret those changes. From that assessment jaw angle implant styles and size is determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been suffering with rib pain for over 2 years now. I can’t walk or do activities without burning pain in my left side. I believe the worst are ribs 11 and 12, possibly 10. I saw that you’ve done surgery for the bottom ribs hitting the iliac crest. I am not sure if thats what happening to mine or not, but I am in a lot of pain. Are all CT scans 3d? I had a CT scan (with contrast) in 2017 when this first started but they did not find anything. I’ve also had a thoracic MRI but nothing found. I am running out of options and not sure wha to do.

A: I obviously can not say for certain whether #11 and #12 rib removals would be the cure for your symptoms.  In costo-iliac syndrome the long lower ribs (or shortened waist on the affected side) can impinge upon the iliac crest. This can be a source of pain that occurs or exacerbated when one bends over onto that side and the ribs actually touch the iliac crest. Otherwise all x-ray studies would usually be negative as they are done in the upright position. This is typical pain that occurs when one bends over but is relieved when one stands straight.

Whether any of this applies to you I can not say. You would certainly not want to got though such rib removals and end up with no relief of your symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two large dents (step-offs) and a large bony bulge (on left jawline) that resulted from a bad sliding genioplasty done in 2009. I just want my straight jawline back but concerns over someone not experienced in bone work, particularly in what I’ve been told is a complicated repair, have resulted in my waiting years. However, it’s time to do something and from what I’ve seen and read of your work you have performed these types of repairs before. I have pictures that will show the deformities and happy to send. Would you be willing to discuss my situation? Thank you very much for your time.

A: A 3D CT scan is needed to have an accurate assessment of both the bony stepoffs and the bony bulge. I suspect the bony bulge is due to a shift of the sliding genioplasty resulting in one wing that sticks out. This also contributes to a larger bony step off on the opposite side than would otherwise exist. This would ned to be burred down. The bony setoffs from a sliding genioplasty can be treated with an overlay implant. For the sake of absolute accuracy I would prefer to make custom implants to fill in the defects which can be designed off of your 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if it was possible to widen or enlarge my head, it is small. That along with a jawline augmentation. Is it possible to do simultaneously. How much would that cost? 

Also are there any long term side effects of placing implant on the skull? Such as headaches, or increased chances of other complications? 

A: In answer to your head widening and jaw widening questions:

1) It is possible to concurrently widen your head (temporal augmentation) at the same time as widening of your lower face.(jawline augmentation)

2) Both head and jaw widening will require custom implants to do so.

3) I have never had a patient who has developed any problems with headaches after any form of skull augmentation. This is an extracranial procedure that has no effect on the brain.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in ear reduction surgery. As you can see from the photo, I already had this surgery done but I would like to achieve better results. 

1. Could you please tell me what would be the total price of the surgery (incl. medication, preparation etc.) 

2. Will you be using dissolvable stitches? 

3. Could you use small bandages (patches) instead of big ones that go around the head? 

I took a measures and it turned out that the reduction should be around 5 mm.

A: In answer to your ear reduction questions:

1) Whomever did your original ear reduction used an inappropriate technique resulting in significant notching of your helical rim in a too high superior position.

2) But you are stuck now with using that location for the back cut across the helical rim. Although I believe I can make the helical rom smoother with a secondary ear reduction.

3) I will have my assistant Camille pass along the cost of the procedure to you on Monday. It can be done under local anesthesia.

4) Dissolveable sutures will be used.

5) Only antibiotic ointment is used as a topical dressing.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering what I could do to get a defined, sharper chin that projects downward more. I would like a more heart/diamond shaped face. 

I am content with my jaw definition/angles, but I want to project the chin and make it sharper like the model’s. 

I don’t think i would need an immensely dramatic chin implant, but I’d like to know what you think could achieve the result I desire. 

I’ve reviewed my options of a pre-made chin implant and a custom one, and I’m still not too sure what would suit me the most. 

Could the results I desire be achieve with an off-the-self chin implant? I also wanted to know what a semi-custom chin implant is, and what is the cost of custom and semi-custom chin implants. How many millimeters of projection are ample for this result? 

I’m really eager to hear what would work best for me. I appreciate you taking the time out of your day to respond! 

Thank you

A: In answer to your chin implant questions:

1) The dimensional needs of bringing your chin forward and down with a square shape can only be achieved with a custom implant design. Most likley this is a 45 degree projection of 5mms forward and 5mms down. No standard chin implant style can achieve these type of dimensional chin changes.

