Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a corner of mouth lift. I have tissue hanging over my mouth corners that makes a deep marionette line. What can be done to correct it? Have a attached an unflattering picture for your assessment.
A: Thank you for sending your picture. If you look closely what you have, it is not a true downturned corner of the mouth (only very slightly is the commissure turned down) but rather there is an overhang of facial tissue along the marionette lines. While there is some mild benefit to be gained by a corner of the mouth lift, most of the problem needs to be improved by a lower facelift to pull back the tissues that have descended and fallen forward. Thus a lower facelift with a corner of the mouth lift is what is needed for an ideal improvement. That is the only combination of facial procedures that would be worth the surgical effort. It is not uncommon to do a combined facial rejuvenation surgery of a doer facelift with a corner of mouth lift. This improves the shape of the corner of the mouth, reduced marionette lines and gets rid of jowling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was involved in a car accident a while ago that required my chee bone to be repaired. The surgeon that operated on me performed the surgery was a plastic surgeon, rather than a craniofacial or maxillofacial surgeon. My cheekbone fracture was secured together with plates and screws and was performed entirely through an incision in my upper gum.
It’s been a while since the surgery and I swear in my eyes, the cheek on the operated side looks different. My friends don’t seem to notice but I swear it looks slightly off. I think they just never notice because I’m always moving and they never just look at my face straight on.
I feel as if the cheek flesh/apple cheek underneath my eye has shifted downwards. I can tell because in my photos prior to the surgery, when I smiled widely, the bump of the cheek (the fleshy apple cheek bump) was a lot closer to my eye. Now it’s more in the middle of my face, noticeably lower than it was before. I don’t think any resuspension was done after the bone repair.
Since I am young a midface lift on one half of my face is just out of the question. Is it possible to relift the soft tissues and somehow have them heal and stick to the cheekbone higher?
Ideally I wouldn’t like any scars on my face, but hidden oral and scalp incisions would be alright with me. Also, are there any absorbable solutions, as I’m a little bit iffy in leaving permanent devices in my face.
A: By your description your cheek sag may be exclusively soft tissue or it ma be combined with some residual bony displacement as well. I would need to see pictures of your face to help make that determination. But a cheek lift can be done through a lower eyelid, temporal scalp incision or even an intraoral approach could be used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, ; I am a young male patient. I contacted you about a month ago asking questions about lip advancements. I just wanted to elaborate further.
I feel like my lips are a difficult case. Like I said previously, my lips are quite full already and I have 5mm Permalip implants in the top and bottom lip. The only thing I’m afraid would be a problem is that my lips are very close to my nose already, however I really would like bigger lips and increased vermillion height and size. My nose is really close to my lips due to a hanging collumela (a result of my nosejob). The hanging collumela is not very visible from the sides, but its very visible from the front view. It gives the look of a very droopy tip. I’m wondering if lifting my columella a bit would give some more distance between my nose and lips and, therefore, make a vermillion advancement more aesthetically pleasing?
I know that a collumelar correction is quite a simple procedure and I would eventually want to get both the vermillion advancement and columellar correction done together.
I really don’t like lip fillers and I really would want something permanent that would increase vermillion height. I am very aware that my lips fit my face well, however I have had them bigger and I really love the look of them larger.
I have attached a picture of my lips from front and side views. I have also attached photos of my desired goal.
A: Thank you for sending your pictures. In answer to your lip advancements questions:
1) I would not view a columellar reaction procedures as ‘ simple’. It may not be as complex as a full rhinoplasty but getting the columella up to any significant degree is not easy or predictable. And you do not have a true hanging columella so I would view that procedure for you as probably not very productive.
2) You have described your lips as a ‘difficult case’ and that would be correct given what you are trying to accomplish. You can’t have a vermilion advancement without shortening the distance between your nose and upper lip…and any significant columellar retraction is not likely to occur.
3) While it is important to have surgical goals, your ideal goals are not going to be achievable given your anatomic limitations. Something has to give so to speak.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a secondary rhinoplasty surgery. I was just reaching out in regards to a prior septorhinoplasty surgery I had done. I am now one year post op and am not happy with the changes hang have been done to my nose shape. The changes that were done made my profile different and my nose appears shorter in height and length and not as wide. Cosmetically I am not happy because it is smaller and does not fit my face. My concern is that my nose appears wider but its actually thinner by bridge and middle of nose, its length is shorter due to the upturned tip, the nasal base and tip is a little smaller, and height isshorter due to dorsal hump being taken down. My goal is to restore to original height, length, and width like it used to be. Can cartilage be added to upper and middle of nose to make width wider again? Can nasal bones be out fractured to help increase width? During revision can bones be reshaped? Is this possible if osteotomies were used previously? Can fascia be used to add some volume back to nose and appear softer? The goal is to have nose appear more natural and not such harsh lines to look like a nose job has been done. In addition my nose seems to be congested more now than before. Any recommendations for tests to see what is going on?
A: In essence you are describing a secondary rhinoplasty to build back out the nose making it closer to what it originally was with emphasis on dorsal and tip augmentation as well as nasal bone widening. While there is no ‘returning home’ in an exact way so to speak, improvements can be made to augment the nasal areas that were reduced as well as place spreader grafts in the middle vault to improve breathing.
