Your Questions

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

Q: Dr. Eppley, I wasn’t aware that cheekbone reduction surgery was offered in the US as it is rarely heard of and is over shadowed by cheekbone augmentation. 

I hope you can help me as I am worried for my face. I’m one week away from being 3 months post op from cheekbone reduction. My zygomatic body was reduced by 5mm on both sides, pushed in and fixed with screws after a temporal cut to the end of the zygomatic arch (also fixed).

Two or three weeks after the large swelling went down after surgery, I noticed that my nasolabial area looked like there was wrinkling. I asked my surgeon about this and he said it was due to all the swelling in my cheeks. This being such a major surgery, I simply nodded and brushed it off and returned to my home country. 

Now that I’m so close to the three month mark, I am starting to get nervous. The nasolabial puffiness/wrinkling improved only slightly since that time I consulted with the doctor about it, but they are still deeper than it was before surgery. Specifically, the malar bag area seems slightly puffier than before and I’m not sure if it’s residual swelling or slight sagging as I’m only in my early 20s.

I consulted with two plastic surgeons in my own country, though they do not have experience with zygoma reduction. 

One surgeon said that three/four months would generally be the result I’ll have. He explained that the tightness of the zygomaticus minor and major loosened after moving my cheekbones inwards, so the puffiness was not a surprise as they wouldn’t “tighten”. Moreover, a cheeklift was not suggested but adding cheek implants (though it seems counter intuitive to add cheek implants after I went through surgery to make them less prominent.)

The other surgeon said swelling would last up to one year to 18 months, then showed me out with no other suggestions. 

I hope you can advise me on what to do, with your experience of performing this surgery. Is it possible that I still have residual swelling at this point and should wait a couple of extra months or would the swelling have dissipated by now? 

Or at 3 months is this pretty much the result I’ll have. Would an extra 3 months waiting show any noticeable improvements in your opinion?

A:The short answer to your question is, while it takes 6 to 12 months to appreciate every final detail from any kind of facial bone surgery, what you have is largely the result it will likely be. While cheekbone reduction surgery is effective at narrowing their prominences, the cheekbones are midfacial skeletal structures that provide soft tissue support. As a result in some patients the tradeoffs for such maneuvers are associated soft tissue changes which always is in the downward direction most commonly sagging in the lower cheek areas often seen as a more prominent nasolabial fold.

Dr. Barry Eppley
Indianapolis, Indiana 

Q: Dr. Eppley, I am interested in thigh implants. I wish to increase the volume of the thighs, the front and the back, I am aware that there are limitations and that everything is not possible at once. The front of the thighs, so that they grow wider would be desirable. I understand that it is probably not possible to do both the front and the back of the thighs at the same time. 

A:Thank you for sending your pictures and detailing your thigh implants augmentation objectives. You have now have thigh-calf disproportion after your calf implants. Augmenting the calfs is a very successful procedure because there is one defined muscle belly and the implant-muscle ratio is fairly high. (a lot of implant for the size of the muscle) Thigh augmentation, while it can be successfully done, is not as easy to get such a good result as calf augmentation because there is not one muscle that makes up the thigh and any implant-muscle ratio is going to be much much lower than that of the calfs. 

That being said, there are two fundamental approaches to thigh augmentation. The most biologic approach, although not one that produces the most augmentation, is to place the implant under muscle fascia. (which is always preferred in implants if possible) This largely leaves the rectus femoris muscle on the anterolateral thigh which is the largest muscle belly. The other approach is to ignore subfascial placement and place it on top of the muscle fascia. In this way a larger augmentation can be done as it does not have to stay within the defined underlying muscle fascial borders. It has a slightly higher risk of infection and implant show although the latter can be overcome by implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would such 3D custom facial implants still have a risk of asymmetry after they are inserted? I have been told that as the implant is printed to perfectly mold to every crevice and shape of your own bone, there would be no need for fixation.

A:It does not matter how any 3D custom facial implants are made or their material, they all have risks of asymmetry as they still have to be surgically placed through limited access incisions. Such surgery is not like Lego Blocks or mounting the implants on a skeletal model, they don’t just snap into place. It is far harder to do than it looks due to the presence and importance of the overlying soft tissues and the limited visualization to the bone sites that the surgeon has. A 3D design process makes it look ‘easy’ because you are just looking at the bone model but that has little to do with actually doing the surgery to place them.

