Your Questions

Q: Dr. Eppley, I am interested in genioplasty however I would prefer biodegradable fixations. Is that possible for a lateral genioplasty. My chin is asymmetric therefore my chin would need to be moved to the right. It does not need advancement.

A: The use of metal plates and screws in common in all forms of bony genioplasty. Lactosorb biodegradable fixation devices have a long history of use in craniomaxillofacial surgery. Its use is not the most common in orthognathic surgery including bony genioplastigs. But it can be used for a genioplasty of the bony movements are not excessive. Sliding the chin to one side without an advancement is a fairly stable movement that maintains good bone contact. So the use of biodegradable devices is possible in this situation. It will cost more than the use of small metal plates and screws but it can be done if one is so motivated. It will require the use of 2.0 mm devices which will need to be prepped for the screws. The screws will engage the bone well in the downfractured segment. The only question is how well they will engage the thinner bone in the superior bone segment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 23 years old. I’ve had undereye hollows or dark circles since I was a senior in high school. To hide them, I have to pack on a lot of concealer and foundation, layer after layer, and I’m tired of doing it!

I’ve tried fillers, but they never last long (maybe 3-6 months.) I think they tend to last a lot shorter of a time because I am young and quite active. It’s taken quite a toll on my wallet and to be honest, I can’t really afford multiple top-ups every year anymore.

I’ve actually consulted some surgeons on doing fat grafting for under the eyes, but most of them have told me the same thing. My undereye skin is thin compared to the skin everywhere else, and that they couldn’t guarantee that there wouldn’t be any lumps and bumps from the fat. 

So, I’ve been looking into undereye surgeries for Asians to correct my type of issue. Where better than Korea, where they specialize in Asian surgeries?

I’ve been looking at lower eye surgeries for young individuals in Korea and came across something called under eye fat repositioning. A fair amount of clinics seem to offer this type of surgery where they somehow relocate unnecessary fat swollen in the lower eye to the more hollowed parts. 

I was wondering what is your insight onto this procedure and would it be beneficial to me in reducing my undereyes?

They say no wrinkles are incised, making it different from a lower bleph, and I’m not really sure what to make of this.

What would be your suggestions to a long-term solution to my problem? I understand that no surgery can stop the ageing process but for me, surely there would be some long-term solution that at least slows down the aging process under my eyes?

A: Thank you for your inquiry. In answer to your undereye hollows treatment questions:

1) Transpostiion of infraorbital fat out to the undereye area is a commonly performed lower blepharoplasty procedure today. However you have to have herniated or protruding infraorbital fat to do so….which you do not. Thus this form of ‘fat grafting’ will not work for you. You will have to bring fat from somewhere else into the lower eyelid to do so.

2) You have touched on the potential issue with injection fat grafting, that of irregularities. It can be an effective treatment if the fat is micronized, where the risk of irregularities is very low, but this also lowers its survival percent.

3) The other fat grafting option for undereye hollows is a dermal-fat graft which is harvested from some other body location and then placed through a lower blepharoplasty incision. This tends to survive better than injection techniques with a lower risk of irregularities but does have a donor harvest site. (scar)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have perioral fat mounds. I would like to know about options to remove them. It seems like a fairly uncommon problem and most plastic surgeons in my area are unsure how to treat it. I live out of state but I would possibly be willing to travel. I would like to see before and after photos, but I could not find them on your website. Could you tell me where to find pictures for this procedure. I may be interested in scheduling a virtual consultation sometime soon. 

A: Thank you for your inquiry in regards to perioral mound liposuction. I will have my assistant Camille contact tomorrow to schedule a virtual consultation time. In the interim I would encourage you to check out my other website, www.exploreplasticsurgery.com and search under Perioral Mounds. There you can see many blogs on this topic as well as some before and after picture results. While the treatment of perioral mounds is uncommonly done, that does not mean it is not very effective. The use of microcannulas allows for controlled removal of this small area of subcutaneous facial fat from a very small incision incision inside the corner of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 26 years old and of Asian descent. I recently flew back to my home country of Korea two months ago to get jaw angle reduction surgery for cosmetic purposes. I unfortunately didn’t communicate to the surgeon well enough (as I had thought) that I didn’t want my jaw angles amputated up to the ear, but that’s what happened and it’s something that doesn’t cause me a lot of distress and I can just deal with it. 

What does cause me distress is the newly founded pudginess or fullness of my submental area. It may or may not be residual swelling as I am only 2/3 into the minimum “full recovery” of three months, but I would like some insight if you will.

I did read a past response on courses of action, in the case the pudginess or double chin effect remains after recovery. From memory it was a soft tissue tuck from under the chin or chin liposuction. I am open to both these ideas to get rid of the double chin if it does not retract. But I do have some questions which I hope you will answer.

(1) How would liposuction help if the double chin is caused by excess soft tissue sag and skin? I do not think I had a lot of fat underneath the chin area prior to the surgery and a double chin only appeared when I smiled. Do you think that something like CoolMini fat freezing would still be beneficial in my case?

(2) If liposuction of the chin area is not the solution in my case, I would be interested in a soft-tissue tuck instead. What happens with a soft tissue tuck? Is excess skin and tissue excised from beneath the chin area? How long is the scar?

(3) As I am Asian and I personally tend to scar quite badly, I am worried that if I were to proceed with a soft tissue tuck, it may leave a nasty scar from underneath the chin. Are there any other potential methods to reduce submental fullness from jaw angle amputation or reduce the scarring from underneath?