The key to doing so comes down to one basic need…you have to have enough cartilage graft to do so. For this type of nasal reconstruction (rhinoplasty reversal) you really need a cartilage rib graft to do so. (aka rib graft rhinoplasty) That supplies all the necessary cartilage graft to build back out the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My three year old son has a high cephalic index around 88/90%. We are interested in early skull reshaping surgery and would like to have some volume added to the back to make it more like 83/85%. Hoping this could be done with 15mm or less. He also has some bossing over the ears that we would like to reduce if possible. Is there a best age to do this procedure. We are thinking of doing it sometime between now and 4 years old if possible. Also curious what material you would suggest or if it would be best to do a custom mold. We are planning to set up a consultation if this is something we could have done and we could get a few questions answered ahead of time.
A: Some general early skull reshaping surgery comments are as follows. At this young age the width of the head can not be reduced due to the thinness of the bone and overlying muscle. Occipital or back of the head can be done but the only material I would ever use at this young age would be hydroxyapatite cement. But the scalp is not likely to allow for a 15mm expansion of the outer contour of the bone. At best it may allow for up to 10mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some facial implant questions regarding silicone implants. It seems as if some “experts” on different forums believe that jaw iimplants and cheek implants with silicone are inferior to harder materials such as Medpor or PEEK due to the fact that silicone is softer and thus when subjected to pressures from soft tissues they may not retain the inteended sharp and angular look at, for instance, the edge along the mandible or along the lateral part of the cheekbones. (including zygomatic arch) Instead they claim that they may give a more rounded appearance that simply adds volume without retaining the sharp edges of identically designed implants made from hard materials.
1. Would you please comment on the above?
2. Are there any limitations on how you can customize silicone implants? For instance, can you customize them so they gradually taper off to 0 mm thickness, so they gradually blend into the existing bone structure around the eye area? Can you customize them to have a sharp, defined edge?
3. Some doctors claim that putting a screw through a silicone implant in the chin or jaw angles will eventually lead to the screw migrating through the implant because of the softness of solid silicone. Thus silicone implants may dislocate in the future when the screws no longer keeps the implant in place. Would you please comment on this?
A: In answer to your facial implant questions:
1) I consider the argument/opinion about the effects of available material compositions on the outer facial contours as lacking any scientific support. That is a discussion that has never made any sense from a biomaterial/biomechanical standpoint. One simply has to feel a silicone implant and wonder how it could ever be deformed from the overlying soft tissues. What effects the outer contours of the face is the shape and size of the implant not its material composition.
2) You can custom facial implants any way you want, there are not limits to their design. Whether the overlying soft tissues will allow the design to be fully seen and what the design should be to create the desired effects is a different matter with its own limits.
3) What keeps an implant in the placed position on the bone long-term has nothing to do with any screw fixation. It is the scar tissue/encapsulation that is eventually responsible for its positional stability. Screws are used in the short-term to maintain position long enough for this encapsulation process to occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an ear reshaping question about the procedure where the helical rim is folded in and it not being able to do be done at the same time as scapha reduction. Is that the case even if the scapha reduction doesn’t include an incision on the helix? I’ve attached an example to help me describe what I mean.
So basically, is it possible to have that kind of scapha reduction done and folding in the helical rims at the same time? I’m thinking that could be a less radical kind of reduction, while still reducing the size.
A: In answer to your ear reshaping questions:
1) What you are showing is a very limited form of a scapha reduction. It really folds the ear down a bit rather than a true vertical height reduction that requires a back cut cross the helical rim down at the middle part of the ear to create the reductive effect.
2) This limited form of a scapha reduction can allow a helical rim repositioning at the same time. Since there is no incision on the inside of the helical rim done at the middle third, an incision can then be safely made on the back of the ear in this area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip reshaping surgery. My main goals are to increase vermillion height and make my lips look larger and rounder (the shape of the lips in the pictures). I also would like to have a less prominent cupid’s bow to make the lips look rounder (like the pictures).
My questions are:
1. Would the vermillion advancement for bigger lips with increased height and roundness be out of the question? I’m not looking for the goal picture size exactly, but something somewhat close to the size and shape.
2. If I’m not a candidate for a vermillion advancement, what lip augmentation option(s) would you recommend to get results close to the ones I want?
A: In answer to your lip reshaping questions:
1) Only a vermilion advancement can increase the size of the whole lip and make a less prominent Cupid’s bow at the same time. It does so by removing skin above the lip to create the type of lip shape one desires. This would be of particular value in reducing the shape of the Cupid’s bow area where more skin would be removed compared to the sids of the upper lip.
2) A vermilion advancement is your only option based on your lip size/shape goals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m one month post operation from a jaw/mandible reduction and horizontal chin reduction surgery using the T-osteotomy method. I have some chin reduction concerns.
I’m loving the angle of my jawline but I’m very worried because it’s been 4 weeks and my chin looks very very pointy. My surgeon seems to have removed a lot more bone than I was expecting. I had a very very square face prior to the surgery and my surgeon said he removed a good 1cm wedge from the middle.
