Your Questions
Your Questions
Q: Dr. Eppley, I was wanting to know if there is anything you could recommend to remove what I have heard are called forehead horns.(forehead horn removal) They are wide and stick out of the left and right side of my forehead. They get bright when light shines on them and I feel more insecure as I grow older and they grow. My idea is that I have a large forehead so smoothing out the bone (forehead horn reduction) and bringing my hairline forward so the hair closer to the top of my head moves towards my front face. (forehead reduction)
Thank you please help!
A: Thank you for sending all of your pictures. What you have are classic forehead horns. The incision location of a hairline advancement procedure would be the only way to access them for forehead horn removal. While a combined hairline advancement and forehead horn reduction is a logical set of procedures to put together, the incision location must be carefully considered in a young male as the long-term stability of the frontal hairline may or may not be assured. In essence you don’t want to trade off one aesthetic problem for another….horns vs scar in a male with closely cropped hair.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had off the shelf Medpor chin and mandibular angle implants in for the last decade and desire a greater degree of augmentation and resolution of underlying asymmetries that could only be achieved with custom implants.
My two questions are; 1) can 3D CT modeling be done with the current implants in place, and 2) will removal and replacement of current Medpor implants really carry a large risk of disfigurement?
Thank you in advance for your reply.
A: In answer to your Medpor facial implant removal and replacement questions:
1) Your indwelling chin and jaw angle implants are not a problem for designing new custom implants as they are digitally removed to do so in the designing process. Having existing jaw implants in place does help in designing new implants as having a known effect guides what an improved effect should look like.
2) Having removed and replaced many Medpor facial implants I am not certain where the concept of causing facial disfigurement emanates. Certainly their removal poses greater difficulties than if they were silicone implants, but their removal does not cause facial disfigurement/deformity that I have seen. Their removal often causes greater temporary swelling due to the more extensive tissue dissection needed from the adherence of the soft tissues to the implant surface.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just underwent breast implant revision with new and larger implants. I just wanted to follow up with you on my revision. No pain to complain about. No pain meds needed just the antibiotic. I was a bit worried about the shape of the right implant as it still looked a bit odd in shape. However they are gradually taking on a very nice shape. The projection is perfect. I am very pleased with your work. Thank you!
I have two questions:
1) Will these implants drop and fluff during the next 6 months or will they hold the current shape. I really like the shape and strong projection. There does not seem to be much swelling.
2) There seems to be a lot of “gurgling” going on. I assume this will absorb into my body over the upcoming weeks.
Dr Eppley, thank you again for your outstanding work and patience with me.
A: Thank you for your early breast implant revision followup. I did debate with myself in surgery as to whether to go with the 350HP or the 400HP. The latter gives more projection but would also make the breast mounds overall bigger…so I went with our previously discussed 350s.
In answer to your questions:
1) Now that the lower poles of the breasts have been released there will be a lowering of the implant (dropping) as they heal as the scar impediment to do so has been removed. This generally takes about 6 to 8 weeks to finalize.
2) The gurgling you hear is some irrigation fluid used to wash out the pockets before placing the implants as well as an ‘air space’ existing between the implant and the overlying soft tissues. The fluid will be absorbed and the tissues will shrink back down over the implants in the next few weeks of further healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m thinking about having a custom jaw implant or a custom wrap around jawline implant. I’m a male who has a round short chin with a smooth jaw. I want my lower third of the face to be longer and wider. Not so much of a horizontal projection on chin but a significant vertical height and definitely a square,defined chin. So I roughly measured the projections I want myself. They are:
Chin width 4cm – 4.5cm not mm
Chin vertical projection 8mm – 10mm
Chin horizontal projection 3mm
Mandibular vertical projection 1mm – 2mm
Mandibular horizontal projection 5mm
Do you think this dimensions are realistic or achievable? And thank you for your consideration!
