Your Questions

Q: Dr. Eppley, Thank you for all the info you generously gave me on midface implants. I came across this image on your website. I wonder if it’s a combination of premaxillary implant and cheek implant. In addition, I feel a bit nervous about having this surgery. It seems like you are the only doctor who talks about it. When I look up premaxillary implant, there is a poor amount of info found on Google and all that info are written by you. I found absolutely nothing else other than the posts you wrote, not the info nor any before-and-after photos. I tried to search in a different language too but nothing. Other doctors seem to work on only cheek implants. Did you ‘invent’ this surgery? Or does this surgery go by another name? Or is it just that this surgery isn’t popular? 

I honestly feel weird about this and feel more anxious when no info can be found on the internet. On one hand I really want to improve my appearance, on the other hand, I can’t just have a surgery if i don’t feel well-informed. Is there anything about this you can tell me?

A: The custom implant image to which you refer is a total midface implant that covers the paranasal, premaxillary, anterior cheek and infraorbital rim areas. Implant augmentation of the base of the nose (premaxillary-paranasal region) has been around for decades. It is not ‘popular’ because it is not commonly requested and almost all surgeons have no experience with it. In my experience midface implants have moved beyond trying to use various implant materials not specifically designed for it to try and make it work. The use of custom implants designed and fabricated from the patient’s 3D CT scan allows for midface augmentation results around the nose that have previously been unattainable in any other reliable way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, regarding jaw angle reduction or removal (traditional jaw angle amputation) where the surgeon cuts off the jaw angle at the mandibular ramus. Will the masseter muscle also be cut?  (looks like the masseter muscle covers this area of the bone) If the masseter muscle gets cut, then what will happen and what will be the potential consequence?

A: In jaw angle reduction surgery the masseter muscle is first lifted off the bone through subperiosteal dissection. Then the bone is cut and the muscle falls back into place during closure. Thus no muscle is cut unlike that of the bone.

While no muscle is cut during jaw angle reduction surgery, the muscle will retract upwards to the new lower border of the jaw angle when it is amputated or removed in an oblique full thickness bone cut fashion. This does not affect its function or mouth opening/closing. But between the bone removal and muscle retraction the shape and support of the soft tissues will change over the angle area. Facial width will definitely be less and hopefully there will be no soft tissue sag as a result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wrote to you before about my chin implant removal problem but I wanted to wait a little bit more to have a surgery. I am 22 years old and had a bad chin implant surgery  six months ago. The chin implant was the extended anatomical type, Implantech brand, small size 5.5mm. The incision was submental and implant stayed in only 2 days and was removed due to not liking it at all. It was a big mistake for my face. Its been is months and even though it improved with time, its not exactly how it was before both the shape and size of my chin. My chin is wider, longer, and bigger than before and it  feels squashy inside and not tight as before. But now I see that,my jaw is also larger. My jaw was never touched in the surgery but somehow it effected it  too. My jaw is obviously larger than before and its square. My jaw used to be V shaped and my face is now more square. My lower face looks heavier and not lifted. What can be the reason for my jaw to be larger? Is there a solution for that? Since you are one of the most qualified chin surgeons in the world, i thought maybe you know why and maybe you have seen something like that before. I am sending my pictures. Thank you so much.

A: I do remember your chin implant removal case and patients have come forth before with similar findings. While not common it results from the tissues being lifted off the bone for implant placement and they never reattach like they were before the implant. It should not have affected your jawline per se since those tissues were not lifted off of the bone as the wings of the implant does not go back that far. But that is the effect of the tissues along the chin and backward having an inferior descent creating the change the shape your jawline from the front.

Options for improvement are either a submental chin tuck, a jowl tuck up or a combination of both.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 30 year old male and have been debating about a skull reshaping procedure for the past five years. Attached are some profile pictures of my head shape and two pictures of my expectations. I was hoping to round out the back of my skull and shape it in a way that makes my jaw line more prominent/visually appealing. I’m sitting here wondering about the following factors:

1) Are my expectations reasonable/attainable?

2) Am I even a good candidate for this?

3) Is the scarring blatantly noticeable?

4) Will altering the back to improve the profile affect the frontal view (eg…head on)?

A: Thank you for your inquiry and sending your pictures. In answer to your skull reshaping questions:

1) The morphed images of the back of your head are fairly realistic, being able to achieve 80% to 90% of that change as a one stage skull augmentation procedure.

2) One is a good candidate for this surgery if their expectations are in line with what can realistically be achieved.

3) The implant is placed through a small horizontal incision low in the occipital region. This is a scar that is barely detectable without hair and undetectable with hair.

4) Changing the back of the head will have no effect on the front of the head/face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I thank you for your pre surgery notes in relation to the psychological effects of living with a new jawline implant have become apparent this weekend.  I think the initial panic set in and I’ve had to take a step back and think about your comments again.  I think the initial feeling is that the implant is way to big – but again I’ve taken onboard your comments around swelling and the amount of time that should be allocated to allow this to subside. Aside from this I’d like to ask a few questions: 

1) Can you advise how long I should wait to shave the area under the chin – where the stitches are placed (these dissolve naturally right?)  

2) Will I have a noticeable scar from the skin were the stitches are?

3) If after a number of weeks the implant still looks out of proportion and I decide to have it removed what are the implications? Would the current implant cause a permanent change to my facial features?