And, quite frankly, whomever made the statement that they don’t need fixation because they are perfectly made to the shape of the underlying bone has either never done such surgery or has very limited experience as that is simply not true.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about liposuction irregularities.  i had liposuction 1one year ago to abdomen, then liposuction to flanks and low back. he second liposuction was done three months ago and has left me with irregularities and lumpiness, I suspect due to over aggressive treatment…can you help me? I am in great shape, muscular, thin and healthy, no meds.

A: Some modest irregularities after liposuction are common based on the quality of one’s skin before the procedure and how agres. But if they are significant they often occur in thinner patients where more aggressive liposuction has been done in an effort to maximize the contouring effect on an already thin subcutaneous fat layer. Once this has occurred it is a very difficult problem to improve as further cannula releases and smoothing efforts often will fail or at best produce a very modest improvement. Ideally the best improvement for liposuction rregularities comes from subcutaneous releases and fat grafting but this is both counterproductive to the original procedure and such patients often have no fat to harvest to do so. I would need to see pictures of the liposuction areas to provide a more qualified answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My mother wanted to know if you would recommend anything for her aging eyes, Specifically the hollowness around the upper and lower eyelids. 

A: Thank you for sending your mother’s pictures which shows hollowness (loss of volume) on both the upper and lower eyelids. The question is what type of material/graft can be used to add volume to these area. On the upper eyelids it would unequivocally be fat grafts as the upper eyelids have a lot motion so anything applied there needs to be soft. The only debate there is whether it should be done by fat injections or the open placement of a dermal-fat graft. On the lower eyelids options include fat, tissue bank dermis (Alloderm) or implants. Unlike the upper eyelids the lower eyelids don’t move much so they can tolerate grafts or implants. The one requirement they do have is the skin is thin so whatever is placed there must be smooth. For this reason I would favor cut sheets of Alloderm or autologous dermis to lay under the entire lower eyelid and down into the infraorbital-cheek junctions. Many surgeons inject fat into this area but my experience is that often ends up lumpy and puffy looking.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant put in twelve years ago and I have had intermittent pain and numbness from what I believe was a severed nerve. I read a post that you wrote for another patient’s question that sounded like he or she was in exactly the same situation. You referred to it as neuroma. Can you fix this? If a virtual consultation is better in this situation then I am open to that. Thank you.

A: Being this late out from a mental nerve injury and possible neuroma formation can only be treated one of two ways; 1) neuroma resection and direct nerve repair or 2) neuroma resection and a cross-mental nerve graft. The latter would likely more effective at this late date after the event. Whether either one of these nerve treatment approaches would be reasonable depends on the severity of your nerve symptoms. With symptoms that are intermittent in nature, at the least you should get a 3D CT scan and confirm the position of the wing of the chin amount in that side. I would suspect it is right up against the nerve. With mild symptoms simple nerve decompression can be tried by getting the implant off the nerve for your chin implant nerve pain.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get a sliding genioplasty or maybe shaving plus fillers (on the front, not on the angle of the chin). I want vertical shortening and minimal increased projection (~3 mm) and a bit more definition/chiseling on the front view. I got a rhinoplasty last August, which gives the illusion that my chin is larger. I like my side view way better but the front is worse. I’ve done a lot of research and without a doubt I am going to do something. 

A:Thank for sending all of your pictures. As you may or may not recall this is not the first time that I have seen them. Based on your own imaging and desired goals (vertical shortening and increased horizontal projection) the only treatment option would be an intraoral sliding genioplasty if one wants to use their own bone to accomplish both types of dimensional changes. The other alternative would be a submental approach from below with an inferior border reduction with the addition of a small 3mm central chin implant.

But I think a sliding genioplasty would be the bette choice as it addresses both concerns in a single procedure without an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are you familiar with or have you ever had experience with Parry Romberg syndrome? I’m a 38-year-old male patient (victim) with this disease. I had a muscle flap surgery in my 20s which failed and have had no other procedures since. There is a significant asymmetry as my right cheek has major atrophy in the soft tissue. I was wondering if a custom implant could be made to improve my looks. I’ve never wanted to go through surgery again but I was hoping new technologies may hold some hope for me.