A: In answer to your questions about your proposed jawline implant dimensions I would make the following comments:
Chin horizontal projection – 5mms (yes)
Chin vertical increase – 5 to 10mms (5mms is more realistic)
Chin width increase – I not sure whether you mean in addition to your natural chin width or that this is the amount you want added. The former is very possible, the latter is too extreme as the side tissue can not be stretched that much. (Maybe 1 cm per side)
In the chin area of the jawline the soft tissue chin pad is much more restrictive in allowing it to be expanded than in the back part of the jaw. This is particularly relevant in vertically dropping of the chin. If you want a 10mm increase with the other chin changes, I would also consider doing an opening vertical bony genioplasty of 10mms (this carries the soft tissue chin pad down better) and placing custom extended jaw angle-lateral chin implants to accomplish most of the other changes.
What I would also say about the chin width is that most patients, understandably, can’t appreciate the impact of measurements that they take on the outside of their face for what an implant size should be. That often over estimates the impact of such skeletal augmentations on the face. In my experience, if patients were left alone to devise the implants based on measurements they believe would work, all such implants would be too big. One of my tasks in custom facial implant designing is to help avoid that aesthetic problem or other more significant problems that can come from very large implant dimensions.
Jaw angle width increase – 5mms (yes)
Jaw angle vertical increase – 2mms (yes)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in enlarging the current size of my testicles. (testicular enlargement implants) Do you perform soft testicular implants that go around the testicle to enlarge them up to 3 inches in size?
A: In regards to testicular implants, you are referring to a testicular enlargement procedure that uses an implant that wraps around one’s existing testicle to expand its size. This is different than a testicular implant procedure where a missing testicle is replaced. Testicular enlargement is done using a specially designed bivalved silicone implant that opens up like a clamshell to envelope one’s existing testicles and is closed down around it. This increases the size of the testicles by adding an implant layer around it. An opening for the vas deferens and the neurovascular pedicle remains at the top of the enveloping implant to keep these important structures intact and not to be pinched or compromised as the clamshell implant is closed around it.
Whether a testicle can be increased in size up to three inches depends on numerous factors including the current size of your testicles. I am not sure you may grasp the size of a 3 inch or 7.5 cm testicle but this would be quite large. Even in the XL testicle implants I have done the largest size has been 7 cms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe my upper third of my head is excessively wide so I’m considering temporal muscle reduction surgery. ]But my jaw is also small relative to the rest of my face so my question is. Is itt possible to combine jaw implants with temporal muscle reduction surgery, or could the extra mass cause functional issues? Thanks.
A: Jaw implants and temporal muscle reduction can be performed during the same surgery. Besides each being performed at two separate anatomic sites, their muscular effects are on different masticatory muscles. (temporal vs masseter muscles) As a result their temporary muscle effects are not functionally additive to create any long-term jaw dysfunction.
The combination of temporal muscle reduction and jaw angle implants will bring the upper and lower thirds of the face into better proportions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ankle fat grafting. I would like to know if fat augmenting will be good for my leg and ankles. I have very thin legs and ankles and I’m unable to wear heels because it hurts. I am also ashamed of not being able to wear skirts and dresses which I love to wear and can’t.
A: Fat grafting to the lower extremities, particularly the ankles, has a low rate of fat retention for most patients. As a general rule injectable fat grafting works best in areas that already have some fat. (good recipient site The thinner the natural subcutaneous fat layer is the less fat grafting takes. This may be partially overcome by a large amount of fat grafting if one has adequate donor sites to harvest. While injectable fat grafting may not have a high predictable take in the ankles, it is the only treatment option that exists for making them bigger.
Ankle fat grafting should be undertaken with the knowledge that it may likely require more than one treatment session. Thus the importance of having enough donor sites to undergo more than one fat harvest and grafting surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have noticed that you have some bone cement skull reshaping before and after pictures and in some Real DSelf posts of the past. I have noticed you suggesting bone cement to fix flat heads.
1) Has your opinion on bone cement changed over time due to the subpar results from it? Or maybe you’ve refined your skills with implants?
2) Why is bone cement subpar? Wouldn’t it be easier to use them on easy/non-severe cases?
3) Would you still use bone cements if a patient wants it? I’m guessing a lot of patients may not feel favorable with implants…
A: In answer to your questions:
- The development of 3D imaging and implant printing in the past five years has revolutionized how skull and facial implants are done. For skull augmentation, custom implants have made bone cements for most skull reshaping procedures an almost historical procedure.