4) How quickly could we move from making the decision to remove the implant to actually removing it ? (i’m not suggesting this at this point, I’d just like to understand the process)

A: in answer to your custom jawline implant recovery questions:

1) It is important to realize that you are just less than 4 days after your surgery…when things look their worse. A lot will change in the next 2 to 3 weeks when you will feel much more comfortable with the way your face will look.

2) Having done hundreds of custom jawline implants there is no way this design would ever be considered too big. Conversely, in a month or so you will likely feel the other way….thinking maybe I should have gone a bit bigger.

3) You may shave under the chin at 7 to 10 days after surgery.

4) Implant removal will likely have no adverse effects on your preoperative facial shape, particularly when it is this small size.

5) Any removal of the implant before 8 weeks after surgery, when you have had time to fully see the actual facial changes and adjust to them, would be capricious.

6) Implant removal could happen within a week if one decides to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial implant revision surgery and fat grafting.Three months ago I underwent surgery with the following facial concerns/objectives, a weak chin (needed more projection and wanted in squarer in appearance), a weak jawline (wanted very strong, defined jaw line), hollow eye area and wanted slightly wider mid face. For those concerns I had a Terino Square – Style I chin implant, buccal fat reduction and fat grafting to under eye area and temples. 

Although I can see an improvement in the projection of my chin in side profile I would have liked the chin to be wider. The chin implant alone has not provided me with the jaw line enhancement I wanted – disappointed with the results. The fat grafting carried out in the eye and temple region was very conservative and provided minimum results/very subtle improvements and my understanding is that the areas treated could further diminish as the fat reabsorbs. However I am happy with the buccal fat reduction.

After evaluating the outcome of my procedures and completing extensive research (including your website and case studies) I feel I have a much better understanding of what I want to achieve and treatment options available. I I would like my chin to be slightly wider in front view and feel that the going up a size (Terino Square Chin – Style I – large) could achieve this effect. I would like a much stronger and more defined jaw line. I feel my jaw angle is very high and that I have a vertical deficiency.  I am very interested in the Vertical Mandibular Angle implant.  I am open to custom implants if it will provide me with a better outcome – I am seeking a straight line back from the chin to the jaw angle point and after reading some of your articles understand that the potential dipping between implants needs to be considered. I would like to add more volume and increase width slightly through implants or fat injections. For the temples, I feel my head is narrow and would like it to be fuller and wider (smooth surface with gentle curves).  I think further fat injections could help.

A: Thank you detailing your recent lower facial surgery history as well as your objectives. In reading through them I can make the following comments:

1) A Style 1 square chin implant lacks adequate width (45mm) for  most men that seek a more square chin look. It almost has to be out to 50 to 55mms to have a more square effect.

2) A chin implant by itself is never going to create a jawline effect as the chin is but one-third of the total jawline.

3) Fat grafting in younger men of average or thin body frames rarely has much persistence and, at best, produces subtle/minimal results. 

4) The only way to have a straight line from the chin back to the jaw angles is with a custom jawline implant.

5) I would have little confidence in fat grafting to the temples. It is a broad area and requires a lot of fat just to have just a little result and would not likely ever end up ‘fuller and wider’. Temporal implants are far more effective and have an assured volume augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m not sure if I’m a candidate for a custom jawline implant. If I have symmetrical jawbone structure I don’t see why I should need it. In addition, I don’t have the capital for custom one. From my point of view, I have a very weak lower jaw, my chin is very behind plus it is narrow, as you can see from my smiling picture it looks like I have no connection between my ramus and my mental protuberance. In addition, my jaw is narrow as well plus it is not prominent at all since the whole jaw is short. What I’m looking for is both horizontal and vertical improvement in my jaw with non-custom jaw implants that will bring balance to my lower face.  I’m not worried about my chin at this moment because I don’t have the resources.

A: Based on your initial stated objectives of improvement, you are speaking to a total jawline approach. You can’t bring the chin forward, length the jaw angles and make the jawline wider all at the same time unless it is a total wrap around jawline implant.

The most common reason for a custom jawline implant is not asymmetry, it is primarily used when the patient’s dimensional jawline needs exceed what standard implants can achieve.

Standard vertical jaw angle implants are an option if you just want to limit the change to the back part of the jaw only. (jaw angles) But with a revision rate of over 25% using standard jaw angle implants, it would be important to only consider this surgery if your resources are sufficient should the need for revisions surgery arise.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question, and it  involves customized facial implants for the cheeks and chin/jaw. In college I played for the football team and and broke my face. My nose was shattered with an effort made to fix it several times. My cheeks and jaw were damaged and there is a lack of harmony between these facial features (cheeks, jawline, chin) that they once had. That may have gotten worse due to the fact that I was still growing. But I was wondering if these customized implants in both areas could “put me back together” and really give me more confidence. I know you place your cheek implants higher so as not to create a rounded face and to achieve angularity and do CT scans to create a perfectly conforming chin/jaw implant with the degree of jaw “flare” or width and verticality desired. I know very few people choose to have their photo put on the website, but with these tools is it basically possible to create the best/patient desired jaw angle/width and cheek implant/placement? Even “male model quality”? Because I know fillers are always another option but they are not permanent.

My last two questions are these:

1.Would a chin implant eliminate my chin dimple? I would not want that. If it was softened a little, that would be fine, but I wasn’t sure exactly where the implant was placed and how it would effect the soft tissue.