A: in answer to your after jaw angle reduction submental tissue sag/fullness questions:

1) Whether submental liposuction would of benefit for your double chin I can not say as the would depend on the thickness of your subcutaneous tissues. At the last it would be a lot more effective than any non-surgical fat reduction therapy.

2) While a submental tuck would undoubtably be the most effective procedure, I would he very hesitant to do so in an Asian patient, particularly a young female for the obvious scar concerns.

3) Other than liposuction or a submental tuck there are no other procedures to treat your postoperative jaw angle reduction submental fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin reshaping. I was wondering if it is possible to turn a slightly tapered chin into a more curved, U-shaped rounded chin without the use of implants? Are there bone cements of some sort which are able to achieve this?

A: Chin reshaping that involves augmentation can be done using a variety of materials and implants. The problem with the use of bone cements for this aesthetic purpose is their cost, workability and smoothness. It is very hard to get bone cements placed through a semi-wet intraoral approach in a tight subperiosteal tunnel that will allow them to set up and be shaped properly. It is not impossible but their use is much more potentially problematic than that of preformed implants. Hydroxyapatite cements are mixed into a putty intraoperatively and then applied and shaped. Until they are fully set they are easily deformable. While partial set is achieved in 10 to 15 minutes, a full set may take a day. Based on these working properties it is easy to see how they can be potentially problematic for stable and assured facial bone augmentation. The use of hydroxyapatite granules is not any better as granules do not acquire a stable set shape during surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Around half a year ago, I underwent cosmetic malar bone reduction to correct some facial asymmetry. I’ve always been conscious of the asymmetry of my cheekbones and always had my hair down to cover their protrusion.

The surgery did reduce the cheekbones. When my face is in a still, non-smiling position, there is still some very very minor asymmetry but only in my eyes.I understand that perfect symmetry can’t be achieved.

However, though the surgery solved one problem, it gave rise to another.Though my surgeon corrected the asymmetry to the best of his abilities, I’m now worried about my right side. My right side initially has less of a protrusion prior to the left but my surgeon reduced the zygomatic bone by the same amount as the left.

I’m finding that on the right side of my face (right in front of the ear, right underneath the zygomatic arch bone, not the anterior bone) there is a very slight depressed area of tissue or bone (?) when I smile. I am annoyed because I spent money to fix my asymmetry problem and now I have another from trying to fix it.

I’m finding that when I smile, my bottom side on the right side juts out right underneath the depressed area. The left side doesn’t seem to have this problem and fully curves out when I smile. It makes me look lop sided when I smile and I STILL have to use hair to cover my insecurities.

What can be done to fix this? I know that it’s stupid to fix something on your face when it’s in a smiling position but I just hate that my face has become lop sided after I tried to fix lopsidedness from another area. I would like a more permanent solution if there is one.

Can hydroxyapatite cement be used to build out this area?

A: Certainly the depressed area could be augmented as it probably represents the infractured portion of the posterior zygomatic arch. There are a variety of materials that would be used to achieve this augmentation of which hydroxyapatite cement would be one of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been experiencing headaches in the occipital region for over 10 years. I’ve had injections and tried 3 different medications to no avail. It is to the point that I take 3 Alleve every other day. The pain even radiates down to my neck and shoulders and sometimes to the top of my ear. I wonder if this procedure would be helpful. My insurance is Anthem Blue Cross/Blue Shield. I’m really starting to worry about what the Aleve is doing to my body. I have not tried Botox injections yet (even though my Neurologist wanted me to try them) due to the cost. Interested to know your thoughts. The pain comes on the right side straight over from the bottom of my ear in that little indention.

A: The critical questions in candidacy for migraine surgery are: 1) does the origin and location of the migraines coincide with a cranial nerve exit point from the skull/location and 2) does it respond to Botox injections.

Based on your description it is it clear where the exact location of the migraines is A picture pointing to it would be helpful. Having the migraine location receive Botox injections would also provide useful information.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have heard and read that you are pretty innovative with techniques. I am a woman with unfortunately narrow hips. I had previously asked about hip implants. I’ve been doing some reading on these hip implants and they don’t seem to actually make the hip appear much wider. They seem to more smooth the hip out without width being the primary goal. They seem to fill in the hip dip between muscles.

I know many women who would love to have substantially wider hips, or at least the illusion of bring wider. I’ve contacted quite a few doctors about this and the responses are less than favorable with no one really willing to think outside the box to get this done correctly with natural looking results. I’m not a doctor and I have no clue what is possible in the medical field. That’s why Im contacting you. 

It seems hips are not actually the issue the more I look at anatomy, but the angle of the femur toward a wider pelvis and the way muscles form? If this is the case I really don’t want to perform any bone surgery (hip replacement or lengthening). 

Is there a way to get substantially larger hips, 2-3″ at the widest point (slightly below greater trochanter)? I envision it taking 2 implants, firstly from the actual hip bone tapered toward the greater trochanter. Secondly from the greater trochanter (actually slightly lower) tapered toward the knee? Would there be a way to anchor these implants in a submuscular position to prevent shifting? Would there be something flexible enough to stretch and move with the body and not appear unnatural while sitting?

Again, sorry, I don’t take surgery decisions lightly unless I understand them on some level. I am trying to figure the best way to stop having to wear hip pads on a daily basis like I have been for the last 3 years. If you have any insight to other surgeons who have been innovative in this area I would love to hear about them or their techniques as well.

Thank you so much for your time.