- The application of bone cements is harder than implants in most skull cases because of the limited incisions used in this type of aesthetic surgery. If you have an incision from ear to ear across the top of your head then the application and correct shaping of a bone cement material becomes ‘easy’. Most patients in an aesthetic operation, however, do not want a full coronal scalp incision.
- Bone cements are a synthetic implant material. There is nothing natural about them. The only difference from that of a preformed implant is that they come in liquids and powders that are mixed and harden after application. But they are still a foreign implant material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle augmentation. I understand it is not a good idea to extend the jaw angle implant back closer to the ear. I have few question for you. Hope that’s okay?
You mentioned standard jaw angle augmentation implants may be suffice. I assume custom made is other option? What is the difference/advantage between off the shelf implants vs custom made?
If custom made, what is the time frame to have them made as I’ll be entering US on 90 day waver visa?
I’m told jaw angle augmentation surgery can be much more complicated then chin and cheek implants ( because main nerve of the face close that area) and not many surgeons do this procedure for that reason. Not sure what I’m asking you here but maybe you can fill me in on your knowledge and experience in doing jaw angle augmentation implant surgery and if it is in f act the main nerve that is in danger? Thank you!
A: In answer to your questions:
1) Custom made jaw angle implants are better if one has significant asymmetry, unusual or altered jaw angle bony anatomy or the patient’s aesthetic needs exceed what standard made implants can do. Custom made facial implants are done from the patient’s 3D CT scan and take about 30 days to design, manufacture and be shipped for surgery.
2) Jaw angle implants are the hardest of all facial implants to perform, and have the greatest risk of complications (infection and implant asymmetry), but it has nothing to do with the facial nerve or any other nerve. It is because the access and visibility to place them from inside the mouth is limited, the precision of placement over the jaw angle bone is critical, most surgeon’s have no experience in understanding jaw angle aesthetics and proper implant selection, there is the risk of masseter muscle disinsertion with improper dissection technique, and the risk of intraoral incisional breakdown, implant exposure and infection is high without meticulous wound closure. In other words the comparative simplicity of a chin implant should never be confused with the challenges of its more posterior cousin the jaw angle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple of questions regarding the custom midface implant that we have previously discussed. Firstly I would want the implant to cover the whole midface including the infraorbital area and extend to the sides of my eyes. However I have previous history of hypertrophic scarring and I am not sure whether just a intraoral incision would suffice or whether an external scar by the eyes would be required. It is the under eye area of my face which I am mainly concerned about.
Secondly I have very minor nasolabial lines and I was wondering whether the custom midface implant could treat these and stop them becoming worse in the future as I age?
Many thanks as always.
A: Such a midface implant design would be placed from incisions inside the mouth only. Getting the implant up and around the infraorbital nerve is always the challenge, and is what accounts for some temporary numbness after the surgery, but can be done through the technique of an infraorbital split implant method. Augmenting the paranasal region can only help the nasolabial lines but any improvement should be considered a bonus and not a expected outcome.
Dr. Barry Eppley
Indianapolis, In
Q: Dr. Eppley, I am interested in secondary rib graft rhinoplasty. I had silicone rhinoplasty done seven years ago. (they used silicone for the bridge and septal cartilage for the tip).Although I am very happy with it aesthetically, I also started getting autoimmune problems shortly afterwards and now have full-blown Lupus. While the link between silicone and Lupus isn’t firmly stablished, I don’t want to take any chances and would like to swap out the silicone for rib. Is there any way I could do this via closed rhinoplasty?
A: You are correct in that there is no established connection between solid silicone implants and autoimmune diseases currently. But I can certainly understand what you would want to replace your silicone nasal implant. While I have no idea of your implant’s size and shape, it can be replaced with a rib graft.
Some general comments about rib graft rhinoplasty in your case would include the following. It may be possible to use a closed approach for the replacement as the implant has an established capsule/pocket. Whether the rib graft should be inserted as a solid piece or in a diced fashion would depend the shape of the harvested rib and its ability to be inserted through a closed approach. It would be important to realize that any form of a rib graft may not have the completely smooth and perfect shape as that of a preformed nasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been reading a lot of your posts online. It seems like you have a lot of knowledge when it comes to facial implants. I am interested in jaw implant revision.