2. What is the infection rate on jaw implants? I know it is higher than chin implants, but thought maybe the CT used to make customized facial implants “custom build” would help  reduce the instance of infection and subsequent removal. Thank-you for your time.

A: Thank you for your inquiry and detailing your facial concerns. First and foremost I would need to see pictures of your face for my assessment and computer imaging to see what may be possible. Second, while custom facial implants can be designed to any shape and dimensions, how to make those dimensions create any specific look is more an art than a science and is not a completely predictable process. Third, a chin implant will not efface or eliminate a chin dimple. Lastly, of all facial implants, any implant that involves the jaw angles has a high infection rate. While the overall rate of facial implant injections is around 1% to 2%, that increases to 3% to 4% in the jaw angle region.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had rhinoplasty done five years ago and developed a recurring abscess on top of my nose several years later. It was needled and cultures which turned out negative. I noticed a suture coming out but swelling with pus still builds up every week . I have been on Augmentin a few times but with no relief. What should I do? Is surgery needed?

A: Your descriptive history suggests that there is a foreign body in the nose that needs to be removed. Whether this is from a permanent suture or from an implant I can not say since I do not know what was specifically done during your procedure. If there was an implant placed in the dorsum of the nose then there would be no question about the source of the infection

But with recurrent swelling years after the original procedure and failure to resolve completely with antibiotics suggests that open exploration is needed to determine the source. Infection after rhinoplasty surgery are fairly rare particularly when autologous cartilage grafts are used. But sutures used inside the nose in rhinoplasty can be a known  source of tissue irritation particularly if there are of the non-resorbable composition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had spoken to you a few weeks ago about the tightness I had from my chin implant. You had recommended a 3D CT scan to make sure the implant was in the correct position. Before I could make the appointment, I started to carefully feel the implant and noticed that the right wing of the implant is heading up in the direction of the right corner of my mouth! This area is where I am feeling the numbness and tightness. I had put botox to relax the muscles but now that I have felt the position, do you recommend to remove the implant to help with the symptoms I have been having? I’m of afraid of another surgery to reposition it and having to deal with the long recovery again. I’m thinking the removal won’t be as bad as the implantation. Do you think the tilt in the implant is causing my symptoms?

Please respond when you can. I appreciate any help I can get and you seem to be the only one with the answers.

A: A malpositioned chin implant can certainly be the cause of various postoperative symptoms, which include tissue tightness. The way to answer the question of whether the implant is the source is to have it removed. On the other hand there is a reason you had the chin implant in the first place and it would be shame to abandon its original objective. (the argument for chin implant repositioning)

The best way to answer the question of chin implant malposition is with a 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I started taking Accutane exactly one month ago – the dose is quite low, at 20mg once daily. I now have a problem / query. I realized I should have had surgery before starting on Accutane. I had an infected jaw implant removed earlier this yea and have terrible asymmetry as the jaw implant on the other side is still in place. I cannot wait 12 months to have this corrected (I say 12 months as the plan was to be on Accutane for 6 months followed by 6 months being Accutane-free)

My question is – how soon can I have surgery (custom wraparound jawline implant at least) seeing that I’ve been on 20mg Accutane daily for the last 30 days? 

A: It has long been believed that wound healing may be compromised in patients taking systemic isotretinoin. The cellular basis of this potential adverse effect is that his drug affects the synthesis of collagen which is essential for normal wound healing.  Despite this contention, animal studies have failed to show adverse effects in wound healing at doses of 4 mg/kg per day. Case reports and cohort studies looking at facial skin laser resurfacing, facial chemical peels, laser hair removal, rhinoplasty, tooth extraction and ENT procedures have failed to show any demonstrable or consistent increase in wound healing problems.

Does this mean that the purported adverse effects on wound healing by isotretinoin are a myth? It is fair to say that most of the clinical studies reported have very low numbers of patients which makes it difficult to really know if those findings are valid. Equally relevant, none of these clinical studies have involved the use of implants which have natural higher risks of complications and is always the ultimate test of wound healing.

Given that most of aesthetic facial surgery procedures are elective and there remains some doubt that isotretinoin  has no adverse effects on wound healing, one should not have surgery while actively on the drug. If you stop the medication now, having been on it for just two weeks, the risks  a wound healing problem from having facial implant surgery a month or two from now should be very low.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty several months ago and have muscle strain in my chin and my lower lip no longer functions the way it use to. My lower lip will not meet my upper lip without force and ends up tucking up under my upper lip when I chew, almost disappearing. My chin bunches up when I close my mouth and now I’m stuck with this open mouth expression all the time. My lower lip has also thinned and falls well below my lower teeth as if it’s being pulled down. My surgeon told me he projected my chin out by 4mm but not sure on the hight. I’ve read message boards of patients with the exact issues as me and say time has not corrected this. Is there anything that can be done to correct this Dr. Eppley? I asked my Surgeon to reverse or adjust my procedure but he will not. I am very distraught and not sure what to do.

A: To have such a cascade of perioral symptoms from a small 4mm horizontal advancement sliding genioplasty is very uncommon in my experience and is more likely with much larger bony chin movements. But that issue aside the question is why you have such symptoms…it is because of the bone movement or does it have to more with the soft tissue closure/adaptation to the new chin position? To give an informed answer it would be helpful to see before and after pictures of your face and any after surgery x-rays if your surgeon obtained them.