A:  I am very familiar with Parry Romberg syndrome and have seen and treated many cases of it. Thank you for sending your pictures, you did very good with them. It appears most of the atrophic defect is in the soft tissue and not involving the underlying bone.  

You have a couple of options that would be far simpler that the initial free muscle transfer that was tried years ago. They include the following:

1) Dermal-Fat Graft placed through a nasolabial fold incision. I can’t tell if there is a scar along the nasolabal fold more not.

2) Dermal-Fat graft placed intraorally.

3) Injection fat grafting to the whole right cheek area

4) Custom midface implant (although the defect does actually involve bone. The concept is to try and push out the overlying soft tissue.

The easiest and probably first option to try is #3, injectable fat grafting. While unknown back in the time when you had your muscle transfer surgery, this is common today and is a standard approach for facial soft tissue defects of almost any kind and location. Its success in Romberg’s disease is variable because of the thing atrophic tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have inquired previously about custom implants however I have my concerns about custom jaw implants such as bone erosion and the fact they negatively impact with age so I am looking toward the chin wing osteotomy surgery option. I would like to know if you can perform a side wing (not increase the vertical size of the frontal part of the chin) but simply increase lateral jaw width and length.

I am interested in having this procedure and then repeating it for further adding width and length to my aesthetic goals. Can you do this procedure and how much does chin wing cost? 

A: Besides the fact that your concerns about jawline implants are unfounded, a chin wing osteotomy can add no width anywhere along the jawline and does not make any change back at the jaw angles. It can only provide vertical lengthening to the chin and the middle part of the lower jaw as well as increased horizontal projection of the chin. It is not a jaw widening procedure no matter how the diagrams make it look like it can. A chin wing is really an extended sliding genioplasty with long back wings to the chin segment.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, i am interested in custom infraorbital-malar implant and a custom wraparound jawline implant. I guess the best way is to do them together? 

I would be interested in predictions of custom infraorbital-malar implants and custom wraparound jawline implant, does separately and then together. 

I am also interested in before and after pictures of patient who had either such custom implants.

I guess it’s irrelevant if I do Veneers before or after?   

A: Thank you for your inquiry and sending your pictures. I will have my assistant Camille contact you to schedule a virtual consultation time. In answer to your general questions:

1) Whether one does more than one custom facial implant at one time is a personal decision not a medical one. But it is certainly common to do so.

2) Due to patient confidentiality patient pictures are not distributed without their permission…which is done by very few patients. Any such permitted pictures would be posted on the website, www.exploreplasticsurgery.com.

3) You are correct in regards to veneers, it is irrelevant whether they are done before or after. But because of the intraoral approach for much of a custom jawline implant, I would vote for veneers after that procedue is completed. to avoid any trauma to them.

4) Computer imaging of your pictures will be done after the virtual consultation is completed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am iunhappy with the appearance and shape of my chin. My bite was corrected with braces, and my chin isn’t receding or over-projected, but it is admittedly quite narrow and pointy from the front view. 

I have a tapered heart-shaped jawline/face which only serves to exacerbate my self-consciousness about my narrow and pointy chin.

I have consulted with a local surgeon, but I found out you are the go-to expert on facial bone surgeries and chin surgeries through RealSelf. I really hope you could provide some insight onto the options I was provided so that we can have some foundation to go off of during the video consultation. 

My surgeon, who is a plastic surgeon with a craniofacial background, assessed my chin at a consult and gave me three options. I would really appreciate your opinion on the suggestions as a medical expert so that I can have the best surgical plan to achieve what I desire.

(1) A laterally widening genioplasty. I was advised this would be an option as only a minor widening effect was needed. 

Would this bone widening make my lower facial shape more rounded and less angular, or would it just make my chin flat and square? Would I still have a natural curve to the chin? I’m a little worried it will make my chin more masculine looking.

(2) Hydroxyapatite on the sides of the chin. As a craniofacial surgeon, he mentioned he had quite a bit of experience with this material and that it could be placed on the sides of the chin and shaped.

However, from looking through your blog, this material seems to be quite unforgiving for augmentation purposes. I’m worried about potential asymmetry and not being able to remove the material if the shape is bumpy or doesn’t achieve what I want.