I had silicone chin and jaw angle implants sic weeks ago and I went too small. I want bigger all around. My surgeon says to wait another two months to see if I like it and if I don’t like it he’ll do a revision… I don’t know if I want to wait that long if I don’t absolutely have to.
My questions to you are the following:
1. How long do you think I need to wait before I can get them replaced with bigger dimensions
2. Is there any physical reason why I can’t replace them now ? Like do I need to wait for scarring / healing or anything like that?
3. What will the recovery be like since it’s a revision and the tissues and muscles have already been distributed and will go through all of that again. Will the healing/swelling be more or less than the first time?
4. He used screw fixation. Is that going to be a problem to unscrew and then re screw?
Thank you for your time
A: In answer to your jaw implant revision questions:
1)Three months is the require time to wait for performing almost any facial implant revision. The tissues must be allowed to heal fully and the patient needs adequate to fully appreciate the results.
2) Your incisions are not zippers, they can not be opened and closed in close intervals and expect them to heal normally. Adverse incisional healing over an implant can result in loss of the implant.
3) Many facial implant replacements, particularly if the implants are bigger, have a recovery that is just like the first time and even more so.
4) Implants can easily unscrewed and removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wanting to know if there is anything you could recommend to remove what I have read as forehead horns. They are wide and stick out of the left and right side of my forehead. They get bright when light shines on them and I feel more insecure as I grow older and it grows. My idea is that i have a large forehead so smoothing out the bone (forehead bossing reduction) and a reduction of my hairline so the hair closes to the top of my head moves towards my front face.
Thank You, Please help!
A: The forehead horns that you have are classic in my experience and are all known aesthetic deformities of the forehead. The forehead horn reduction is a procedure that I do regularly. The challenge in doing this procedure in a male is the location of the incision needed to do it. As you have already mentioned you are considering a frontal hairline advancement. Such a procedure provides ideal access for a forehead horn reduction procedure. The only question now in a young male is what is the long-term stability of your frontal hairline? That would be the key question in moving forward with either procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had large deltoid implants placed over a year. After the swelling went down, they’ve given me a rather deformed appearance. I can send you pictures. Is there anything that can be done to give me a less deformed appearance? Someone recommended a fat graft would be the least risky alternative but he also stressed that the results from a fat graft might not last. I hope you can help. Thank you.
A: Thank you for your inquiry. I would need to see some pictures of your shoulders to best answer what may be able to be done. But my suspicion is that the implants are short in surface area with a projection that makes them stick out like ‘bumps’ on your shoulders rather than blending in and having a more confluent look to the surrounding shoulder contours. Your options would be to either replace them with custom implants that are better designed and softer or remove them and then secondarily do fat grafting. Fat grafting would only be an option if one has enough fat to harvest to perform the procedure and with the understanding that the survival of fat grafts is very unpredictable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had microtia reconstruction of my right ear back in 2006. I am not happy with the results especially looking at the pictures you have posted in your Instagram accounts. The quality of your performance is stunning. While I am now 42 years old I am not ready to say this is the best it can be. Any recommendations from your will be greatly appreciated!
A: Thank you for sending your pictures. Microtia reconstruction surgery is very difficult in getting good results so your outcome is not entirely rare. You have two options to improve your ear shape at this point depending on how far you want to go with it. The first approach, the more conservative one, is to keep the cartilage framework you have, remove the overlying skin and hair on it and replace it with a skin graft. I would also shorten the earlobe and make it fit the bottom of the framework better. This approach will get rid of the hair and allow the details of the cartilage framework to be seen better. The second approach, a more aggressive one, is to get rid of the current reconstruction and replace it with a either a new cartilage framework or a 3D computer-generated implant from the shape of the other side and then cover either one with a TPF flap and skin graft.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I am interested in either chin implant removal or chin implant modification. I had a square medium chin implant placed three years ago from an incision under my chin. I’m strongly considering having it revised or removed. Ever since the implant was first placed I disliked it and have felt there are problems. I seriously regret having made the decision in the first place as I feel that the implant slightly affects my speech, making some words more difficult to pronounce. At times it feels hot and the skin on my chin looks red and irritated. If I grow any facial hair the hairs now point upwards instead of growing in a normal pattern due to the change in skin position.