I made it firm in the consultation that I wanted a natural curve (U shape) to my lower face, and did not want a pointed v-line. I’m very worried that my surgeon still didn’t fully understand what I wanted.
I understand that there’s swelling but I read that the 3-4 week post op genioplasty look is usually similar to what you get. My chin looks like a triangle and my parents and relatives can instantly tell that it’s not a natural chin because it tapers in way too much. I legitimately told my surgeon I wanted a noticeable natural change, like as if I’ve lost weight – But I’m very afraid that he did not deliver and overcorrected.
What are my options here? Can I do a reverse T-osteotomy with a bone graft to widen my chin to the desired width? How much extra width can I expect from doing this?
Or will the look of the chin soften up over time? Though I highly doubt the change could sustain such a huge change. I have yet to face any friends as I am very afraid to face them like this.
A: At one month after this type of chin reduction surgery if you think it is too narrow then it is. The more typical concern is that it is still too wide and not narrow enough. Time and further healing will not make it more wide or less pointy.
The good news is that the chin can be re-widened by the placement of an interpositional cadaveric bone graft. That width can be any amount desired.I would not think you would take it back out the full 10mms that was removed but probably 5 to 6mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I messaged you about my jaw and cheekbone reduction enquiries not too long ago. I’m still early in the cheekbone reduction recovery stage but I was wondering about something else.
My doctor said it is good to practice opening my mouth as wide as I can after surgery. It’s barely been the start to my second month of recovery and I can open my mouth to fit two fingers.
However, I’m reading online that extensive mouth opening should be avoided for the first few months as the masseter muscle can pull down the zygoma body even if it’s fixated. Is it possible that I’ve done some damage to the fixation due to pushing myself to open my mouth widely every day?
A: My first suggestion is that you follow the instructions provided by your surgeon who you trusted to perform the operation rather than online commentaries of unknown expertise and experience. That being said, at this point in your cheekbone reduction recovery you should be working on getting your jaw opening rehabilitated back to normal. There is little concern about bony displacement with plate fixation, early after surgery or months later. Stretching your mouth open should be done freely at this point in your recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have looked at the first draft of my custom jawline implant design. I would like the jaw angles to drop down further. According to my measurements I need about 31mms downward. What do you think?
A: Thank you for your input on the custom jawline implant design. The only tricky part of your jawline implant design is the vertical increase of the jaw angles. While any increase in the vertical length of the jaw angles can be designed and made, the critical question is whether the overlying masseter muscle will follow the implant downward. If it doesn’t the implant sticks out ay the bottom but the masseter muscle sits above it like a ball…this is probably not the look any patient is going for. There is no exact formula as to how much the vertical length of the jaw angle can be dropped in any patient until this occurs. What I do know is that I have never dropped a jaw angle past 20 mms and even that is risky. Your drawings are probably inaccurate from the standpoint that the measurement of 31mm doesn’t account for the thickness of the overlying soft tissues. So 31mms is probably closer to 25mms. I have started out with a more modest drop of 12mm on the higher side and would be willing to increase it to 18mm. But I think once you go last that there is a real risk of masseteric muscle dehiscence. (there is one at 18mms too but we have to take some risk to get closer to the aesthetic goal)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was told a cheek implant is necessary to elevate the lower eye lids to shape it more lateral to create this look. I am not sure how this makes any sense. While some also suggest that throwing in there a mid face lift can push the eyes as well to give such results. Another oculoplastic surgeon said that he likes to use grafts either from the mouth or alloderm as such drastic lateral canthoplasty will take more than a canthoplasty and also he mentioned the orbital bone and cheek / facial structure needs to be assessed in order to create such looks that my cousin and I are seeking. Something about how the cheek implant can create a desired look of this.
I am not sure if the photos were attached however I will attach them again. I hope this is something we can potentially convince you to do as we wish to boost our potential as models in our hobby. We would love to visit you personally but we are dispersed around other states as college students. So if possible let me know if the results are permanent and if this is something relatively easy fr you to do and if a cheek implant is necessary.
A: A cheek implant has nothing to with influencing the position of the repositioned lower eyelid. What is more useful is an interpositional graft like Alloderm as the eyelids need more tissue internally. Just stretching them upward alone with a lateral canthoplasty will develop some relapse because a truly elevated and sustained eyelid position ultimately needs more tissue.
While a cheek implant has nothing to do with the sustained position of the outer corner of the eye, it is needed if one wants a higher cheekbone look which is a separate but related aesthetic issue by proximity. The only implant that can help the position of the lower eyelid is a true infraorbital implant. But it does not negate the need for an interpositional lower eyelid graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for solutions to improve my paranasal area. I have quite chubby cheeks for my age and with my paranasal area slightly sunken in, it gives the illusion or shadows of nasolabial folds, thus making me look quite older.
Where I live, fillers are quite expensive compared to that of Asia and the US and it’s a maintenance cost I can’t afford forever. Mores o, I have heard many nightmare stories regarding the more “permanent” or “long-lasting” fillers, so I would like to stay way way clear of those.
In regards to paranasal implants, I’m not interested in having any foreign materials in my body as I am scared of infections. I have also heard that they can augment a person’s smile due to their rigidness. These honestly are not common in my country either. Moreover, fat grafting in areas of movement in the face don’t seem to last long at all.