But in refractory cases like yours where the symptoms did not improve with time, a reversal procedure would be the most logical approach to improving your current symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question for nipple lift surgery. I am considering redoing my breasts implants. If I did, in what scenario could we use the gummy bear tear drop implant? Could it be the same 250cc or would we have to increase it, and by how much? Also, if we put in a new implant (I would prefer medium profile and I currently have high profile) would we have to use my armpit incision or could we use the nipple lift incision? And if we use the nipple lift incision, will it cause a worse scar? Please let me know, thanks!

A: If you were to replace your breast implants it would be possible to use your existing axillary scars, particularly if the implant size is not going to increase by any significant amount. While a tear drop shaped implant can be used, they are highly prone to rotate when placed into a pre-existing pocket. So their use in an existing pocket should be approached with that risk in mind. (the textured surface really only grabs fresh pocket tissue not that of a smooth capsular surface that has been created from an existing implant) You would be better served to use a lower profile round smooth which would naturally develop profile closer to that of. tear drop but with no risk of shape malformation with implant rotation.

The nipple lift incision is too small for implant insertion. And even if it weren’t it would end up with a worse scar than would be created from a nipple lift alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I started taking Accutane exactly 2 weeks ago – the dose is quite low, at 20mg once daily. I now have a problem / query. I realized I should have had surgery before starting on Accutane. I had an infected jaw implant removed  in August 2017 and now, in my eyes, have terrible asymmetry as the jaw implant on the other side is still in place. I cannot wait 12 months to have this corrected (I say 12 months as the plan was to be on Accutane for 6 months followed by 6 months being Accutane-free.) My cheek implants are also contributing to asymmetry (they are visibly misplaced).

My question is – how soon can I have surgery (custom wraparound jawline implant at least) seeing that I’ve been on 20mg Accutane daily for the last 2 weeks? 

A: It has long been believed that wound healing may be compromised in patients taking systemic isotretinoin. The cellular basis of this potential adverse effect is that his drug affects the synthesis of collagen which is essential for normal wound healing.  Despite this contention, animal studies have failed to show adverse effects in wound healing at doses of 4 mg/kg per day. Case reports and cohort studies looking at facial skin laser resurfacing, facial chemical peels, laser hair removal, rhinoplasty, tooth extraction and ENT procedures have failed to show any demonstrable or consistent increase in wound healing problems.

Does this mean that the purported adverse effects on wound healing by isotretinoin are a myth? It is fair to say that most of the clinical studies reported have very low numbers of patients which makes it difficult to really know if those findings are valid. Equally relevant, none of these clinical studies have involved the use of implants which have natural higher risks of complications and is always the ultimate test of wound healing.

Given that most of aesthetic facial surgery procedures are elective and there remains some doubt that isotretinoin  has no adverse effects on wound healing, one should not have surgery while actively on the drug. If you stop the medication now, having been on it for just two weeks, the risks  a wound healing problem from having facial implant surgery a month or two from now should be very low.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old male from Europe looking for a surgeon who has experience with facial implants, in particular with cheek implants. I had Medpor cheek implants placed one year ago but I am not happy with how the result turned out. They are placed too low on my face and the size of the implants is way too small for the result that I was looking for. I wanted to have bigger implants placed more on the “outside” of the face to make my narrow face wider and give it more of a feminine and oval shape. Since I think that the standard range of silicone/medpor implants will not fit my expectations regarding the size of the implant, I was looking for custom cheek implants with a very big/important projection.

As I said before, I am not from the US – could you maybe explain to me how it works for international patients to have surgery with you. Do I need to come for a pre-operative consultation or would a consultation via Skype be sufficient? and plus, since I am looking for custom made implants, would it be OK for you to have a 3D scan of my face and discuss the options via Skype and email?

Thank you very much in advance for your assistance.

A:Thank you for your inquiry and your detailing your history. By your description it sounds like what you are looking for are what I call ‘malar-arch’ cheek implants that extend much further back along the zygomatic arch. This produces a much more dramatic sweeping effect to the cheek augmentation result. These type of cheek implants are best made in a custom fashion from a 3D CT scan. All subsequent discussions and preoperative planning can be done in a virtual fashion (Skype and email)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in elbow lift surgery. In reading online one of the surgeons on there said:  “Realize that a scar on the elbow does not heal very well. The scars tend to go wide as the area bends so much and separates the scar.” Is this true even if I take say a month and don’t bend my arm all the way? Another wrote:  “I have found a combination of Sculptra and radiofrequency treatments like Venus legacy and Thermage help increase the tightening in this area. Fractional laser like Fraxel added, can help increase collagen as well.”
What’s your experience been with those modalities?

A:The key to a successful elbow lift is ultimately how the scar does as one does not want to tradeoff one aesthetic problem for another. The key to a limited width elbow scar from a lift is the zone of excision, where it is placed and how much is removed. This is determining by preoperative markings with the elbow in BOTH extended and 90 degree flexed positions. If the surgeon only takes into consideration the amount of tissue removed in the extended position, it will be too much and a wide scar will result. It is first marked in the extended arm position and then checked and reduced in the flexed position so not too much skin is removed and tension is placed on the wound closure. This is a basic plastic surgery concept but often overlooked. The name of the game is maximal skin removal with the best scar result. In aesthetic surgery the scar result takes precedence over the maximum skin removed.