I have wanted to have the implant removed/revised for a long time, but I am fearful of any further complications or chin ptosis/sagging that could occur. Please could you advise me of my options?
A: By your own description you have answered the question as to what you should do….remove it. (chin implant removal) Since it was originally placed through a submental incision, and its removal would be so done also, the issue about the risk of postoperative skin sagging (ptosis) becomes an easily adverted problem with a simultaneous submental soft tissue chin tuck done at the same time. The issues with chin ptosis after implant removal are much more significant and harder to effectively manage when the chin implant removal is done from an intraoral approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The rib removal surgery has me interested and I would really like to ask some questions. Is it possible for the waistline to become very indented after rib removal surgery and by many centimetres? For example, would a person with a straight, rectangular waistline/torso be able to have a more curvier waistline after the procedure and by how much centimetres or to what degree?
A: The waistline after rib removal surgery will be come more inward or indented after surgery, that is the goal of the surgery. Whether it will become ‘very’ indented or more modestly so is an individual result based on how much the ribs, latissimus dorsi muscle and fat influence the waistline shape. This is what I also always of a wedge removal of the latissimus dorsi muscle with each rib removal surgery as well as liposuction of the flanks if indicated.
I can not and do not put numerical amounts of change on the waistline reduction as there is no way to make an accurate prediction in that regard. But based on the framework of your question, I suspect that the degree of waistline reduction you are seeking (‘very indented’) is not a realistic goal with any waistline reduction procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have Caliber-Persistent Labial Artery (CPLA) in my lips with visible pulsating on middle upper lip on the right side. I am curious to know if you heard of the more conservative methods in treating CPLA? Would you be willing to try these two simple methods before doing a surgery?
A couple of doctors that have successfully treated CPLA in multiple patients by using triamcinolone (kenalog 40): “In view of the size of the lesion and concern over the functional and esthetic impairment that might result from surgery, the patient was treated with triamcinolone (40 mg/ml) injected at low pressure into the lesion, which caused the formation of deposits of colloidal particles within the lesion. The procedure was repeated twice at 2-week intervals. Subsequently, the lesion was found to have completely regressed. The favorable therapeutic results achieved”
A doctor has treated CPLA in multiple patients using high-frequency electrocautery. It is described that the successful use of a 30-gauge hypodermic needle to deliver a low-powered, high frequency electrical current from a hyfrecator. This inexpensive, simple approach was used in 8 patients.
A: I can not speak to these dermatologic approaches to CPLA as I have never done them nor would I have any confidence in their success despite what is reported. I simply do not believe they would be effective long term in a high flow lip artery. I think the only assured approach would be one of a double ligation encompassing two points to cut off the flow to it from both sides.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have arranged a surgery with you for bilateral posterior temporalis muscle removal later this year. I have asked you before if will have any problems with chewing or jaw movement after the surgery, your answer was no. When I am chewing food though, with my back teeth(mostly), I am feeling the movement of the muscles above my ear. Isn’t that the muscle we are going to remove? Or are those movements of muscle under the scalp bone? Did anyone of your patients of the same surgery report anything related to jaw movement or chewing problems?
Thanks so much for your time.
A: As I have stated previously there has not been a single case of postoperative jaw dysfunction or pain with posterior temporal muscle removal for head narrowing puroposes. This would be expected given that it is the posterior temporal muscle that is removed which makes a very minor contribution to jaw function. The reason it is hard for you to wrap your mind around the concept that removal of this portion of the temporal muscle causes no dysfunction is two-fold; 1) your anatomic understanding of the function of this muscle is understandably limited and 2) you have never performed this procedure and then followed patients afterward to see their outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reverse frenulectomy procedure. About one month ago while my tooth was being filled a dentist without my knowledge and permission did lower a lower lip frenulectomy with laser. This has caused lower lip ptosis. My orofacial esthetics is altered in a very bad way. And since most of my mandibular teeth are missing I have lost the proper reinforcement for my temporary partial dentures. Do you do the frenulum reattachment procedure? If yes do have any experience in successfully restoring it?