Then I came across a dermal fat grafting post on Real Self by you, while I was surfing through Q&As regarding the matter. With your experience of the surgery,
1. What are the pros and cons of using dermal fat grafting to project the paranasal area and get rid of nasolabial lines?
2. Is this a more long lasting and permanent solution to my matter?
3. I understand that some tissue needs to be harvested from somewhere, and that’s something I’m okay with if this is a good solution to my matter. Is the buttocks the only viable area of harvest for someone of my age or is there a more hidden area of harvest available?
A: A dermal-fat graft is a well known procedure that dates back over 100 years. While injectable fat grafting is better known today, there are still roles for dermal-fat grafts for small amounts of augmentation such as in the face. Dermal-fat grafts actually survive better than injected fat grafts on a volumetric basis as long as their size does not become too big. As long as the patient can tolerate a harvest site (the lower buttock crease is just one potential harvest site), such a graft is an option for paranasal augmentation. Given the restrictions you have imposed on material options (no fillers and no implants) fat grafting would be your only option. The debate then becomes should it be an injected fat or a dermal-fat graft? There are pros and cons for either fat grafting approach in the face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very appreciative of your insight, it is amazing to even get a glimpse into your wealth of knowledge of facial surgery.
Is there any particular reason why the potential negative effects of cheekbone reduction only become evident after 3-6 months? No medical education here, but why wouldn’t the sagging not be evident straight after the surgery is over, right after the tissues have been peeled off the face?
In regards to the sagging, apart from the wide dissection that is required for the cheekbone to be reached for osteotomy – Are there any patient characteristics that would contribute to potential sagging? (eg. thick/thin skin, facial flatness, etc.)
Thank you again for your time.
A: Healing after any facial bone surgery requites two stages, swelling/edema resolution (first stage which takes 6 to 8 weeks to fully resolve) and then tissue contraction. (second stage, what I call the shrink-wrap effect, which takes 3 to 6 months to fully occur)
As a result of the natural healing process around facial bone reduction sites, It takes that long because the swelling supports the tissue initially and masks whatever sagging may subsequently occur. When the second stage of healing occurs (soft tissue contraction and tightening around the bone) the position of the overlying soft tissue becomes revealed.
It is easy to see how the loss of bone support allows the cheek tissues to be contacted down in a lower position. What is a more interesting question is why it does not occur in every case of cheekbone reduction… which it does not. This undoubtably occurs because of the variations in each patient’s anatomy and differences in surgical technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in hip and thigh implants. I have the following questions:
- My one hip is a bit flat, would it be possible to have a small hip implant on one side as well and a larger hip implant on the side that needs more volume?
- Do you see any issues with putting a thigh implant on my thigh where I have a skin graft? I touch the skin and seems it would stretch. I wanted to get your thoughts on that.
- After the procedure, when can I start:
a.- Walking a bit (around the room)
b.- Walking normally without pain
c.- Doing exercises in the gym
d.- Lift weight?
4. How many check-ups do I need after the procedure? I live out of town, I would like to start planning how long I should plan to be in Indianapolis.
5. Are implants going to be positioned under the muscle or over?
6. Can muscles still grow with exercise having an implant in there? Would this affect the shape of the area?
7. How long does it take to get custom implants?
8. Should I meet with you in person to take measurements and finalize everything before scheduling the procedure?
Thanks much!
A: In answer to your hip and thigh implants questions:
1) Since the hip implants are custom designed, they can be made to any reasonable dimension on either side of the hips even if they are different.
2) I do not envision any issue with placing a thigh implant around/under the skin graft site.
3) Your recovery would, of course, be a progressive one but you need to begin walking and moving around immediately. Back to unlimited exercise is going to take up to 6 weeks after surgery.
4) You should be able to go home within a few days after the procedure. Followups would be done in a virtual fashion.
5) In the hip area implants are placed one top of the TFL fascia. (above the muscle) In the thigh area, if possible, they are placed under the muscle.
6) Muscle hypertrophy through exercise is still possible even with an implant in place.
7) Most custom can be made, sterilized and shipped for surgery in about three weeks.
8) The method that I use to design custom hip and thigh implants is to mark the patient where their desired areas of augmentation are, make a paper template and then determine what their surface projection and contour would be. Sometimes a silicone moulage model is made. In many cases the patient can do the former paper template method and we can discuss vis Skype to work out the details. But certainly seeing you in person would be ideal but is not always completely necessary based on the complexity of the implant shapes needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal for body contouring purposes. I have the following rib removal questions:
1. Estimated cost for the surgery
2. Recovery period after surgery, especially if flying in for the procedure
3. Whether fat removed from flanks during procedure and can be transferred to the breasts
Thanks in advance.
A: In answer to your rib removal questions:
1) My assistant will pass along the general cost of the procedure to you on Monday. Only she knows the answer to this question
2) Most patients return home in three to five days after the surgery. How much more recovery is needed depends on what physical activities to which one is recovering. It is a gradual recovery and most patients return to full physical activities by one month after surgery. There are no restrictions after rib removal surgery so you do whatever feels comfortable. You should probably take two weeks from work or three weeks if the work is more physical.