For excess skin around the knees, and any joint for that matter, non-surgical modalities will be only of benefit to the provider of them. While most of these non-surgical treatments are largely harmless, only surgical excision can really get rid of loose skin just above the elbow

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could answer a few questions regarding the custom wrap around type jaw implants I came across on your blog. I had a BSSO, Lefort 1 and sliding genioplasty about 8 years ago. Following that, I had custom medpor jaw implants placed to correct some significant notching that had developed around my jaw angles and along the genioplasty site. These implants added no length and very little width, only enough to make my jaw symmetrical. My bite is now perfect, and from a functional standpoint the surgery was a success. However, I have been extremely unhappy with the aesthetic results. First, my jaw remains very steep and narrow, giving the lower portion of my face an elongated, weak shape with an odd shaped protruding mouth that looks as if I have to strain to keep it closed. Also, my chin has a bit more horizontal projection after the genioplasty, but still looks relatively long and weak, especially when viewed from the front.

I am interested in the wrap around type implants because it seems to me that my lower jaw is deficient in all three dimensions. Also, I am not looking for anything too drastic, I would just like a more balanced, masculine lower face shape. I would like to know if I am a candidate for this surgery, given my previous procedure. Second, I noticed that you typically use silicone implants. My current implants are Medpor, and I really like how they feel completely natural, as if it’s my own bone. I don’t know if this has anything to do with the tissue ingrowth seen with the Medpor material, but I was wondering if there are any major differences in sensation when using silicone.

A: By your very own description you are the exact patient who is only going to get a much improved jawline result by a custom implant approach. Your history of prior jaw surgeries does not preclude you from having a jawline implant but the scar tissue and implant removals do make it more challenging than the patient who has never had any prior surgery. But in my practice your history is common and about half of custom jawline patients have a prior history of bone or implant surgeries.

The perception that Medpor implants feel ‘more like bone’ than silicone is a myth. There is no biomaterial or biomechanical basis for it. With bone as the implant backing, all currently used implant materials will feel the same.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Can I get hip implants if I have PMMA injections already in my hips? is it best to have it removed or just some of it removed beforehand? Because my hip area is already tight and some days I am in pain. These hip implants were not heard of when I got the PMMA injections. It still was not enough to make a difference that I don’t still get told I look like a man from the waist down and I still barely fit into trousers so it didn’t exactly make me curvy for how much was injected. I am meant to be petite, and that is fine, but I still wanted better proportion. I’m 5’m 2” and 103 lb. I do have a doctor that will try fat grafting although I’m thin. He said he could also remove some or most of the PMMA. But I had big indentations without the PMMA so that might leave me looking worse, especially with really not enough fat to maybe fill it back up, let alone to get bigger than I am now. The only thing that could still be worthwhile about that is he would be trying to slim my waist more and that would help my waist to hip ratio, but won’t change fact I have big shoulders so I would still look manly without bigger hips and only a smaller waist.

A: If you have PMMA material in the area of potential hip implants and the tissues are tight and it has some pain associated with it, you would not be a candidate for hip implants. There would be a substantially increased risk of infection. It is never wise to put implants in any tissue bed that is not in a near pristine condition, does have foreign material in it and has inadequate subcutaneous fat thickness. If your hip areas are pretreated with fat injections and the tissues become softer, you may then become a potential candidate for hip implant surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was curious about a bony genioplasty as a cure for lip incompetence. Have you had success with that in the past? It seems like a genioplasty is the only way to fix this. I have a quite large chin. Unlike many people with lip incompetence I am more in a need of vertical chin shortening if possible.

Also I’ve read a lot of your articles and you’ve mentioned doing septoplasty and turbinate reduction. I do have sinus issues and have been told my septum is slightly deviated and my turbinates are enlarged and my nasal passages are quote narrow. I don’t know if you could expand the nasal passageway, but that would definitely benefit my breathing. Do you still perform these ENT procedures. I would prefer to knock everything out at once. 

A: A sliding genioplasty may have some benefit in the improvement of lip incompetence in the horizontally deficiency chin. But whether it would be of any benefit in the vertically long chin is far less certain. At the least it would not be a detriment to it in the intramural vertical reduction wedge genioplasty.

For nasal airway function, inferior turbinate reduction offers a greater cross-sectional area improvement than septal correction in most patients. But any septal deviation would be corrected at the same time, even minor, due to anatomic proximity. 

Any form of nose surgery is commonly combined with any method of chin reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i would like to know if a 11mm advancement genioplasty could be reverse to 3-4 mm. I’ve had the procedure done about 3 month ago and I don’t like the result. I feel my chin is still swollen but I hate the fact that now my upper lip look thinner and my chin longer et my face more masculine. Will the soft tissue go back to normal after reversal? What are the risk? And how many time you have perform this type of procedure and what was the outcome ? Thank you!

A: A sliding genioplasty can be successfully reversed from 11 to 4mms. Th risks of the surgery are identical to what they were at the time of the original procedure, it is just the same operation with different direction of bone movement. It is probably best that you don’t take the chin all the back to its original position as the the recoil of the soft tissues is less assured. It is important to realize that not all of the soft tissues are going to return to exactly what they were before the original genioplasty procedure.

