Your Questions
Your Questions
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
Q: Dr. Eppley, I had an otoplasty done several years ago to correct my protruding ears. When I saw the results, I was disappointed and thought my ears were undercorrected. I decided that I wanted another operation. We did the operation again 3 months after the previous operation, which I think caused my antihelix to thicken. nI don’t mind that my antihelix is thick, I do mind how close my ears are to my head. I also developed a telephone ear deformity. All I would like to do is return back to how my ears looked before, but I know that might be difficult. How difficult would it be to return it the original shape and protrusion or something close to the original shape and protrusion?
A: I would need to see pictures of you ears, both now and before, to better answer your question. But I think the question is not whether your ears can return to their initial preoperative state, because they can’t, but how close or what type of result, could such an otoplasty reversal come to it. There is no going back home, so to speak, there is only how much closer to home can you get. Very few surgeries are ever 100% reversible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i am writing to you for some possible assistance. I was reading a thread just now that was posted a few years back about bulging temple veins. One of the gents on the forum talked about how he went to you for treatment for his” wiggly worms” on his temples. I have the same issue much more mild though on my right side, i thought i would ask you if you know anyone personally that resides in my area that does this procedure and is very good at it? It is a old post so i was curious, has treatments become more advanced since then? Like it can be done with lasers now or is done with just a trip to the surgeon office? I don’t know the first thing about all this and that is why i have come to you, i don’t mean to bother you. This gent spoke very highly of you and thought i would enquire.
A: What you are actually referring to are known as prominent temporal arteries, not veins. This is the type of prominent vasculature that occurs most commonly in men in the temples and forehead region. The only technique for their reduction/removal is my multipoint ligation technique. I could not tell you whom in your geographic area may perform this temporal artery ligation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for the informative consultation a few days ago, I am currently in the process of narrowing my choices. I just had a few questions.
1.) What are the odds of long term side effects with genioplasty vs jaw implants? Is one significantly safer than the other?
2.) Would a custom jaw implant benefit my chin as well? If yes, would it benefit my chin to the extent a genioplasty would?
3.) Would a custom jaw implants be much better than standard implants in terms of symmetry?
A: In answer to your questions:
1) A genioplasty (chin) and jaw angle implants carry with them different risks. I am not sure I would ever say one is safer than the other but because the jaw angles involve an implant and the chin is done by moving one’s own bone, jaw angle implants carry a risk of infection than a bony genioplasty does not.
2) By definition a custom jawline implant wraps around the entire jawline from angle to angle and crosses the chin. An implant can create the same amount of horizontal augmentation that a sliding genioiplasty but also can widen the chin which a genioplasty can not do. (it actually makes the chin more narrow from the front view)
3) One of the benefits of a custom jawline implant approach is that it is one piece, using standard implants is a three implant approach. This reduces the potential risk of asymmetry both by its design and placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young female and am interested in lip advancements. I just have a few questions about the lip advancement procedure. I have pretty full lips. I have lip implants in currently and I like them. However, I would like my lip size to be a lot bigger. I don’t like fillers at all and, after reviewing what is offered, I am most interested in the vermillion advancement. My questions are:
1) Would this option of lip enhancement be good for a young person who dislikes lip fillers?
2) Can I have a vermillion advancement with Permalip implants in?
3) How big would I be able to make my lips with the vermillion advancement? I would want a big difference.
4) Would I lose any current lip projection (volume forward/pout), after the advancement?
A: In answer to your lip advancement questions:
1) Short of injectable fillers and implants, a surgical lip advancement procedure is the only option for making one’s lips bigger.
2) A vermilion advancement can be done with lip implants in place.
3) As a general rule, lip advancements can increase the vermilion show of the lips by 4 to 5mms on the upper lip and 3 – 4mm on the lower lip. Lip advancement are very powerful procedures for increasing lip vermilion show and their perceived size.
4) Lip advancements will not decrease the forward projection of the lips.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am still considering having the buttock implant removal. I really wish I had done it at the same time as the facial implant removal.