3) There is never enough fat removed from the flanks to be enough for any appreciable fat transfer to the breast. It requires a lot more fat do so than what the flanks have to give.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 31 years old and I’ve been overweight for most of my young adult life. I’ve spent the last three years trying to lose weight and I’ve managed to lose a whopping 110 lbs.
I am proud of myself for what I have achieved thus far, but a problem remains. As I am still young, I was counting on my skin elasticity to bounce back and tighten up everything. It’s worked slightly for the body, and I’ve accepted that later on I’ll need a surgery to remove the excess skin if it doesn’t retract further in the future as I continue to lose weight.
However, my deepest concern lies with my face. Around the back end of my jaw especially, I am able to pinch and pull a lot of excess (of what I think is excess skin and stretched tissue?) The chin area has done better – I have no jowling of the noticeable sort.
My body does bother me but at least I can hide it under clothing. My face on the other hand, is a problem. I feel like a bulldog.
I feel as if there is too much excess to have any worthy outcome from any lasering or tightening treatments. Dr Eppley, what are my options here?
Is a facelift an option in my case? I have no medical knowledge of any kind but is there some sort of lift procedure for the face where the SMAS is left alone but the excess skin on top is cut off?
A: Thank you for your inquiry and congratulations on your efforts at weight loss. Any person that loses as much weight as you have will develop loose/extra skin around the jawline and neck. Such excess tissue is into going tor respond to any non-surgical tightening methods. Only a lower facelift (neck-jowl) lift will suffice to lift and remove what is likely inches of loose skin.
I would need to see pictures of your face to provide a more qualified answer as to your exact needs for improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your surgery expertise and I hope you can help me.
1. I had a “chin wing” osteotomy a couple of years ago. Can jaw implants be placed on top of this? And does it increase the likelihood of post-surgery complications?
2. I’m interested in custom midface implants, specifically to achieve what I refer to as the “high cheekbone” look you see on certain male models. So this targets specifically the zygoma prominence and the zygomatic arch. My question is my cheekbones have been described as medium, when I’ve asked different surgeons whether I have high, medium or low cheekbones, so can your implant raise the cheekbone higher? or can it only be placed simply on top of the existing cheekbone and thus increase lateral and anterior projection but not raise it in the superior direction?
3. What incisions are used exactly for the cheekbones? Lateral canthus? Or something else? Is it scar free or does it leave a permanent mark?
4. I want to reduce scleral show. I’m assuming the correct approach is a custom infraorbital implant in combination with a high cheekbone/zygo arch one?
5. My biggest goal with the jawline implants is to create a highly angular facial lower third when viewed front on. I want a somewhat square chin, that extends downward slightly but blends in with the natural curve of the face. I also want a sharp-ish jaw angle from the side, but not a ridiculous 90 degree one as it looks overly artificial. So I guess my desire is something that looks sharp, angular, well defined but not over sized or fake looking. To stress my biggest desire is the shape of the jaw front on. Tom Cruise in his 30’s had an amazing one in a million dynamite jaw in my opinion – a shape like that is what I want. But I don’t know if my face is too round for that to be achieved. What do you think?
6. What’s the waiting time for procedures?
7. Is custom midface implants too much in combination with jaw implants? Does it increase the likelihood of infection?
A: In answer to your questions:
1) I am very familiar with the chin wing osteotomy and have placed custom jawline implants in patients who have had the chin wing osteotomy procedure done previously numerous times. While the chin wing osteotomy has its benefits, it is not a total jawline augmentation procedure.
2) Custom made cheek implants can be made in any shape and dimensions desired. There are no limits as to how they can be designed. The key, therefore, is to determine what those implant dimensions are given what the aesthetic results the patient seeks.
3) The incisional access to the cheek implants depends on the style and dimensions of the implant. Unless there is an infraorbital component to it they are usually placed from an intraoral approach.
4) While adding support to the infraorbital rim is an adjunct to reducing scleral show, it is not usually completely effective as a stand alone procedure expect in the most minor amounts of scleral show. Usually an interpositional graft needs to be added to the lower eyelid to drive up the lid margin.
5) The aesthetic effect of a jawline implant is highly influenced by the face in which it is put. Thinner faces with smaller amounts of subcutaneous fat get the best results. Without knowing what your face looks like I can not tell you how realistic or unrealistic such facial reshaping results are.
6) Custom implants take about one month to designing fabricate for surgery.
7) Custom midface and jawline implants are commonly done together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Late last year I underwent cheekbone surgery on the left side of my face to correct some asymmetry. I wasn’t aware that this type of surgery was offered in America, so I had this surgery in Thailand. From my understanding of the surgery, I had an L shaped wedge of 5mm taking out of his front body cheekbone and the back thin cheekbone was moved inwards through a cut in the sideburn area. Everything was fixed with metal screws. Ideally I would have undergone the back cheekbone cut-only surgery to correct my asymmetry, but the doctors who consulted with me in Korea were too pushy on having additional surgeries and did not make me feel comfortable to have surgery there. The hospital in Thailand where I did the surgery did not offer this other type of cheekbone reduction either.
It’s been four months since the surgery now and much of his swelling seems to have gone down. Around the left jaw area, I don’t seem to have any jowling or excess skin happening which is a good sign.