Of the many reversal sliding genioplastigs I have done (from 6 weeks after to surgery to 14 years after the original surgery), patients were happy to have less chin projection even if some of their soft tissues issues were not completely cured.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I have a question regarding shoulder widening surgery. Have you ever performed a clavicle osteotomy or know of anyone having this done? Would widening of the clavicle in turn move the scapula? I know its extreme but do you think this is safe and effective? I’ve been researching on surgeries to broaden shoulders and I’m very interested in the clavicle osteotomy but there is hardly any information on it. You are the only expert in this field that has at least talked about this procedure. Please could you shed light on this operation.Thank you.

A: There is very little information in regards to clavicular osteotomy because it would be considered an ‘extreme’ surgery in the quest for wider shoulders. There are other more conventional forms of shoulder widening that would be considered equally effective including deltoid (shoulder) implants and fat injections.

Clavicular osteotomies would be considered only for the most of motivated of men for the following:

1) Only one shoulder is done at a time with a 3 to 6 month spacing between the two sides.

2) Recovery would be considered similar to that of a fractured clavicle.

3) It requires plate and screw fixation with an interpositional allogeneic bone graft.

4) There will be a resultant scar over the clavicular osteotomy site.

5) Clavicular gap widening would be 2 to 2.5 cms maximum.

For all of these reasons it takes a very highly motivated person to consider this approach to shoulder widening surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am confused about the differences between standard and custom facial implants. A custom approach would seem to be better since their shape would be more assured to achieve the desired facial shape change. Since facial implants are not adjustable during surgery one would want to have the best implant shape possible going into surgery.

A: Let me provide with some further clarifications as misconceptions about standard and custom facial implants are understandable common.

1) All facial implants are made of malleable material which is always adjustable whether it be shape (reduction) or adaptation to the bone. (shape and/or implant fixation) Such adjustments are commonly done even on many custom facial implant cases. The only feature of any facial implant that is not alterable is that volume can not be added to it.

2) Custom implants are made from the patient’s 3D CT scan. But what those size and shape dimensions of the implants should be for any patient’s aesthetic desires is an artistic guess for which the surgeon and patient have no assured way of knowing the actual outcome. The computer can certainly not tell us, it only creates what it is told to do. Whether the ‘input’ is the desired patient’s ‘output’ is not always 100% predictable.

3) As a result of #2, over 50% of patients that receive custom facial implants go on to have revisional surgery or have new custom implants made to get closer to their desired aesthetic facial result.

4) Patients that have indwelling facial implants, like you, have an advantage in custom facial implant design because they have a known external aesthetic effect from their previous surgical efforts. That does help in knowing how to improve their existing facial implant shapes and sizes. But this does not make such a patient immune or eliminate the risks of undesired aesthetic outcomes or implant asymmetry in bilateral unconnected implants.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, after a lot of consideration I am now actually considering to do a full facial reshaping surgery. However after you see my pictures you might tell me if it is possible or if there are any limitations. I have attached a picture of the face profiles that I like. I put a picture of my actual face and a picture of my desired result. I will explain what I wish and you tell me if it’s possible or there are limitations. The whole idea of this is to bring the eyes as front as possible. 

1)Brow Bone Reduction to move back the brows as much as possible. My desired result would be where my eyebrows are in line with the eye lashes.
2) Rhinoplasty to reduce the nose as small as possible with a nice curvy shape and the top entering in line with the eye lashes.
3) Brow contouring since I will have a lot of excess skin there so I think I will be needing a brow lift.
4) I would consider reducing my forehead by 1cm or 2cm.
5) Upper lip lift (the space between the nose and the upper lip needs to be less. 
6) Chin reduction . a shorter and narrower tip,also resulting in a horizontal jaw.
7) A little facelift that would cover the old scars I have from my past facelift ten years ago.

I have studied this very carefully as to see that they are possible. I am guessing the major surgery is the brow bone reduction. 

A: Thank you for your sending all of your pictures and detailing your facial reshaping surgerygoals. In answer to your questions:

1) BROW BONE REDUCTION – you are demonstrating a maximal brow bone reduction result which wold require an osteoblastic bone flap setback technique to achieve.

2) RHINOPLASTY – The limitations of your skin thickness will prevent making your nose from becomingas small as you have imaged.

3) BROWLIFT – Your imaged results clearly show the need for a browlift with the brow bone reduction.

4) FOREHEAD REDUCTION – I assume you mean by this a frontal hairline advancement to reduce the amount of vertical forehead skin show. Whether your hairline could support this type of procedure can not be determined based on the side view pictures shown. If it did a 1 cm reduction is realistic but not a 2 cm reduction.

5) SUBNASAL LIP LIFT – That is a straightforward lip procedure of which your long upper lip can benefit.

6) CHIN RESHAPING – This type of chin change can be done by an intraoral t-shaped bony genioplasty technique or submental inferior border shave chin reshaping method

7) FACELIFT SCARS – That is the type of preauricular facelift scar I have never seen before. It can not be relocated back into the preauricular skin crease as you have illustrated. Besides not having the skin laxity to do so, even if it were possible your sideburn hair area would become aesthetically distorted.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I came across your Paranasal implants examples on this website,  
http://exploreplasticsurgery.com/category/paranasal-implants/

To make sure that we are on the same page, below is a picture of my lateral facial profile. I am unhappy with the fact that I have a slightly prominent mouth. I am also unhappy that the angle between the bottom of my nose and my lip is an acute angle, which is around 55 to 60 degrees. And I want to let you know that I have had a nose surgery to heighten my nose already.  