A: The three frenal attachments in the mouth (maxillary, palatal and mandibular) are mucosal bands of tissue that connects a soft tissue mobile structure to a fixed bony non-mobile structure. In the case of the mandibular frenum it attaches the lower lip to the front part of the tooth-bearing part of the lower jawbone. (alveolus) Inside the mucosal frenal bands are thin muscle fibers which connect the orbicularis muscle to the bone. Cutting the frenum normally would not cause a lip ptosis or oral incompetence because it is done for high or abnormal frenal attachments. What may happen in more normal frenums that undergo release may be different.
There is no specific procedure for recreating the actual frenal band. (aka reverse frenulectomy) But the effect of doing so can come from two types of vestibular procedures. A horizontal vestibuloplasty can be performed that raises the level of the midline alveolus and brings the lip closer to the alveolus. The other approach is a midline vertical vestibular suspension where a suture attachment is done which most closely resembles a frenulectomy recreation. Either procedure is performed under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ear reconstruction. I got bit by a dog a year ago and lost the lower third of my ear. I have attached pictures for your review.
A: Thank you for your inquiry and sending your pictures. Your traumatic injury represents a classic case of reconstruction of the lower third of the ear…the hardest area of the ear to remake. To do so requires a two-step procedure with the first stage being to raise a skin flap from behind the ear and attach it to the visible edge of the missing ear section. After 8 weeks the attached skin has gotten a good blood supply of its own and it can be released from its base, rolled to make both a back side as well as front side of the missing area and closed over a cartilage graft or implant to support the lower helical rim and where the earlobe would be. This keeps moist of the scar to do within the shadow of the ear rim.
Both stages of this ear reconstruction could be performed as an outpatient procedure and each takes about an hour to complete under IV sedation or even local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have researched Coolsculpting and Smartlipo and feel that Smartlipo is better for me. I go to the gym three to five times a week and for years have been trying to get my abs looking better. I’ve tried many diets and working out but nothing works.
A: Thank you for the inquiry and your interest in Smartlipo. There are some standard misconceptions about Smartlipo. First there is no comparison between a non-surgical procedure like Coolsculpting and a surgical one like Smartlipo. They are radically different in both execution, recovery and results. The short version of the story is that a surgical fat removal procedure is always many fold more effective than a non-surgical one.
Smartlipo, while cleverly named and marketed, is not a non-surgical procedure. It is just as invasive as any form of liposuction, involves the same degree of trauma, and has the identical recovery. It is not a ‘minimally invasive’ procedure and does not create a shortened recovery time or superior results. Like all forms of energy-based liposuction it simply uses a different energy form to help break up the fat but this does not result in less trauma, bruising/swelling or recovery. It is also a procedure that does not usually go well if trying to do it under local anesthesia. It is far from a comfortable experience for the patient and the results subsequently suffer. The best liposuction results come from being done under general anesthesia unless the fat area being treated is vey small.
Having owned and used Smartlipo for over five years I can testify that, while theoretically appealing, it does not create improved clinical results in my hands. And at operative times that are twice that of other forms of liposuction, with associated increased costs, I have subsequently abandoned its use. My preferred form of liposuction today is power-assisted liposuction (PAL) done under general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I went to get a lower face lift. I felt like I was starting to look “loose” around my neck and jawline. The doctor suggested a genioplasty because he felt it would give me a better result than a lower facelift. I told him that I didn’t like the sharp edge of my chin where it meets the labiomental fold. He told me the procedure would soften it. I did not go into this surgery wanting to look “different”. I always felt like I was pretty and I liked my face, especially my smile. I just wanted to be tight under my chin again and soften the front of my chin if possible. I guess I was naive about what this surgery would actually do.
It’s been one year since the surgery and I am still unhappy with the results. I think I look ok as long as I’m not smiling, although my lower lip appears much smaller and seems to roll inward now. A lengthening of 10 mm was done. There was no chin advancement. The harsh edge of my chin below the labiomental fold is softened. However it appears that it was done by bringing the labiomental fold forward, not by actually changing that protruding edge of my chin. When I smile my chin gets quite large and prominent. Instead of starting under the fold, it bows out and starts at the bottom of my lip. My lower lip no longer pulls down in a straight smooth line. The center of my lower lip now curls inward towards my teeth, I assume because the labiomental fold is not as recessed anymore. If it weren’t for the lower lip being the way it is, the chin itself might not seem so big.