However, the apples of my cheek now seem slightly lopsided, and it’s most evident when I am smiling. My cheek flesh seems tacked on but it has tacked on slightly more down than it was before, if that makes any sense.
It was an understandable risk. I have read through your blog after finding it online, and it makes logical sense that when flesh is taken off bone, it doesn’t stick back down to the bone (as much as we would love for that to happen.) It’s not an evident or drastic sag, but unfortunately it is quite noticeable.
Do you have any suggestions on what surgeries or alternatives I can pursue at this point to just slightly lift this cheek tissue a bit higher up? At a year post-surgery I plan on getting the metal screws out. When the cheek tissue is relifted to remove the metal screws out, is there some method to get the flesh to stick back down higher at the same time.
Or do you suggest that I just leaves the screws in? Would relifting the flesh to remove screws just result in making the drooping worse?
A: In answer to your cheekbone reduction sagging questions:
1) It is not an absolute necessity that the metal plate and screws are removed. While it is not likely to cause further soft tissue sag, there is always that risk.
2) The only reason to remove the metal hardware is if the primary reason for the surgery was to try and address the soft tissue sag through a lift or resuspension procedure or even the placement of a small implant. The hardware removal then becomes a coincidental part of the procedure.
3) Other non-intraoral approaches to managing the cheek sagging may be a cheek lift procedure done through a lower eyelid incision or even fat injections to add back some volume.
4) Each management strategy to sagging after cheekbone reduction (intraoral resuspension, implant augmentation, transcutaneous lowe reyelid cheeklift and fat injections) has their own advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what is rib removal recovery like? I understand it is two to three weeks, but is that time spent in bed, or is it closer to recovery the first week, then taking it easy for two more weeks or something different? i work at a job that is not too stressful physically, but it does require that i can stand, occasionally sit and move close to normally. Thank you!
A: The answer to your question is the latter in your description. It is a progressive recovery based on increased activity starting from right after surgery with the goal of being back to all normal activities within 3 to 4 weeks after surgery. In short there are no restrictions after surgery, you do what feels comfortable. It is important to remember that you can’t hurt the rib removal site no matter what you do. You can not hurt the ribs as they have been removed unliike a rib fracture where one is trying to get the bone ends to heal. The recovery is more about muscle and soft tissue healing. So as soon as one feels more comfortable after a week or so after the surgery, it is important to get moving and stretching to help one recover faster.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, From your blog, I’ve read that weak cheekbones can contribute to midface aging. Does this mean that with zygoma reduction, there could be potentially adverse side effects in the future, even if the surgery was a deemed “a success” say a year after the surgery? Would taking out a wedge of bone from the zygoma body and sliding the zygoma arch in be a catalyst for premature aging years after the surgery?
A: The potential negative effects of cheekbone or zyoma reduction, tissue sagging, is something that will become evident 3 to 6 months after the surgery. If has not occurred by then it will not. Whether cheekbone reduction contributes to premature aging is not known. There is no medical literature that supports this potential long-term concern in a zygoma reduction surgery where no after surgery tissue sag as observed. This is not something I would worry about if one has had a successful cheekbone reduction surgery at one year after the procedure and no such soft tissue sag ha occurred.
An interesting question is why soft tissue sag occurs in sone zygoma reduction but not all of them. In fact it appears to be a relatively small occurrence but one that definitely exists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have interested in some combination of cheek and jaw implants. Although I’m not yet 100% certain which procedures I’d like to have done, I have a few brief questions regarding these surgeries.
1) For jaw implants, do you think it is necessary to have custom implants created if a male patient wants to get the sharp “flare-out” at the jaw angles? Or is there an off-the-shelf implant that can create this “look?”
2) In regards to cheek implants, do you think it is necessary to use the custom-designed male cheek implants that you have written about on your website for someone who wants the sharp “male model” look, or can standard silicone cheek implants be altered to satisfy patients with this desire?
Thank you for your time and consideration, and I look forward to talking further with you soon.
A: In answer to your cheek and jaw implants questions:
1) I am not certain what the exact visual image of the ‘flared out’ jaw angle look to which you refer. It may or may not be able to be done with standard jaw angle implants but that would depend on what that look is and whether your facial anatomy will even allow that to occur. Many young male patients have an unrealistic or unachievable jawline reshaping goal.
2) Without question no standard cheek implant can create the so called ‘male model’ look because they all lack the necessary posterior zygomatic arch extension to create it. Either true custom or special design cheek implant designs are needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 37 year old man who is extremely self conscious about the shape of my head. I’ve longed for a nicely rounded back head. Through my research I recently learned of your practice who performs surgical back of the head reshaping.
I typically where my hair rather short…prefer it to be shorter than the pictures attached. I think the custom implant is the way to go for me, but am concerned about a really noticeable scar. Would these sutures be similar to those use on the face when cosmetic work is done?
How do you determine if a two step skull implant process is required?
Another concern for me is if l the implant will create a “pulled look” in my face and pull my hair line back?
Where do you suggest making the incision?
I look forward to hearing from you.