A: Since hip implants are not standard body implants that are frequently performed and so few surgeons actually do them, there are no established techniques for this type of body implant surgery. (implant design and shapes, pocket locations etc) Thus there are numerous misconceptions about them which can lead to your perceptions about them…both accurate and inaccurate. From that perspective I provide the following comments based on my experience with them.

1) There are no standard preformed manufactured hip implants. So what surgeons use for hip implants can widely vary. Unless the surgeons makes them custom for each patient based on the area of hip coverage desired, what is being used are implants ill suited injections many patients for the desired effect. I suspect the most common implant used for the hips are round buttock implants..and it is easy to see how that would be used for hip indents to fill it in. What that is a valid type of hip implant if that is what the patient wants, I would not consider that location or type of implant what many patients want for creating a more substantial hip width effect.

2) Non-hip implants are often placed in the subfascial plane on top of the TFL muscle. What it is always a good idea to place any implant in the body below as much vascularized tissue as possible, the TFL subfascial pocket is more limited in terms of the area and amount of hip augmentation that can achieved. Thus subfascial hip implants are by definition much smaller and only modestly effective.

3) Covering a larger area of the the hips requires a custom made implant as its surface area coverage needs to be much bigger. Surface area coverage for a hip implant is far more important for more significant hp augmentation than projection. This is also critically important to avoid the ‘bump on the side of the hips look’. A broad covering hip implant with feathered edges (not rounded) is also necessary to avoid visible edge transitions.

4) Such hip implants as indicated in #3 by their surface areas coverage must be placed above the TFL fascia in the deeper subcutaneous fat layer to allow for such broad hip coverage.

5) I doubt that but would be necessary to hace a hip implant that needs to be 2″ to 3′ inch to achieve a very substantial effect. Such central projections of the implant at that amount may also prevent the important feather edging of the implant given the disproportion between its height and diameter measurements.

6) All body implants today are made of very low durometer solid silicone. This makes the very soft and flexible and, as a result, they do not interfere with normal range of motion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m three months post op from zygoma reduction, and I’m just planning some backup procedures in the case of facial sagging even though I am only 23.

I would greatly appreciate it if you could answer some of my queries.

My procedure involved a 4mm resection of the zygomatic body and an inward push of the zygoma bone unit from the sideburns.

1) My understanding was, the side tissues of the face (near the ear) would not sag but simply move inwards with the inward push of the zygomatic bone. However, I’m finding that my bottom half of my face, specifically the tissues underneath where the zygomatic arch area is, are bottom heavy. Could this be sagging or residual swelling as this area is a lot puffer than the actual reduced cheekbone area.

2) How does a cheek resuspension procedure from the temples work? I’ve tried researching this but I simply don’t understand how a little suture can pin up all the tissues higher to the face.

Would this be a permanent suture or can dissolving methods be used? Would there also be hair loss? Would having screws be a hindrance to resuspension?

A: At three months after zygoma reduction, the fullness that you are seeing in your lower face is likely cheek sagging. But like all facial bone surgery I would give it a full six months after surgery to be sure all the swelling has subsided and the tissues have maximally contracted back down.

There a variety of surgical strategies to deal with the cheek sagging from tissue resuspension to facial defatting. In cheek resuspension there are a multiple of ways to perform it of which the temporal approach is but one of them…and it is my least preferred method because ideally the lift of the tissues should be more vertical rather than oblique. The true vertical cheek resuspension are either a superior cranial lift (pull) technique or an intraoral endocrine push technique.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in a browlift, sliding genioplasty, and cleft chin reduction.
I want to achieve a slimmer more sculpted face, I want the sliding genioplasty (with central wedge reduction) to give me a more v-line chin and for my profile to look sharper. 
I would like to fill in my chin dimple with fat from the rest of my face. I want my face to be skinnier. 
And I would like a hairline browlift because from what I’ve read, the results are more permanent and it doesn’t make your forehead bigger. I just want to stop having to raise my eyebrows myself 24/7. 

What is the recovery like for each procedure? 
Will it take a long time for swelling to go down until I look normal?

Also I want to get invisalign, do I have to wait a certain amount of time after a sliding genioplasty to get that? 
And I have tmj so I want botox on my masseter muscle, do I have to wait a certain amount of time to get that after sliding genioplasty?   Thank you! 

A: Thank you for detailing your concerns. I would need to see pictures off your face to determine whether the procedures you seek can be done with achieving your aesthetic goals.

A sliding genioplasty can be done to bring your chin forward and down (which helps make as face look thinner) if that type of chin change will work for the rest of your face. At the same time a central wedge reduction can be done which can have narrowing effect also. The chin dimple can be filled in with injected fat at the same time. It takes about 3 weeks before most of the chin swelling goes although it really takes several months for the true final result to be seen. There is no correlation or effect between Invisalign and chin surgery. The same applies to the masseter muscle and its treatment with Botox injections.

When it comes to the pretrichial browlilft you are correct in that it is the only browlift technique that does not change or can even lower the vertical length of the forehead.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I saw you on the Real Self. I’ve realized that you are one of the very few surgeons who do bone cement forehead augmentation. I have somewhat of a flat sloped forehead.

I know this might be a little too much to ask without pics but what is the ball park price for you performing this procedure? Thanks much.

A: While I have used the technique of bone cementorehead augmentation a lot in the past, it is not my preferred technique today for aesthetic forehead augmentation. I prefer the use of custom forehead implants which allows the procedure to be done through a much smaller scalp incision with much great accuracy and smoothness than the use of intraoperatively shaped bone cements. They have a much lower rate or revision as they shape and thickness is preoperatively determined and made,.