1. Have you removed many subfascial buttock implants?
2. If so, are there many potential complications with this surgery?
3. Will I need drains?
4. Is there much pain afterwards?
5. Would I need to stay in Indiana long? It would be great if I could just stay 3 days or so. Or would I need to stay to have stitches removed?
A:
In answer to your buttock implant removal questions:
1) I fortunately have rarely just removed buttock implants without some form of replacement. So I certainly have not done ‘many’ and never hope that I have to.
2) Like all implants removals anywhere on the face or body, there is going to be generalized tissue deflation/flattening effect. Your cheeks are a good example fo what happens when you remove the underling support from a projecting prominence.
3) A drain is not needed.
4) Any postoperative discomfort will be a fraction of what its as to place them. Your facial implants are a good example of what ti expect.
5) You should be able to go home in one to two days at worst. All sutures are under the skin and are dissolveable.
Dr. Barry Eppley
Indianapolis, IndianaButtock
Dr. Eppley Q: Dr. Eppley, Can you please give me some information on custom facial implants? If I decide to go ahead with the procedure how much time do I need in the USA?
From the date that I arrive –
to have the CT scan,
to manufacture the jaw or skull model ?
To sit together and design the implant
To manufacture the implant
To operate
To leave hospital
To be able to leave USA ?
I am extremely concerned about infection – because I have just had cervical disc put into my neck. An infection my spread to them and create a big problem causing them to be removed.
Also extremely worried about pain – that is the one thing keeping me from going ahead – how can we totally control this ? Can I stay in hospital of the first couple of days so that I can get stronger IV pain medication \?
A: In answer to your custom facial implant questions:
1) The design and manufacture of custom facial implants is a 4 to 6 week process. Therefore patients get their 3D CT scan in their local geographic region and send it to me. I then take the scan and do the design process. Patients only come here for the surgery for the obvious practical reason.
2) The design process is done in sessions with engineers from 3D Systems. Patient do not directly participate in these actual sessions. I then take the design files and share it with the patients for their input. We have three design sessions to come up with the final approved implant designs.
3) The surgery time for a custom jawline implant is 2 hours.
4) If you are coming by yourself, and given your immediate pain concerns, you would stay overnight in the surgery center. This surgery is not performed in a hospital as that changes the cost of surgery significantly.
5) You would fly home when you are comfortable doing so. Each patient is different but I would give yourself at least 5 days after surgery before leaving.
6) While infection is always a concern in jawline implant surgery, I would have no concern about it spreading to your cervical disc implants should it occur. When occurring it remains localized to the implant pocket.
7) While the most common postoperative custom facial implant issues are aesthetic in nature, infection is the one medical issue that we pay a lot of attention to try and avoid through a host of strategies. But infection is not something that ever occurs immediately, its occurrence is always in the range of 3 to 6 weeks after surgery…a time that surprises patients as they think they are well past it at that point.
8) While every patient is different about pain, that has never been a postoperative issue that has been a problem with any custom facial implant patient. You may every well be different in this regard although I would think your cervical disc surgery would have been far more painful than jawline important. While one would receive IV pain medication in the overnight stay int the surgery center, there is no capability to go to a hospital for IV pain medication after the first night after surgery.
9) Pain is not something I worry about in any patient as that seems to be well controlled by standard pain medication. What I do worry about is that few patients are psychologically prepared for the large amount of facial swelling that will occur (from the patient’s perspective) and the duration of time that it takes to go away. This can be very psychologically destabilizing for some patients…and they are always the male patients that have the most difficulty with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple questions about some problems I have with the lower third of my face and lip area. To begin with, I’ve noticed that my lips have begun to age. My upper lip looks quite long, and I’ve always had a downturned mouth and aging has exacerbated it. I look extremely sad/angry, even when I’m not. I have vertical maxillary excess, causing bite problems and lip incompetence too.
Is there anything I can do to fix all this? I was thinking a combination of a corner lip lift, upper lip lift and facelift would address the lip problems, but I would still need something done for my maxilla, to shorten it and help with the lip incompetence.
Thank you very much for your attention.