I have read on your website as well as other Paranasal Implant cases done in other countries. I wonder if a Paranasal implant can be done on me in your opinion to make my nose look a bit taller, and to make my mouth less prominent, and to get a larger degree between the bottom of my nose and my lip.

I look forward to seeing your email. Thank you.

A: What you are referring to is not a paranasal implant per se as that will only augment the side of the nose underneath the nostrils. To change the nasolabial angle and add more projection above the mouth, the central premaxillary region needs to be augmented. Whether that needs to be combined into a premaxillary-paranasal implant design  for a more overall nasal/midface effect depends on your aesthetic goals. With either midface implant style, however, the nose is not going to become ‘taller’ as a result.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions in regards to brow bone augmentation.

1. In most of your work in this area of face, a more pronounced upper brow bone area can be noticed from the profile view, which actually is the main purpose of the procedure. However, I feel that the lower part of the brow bone (where the upper eyelids and the brows meet) isn’t affected much except in this case where bone cement was used.

Does this bigger augmentation amount (compared to other patients’ results) in the upper brow area have to do with the material used or with the soft tissue anatomy of the patient?

2. I’d pursue brow bone augmentation to mostly augment the part of the brow bone I talked about before. Is this the right operation for me? If yes, are injectable fillers a good yet temporary alternative to achieve similar augmentation degree to your result that I previously linked?

A: In answer to your brow bone augmentation questions:

1. Actually the differences between using a custom implant or bone cement are exactly opposite of your supposition. It is far more predictable and effective for lower brow bone augmentation to use a custom implant if it is designed to do so. It is very hard to get bone cements that low due to the working properties of the material.
2. Injectable fillers are always a reasonable test for any form of brow bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in hip implant augmentation and have some questions for you.

1. Knowing that I do not have enough fat for the Brazilian style fat injections, what are the relevant considerations when selecting either synthetic injections or the silicone implants? (Everything I have read suggests that the synthetic injections are likely to be more dangerous, provide less certain results, are of limited life, and more expensive, but would like to have a first hand professional assessment.)

2. Going on the assumption that you recommend the silicone hip implants, is the 2″ addition to each hip achievable?

3. Would a silicone implant move with the body and look reasonably natural in all positions and further how would such an implant feel?

4. Are your silicone hip implants customized for your client and how specifically are they crafted?

5. How secure are these implants after insertion, are they held by a muscle like a butt implant?

6. Do you have pictures showing the before and after of this specific procedure without accompanying injections?

7. What would the normal life of such an implant be?

8. From your website the procedure is listed at around $5500-6500, does this still seem reasonable in light of the details provided and are there any other fees that she should be aware of?

9. Given that a Silicone butt implant is already in place would there be any issues with adding a hip implant or in customizing the shape to work with the butt implant?

10. As noted, the butt implant took place Sept 29, 2017. How long would it be advisable to wait before undergoing a hip implant surgery?

11. What will recovery look like generally? Specifically, she will be coming via a 4 hr flight, how long must she plan to stay in Indiana after the surgery before being able to fly back. (Additionally, how many follow up visits will be required, particularly if after the flight is allowed?)

12. On some sites this surgery is connected with the need to wear some sort of structured garment during the healing phase, is such a shaping garment required for your procedure, and if so how long must it be worn.

13. How long is it generally recommended before returning to work following the procedure?

14. Probably aligned to the flight question, but how long before she will be able to drive?

15. How long before more restrictive clothing like jeans may be worn?

16. Reviews and other information about your practice seem very positive, but just as a point of clarification, where your site lists “board certified in the specialties of Plastic and Reconstructive Surgery” does this mean board certified by the American Board of Cosmetic Surgery?

17. Will you personally be performing the procedure?

A: In answer to your hip implant questions:

1 The concept of using synthetic materials and injecting it into body areas for augmentation is a fundamentally dangerous one. While it may be successful for some people without complications, some patients will suffer foreign-body reactions which will be both difficult to treat and will end up in various amounts of tissue destruction. In essence such injections are not truly reversible. Conversely hip implants are completely reversible without ill effects on one’s health for either medical or aesthetic reasons.

2 The amount of hip augmentation achievable by implants depends on numerous factors include the thickness of the soft tissues and their ability to safely stretch and accommodate the implants. Probably 2” or a 5 cm thick implant is too much particularly in a thin person.

3 Hip implants are ultrasoft and very flexible so they do not interfere with movement and feel about as natural as an implant can feel. (no implant can ever feel perfectly natural since it is an implant not natural fat tissue)

4 All hip implants are custom made based on measurements taken on the patient for surface area coverage. (aka implant footplate)

5 All implants, regardless of body location, are held in place by the initial tissue pocket made and the scar capsule that ensues.

6 Patient pictures are confidential and are only released by the permission of the patient.

7 All implants last a lifetime as they are made of a non-biodegradable material. 

8 The cost of the procedure will be forwarded to you by my assistant.

9 With a buttock implant in place, it is importantly that the two implant pockets do not connect. If the buttock implants is intramuscular this is not a concern. But if the buttock implant is subfascial, the design of the hip implants must take its location into consideration.

10 Three months should separate the placement of buttock and hip implant surgeries.

11 Most patients can fly home in 3 to 5 days after surgery but such travel is really based on how the patient’s comfort. There are no specific followup visits scheduled unless there are urgent issues. All followups are done on a virtual basis.