That being said the use of bone cements for forehead augmentation consist of two types of material, PMMA bone cement and hydroxyapatite bone cement. Both need to be placed using a full coronal scalp incision. I will have my assistant pass along the cost of either bone cement forehead augmentation to you by tomorrow.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I came across your RealSelf posts on facial reconstruction surgeries on jaw reshaping and cheek reshaping. I am very much interested in the cheekbone reshaping surgery, however I feel as if I am too close to the age where my skin and tissues just wouldn’t snap back enough. From your website and blog, I understand that the side effects really have to do with anatomy, technique, etc, but are there any extra preventative measures that can be taken during the surgery to secure the tissue to its rightful position at my age?

May I further ask, once someone has had the surgery, how does one know whether any facial changes (sagging) is a result of ageing or a result of the surgery? Is there a clear visual difference between what ageing sagging looks like and sagging deep tissue looks like?

A: Thank you for your inquiry. I would need to see pictures of your face to determine if cheekbone reshaping reduction surgery would be beneficial. At your young age tissue elasticity is not an issue when it comes to the risk of cheek sagging after bone reduction. That is more relevant at ages 40-45 and over, ages when patients rarely have this procedure done. The point being that tissue sagging after this surgery is not caused by lack of tissue elasticity in most cases.

The preventative measure that I do during surgery is to resuspend the cheek soft tissues to the metal hardware used to fix the bone segments. This can temporarily make the cheeks look too high/full but that always goes away as the swelling resolves and the tissue contraction process occurs.

Facial aging is more global and does not just occur in one facial area. Conversely sagging after cheekbone reduction occurs in just one area and looks different.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I HAVE SOME HIP IMPLANT QUESTIONS

1. IS THERE ANY RISK TO DO THE HIP IMPLANT BIGGER 14 CMS X 30 CMS X 4 CMS AS YOU PROPOSSED, (TO DAMAGE A NERVE AND BE DISABLED FOR LIFE)

2. IS THERE ANY PROBLEM DOING HIPS AND BUTT AUGUMENTATION AT THE SAME TIME, CAUSING MAYBE A MULTIPLE SEROMA LIQUID AND THEREFORE AN INFECTION.

3. IS THERE ANY PROBLEM PLACING THE HIP IMPLANT NEXT TO THE HIP JOINT (MOVILITY PROBLEMS)

I APPRECIATE YOUR ANSWERS

A: In answer to your hip implant questions:

1) There are no motor nerves in the area where hip implants are placed.

2) Any time you combine implant procedures, each of which have their own risks of infection and serous formation), the risks are increased. In other words if a single implant has a 10% risk for infection and seroma, for example, if you put four implants in then that risk is increased four fold or a risk of 40%. So yes the more implant you put in the greater the risk of potential problems. 

3) There is no problem having a hip implant placed over the hip joint as they are in completely different tissue planes or levels.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin widening surgery.  I would like a wider, more rounder looking chin. I hate the triangular shape of my lower face when I smile.  I would like to stay away from implants. What can I achieve with an osteotomy to make my chin wider.

A: Thank you for sending your pictures. When it comes to chin widening surgery, I can appreciate  your desire to stay away from implants although it is fair to point out that an implant is the simplest and most effective method to achieve what you want. Using a 3D CT scan a custom chin implant can be designed to widen the chin. It can be inserted through an intraoral approach.

While the chin can be expanded by osteotomy, one of its problems is that a step-off may be created at the sides of the chin which would become most apparent when smiling as the soft tissues are stretched back along the bone. This is an aesthetic issue that may or may not be an issue. It can be always be felt but is not necessarily visible. This can be somewhat lessened by the design of the midline osteotomy and the shape of the interpositional graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent a cheekbone reduction procedure which involved an L osteotomy of the zygomatic body of 5mm. The back end of the cheekbone was cut via a preauricular incision and the whole cheekbone unit was pushed forwards, fixed with screws.

1) Is 5mm a large amount of resected bone for the zygomatic body? My surgeon assured me that it is within the normal range and that a large amount is considered 6mm of bone or more. The numbers being so close make me extremely nervous.

2) Will wearing the facial compression band at 4-5 weeks post op help prevent sagging in any way. My surgeon did not perform any preventative resuspension methods as you do, and this makes me extremely nervous about the potential sagging. Does this lack of prevention make my chances of sagging higher? In your experience, does a lack of preventative suspension of the cheek result in sagging usually?

3) Though it’s been almost 5 weeks, my midface is unusually swollen. I am in my early 20s and the area next to my nose is particularly swollen, essentially it looks like I have quite distinct malar fat pads. Is this a potential symptom of sagging or could it be swelling? If so, why would this area be so swollen and not the actual cheekbone area.

4) As I did my surgery overseas, I am unable to go to my check ups. I will have to undergo CT scans in my home country to ensure bone union. At what point should I expect bone union or non union to have occurred. When would I be able to start eating hard foods without worry?

A: In answer to your cheekbone reduction surgery questions:

1) A 4 or 5mm vertical wedge reduction is the typical amount of bone removed in the anterior cheek osteotomy.

2) No external compression wrap is going to help the cheek soft tissues heal better or prevent any sagging. The occurrence of soft tissue sagging after cheekbone reduction is not common even if preventative measures are not done. Whether you are at an increased risk for it I nor anyone can say. Time will answer that question.

3) Swelling and tissue contraction after this or any type of facial bone surgery takes a full six months to see the final result. So you are only 1/4 along in your full recovery.