A: In answer to your questions about back of head reshaping:
1) Generally scalp scars heal really well and can be very hard to see even in short hair. In my experience, for a variety of reasons, they do best in thicker scalps. For occipital skull implants the incision is placed low on the back of the head with a horizontal incision at about the level of the top of the ear and is usually about 7 to 8 cms.
2) Computer imaging is done to determine what you consider a ‘nicely rounded back of the head’. That will tell me how much augmentation is needed and whether a one stage or two stage approach is needed.
3) The implant will not pull up on your face or pull our frontal hairline back.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young adult male who is three weeks post-op from jaw shaving and cheekbone reduction (front and back end osteotomies) surgeries in Korea. I understand that these surgeries take quite a while for the swelling to subside but I have a question I must ask.
When I look in the mirror now, I have developed quite distinct nasolabial lines which were definitely not there prior to my surgeries. I am still quite young and I am starting to feel paranoid.
Are these nasolabial folds the result of sagging or is it the swelling even though I am already 3 weeks post op? Will they go away over time?
A: The short answer to your question is that after jaw shaving and cheekbone reduction it would be important to let all the swelling go down, which takes up to 3 months or more after surgery to see the final facial shape result. Only then will you know if the soft tissue effects you are seeing now is the result of the loss of cheekbone support. For now you can assume the appearance of the nsaolabial folds is an effect of the swelling. But time and healing will provide the definitive answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to ask about facial implants for under the eyes, I believe they are known as custom infraorbital rim implants. I have inherited hollowed eyes and I would like to ask how well are the implants attached, if it moves while smiling and if you can feel it. Thank you in advance.
A: The ideal treatment for undereye hollows is a custom infraorbital rim implant that sit on top and in front of the infraorbital rim ad can extend out onto the cheek a bit if so desired. They are secured to the bony rim with miniature screws so they will never move. They do not affect smiling or lower eyelid movement. A good fit to the bone and implant design allows them to usually not be felt.
While it is more of a surgical procedure than the traditional use of fat injections, the effectiveness, smoothness and permanent volume of the implants can offer in the properly selected patient a good correction of underage hollows.
A custom infraorbital rim implant is made from a 3D CT scan where the coverage and dimensions of the implant are preoperatively determined and controlled.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Last year I went to a famous Chinese plastic surgery hospital for cheekbone reduction surgery. My cheeks were not extremely big but only had mild protrusion, but I still decided to go through with the surgery to get a thinner face. At 4 months after operation and after all the swelling went down, I was very pleased with the result. Now it has been almost 8 months since my cheekbone reduction surgery but I am starting to have a problem. I have attached a recent photo of me. The top photo is unphotoshopped and the bottom photo is what I would like to achieve.As you can see from the unphotoshopped photo, my face is saggy from excess skin and this extra skin is pulling my face down so I have deeper nasolabial folds. I would like to get more surgery done to get the bottom photo look (permanent solution), but I will not be returning to the Chinese plastic surgery hospital. My previous surgeon said the saggy skin is because I am naturally getting old (I am very young and my skincare routine is very good!!!)
1~ Please can you explain why my skin starting to sag at 8 months after the surgery? If I leave this skin alone will it get worse or shrink?
2~ What surgery should I do to achieve the bottom photo look. I would like a permanent solution as I cannot keep flying overseas for touch up.
I would not like cheek implant because I underwent surgery to get rid of my cheeks in the first time. I would like to just cut the excess skin off but I do not know if there is a surgery for that.
A: Thank you for your cheekbone reduction surgery inquiry.
1) Your facial skin has sagged for one very specific reason…cheek bone support has been reduced and it has required the detachment of cheek soft tissues to do so. This is not a surprise and is one of the very well known aesthetic complications (technically it should be called a tradeoff) of doing this surgery. While it does not occur in every one who has the procedure, it is not rare. What you have now learned is that every cosmetic surgery has aesthetic tradeoffs, some procedures more than others.
2) There is no surgery to help you achieve your desired look now…not a cheek lift or even liposuction.
3) The soft tissue say you have now will be stable for awhile because of your young age. But when aging does eventually set in it will become worse as it does in everyone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Sorry that I was groggy right after my skull implant surgery and I didn’t had a chance to ask you some questions and I hope I can still ask you through email.
1) I know you usually use dissolvable suture for skull implant and planed the same to my case, but at the end you used staple sutures. Is it because it was too tight?
2) I remember you mentioned that my surgery “was fine. and it’s really tight”. Is there anything that I need to be aware due to it’s tightness? Did the implant need to be trimmed or altered in order to put in during the surgery?
3) I am trying to palpate the implant but have a hard time to locate due to the pain and numbness of my scalp. I am wondering later on am I able to palpate the implant when it’s fully healed?
4) Please tell me how you want me to remove the staples.
A:Thank you for your early followup. In answer to your skull implant surgery questions:
1) Metal staples were used for your skin closure because it was very tight and I did not trust dissolvable sutures. The good part of that is that means you have gotten the absolute maximum amount of skull augmentation that your scalp will permit.
2) The implant was not modified in shape in any way. It was placed with the outer contours as depicted in the 3D planning pictures.
3) You probably will not be able to tell where the implant is when all the swelling goes down and the scalp feeling returns.