2) A semi-custom implant design is using another patient’s custom implant design that may (or may not work) well for someone else.

3) My assistant Camille will pass along the cost of such surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been following for website for years now. I think you are the right person that I should go to. I am looking for forehead implant, more masculine forehead, more brow bone projection, less backward vertical slope of forehead, more typical handsome male model forehead and more deep set eyes. I am an Asian male so I have very little browbone (flat) and small frontal air sinuses. I have sent my pictures.

 I have some questions:

1) How long does the swelling and bruises last? I would like to have this done may be early September so it will give me  6-7 weeks after surgery before my cruise. 

2) How much does it cost for Forehead implant?

 If we can not get this procedure done in early September then it has to be in February 2020.

Thank you and I would love to hear back from you.

 A: In answer to your forehead augmentation questions:

1) Most forehead augmentation patients will have resolution of their bruising and the major part of their swelling by three weeks after surgery.

2) Given that it takes up to a month after receiving the 3D CT scan to have the forehead implant designed and manufactured, the earliest surgery date would be mid to later September.

3) My assistant Camille will pass along the cosy of such surgery to you later today.

4) I have also attached one type of forehead augmentation change that could be achieved in you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in hip implants and rib removal/rib resection surgery for a smaller waist and longer torso done by you. A few questions regarding rib removal surgery. 

1. Can one reproduce after such surgery? 

2. What are the most common risks/long term side effects associated with such surgery? 

3. Can one resume physical activities such as yoga, working out, swimming and rock climbing after they are fully recovered? 

4. Are the organs still protected, are they at more risk of being damaged after such surgery? Can one still breathe properly for the rest of their life after such surgery?

A: Thank you for your inquiry and your very good questions to which I can say the following:

1) Rib removal surgery does not interfere with one’s ability to get pregnant.

2) The most common risks really come down to two issues, 1) acceptance of small back scars to do the surgery and 2) unpredictability of how much waistline reduction can be achieved.

3) There are no physical activity restrictions when one is fully recovered.

4) Since rib removal is subtotal there is no loss of organ protection or risk of organ injury as well as there is no short or long-term pulmonary dysfunction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am still contemplating getting fillers for jawline augmentation. it has been awhile since I contacted you. Is there any new filler that is a injectable solid or implant so I don’t have to worry about migration or accidentally injecting into an artery since it would stay one piece. I read somewhere there was one in development that injects as a liquid but immediately becomes a solid? Is there a bone paste that can be injected also that can be injected along the jawline? Anything else new that is in production I am looking for augmentation in my jaw and chin, perhaps cheeks and nasolabial too? Is the jaw and chin the least likely to have a accidental injection into an artery and you go blind, any reports of this? Is there any type of imaging that can show where the actual arteries are in the face to stay clear of while you are injecting?

A: 1) I know of no new injectable fillers that have any of the properties that you describe/desire.

2) Do not confuse so called injectable bone cements with that of injectable fillers. They have very different properties and are not used the same way.

3) There is no type of imaging that exists to avoid arteries doing injections….that only currently exists for veins around the eyes..

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Qn about staging multiple surgeries I intend to have rhinoplasty with another surgeon. In particular issue is the transition between glabella augmentation and brow bone augmentation (deep set eyes effect) 

However I am considering doing the following with you: 

– forehead/brow implants (brow bone augmentation for deep-set eyes effect, more square from front, reduce slope) 

– custom midface implant 

– custom jaw implant 

Questions:

1) Which order should be done from first to last (rhinoplasty/glabella augmentation & 3 implants)? 

(Issue is the transition between glabella augmentation & brow/forehead augmentation) 

2) Can all 3 implants above be done on same day or does it need to be staggered on different days? If so, what is priority order of the 3 implants? 

3) Will brow bone implants change the shape & height of the upper eyelid crease? 

Regards

A: In answer to your custom facial implants questions:

1) All three implants can be done at the same time.

2) I would think the rhinoplasty would be done second as how the nose is set may be influenced by all of the other facial changes.

3) Brow bone augmentation would not typically be thought of as changing the upper eyelid crease…although the short term swelling may make one think so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Some surgeons say pectoral implant on male chest lasts life time while other are saying it will last about 10 years. May I know what you think about the life expectancy of the implant? Thanks!