4) You can start eating hard foods any time now. The value of postoperative CT scans is dubious unless a problem develops. (chronic pain/swelling, aesthetic asymmetries etc) It would be exceedingly rare that facial bone sites don’t heal. If you go on to have a satisfactory result then getting a CT scan is unnecessary. As a surgeon I love to see the before and after scans to see how I did, but it is not essential to check for bone healing in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I like the idea of reducing the bones on both sides to create a more even look. Could a forehead reduction by hairline advancement be done at the same time? Whats the recovery time for this time of procedure? Would it change any facial asymmetry other than my forehead? By reducing the bone could that put at risk to have a fragile head for the rest of my life? I guess what I’m asking could I live a normal life after surgery? Sorry to load you with questions I’m just so curious since this is the second time i reach out to a plastic surgeon for this type of reconstruction and the first one advice no surgery. Thank you for your time.

A: In answer to your forehead reduction questions:

1) A hairline advancement and bony forehead reduction is often done at the same time. This is also the most convenient way to do both procedures.

2) The recovery is largely about swelling which is largely gone by 10 to 14 days after the surgery.

3) Since the face below the forehead remains the same, its natural symmetry/asymmetry is unaffected by any forehead shape changes.

4) Removal of some of the bone on the forehead does not make it weaker or more fragile. There is still plenty of bone left for support.

5) This surgery is not going to affect the longevity of your life. Its goal is to improve the quality of the rest of your life.

6) Your first plastic surgeon probably recommended against it because he/she does not know how to do the surgery. Surgeons often recommend against surgery if which they have lack of knowledge about it. Never confuse ‘I can’t do it’ with ‘It can’t or shouldn’t be done’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implant replacement. I am an Asian patient that has very flat cheeks and did cheek implants four months ago. I had 4mm implants but after the surgery i felt my cheeks were still too flat looking. I had an additional 1 syringe of injectable filler per cheek also but still not happy with the results. My doctor said he will swap the 4mm implants for 5mm but I don’t feel 1mm will achieve the look i want. I want a second doctor’s opinion as my doctor refuses to go any bigger. I have attached photos of myself before and also the cheek look i desire.

Thanks! 

A: The problem you are experiencing with the discrepancy between your desired cheek augmentation goals and the results you have achieved are more than just size or thickness of the central part of the cheek implant. There is a fundamental difference in the style or shape of the implant. You are seeking a result that can only be achieved with an extended cheek implant that has a long zygomatic arch component to it. All standard cheek implants that are currently commercially available do not offer this style of cheek implant. Your surgeon is trying to achieve your goal with an implant that simply can not do it regardless of implant size. But that is understandable as that is all he/she knows. Only a special design or custom cheek implant can achieve that type of facial look with cheek implant replacement surgery..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty revision. Please see attached my before and after photos and X-rays. I have also attached a photo of my ‘before’ photo which I edited to show the sort of result I was initially wanting. It is difficult for me to judge objectively what looks most attractive on my face so I would appreciate your opinion on my edit.

I am unhappy with how my face now looks 4 months after surgery. I feel my chin looks bulkier and my soft tissue falls under my chin slightly which doesn’t look attractive. My lower lip is also pulled in. Overall I feel that my face looks less attractive, less feminine and out of balance. It has really affected my confidence.

I am due for a second surgery to have my plate removed with my surgeon next week but I haven’t booked it in yet because my surgeon said he isn’t interested in cosmetics and will not try to correct any issues I have with how my chin looks. I wanted another opinion because perhaps my previous surgeon isn’t the right person to do my surgery since our goals aren’t aligned.

Do you think it is possible to solve my concerns with surgery? Is it possible that there is still swelling to go down and things may improve on their own? I understand it is difficult to give advice based on photos but any advice would be very appreciated.

A: Thank you for sending your pictures and x-rays. What is clear is your desired chin augmentation goal and the result you have are dimensionally discrepant. Your sliding genioplasty result shows a horizontal advancement of perhaps 6 to 7mms giving you a result where the chin projection is out to the level of a vertical line dropped down from the lips. While this may be an acceptable goal for a male this is to what most women want and is clearly different than our desired goal.  Your ideal imaging is showing about a 3mm horizontal advancement with a 2 to 3mm vertical shortening or upward inclination as the chin is moved forward. This is much more consistent with a more feminine appearing chin.

Rather than just having the plate and screws removed you can have your osteotomy repositioned/redone to better achieve your chin augmentation goals.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in buttock implant replacement surgery. How often do you do buttock implants weekly or monthly ? I really want 712cc. I know 548cc implants are available but that makes no sense to get when I already have 490cc. I believe Implantech has 600cc round but it won’t give a lot of projection like  the 712cc. I only want 712cc intermuscular. I truly hope this is very possible. Because when it’s not intermuscular I heard it doesn’t last and it will move around and possibly flip around. I also was told it will eventually sag.

A: I place buttock implants regularly. I would agree that to see a change in buttock size going from 490ccs to 548ccs will not make any visible difference. Only a several hundred cc size increase will be sufficient. So there is not a debate about the need to go 712cc to make an appreciable change if you are to have buttock implant replacement surgery..

That being said, there is no way any surgeon can know until surgery whether a 712cc implant will fit into an intermuscular space that has been previously expanded to 500ccs. It may or may not but that can not be predicted beforehand. I would think that a larger buttock implant size is possible because of the previous implant. But what that size would be would only be known in surgery and a range of increased buttock implant sizes must be available.