4) The ear sutures are dissolvable so they will eventually fall out on their own. But they can be trimmed off now if they are irritating.
5) The scalp staples can be removed anytime 10 days or so after surgery. Since you have the staple remover it is a matter of finding someone to do it, it is easy to do. Whether that is a friend or any medical personnel who feels comfortable doing it is the only question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve read a lot of your responses on RealSelf, as well as sifted heavily through your blog and website. I appreciate you taking the time to read about my situation.
I am Chinese and as I grew into a teen I started noticing that my facial structure is very asymmetrical. My chin is in the centre however, the angle of my jawbone is different on both sides. Though not severe, it is still quite noticeable. My cheekbone on one side protrudes more than the other..
I understand that you are well aware of the aesthetic desires of most east asian cultures – by that, I mean the v-shaped chin and jaw line, as well as a slim malar area. My question to you are:
1). is it feasible to have facial bone contouring surgery on just one side of my face so that my features can become symmetrical?
2. As I am still quite young and my skin elasticity is quite good, would my “excess” soft tissues and skin around the cheekbone area and the jawbone area also “shrink” in size to stick to the reduced bone structure?
Many patients on RealSelf or those who have undergone malarplasty seem to come to you for advice regarding their ‘sagging’ of tissue on your website. I am definitely not keen on having one side of my face extra saggy.
3. Do you employ the same techniques as those in China and Korea? How can I avoid sagging like a bulldog and getting a double chin with these procedures?
A: In answer to your facial bone contouring questions:
1) It is possible to do facial bone contouring on one side on the face if that is indicated, I do it all the time. A 3D CT scan would provide a good diagnostic evaluation of your facial structure to best answer that question.
2) Generally younger patients do better with soft tissue contraction around reduced facial bones. But there are limits at any age of how much bone can be reduced and successful tissue contraction around it to occur.
3) The bone techniques used (osteotomies) for facial bone reductions are not unique to any country as there are only so many ways to do any surgery. What is likely unique is the individual approach taken for each patient and the balance struck between the amount of facial bone reduction done vs the soft tissue risks of sagging vs the patient’s aesthetic goals. Having expanded my experience with some training in China they tend to be very aggressive because many of their patients do have really big cheekbones and jaws. But not every Asian patients does so the exact same operation for everyone will have some slightly different aesthetic outcomes. (e.g., soft tissue sagging)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question I was hoping you could shed knowledge regarding delayed jaw implant infections. I had jaw implants placed two years ago and just yesterday I noticed some tenderness on the right jaw implant, specifically more on the bottom/underneath, in the middle of the jaw line (as opposed to any tenderness at the back of the mandible). No noticeable swelling as of yet, and no trauma to speak of…..but I did get over a bad bacteria-based throat infection about three weeks ago, so hoping the bacteria didn’t travel and infect the implant. In your experience, are late-stage (over at least a year) bacteria (so non trauma initiated) jaw implant infections a pretty regular occurrence? Anything I should really watch out for before seeing a doctor?
A: In my experience such potential delayed jaw implant infections have not occurred…unless there is some small opening in the original incision lines inside the mouth. (that is known or unobserved) The occurrence of blood borne infections seeding an implant would be extremely rare. I am sure in the annals of surgical history it has happened but not something that would ever be considered either common or expected. To make an analogy, think of all the women in the world that has breast implants and the common illnesses that occur but yet we don’t hear about such delayed implant infections occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley ,I might just take this moment to get a full understanding of the silicone custom jawline implant by asking some questions:
1. The common problem of bone erosion with silastic implants is eliminated if the silastic implant is customized and fixed with screws?
2. Custom made silastic implants are made to last a lifetime inside the patient? In other words, there is no need to replace them unless the patient desires to do so.
3. In my case the silastic implant would be inserted intraorally since the PEEK implant will be extracted this way?
4. You would let me be involved in the designing process from start to finish and will show drafts and answer emails if the patient tries to engage you in the design?
5. You are willing to design implants that do not just provide volume in the right places but also correct asymmetries between the facial halves?
6. Do you have any computer program that could reasonably project how a finished implant design (for both the cheekbones and the mandible) would make my face look before we manufacture the implant?
7. Your finished implant design can be scrutinized and revised, if necessary, until we are both satisfied that it would fulfill my aesthetic wishes?
8. Implants are made well in advance and would only be manufactured with my explicit consent?
Kind regards
A: In answer to your silicone custom jawline implant questions:
1) All implants on the jawline, regardless of their composition, create some degree of passive implant settling and even bony overgrowth particularly back at the jaw angle area. These are natural phenomenon when placing implants on bone that is most manifest on the mandible. The concept of ‘bone erosion from silicone implants’ is both misunderstood and erroneous.
2) All implants for the jawline (silicone, Medpor, PEEK etc) are permanent materials that do not undergo degradation of the material over time. From a material standpoint they are lifelong devices.
3) If your PEEK implants were inserted intraorally then silicone implants can be done as well.
4) to 7) I have a very specific protocol on how custom implants are designed with patient participation. I have attached a document which explains the details of this process that every custom implant patient is required to read and sign before the implant design process is ever started.
Dr. Barry Eppley
Indianapolis, Indiana