A: This is a question to which there should not be a mystery or any point of confusion., Pectoral Implants are made of a solid soft silicone material which will last a lifetime barring any unforeseen trauma. They should not be confused with breast implants, which are gel-filled devices, which will not last a lifetime. While there may be some places in the world tat may use gel-filled type pectoral implants, here in the U.S. only solid silicone pectoral emplace devices are manufactured and implanted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When I initially chose to do a genioplasty it was a decision based on genioplasty and rhinoplasties often being two procedures that complement each other. But I think because I never had any real concerns with the chin itself is the reason why I have been left disappointed with the result both from an aesthetic point of view and functional as per our earlier conversations. Moreover when I spoke with a maxillofacial surgeon at my hospital this week he said the horizontal deficiency was so minimal at baseline that a genioplasty should never have been done.

When I think back prior to having any surgeries my concerns with my face were fixated on a hooked nose from the side view and an upper/mid face that looked simultaneously angry/coarse and recessed. I’ve never been able to pin point exactly what it was that I didn’t like and I have never gone into detail about these concerns with any surgeon in the past which is why I think previous surgeries may have been premature and perhaps unnecessary.

The genioplasty was done last yeaer, and I had an open rhinoplasty done the year before. The rhinoplasty itself I think the side view is certainly an improvement from baseline however I also think it does look a bit too feminine while the front looks a bit unappealing and unnatural at the tip area.

I am wondering if we could perhaps have a detailed consultation to discuss if further surgeries are warranted (in addition to reversing the genioplasty) and if so, would this consultation perhaps best be done in person as opposed to over Skype.

My end goal is still to look like me, just a more balanced version that looks natural. I am hoping for a very honest conversation about what is in my best interest as I have worked hard to reach the career point that I am in and am a bit ashamed with myself that my body image issues have suddenly become this big of a problem for me

Attached are my preop photos before any surgeries were done and my current photos taken this week. I would appreciate any honest suggestions you may have.

A: My short comments are:

1) You have very nice results from you rhinoplasty and sliding genioplasty. I think those are very good improvements and almost all patients would be happy to have those changes.

2) The statement that your sliding genioplasty ‘should have never been done’ is completely off base and misinformed. You had a vertically and horizontally short chin for which the sliding genioplasty was a perfect treatment for that type of aesthetic chin deficiency.

3) If these type of changes are largely unsatisfactory I would be very concerned that any revision of them will end up any better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you again for you prompt response, and please find the previously mentioned photos attached below.

*Please note I’ve included the frontal photo me smiling that is when I feel my area of concern is most pronounced

The green on Area of Concern photo indicates bone that I would like brought ‘in’ to reduce width of face. This is on the sides of my face starting parallel to the corner of my eye and goes down for 4cm.

The purple/pink indicates the area starting under my eye sockets and going down 3cm to the bottom of my nose where I would like to reduce the extent to which the bone comes forward from my face.

A:Thank you for sending all of your pictures and a good description of your concerns and objectives to which I can say the following:

1) The cheek area you have highlighted in green can be reduced in width and is done so by anterior and posterior cheekbone osteotomies…which moves the zygomatic arch width inward which is the primary source of facial width increase in that area.

2) The area you have highlighted in purple, however, is not going to be reduced by any form of bone reduction. This anterior cheek area thickness is comprised of soft tissue which becomes exacerbated (bunches up ) when you smile. (This is a very common facial concern in smiling) The underlying bone is actually concave in contour (not convex like the zygomatic arches) and this is not a bony protrusion that can be reduced. Any further bone reduction in this area, besides not having the eternal desired effect, will expose the maxillary sinus which lies immediately beneath it.

3) The purple cheek area is a facial region for which no effective soft tissue reduction is possible. Cutting out the soft tissue is not an option as permanent injury to branches of the facial nerve will occur. Liposuction of this fibrofatty tissue in this area is ineffective. I have tried its many times and it never produces any improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have viewed your custom facial implant results and you have mentioned that attractive results depend on the soft tissue. I’m not sure if mine is thick or thick but is there a way to thin or reduce the soft tissue to make my face looked more defined with the implant. Also say if I have thick soft tissue would PEEK material give me more angularity and stretch than silicone? Thank you

A: In answer to your facial reshaping and custom facial implants questions:

1) There are a limited number of fat reduction procedures of the face (buccal lipectomy, perioral liposuction) that can be performed. Thus the results of trying to reduce the soft tissue thickness of the face are very limited.

2) It is a fallacy that one type of biomaterial over another offers superior show of a facial implant through the tissues. This makes no biomaterial property sense despite the it is a common misconception that is frequently stated. This might be true if the silicone material as like a breast implant (soft) but it is solid silicone which is quite firm.

Dr. Barry Eppley

Indianapolis, Indiana