Dr. Barry Eppley

Indianapolis, Indiana

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

1. Before operation:

    1. Do we do any scans beforehand to know what can be removed (and what is bone/muscle)?

    2. Is it necessary to drill bone? What are the risks of bone drilling?

    3. If bone drilling is not necessary, will we be able to know beforehand what kind of results can be achieved without it?

2. During operation:

    1. Is it conducted under general anesthesia? 

    2. I understand you pass through the ear crease behind. Is it possible that you may need to make an incision elsewhere during the operation that may end up being visible?

    3. How is muscle removed?

    4. How long does the operation take?

3. After op:

    1. How long is there pain for? How long is there swelling for?

    2. Is there a risk that the muscle can grow back bigger?

    3. After how much time are results permanently visible?

In general, what are the risks of complications? I understand it is an uncommon procedure and you’re the only doctor that does it. Beyond the complications you’ve had so far with this procedure (if any), are there any other “possible” complications that could arise that I should know of? 

Thanks and best,

A: In answer to your temporal reduction surgery questions:

1) I usually do not get scans as there are not helpful.

2) The posterior temporal reduction is most cases is a complete muscle removal and does not touch the bone.

3) The muscle reduction always produces a 5mm to 9mm reduction in the width of the side of the head.

4) The procedure is done under general anesthesia.

5) The operation takes 90 minutes to perform and is done from an incision in the posterior ear crease.

6) Most patients have minimal pain afterwards.

7) Some swelling may appear in the face several days after surgery which resolves by 7 to 10 days after surgery.

8) The muscle can not grow back.

9) The results are usually visible immediately although the swelling will temporarily efface the results a day or two after surgery for a few weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to learn more about cosmetic rib reshaping. I am a 29 year old transgender woman, at 5’7″, 135 lb, with a 29.75″ waist and 36.25″ hips. I had fat grafting from my belly to my buttocks two years ago and consider the result a great improvement, but I am still unhappy with the protrusion of my ribs and my androgynous waist to hip ratio. I have attached pictures for your view and am wording whether rib removal surgery would be of benefit.

A: Thank you for sending your pictures for consideration for cosmetic rib reshaping surgery. Your waistline shape is a common issue amongst many male to female transgender patients. Your body frame from the frontal view maintains a straight line. In the goal of more feminine waistline it is almost always a need for a combination approach of reducing the horizontal waistline (creating a curved concavity) and adding some curves (convexities) in the hip//buttock region. For the concavity part this is where the role of rib removal has a place in thin body frames like yours. At the same time doing further liposuction of the abdomen, flanks and back and transferring what little fat there is to your hips would be a reasonable combination approach. Implants often have a role to play in the buttocks and hip regions but one final effort at fat grafting with rib removal would be a complete autologous approach to your body contouring efforts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Zygoma reduction was a major surgery for me, and as much as I put my faith in my surgeon, I understand that there’s no guarantees with any surgery. I would like to keep a back up plan handy, in the case that things weren’t able to end favorably. In the case that sagging happens, I’m interested in getting cheek resuspension surgery or Endotine cheek lifting to lift the cheek tissues back up higher. My surgeon does not provide cheeklifting or endotine lifting surgeries, so my ultimate plan is to fly to your practice in Indiana. 

However, I’ve read on your blog, of someone else’s experience of zygoma reduction. (http://eppleyplasticsurgery.com//can-a-cheek-lift-fix-my-sagging-face-after-cheek-bone-reduction/) With this individual’s experience, you stated that their tissues were scarred and atrophied from their cheekbone reduction, cheekbone reduction reversal, and endoscopic midface lift surgeries.

What do you mean exactly when you say their soft tissues have been ‘scarred’ or ‘atrophied’ from the surgeries?

I was wondering if this case would apply to me as well. I’ve already undergone zygoma reduction and lifted the cheek tissues up once. If I were to get the titanium screws removed (ideally I would), the cheek tissues would be lifted twice. If I were to undergo a third surgery (cheek resuspension) and lift the cheek tissues off the bone a third time, would this result in atrophied and scarred cheek tissues as well?

When the tissues are atrophied and scarred, what effect does this have on the external appearance of the face?

A: All surgeries in the face cause tissue damage and some degree of scarring and tissue atrophy. How relevant this effect is depends on many factors but is of greater relevance in facial bone reduction surgery than facial bone augmentation surgery. (unless you remove the augmentation) With less bone support the overlying tissues will contract as a natural part of healing. While everyone thinks that the tissues contract in a 3D fashion around the reduced bone (in, down and up, they may not and the tissue contraction may be more of a 2D effect. (in and down) The young age of the patient and good tissue elasticity makes it far more likely that a 3D tissue contraction effect will occur but this is not necessarily assured.

The more times you enter a surgery site the more scar that is created. Whether this scar is detrimental depends on what is being done. For plate and screw removal this dissection is such more limited so it is less likely to have any cheek sagging effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m 9 months post operation from a zygoma reduction and jawline reshaping surgery with a surgeon in Korea. I am 23 years old, soon going on 24, and I’m finding that I’ve developed a double chin. I exercise 3 times a week, am a normal weight for my height, and this double chin was definitely not there prior to my surgeries. So I’m suspecting that the surgeries instigated this double chin, whether its excess skin/tissue or the fats from my face sliding downwards. 

From touching the area myself, I’m unsure whether what I’m feeling is fat or tissue. Could you please help me on what I should do next to eradicate this problem?

Why did this double chin slowly start to appear over time? My jawbones weren’t over-resected and my zygoma reduction wasn’t over-resected either. As I am young, I was expecting for my skin and tissues to redrape themselves over the new structure.