I feel like I took a chin I didn’t really like and exaggerated the size to make it the focal point of my face. In the process I lost the smile that had been the most attractive thing about me. Regardless, the recovery was so long that I had decided to try to live with it. Should I go ahead and have some sort of revision done ? Is it possible that the metal plate and screws are the reason for the labiomental fold not being as deep, and if so, will removing them allow my lip to roll forward instead of back? Is it possible to remove some of the length from the bottom of my chin bone as opposed to cutting through the center and resetting the bone? What would recovery for that be like compared to cutting through the bone and moving it? I’m attaching pictures “before” the surgery, an X-ray of the metal plate and screws, and “after” photos.
Thank you for your time.
A: Thank you for sending all of your pictures and detailing your concerns from which I can make the following comments about potential chin revisional surgery:
1) It appears you had a vertical lengthening bony genioplasty. Whether you were really a good candidate for that procedure initially can be debated but what it has done is take someone with a naturally pointy chin and now make it more pronounced with smiling with a 10 mm dropdown. It can be difficult to know how an expected chin will look before surgery in both a static and dynamic manner.
2) With every bony genioplasty that involves expansion of the bone, whether it be horizontal or vertically, there are going to be some changes to the lower lip and its function. Every one of those changes you have and they are largely irreversible. (Or some assume when you consider any type of revisional surgery)
3) I think it is clear that you should probably shorten your chin back down to at least 5mm two 7mms less.
4 ) Based on #3, the only way to shorten your chin, remove your hardware and put no hardware back in is to do a submental shave off the bottom of the chin. This submental chin surgery will have a much easier and shorter recovery than an intraoral chin osteotomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in extreme facial reshaping. I want a well defined chin and jawline with high cheekbones and sucked in cheeks between them. I have taken my pictures and did some computer imaging for the facial changes I am seeking. What are your thoughts?
A: Thank you for supplying your imaged results and a very detailed analysis of your desired outcomes. I can see that you have put a lot of thought into these changes. For this type of extreme facial change, and it is appropriate to call it an extreme change (from a surgical standpoint not a personal one), I can make the following comments:
1) You are correct is assuming that only a custom jawline and cheek implants can ever approximate this type of facial change.
2) It would be fair to say that your imaged results are not a completely realistic outcome for a variety of reasons including soft tissue tolerances and the inability for a 1:1 correlation between the implant design and the exterior desired outcome.
3) Having done over 500 custom facial implants, I can tell you there is no current technology that can take a photoshopped image and translate that into an implant design that will guarantee that outcome. Implants are designed on the 3D CT scan (bone) and it has to be estimated what type of implant shape, thickness and contours might create an outcome that would come close to the patient’s desires. Custom implant designing remains an art form and not an exact science.
4) The extreme indentation between the cheeks and the jawline is not realistic. While the size of the implants and your thin face will help a lot in that regard (and even buccal lipectomies will help also), it would be unlikely that such a contrast between the augmented skeletal contours and the unsupported soft areas between them will be that substantial in contrast.
5) By far and away the most common need for a revision in custom facial implants in general and in such extreme facial changes in particular is high. To not be subtle about this possibility, presume it is 50% or greater. This is particularly true in the patient who before surgery has done a vey detailed analysis and has a very specific facial outcome in mind. This is not a personal statement about you, as I have many such facial patients of which many are men, it speaks more to the imprecision and limitations of the surgical process. (Anything can be done on photoshop which may or may not be translated to the patient’s outcome) It is important to point out that patients assess their after surgery outcomes with the same zeal and analysis that they did before surgery. As a result it would be extremely unlikely that the patient’s exact aesthetic target will be achieved most of the time.
6) Your biggest risk of aesthetic ‘complications’ is in the jawline. Dropping down the jaw angle that much with such widening poses a real risk for masseter muscle disinsertion and retraction with ‘implant reveal’ over the jaw angle area.
7) While infection is the dreaded complication of any facial implant, that risk is fairly low. (< 5%) The real complications, as noted above, are aesthetic in nature.