With your experience of the material, should we even entertain this option? It does seem less invasive than a bone-cutting surgery but there seems to be so much more that could go wrong (eg. asymmetry, not the right shape.) Can this material get infected?

(3) Lastly, the surgeon mentioned an implant but he did mention that off-the-shelf implants wouldn’t be suitable for my case, considering that no other dimensions of her chin need any augmentation. 

A custom implant was possible but it added on thousands financially, and for such a minor augmentation it just didn’t seem worth it. 

I am not sure what is the best option out of what I was advised. I would really appreciate your insight and I thank you for your time.

A: Thank you for your inquiry. Since I have no idea what the chin/face in question looks like nor have any knowledge as to what the aesthetic chin change goal is (I assume computer imaging has been done to determine the exact amount and extent of the chin/jawline widening effect), I can only make the following general comments:

1) Widening of the chin is accomplished by creating more width from the center of the chin back a certain distance along the jawline. That posterior widening extension will need to be longer than one would think and its shape as to be fairly precise to end up with the desired effect that is both a adequate and symmetric.

2) There is little question as to what is the best treatment option to create the desired chin widening effect…computer designed implants based on the bone on which it is intended to augment. Having precise control of their design simply can not be beaten, that is not the actual question you are asking. Because of cost considerations the actual question is what else can she done that costs less that may come close. to their effects. From that perspective I will address your current options.

3) The use of hydroxyapatite granules is very prone to irregularities and asymmetries, it is just not a precisely controllable contouring material in the unforgiving projection of the chin.

4) A widening genioplasty will make the sides of the chin wider…to a point. But there may be step offs along the back ends of the wings of the bony genioplasty when the bone flares out at its back ends when the center of the chin is widened, creating  a contour deformity along the jawline without a smooth transition. You are also correct in that it may have more a chin squaring effect than a rounding one and it does seem to a ‘solution that is bigger than the actual problem’.

5) There are standard prejowl implants that add some width to the side of the chin without increasing its horizontal projection. Whether this should be adequate I cannot say since I don’t know the exact aesthetic chin widening goal based on computer imaging. These can also be made by a special design process for whatever the desired width increases are needed.

6) There are also ePTFE (Gortex) blocks and sheets that can be handmade and carved to create one’s own intraoperatively fashioned ‘custom chin widening implants’. 

In conclusion, trying to cut and move the bone to create the exact chin widening effect one wants is harder than it seems. The chin bone can be cut and centrally widened but precise control of the resultant shape is not assured. Placing granules into a. subperiosteal tunnel and them molding them from the outside is not an assured method of bone contouring with both symmetrym, smoothness and an exact shape is desired. The best method for such minor chin widening, in my opinion, is to get a preformed implant shape to do it. As discussed there are various implant options in that regard.

Dr. Barry Eppley

Q:Dr. Eppley, I am very interested in the Lip Lift procedure and was wondering if you have experience with patients who have a slightly gummy smile? I have found that some doctors say it can make a gummy smile worse and some say it won’t affect it at all.

A: A subnasal lip lift, in the face of a gummy smile, certainly has the potential to make it slightly worse. (more gum exposure) Whether it would have no impact at all on it or whether it would slightly exacerbate it depends on how the lip lifing is being done. (% of vertical skin distance being reduced) Obviously the less lip lifting being done or a vey modest change will minimize its impact on your gummy smile but its aesthetic lip lifting effect would also be very modest. More aggressive lip lifting most certainly will as there will more likely be an elevation of the upper lip smile line. The bottom line is that any effort at lip litfing incurs the risk of making the gummy smile worse, there is no assured way to every say it can not happen. The only way to eliminate that potential risk is to either not do the procedure or do a some gummy smile correction at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I´m a patient who would like to have a rhinoplasty with you in your clinic. I have a big hump and also a big tip. I will make photos this week to send you, In the meantime I would like to know, Is that procedure very hard to perform? Should I worry that my nose won´t look natural after the first procedure?Is it usual to have more than one procedure?

A: Thank you for your inquiry. How difficult your rhinoplasty is and what that potential outcome may be will await the receipt of your pictures and my analysis of them. Seeing the magnitude of the nasal shape changes that are needed and what the thickness of your skin is goes a long way in determining how successful rhinoplasty surgery can be.