Is this a common occurrence from jawline reduction and cheekbone reduction? What should I do!?

A: The simple answer to your jawline reshaping surgery question is that the loss of bone support from a projecting facial structure (like the chin) can eventually result in a submental tissue sag or even chin ptosis. While such a biologic effect is more commonly seen in the cheeks, it can also occur at the chin and along the jawline. And such an effect is well chronicled in the jaw angle region.

It takes a fairly long time after facial bone surgery to see the extent of the soft tissue effects due to he slow resolution and the how well the overlying soft tissues have contracted around the reduced bone. This is why it is often not apparent for 6 to 9 months after surgery.

There are limited number of treatments for these soft tissue redundancies such as liposuction or limited soft tissue tucks. I would need to see pictures of your face to provide a more qualified recommendation.

Dr. Barry Eppley

Indianapols, Indiana

Q: Dr. Eppley, thank you for reading about my request. I am a Korean female.

In Korea, as you already know, many Korean girls desire to have a very heart shaped face – Just like the one I have sent in the photo.

My situation is very different. I was actually born with a heart shaped face. Many of my friends say I was very lucky to be born with this shape, as the taper chin and slim face is very desirable in my country. But…

I desire a more oval face. I feel as if it makes a person look younger, cuter, and more feminine. I do not like my face when I smile, because my chin is so tapered it looks sharp and pointy and makes me look old. More oval face is plump, cute like a baby.

Doctors in Korea do not do jaw implants. When I tell them I want to change my heart shape face, they think I’m crazy and reject my request because there is nothing they can do.

For me to get oval shaped face is important. Do I need jaw implant or can I get some small improvement from chin widening surgery as I really hate my small thin pointy chin. I am very afraid of jaw implant because it is very not common in Korea – the doctors here don’t know how to put in or fix if something goes wrong. Would chin widening surgery give me more rounder bottom half of the face?

A: While it may be common for a Korean female to seek chin/jaw widening, it can certainly be done. There are two fundamental approaches, each with their own degree of effectiveness. 

While osteotomies work well for chin narrowing as part of V-line jaw surgery, they are not quite as effective for chin widening. This is not due to the central chin widening effect but out at the sides of the chin where it has to blend into the jawline to make it wider as well. This can be an area of step-off or irregularity.

A extended special designed chin implant works the best because it provides a smooth widening effect back along the chin into the jawline. As the effect you seek is probably more than just an isolated central chin widening. But you would have to clarify that for me.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 24 years old and I underwent zygomatic reduction and V-line jaw reduction surgery for cosmetic purposes around two months ago. I was wondering, is it possible that jaw reduction surgery can cause sagging around the neck area? I ask this because I’ve started noticing that I have am getting a double chin, when I did not have one prior to the surgery. I know for sure this was not caused by any weight gain, as I have actually lost quite a bit of weight since the surgery due to being on a strict liquid and soft foods diet.

My surgeon had told me prior to the surgery, that because I am in my 20s, my skin and tissues would be able to shrink and redrape themselves to the new bone structure. But I am just really annoyed by the gradual appearance of this double chin. My chin used to have no signs of a double chin pre-surgery, unless I was smiling very widely or looking downwards.

Now I just have a double chin even if I am just looking at my side profile! What can I do about this?? What options do I have when this may be excess tissue and not fat?

A: The elevation of tissues off the chin and jawline to perform V-line jaw reduction v-surgery, with the loss of bone structure/support, always has the risk of creating a soft tissue sag later. This is a well known risk of the surgery and could be the aesthetic tradeoff of this type of facial bone surgery. Since it is only two months after surgery i would give a lot more time to healing and to see the full effects of tissue contraction which could be up to six months or longer after surgery. I can not say whether your condition will improve or not but your tissues need adequate time to fully heal.

If it persists there are options for treatment including liposuction that can be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the approximate cost for rib removal without fat grafting?

This is a rare procedure, and I imagine a fairly traumatic one, considering how the muscle tissue clings to the bone of a BBQ pork rib. What are the potential consequences for mobility and activity? What is the aftercare protocol? Can you connect me to other patients who have worked with you who would be willing to talk about their experiences?

Where will the scars be located, and how large will they be?

Would deliberately fracturing the bones and wearing a corset as soft cast while they heal be a realistic alternative to resection?

A: In answer to your rib removal surgery questions:

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

2) Rib removal surgery, while providing as expected some after surgery discomfort, has not had any morbidity othethan the scar that I have seen. Patients recovery quicker than one would expect.

3) The surgery is done through oblique 5 cms long back incisions.

4) Rib resection offers a more effective waistline reduction with a quicker recovery than rib fracturing. Such rib fractures would not go on to heal and would be a source of chronic pain.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am from China an am 23 years old. Please read my story and give me advice.

One year ago I went to Korea for V-line surgery and the cheek bone reduction surgery because Korea is very famous for Asian small face surgery. My face before was very not symmetric and very ugly and not like a girl !! I have put old photo of my face in the email. If you see photos, you can see that my cheekbone was very very big. My old face – one cheekbone very bigger than the other cheekbone and more meat on the face if you look at the photo carefully.

My Korea doctor used very popular technique called 3D rotation malar reduction. This technique uses L cut in front of cheek bone and cut the back in the hair. Then push the bone in and fix with the use of titanium plates and screws. I do not know how many mm of bone were taken out. 