12 A compressive garment is helpful in the first few weeks after surgery to help the implant pocket heal around the implant.

13 Depending on how physical one’s work is, one should able to return in two to three weeks after the procedure.

14 Driving after hip implants surgery is based on one’s comfort.

15 Jeans can be worn as soon as one is comfortable in doing so.

16  My board certification is by the American Board of Plastic Surgery. The American Board of Cosmetic Surgery is not a board certification recognized by the American Medical Association. 

17  I am the only one available to perform the surgery under my name.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When is it ok to go to the dentist for a deep cleaning and root planning after my custom jawline implant ? And should I tell them about the jawline implant?

A: Dental treatments in the patient with certain types of facial implants (cheek, paranasal and chin and jawline implants) pose issues that make telling your dentist that such implants exist. If screw fixation was used with the implants these will be visible in some dental x-rays. (e.g., panorex) The need to perform local anesthetic injections into the tissues overlying the implants is the most significant consideration.

A deep dental cleaning should not be done for three months after the facial implant procedure. If they are going to perform any local anesthetic injections, whether it is for cleaning or other dental treatments, they need to the aware that an implant exists along the jawline. Inadvertent needle penetration into the implant’s capsule has a high risk of causing an infection. The needs can track bacteria from the mouth into the implant’s surface. Fortunately local anesthetic injections can still be successfully done with some modifications (avoiding deep injections down to the bone) when a complete jawline implant exists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am not quite ready for a facelift but would like to restore the fullness to my face/cheeks through cheek implants. Here are my pictures. I am interested in your thoughts about cheek implants for me. Thank you in advance.

A: You are an excellent candidate for midfacial volume restoration or augmentation through a combined malar-submalar shell style cheek implantas. You are spot on in terms of what would have the greatest anti-aging effect on your face. Such as implant is really like a ‘deep plane facelift’ for the midface. By elevating the cheek tissues off of the masseteric fascia they are allowed to float upward and are supported by the ‘spacer concept’ of the cheek implants.

Like all facial implants proper selection of cheek implant style and size is essential. Particularly relevant is the surface area that they cover in the midface, The aging face with sagging cheeks requires that the implant pocket extend down over the origin of the masseter muscle on the cheekbone.

I would agree that you are not only not ready nor would a traditional facelift produce the type of facial rejuvenation change that would most benefit you in the midface.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It’s a pleasure to meet you. Do you mind if I ask you some question about custom forehead implant surgery? I have read many times about your surgeries on the site.

I have done a bone cement surgery on my forehead and my eyebrow. (custom forehead implant) Can I get more bone cement added onto the current implant? Because I don’t want to remove the current implant. I am happy with the shape, just want to add more. If not, can you take the implant out and reshape it? Or do you have to make a totally new one?

I have got the surgery based on my exact skull model with the 3D printer. So the implant is really well shaped based on my forehead and brow bone. So I just want to add little bit more bone cement on the current implant.

Like one the first photo, there are some gaps between my real bone and the implant . I want to fill those gaps if its technically possible. (Glabella, brow bone) If I need to remove the current one and get a new one , is it possible to make the implant model like the second photo?

Also i found that photo model on your site. Is it possible to add extra bone cement on the part that I circled with purple color?

Thank you so much !

A:  The answer to your fundamental question is that it is not possible to just additional cement to your existing forehead implant to create a result that will be perfectly smooth and even in the areas you have highlighted. Although you did not state what exact material your implant is I would wager that it is PMMA, an acrylic bone cement which is commonly used in Asia but not the U.S. for custom forehead and brow implants.  I have removed and replaced many such forehead implants as their design is often identical to yours and the patient’s desires for an improved implant shape is also identical to yours as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In regards to my pectoral implant revision, I googled PowerFlex 1pectoral implants and it took me to the Implantech web site. I took a look at all their pectoral implant styles. The shape is what I am looking for although the projection is 3.9 cm. It is tempting although I think this would be too large. I noticed on the Implantech site there is a PowerFlex Pec Implant (Novack style 2) that may work for me. It states that this implant is “coming soon”. The shape looks excellent although I am not sure if this would be large enough. The dimensions are 15.2 x 12.4 x 2.2 cm and the volume is 345 cc’s. Do you think this would fit well for me? Not sure what my chest dimensions came to that you took on my last visit. The pectoral implants I have now are 2.8 cm in projection although I would not mind going a little smaller to the 2.2 cm. This time I think the definition and shape are more important than the volume. Also, on the Implantech site they show the original Novack implant that is 15.3 x 12.6 x 2.3 cm and the volume is 300 cc’s. This is a little confusing since the Novack original which is a little larger then Novack style 2 implant although the volume is 300 cc’s (original) and 345 cc’s (style 2). Can you double check the dimensions for the PowerFlex Pec Implant (Novack style 2) with Implantech? 

A: In looking over all the pectoral implants from various manufactures I think the conclusion is the right shaped one is a little too big and those with the right volume don’t quite have the right shape.

The ones you have in now are too big in terms of surface area coverage and could also stand some more projection particularly in the inner and upper poles of the implant.

Given that you have a reasonable acceptable result, albeit with its own issues, the only reason to have pectoral implant replacement surgery is to make a really substantial improvement. To do so it would be best to get the best shape, projection and volume of the implant based on the measurements and numbers that we know would be better….aka just make custom implants for your pectoral implant revision..

Dr. Barry Eppley

Indianapolis, Indiana