While the technical aspect of many rhinoplasty surgeries are not ‘difficult’, the outcomes of such efforts are not always completely predictable due to how the overlying skin contracts over the reshaped osteocartilaginous framework.

Rhinoplasty has well known risks of potential aesthetic issues that may require a subsequent revisional procedure. The usual stated risks is around 15%. Whether your surgery has a higher for lower risk of revisal surgery would depend on what type of shape changes you are seeking.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in an arm skin graft. I have multiple self-inflicted scars on my arm from when I was younger. I am in a much better place now and want to rid myself of their appearance from an earlier time. I have some questions about the procedure:

Where is the skin graft from? I’ve read thigh region. 

Recovery time?

Will the stitches be visible after? And for how long? I had a scar revision done and the interior stitches are still noticeable, dark. It’s been about 1.5 years. 

What is a procedure like this cost?

How soon can this be set up?

I was thinking of tattooing the area once healed, would this be a concern? How long would I need to wait?

Would it be possible/advisable to tan the area to be used as the graft to match the affected area prior?

That is all I can think of for now. It would be great to speak with you. 

A: In answer to your arm skin graft questions:

1) The skin graft is harvested from the lateral thigh.

2) Ir depends on ow you define recovery…to work in a few days depending on what kind of work you do.

3) My assistant Camille will pass along the cost of the surgery to you on Wednesday.

4) You would have to ask my assistant Camille and let her know when is a good time for you.

5) You would have to wait a minimum of three to four months after the surgery.

6) Whether you tan the donor site or not before it is harvested does not affect graft take.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction surgery for my prominent brows.
I have read your posts online and I see there are 2 different options for the scalp incision. What would you recommend for having it the least bit noticeable and the best chance of healing the best?

A: In a male, the scalp incision is usually going to be back further in the hair, rather than right at the hairline because you don’t know how stable the male frontal hairline is. The exceptions to this would be in a male if one wanted to do a hairline advancement at the same time as the brow bone reduction, one had a good familial history of hairline stabiity our one wanted to eliminate any risk at all of any hair damage along the incision line. Having used the hairline incisions in men numerous times for different indications I have not have any postoperative concerns about the scar or the recession of the front edge of the hairline behind it.

But both hairline and more posterior scalp incision can be successfully used and the scars heal well in both locations. But it is important to carefully these incision location choices in the male brow bone reduction patient.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am going through with custom infraorbital-malar implants from a CT scan. However, I am afraid that the prominence of the custom implant would be too much at 5mm. 

1.Is there a general reference for when implants would be extreme when looking at the skull, similar to where mandible angle implant width is considered extreme if it extends pass the zygomatic bone/arch?

2. Is it a bad idea for a surgeon to custom shave down a cheek implant further if it looks too prominent during surgery, even thought the implant was custom designed/fitted already? (I.e good chance of creating an abnormal shaped cheekbone?

3. I heard that custom designed implants at 5mm are more similar to the projection of off shelf implants of 3-4mm, since they have no space between the bone and implant. In general, have you noticed a 5mm custom designed malar implant to be less noticeable/prominent than a 5mm off shelf implant?

4. How much do you charge for a custom infraorbital-malar implant with both the payment to moldhouse and the expense for you to place it?

A: In answer to your custom infraorbital-malar implant questions:

1) For the midface there are no specific skeletal landmarks to keep an implant’s projection inside the ‘aesthetic window’.

2) If the surgeon feels the implant looks too big or unnatural in the cheek area after it is placed, it would be prudent for an adjustment by shaving reduction to be done at that time. I have done that many times as it is far better to have an implant that may end up slightly too small thank one that is too big. The latter has a 100% chance of revision.

3) I have never seen nor have any biologic rationale to the cheek implant comparison you have referenced. In fact it is quite the converse, custom cheek implants can much more easily be oversized compared to standard cheek implants because they cover a much greater surface area and thus their volumetric effects are more profound.

4) I will have my assistant Camille pass along the cost of the surgery to you later today.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am researching for my 20 year old son. He had a large craniectomy done two years ago and the replacement was a plastic implant. They were not able to reattach his temporal muscles and it has left a bump at his temporal area above his ear and a drooping eyelid. Can this be fixed? Can the muscle be reattached? What are the future complications? Thank you for your help.