A: If you have maxillary excess that needs to be treated and would be beneficial to do so, that is what you need to treat first. All the external changes of the lips and face need to await that fundamental skeletal change. You would only do the lip and facelift procedures first if you knew that you were never going to have a maxillary impaction procedure. I would need to see pictures of your face to provide a more qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to ask are cheekbone reductions always bound to have some sort of sagging of the midface area or incur premature aging?I thought I had done enough research on zygoma reduction before deciding to undergo the procedure. I knew there would be risks or trade offs, but I didn’t know it would be this bad.The L-osteotomy surgery I had included a 4mm removal of bone on each side. My front and 45 degree cheekbone was not prominent. Only the lateral of my cheekbones was quite prominent, giving me a strange wide and manly face shape. Why is it that my front cheeks sagged so much after the surgery?
A: When the whole cheek bone has been moved in, depending on the facial type, the risk of soft tissue sagging is a real one. That is whole skeletal support for the midfacial soft tissues, particularly the front part of the cheeks. By your own admission the front part of your cheekbones was fine but it was the back part (posterior zygomatic arch) that created the issue. Thus it would been better to just have the posterior arch osteotomies done with inward positioning as that would have caused no soft tissue sagging at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lip lift in early December 2017. The surgeon took out 7mm of skin in the center of the upper lip. And now it seems that the nasolabial area looks bigger and mouth corners look down turned. I would like to know if the Double Duck would be a good option for me, when can I get the surgery and if you could perform this surgery, how much would it be ?
A: Thank you for sending your pictures, particularly that of the preoperative markings. When this amount of skin resection is done with a flat inferior border in a subnasal lip lift, it can cause an apparent over corrected appearance to the central upper lip and the sides of the lip are left ‘behind’. This creates an upper lip central to side vermilion disproportion and can also cause a downturning of the corners of the mouth. (too much central lip pull)
A strategy to improve to improve your upper lip shape could include the following:
1) Extended corner of mouth lifts with lateral vermilion advancements
2) Subnasal scar revision to try and move the scar line inside the nostril on each side of the columella (this is really a modification of the Double Duck Lip lift procedure)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope I can ask you this: I just had a Facial fat transfer 2 weeks ago. My surgeon is on holiday now. Please help me. I was walking today and I came into a storm with around 38 km/h of wind. Often the wind blew directly in my face for around 20 minutes. Do you think that killed some of the 2 weeks old fat? Thank you so much and warm regards.
A: The simple answer to your question is that I doubt external cold wind could adversely affect the volume retention of a facial fat transfer procedure…at least on a limited time exposue. You are undoubtably drawing this potential analogy from technologies such as CoolSculpting where cold temperatures are used to aid in some fat reduction. While seemingly a relevant analogy it is not. These are devices that are applied directly to the skin and held there for a duration of time to really lower the temperatures of the tissues under the skin. That is quite different than an external wind chill, which while dropping the skin surface temperature, would have a much harder time dropping the temperature of the deeper subcutaneous tissues if only ‘applied’ for a relatively short period of time. Much longer exposures, however, would be likely to do it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In Korea, there are few clinic that offers posterior cheekbone reduction with 5mm sideburn and cut inside the hair (the posterior cheekbone reduction.) Many clinic in Korea also do not offer this method of surgery.
What are the risks of this method of surgery as I am interested in making my face smaller? The clinics I have consultations with told me that there are many revision case because people can feel and see the broken arch bone at the hairline or there is non connection of bone. Is this true? What other risks??
A: Thank you for our inquiry. I have done many isolated posterior zygomatic arch osteotomies (posterior cheekbone reduction) to narrow the width of the face on the sides. (but leaving the anterior cheek bone alone) I have not yet seen the complications which has been told to you such as bone edge visibility or palpability. By definition with plate fixation there is a non-connection to the bone but that is irrelevant as the bone is stabilized and there is always a non-connection of the bones no matter whether it is done in isolation or with anterior cheekbone reduction osteotomies.
Dr. Barry Eppley
Indianapolis, Indiana