My face after surgery got very smaller and I was very happy. The result very dramatic and my face very likeable. But one year after surgery, I have a big problem.If you look at after photos in the email, the meat of my face drooping. There is too much meat on the face and it makes my face look old, chubby, nasal labia lines! I was very angry!! Doctor said 3D rotation malar reduction have little chance of cheek drooping because of plate fixation and bone rotation and because I am young.

I flied back to Korea this month and he say thread lifting is good solution. I was very angry again because thread lifting is not permanent fix and only last very short time. I can’t pay for thread lift over and over until I die. Korean doctor then refused to fix my drooping face, and now I do not know what should I do.

My big problem is the extra meat on the nose making nasal labia lines. What is your advice on how to fix? I try skin tight laser but no effects… What can I do to fix?…

Should I do face liposuction to get rid of the extra meat or redo surgery? Can I do cheek lift to move cheek meat up high when I am still young? Is it possible?

I want to hear your reply soon, thank you.

A: What you have experienced after such cheek bone reduction surgery is not rare and is what can happen when there is loss of bone support. The overlying soft tissues may or may not contract down completely in a 3D fashion. Such effect can take up to a year after surgery to see whether it fully does or not.

The cheek sagging to which you refer/have is not an easy problem to fix. Nothing non-surgical, like lasers or any other device is going to work. Liposuction will largely be ineffective and threadlifts have a temporary effect at best.

Some form of a cheeklift is needed or resuspension of the tissues. An intraoral approach is one option with Endotine fixation. Other superior options are through the lower eyelid or temporal scalp incisions to do the lift. My personal preference is for a cranial suspension technique which pulls the cheeks vertically upward, which is the best direction for resuspension as that is how they have fallen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial feminization surgery. Based on my pictures what are your recommedations?

A: Thank you for sending your pictures. As an older facial feminization patient, the effects of aging must also be considered as part of the facial procedures .My recommendations would be the following:

1) Browlift and Upper Blepharoplasties with Tail of the Brow Bone Reshaping (I don’t think a central brow reduction is that useful)

2) Rhinoplasty

3) Upper Lip Advancement

4) Lower face/necklift

While there are many other potential facial feminization surgery procedures that could be done, I consider these four the most effective and the best value.

The biggest challenge for the browlift is where to place the incision to do it.

In many older facial feminization surgery patients there is a concomitant need/benefit for facial rejuvenation procedures as well such as brow lifts, blepharoplasties and face and necklifts. These are done at the same time as the more traditional facial reshaping procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m very sorry to take up more of your time, but I just had a couple questions about my surgery path and I wanted a second opinion. By a local surgeon, I was referred to a plastic surgeon who uses hydroxyapatite granules for facial augmentation. I was wondering, what are your thoughts on using this method to add the missing width to my chin. I’m not looking to project it further outwards, but as I had said earlier, just to increase the horizontal width.What problems or benefits are there? Or would a reverse t-osteotomy technique be best.

A: I have had to revise a lot of hydroxyapatite granule augmentations of the face. They often end up irregular and lumpy. Hydroxyapatite granules for facial augmentation is an old method from the 1980s, which does have some clinical successes in small areas of facial bone augmentations. But it is a fairly uncontrolled pushing of hydroxyapatite granules blindly into a subperiosteal tissue pocket and hoping it will end up perfectly smooth. Sometimes it does and sometimes it doesn’t.

There is nothing wrong with using an implant material to augment the width the chin bone. But I would favor a more structured or rigid material that could be shaped and fitted without the risk of distortion.

And then there is, as you have mentioned, the chin widening osteotomy method as well. But I would still favor an implant material as it is more predictable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I went to my birth country to get double eyelid surgery. I underwent a procedure called non-incisional double eyelid surgery or suture double eyelid surgery, of which I hope you are familiar. It’s currently holiday period in Korea so I have been unable to contact my surgeon. It’s been over 4 weeks since my double eyelid procedure, and my right eye has healed very well. 

However, on my left eyelid. There is a tiny but clear bump from one of the suture puncture holes. The skin is a darker brown color, which is not the case with every other suture hole, and the feel of the bump is more noticeable. My left eyelid has also started twitching very regularly, and I’m not sure if it’s because of the suture bump or if something has gone wrong with the surgery. 

I don’t mind the feel of the bump from the suture or puncture hole, but the twitching is driving me mad. Every hour or so, my left eyelid will twitch or throb for a couple of seconds. I know there’s botox to stop this twitching but I’ve also read it needs to keep being repeated every couple of months.

1) From your medical knowledge and experience with surgery on east asians, is it normal for the eyelid to be reacting like this so long after the surgery? This was not happening the first couple weeks post surgery, and has started becoming more frequent in the last week.

2) If the twitching will eventually subside, how long should I wait for it to subside as it is actually driving me insane!

3) Is the twitching an effect of the thread lump? When I feel the other puncture holes, they do not hurt when I touch it. But this particular one on my left eye is still a bit sore when I touch it even though it’s almost been a full month. 

As I am an international patient, would you advise me to fly all the way back to have this revised?

A: I am very familiar with the suture or non-incisional method of double eyelid surgery even though this is is not my preferred method for double eyelild surgery.

The bump to which you refer is undoubtably the knot from the underlying suture. It is apparently right under the skin and is more prominent than the others. This accounts for the bump that you feel and the skin discoloration. It is likely this is the source of your blepharospasm as well. Such events when they occur often do not occur for 4 to 6 weeks after surgery when the initial swelling has subsided and the tissues try and return to normal.

If this issue has no resolved in the next few weeks you will need to have that suture removed/replaced for a resolution of your symptoms.

Dr. Barry Eppley

Indianapolis, Indiana