A: Thank you for your inquiry and sending his pictures. What your son has is a temporal muscle retraction which has no functional implications. It can not now be unraveled and lifted back up and repositioned due to muscle atrophy and scarring. To treat the contour defect my approach is to build up the temporal area with hydroxyapatite cement (temporal augmnentation) to replace the bulk that was once there from the muscle. This can be done through his existing scalp incision.

The drooping eyelid is a facial nerve issue for which there is restoration of the motor nerve function that was lost. That is treated like ptosis repair to lift up the eyelid to a better level to the upper rim of the iris of the eye.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip asymmetry surgery. I have upper and lower lip asymmetry. I have had it as long as I can remember. It is present when I am not smiling and becomes more so when I do smile. What can be done for it?

A: Thank you for sending your lip asymmetry pictures and lip asymmetry surgery objectives. In the rest position I can see a left upper lip asymmetry with less very vermilion exposure and the lower lip looks just fine. In animation the left upper lip asymmetry becomes more noticeable and the lower develops an asymmetry the left side of the lower lip staying in the same position while the right lower lip gets pulled down. (which is normal) The lower lip acts like a marginal mandibular nerve paresis where the depressor muscle is not working.

The two things you can do are a left upper lip vermilion advancement to correct the upper lip asymmetry. This will provide improvements at both rest and in animation. Since you can’t bring depressor muscle movement back into the left lower lip side, the initial treatment should be Botox injections into the right lower lip depressor muscle to se how much correction of the lower lip occurs in animation. If successful and the Botox proves that weakening the normal depressor action of the lower lip is effective, one can move on to having a subtotal depressor muscle resections done for a permanent effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone lowering. I would like a few changes on the upper eyelid or lower brow bone area of my face. I have attached an image below with the desired transformation. Do you believe that degree of change to be realistic for both eyes? If yes, would it be possible to do with some sort of upper eyelid filler? Would it be dangerous to inject in the inner eyelid corners as shown in the GIF image? Also, some eyelid surgeons claim filler in the upper eyelid tends to last for much longer time (2-3 years) compared to fillers injected in different areas of the face. Have you noticed so in your practice?

Thank you.

A: Your brow bone augmentation request is not rare in my young male facial reshaping experience. However brow bone (lowering via augmentatio is not possible with any method as you can not drive the eyebrows downward in any reliable and predictable fashion. This is not possible with filler, fat or even implants. That type of periorbital change is simply not an achievable goal. While brow bones can be augmented to create increased horizontal projection, make the soft tissues (eyebrow) to follow the augmented brow bone downward dress not happen

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Where are the incisions for lower eyelid surgery to remove excess skin? I’m 1/2 East Indian so culturally, I do not scar well. I had to get a complete hysterectomy a couple months ago and the scars on my stomach, albeit small, are darkened. I utilized silicon tape to flatten them but the 3 marks are still visible.I can’t have visible scars on my eyes. Just want to make sure this procedure can be done without leaving visible darkened marks.

 A: Lower blepharoplasty incisions are placed right under the lashline of the lower eyelids. Regardless of ethnicity blepharoplasty incisions heal well because of the thinness of the skin and certainly can’t be compared to what happens in body areas below the neck like on the abdomen, back or extremities. Having made lower blepharoplasty incisions for a wide variety of reasons in darker skinned patinents, besides aging, I have not seen increased pigmentation of them. Nor have I see any adverse healing or hypertrophic scars from them. But your concerns are understandable as it would be with any incision on your face. But that being said, when in doubt, the safest course of action is to not make the incisions.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, For an endoscopic cranial cheeklift , is it possible to lift the cheeks vertically without an eyelid incision? My eyelid skin is quite thin and ideally I would not like them cut. How long is the cranial/temporal incision?

2) How many times have you performed this surgery on young individuals in the same situation? I’ve been consulting surgeons who have rejected me for any sort of resuspension or lifting due to my young age and have just been pointed to fillers, which is quite upsetting. 

3) Are the sutures used in this surgery permanent or can dissolving sutures be used? Are they palpable in any way? I know endotine cheek lifts are an option but I do not think that work as well and am scared of the palpability due to my thin skin.

4) You’ve mentioned that two weeks would be the maximal recovery for swelling. I am planning to have this surgery done during my break which is just over a month and a couple weeks, but I would have limited time in Indiana as I am a non-American. Would it be possible for me to have the cheek resuspension surgery, wait out two weeks for majority of the swelling to dissolve, and then undergo a chin osteotomy procedure with my zygoma reduction surgeon back in my home country after the two weeks?

I understand it would be a lot of protracted swelling but is there any reason I cannot.

A: In answer to your endoscopic cranial cheeklift questions:

1) It is usually best to have a small incision at the eyelid so the subperiosteal dissection can be thoroughly completed and connect the tunnel between the skull and the intraoral incision for full cheek mobilization.

2) Most of these cranial suspended cheek lifts have been done on older patients. I have done only a handful on younger patients who have either had cheek implants removed or have had cheekbone reduction surgery.

3) The suspension sutures used are dissolvable.

4) I see no reason you can not have a chin osteotomy done two weeks after the procedure.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was hoping to also ask you about paranasal implants.  You are the only doctor I know of that does this surgery and I would be very interested to know if you think I might benefit from this?  I have always disliked how the line between lips and the base of my nose recedes backwards.  I have read a lot online about the maxilla bone and how this can grow forwards or down.  My impression is faces are more attractive when the maxilla grows forward but mine seems to have grown down giving me a flatter face, but the surgery for shifting if forwards seems too serious for surgeons to do it for cosmetic reasons.  Therefore I was very interested to read that you can place an implant in this area.  Do you think this would work for me in addition to the other surgery we discussed?

A: In regards to midface augmentation at the paranasal level, you certainly have the face for it, meaning augmentation in this area of your faces would be aesthetically advantageous. Short of moving the teeth and upper lip forward, paranasal-maxillary augmentation (the proper term actually) creates the same effect as a LeFort 1 osteotomy advancement.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have questions about skull implant scars. I need to discuss with you some concerns regarding the skull implant procedure, primarily I am worried about the size and position of the resulting scalp scar. Of course I understand that these probably won’t be known until you have the CT scans and design, however if you could provide an estimate of its size. Can measures be taken in the design to minimize the size of the incision and what effect would this have on the desired outcome? Just as a reminder, my desired outcome is to address the  asymmetry of my head caused by the shallow depression down the right hand side.

A: It may or may not be a surprise to you that over 70% of all skull reshaping patients are men who either have thin hair, are bald, or shave their heads. As a result the location, size and methods used to close a scalp incision so the scar is as close to undetectable as possible is paramount in each and every one of them. No man wants to trade off one aesthetic head problem for another (scar) that would bother them just as much if not more than the original problem. Therefore, regardless of where the incision is located such attention to incisional detail is done in every case. The ultimate rest of that effort is determined by how many men who have had skull reshaping surgery in my experience have gone out to have a requested scalp scar revision…..zero.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, we communicated a few months ago and I wanted to give more time to heal from my sliding genioplasty that I had last year which was advanced 7mms.  I still have substantial numbness on the right side of my chin/lip, though feeling seems to slowly be coming back.  I’ve attached pictures to in attempt to illustrate my dislike of the results.  

I am happy with the advancement,  but feel I need some soft tissue repair.  My chin drops below the bone when I smile, and feels tight at the incision.  I have asymmetry with my bottom lip, left side lower, and lost volume.  Lip feels stuck to gums,  and mental labial fold too deep.  All these issue also cause my chin to be too wide and round, and vertically long. I only had an advancement, no lengthening.

A: Thank you for sending all of your pictures. Your list of chin symptoms are the following:

Tight deeper labiomental fold
Incisional tightness
Lower lip asymmetry and less volume

Chin ptosis
Vertically long and rounder chin

I list these symptoms this way because some can be predicted for a sliding genioplasty and some can not.

All of the incisional and lower lip issues are not rare from an intraoral incision where the chin bone has been advanced and mechanically makes sense.

But when the chin bone is advanced the frontal appearance of the chin usually looks more narrow not more wide. It can become vertically longer if the bone was moved that way or can appear so because the chin is more narrow. Only a postop x-ray can determine the exact chin movement that was done.

I have never heard of or seen chin ptosis developing from a bony chin advancement because the chin tissues have never been detached from bottom of the bony chin and it is being advanced as well. I don’t think what you have is ptosis, just that with the chin bone being more prominent the soft tissues of the chin stick out more but they are not falling off of the bone so to speak.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in body contouring after weight loss of 75lbs after prior bariatric surgery. My desired breast look, which was once a size D cup, is to get back to the size I was before the weight loss. I want to get rid of the extra skin sag on stomach and belly button frowns. I do not want my inner thighs touching, thighs ripple and skin above knees. My butt sags and my back legs ripple. So I don’t know what procedure/ procedures would be best and most cost effective. The lower 360 degree lift? I’m 100% getting breast implants no matter what. The rest is just if I can afford. Thank You.

A:Thank you for sending all of your pictures, they are very helpful in determining what can and can not be done for your body contouring after weight loss. Based the description of your goals, I can make the following comments:

1) While breast implants will be needed to enlarge your breasts to the size you desire, the current state of your breast shape will require some form of a lift. They have sag and asymmetry and placing implants in them will just make them top heavy and drive the nipples down, a look that no patient will find very acceptable. Depending upon the size of implant needed, you would either have to have a breast lift first (with a larger implant) or a vertical lift can be done at the same time if a smaller implant is used.

2) A full tummy tuck is needed to get rid of the loose skin on the entire abdomen. This wold be combined with flank liposuction around the waistline into the back. The 360 circumferential tummy tuck is an option but the benefit of wrapping the skin cut out completely around your body is probably not worth the back part of it since its benefits on the back side would be very limited.

3) While thigh liposuction can be done, achieving an inner thigh gap is not possible. That is not a realistic goal for just about any patient whose thighs touch.

4) There are no effective treatments for thigh or back of leg rippling or skin above the knees, short of a knee lift. But that scar has to be considered very carefully.

In summary the two most effective procedures on you are your breasts and stomach. That is where the value of body contouring surgery is for you.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I see that skull-reshaping/augmentation is a specialty of ours. Can hairline lowering be done along with the skull augmentation. My complaints are: too high forehead as well as head shape too flat on top and in back. Concerns are that once scalp pulled forward, will there be enough room to actually add filler to skull area(s) in need.

A: It is not possible to perform skull augmentation and hairline lowering in the same patient, either together or separately. Skull augmentation needs more scalp to stretch over the implant and relies on scalp stretch to do so. Hairline lowering requires the scalp to stretch to move the hairline lower which also relies on scalp stretch. One procedure works directly against the other.They can not even be staged separately as again one works against the other. If you have a skull implant you will never be able to advance the hairline thereafter. If you have had a prior hairline advancement you will not be able to get even a small skull implant in place due to the tightness of the scalp tissues.. Both skull augmentations and hairline advancements need all the scalp stretch they can get to be effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about paranasal-maxillary implants. 

1. Will the pyriform-paranasal implant offset the shadow created by my large (also high) cheekbones? My ultimate goal is to reduce the shadows on my face to a certain extent, if it can not be completely eliminate. During our consultation, I mentioned that I would like to have the ePTFE block carved into a shape not just cover the pyriform-paranasal area, but also slightly extend to the area that is around the bridge of my nose (not quite the whole cheek area but just a slight and natural extension). 

2. If I decide not to get cheekbone reduction during the same surgery, can I still get it done after I am fully recovered from my pyriform-paranasal implant surgery? My main concern is the order of the surgery. I am fully aware of the risk of potential cheek sagging but wonder if getting pyriform-paranasal implant would have any negative impact on potentially getting further cheekbone reduction in the future?

3. If I decide to have the cheekbone reduction surgery at the same time, I wonder if you could share any before & after photos of patients who had done the same surgery with you? Do I need to speak with your patient concierge assistant to update the surgeries details and get an update quote? Or another virtual consultation needs to be done before that?

Thank you very much for your time in advance,

A: In newer to your paranasal-maxillary implants questions:

1) The paranasal-maxillary implant can be extended higher up along the pyriform aperture more towards the nose. That is one advantage of either preoperative custom designs or hand making the implants during surgery.

3) Having implants in does not preclude having a cheekbone reduction procedure later.

4) I will have my assistantpass along the updated quote.I have all the information I need to do so.. To respect patient confidentiality patient pictures are not passed out.

Dr. Barry Eppley

Indianapolis, Indiana