8) Recovery from any form of facial reshaping surgery, such as implants, takes a lot longer than any patient thinks. You will look reasonable by two weeks or so after surgery but it takes up go two months after surgery to see the true final outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m planning on doing a chin augmentation late this year and, for that reason, have some questions that if possible would like to be cleared out. My questions are:
1 – Judging by the photo attached, how much augmentation do you believe I’m going to need?
2 – Will the procedure change the front view of my face?
3 – How much time out will I need to take out of work after the procedure?
A: In answer to your chin augmentation questions:
1) Unless I do the actual imaging I can not tell you what millimeter change it would be.
2) Every chin augmentation procedure changes the front view to some degree. It is not realistic to expect only one dimensions of the chin to be changed when a 3D implant is placed.
3) Recovery is one of swelling and your tolerance for it. The surgery will create more swelling than you think and it will take longer to go down and become acceptable in appearance than you desire. Half of chin augmentation swelling goes down by ten days and 75% by three weeks. At one point in this time course you will find it socially acceptable but that varies amongst different patients.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i come from Europe but would love to be your patient. I have a question about rib removal. Is it possible to remove all of the so called fake ribs? I can conclude that it is very extreme but wearing a corset would make up fort them missing since I don’t work out or lift heavy stuff. Thank you so much in advance.
A: When you use the term ‘fake ribs’, I assume you mean the unattached or free floating ribs which are traditionally #s 11 and 12. In some patients this can also include rib #10 which may not connect to the subcostal ribs. These are ribs that I remove all the time for horizontal waistline reduction. Their removal works for waistline narrowing because of their surprisingly vertical orientation. Rib removal is not extreme surgery in terms of being dangerous or exposing the patient to undue risks. Nor does the patient have to wear a corset afterwards for protection. Some women do wear a corset after rib removal but this is because they are trying to maximize their waistline narrowing. This is a common procedure in my practice that has no adverse medical sequelae other than the small back scars.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction due to the overly prominent ridge which gives me a Neanderthal look. I have researched the different methods this is done, but I am hoping there is another option that does not leave a large scar since I will most likely experience hair loss.
I am not really bothered so much by the actual prominence, but by the transition to the upper forehead. Is there a way to blend this with some sort of filler or something else?
A: What you are referring to is to fill in the forehead area above the brow bone….a forehead augmentation approach rather than a brow bone reduction approach. This is one valid approach to the strong brow bone appearance in men. This is best done by making a custom implant for the forehead area that has a precise fit and contour to create a smooth and blended approach into the upper forehead. This is made from the patient’s 3D CT scan. Depending on its size it can be placed through very small scalp incisions using an endoscopic technique.
To determine if a brow bone reduction or an upper forehead augmentation should be done is determined preoperatively by computer imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My questions on facial plastic surgery:
1. I plan to go on a course of Accutane but I understand this impairs wound healing. As a result, it is advised not to have elective surgery for 12 yo 18 months after one finishes the medication. I cannot wait that long. Also I have the fistula under my neck (a large hole) it needs to heal first before I can start Accutane…as Accutane negatively affects wound healing.
Does Accutane only affect the epidermis or does it also affect the gums / intraoral incisions to place cheek and jaw implants? I understand that as part of placing the total jaw implant, you make a submental incision – would Accutane affect this healing if the surgery is carried out around 6 months before or after a course of Accutane?
2. Would having a hair transplant cause any problems for facial implants currently in place? For example, could it potentially trigger inflammation or an infection?
3. I need to have revision rhinoplasty – could I do this after having cheek and jaw implants or should I do it before inserting new implants? I’m thinking I might wait 12 months after the Accutane treatment to do this.
4. I was also thinking that perhaps I could have the revision rhinoplasty at the same time as cheek implant replacement and then have the jaw implant done later – is this feasible? After the damage caused by the previous jaw implant infection, I’m very weary and apprehensive about triggering infections. I lived with the previous implant for around 2 years. The remaining jaw implant is Goretex (screwed in) but I believe my current cheek implants are silicone/silastic and not screwed in.
The surgeon who removed my infected implant, only inserts silicone implants due to their ease of placement and removal. His comments concerned me so I want the ‘healthy’ remaining jaw implant removed as soon as possible (but I’ve read it’s best to have the replacement done at the time it’s removed but for me, that cannot be done until I heal fully from the infection.)
A: In answer to your questions:
1) Accutane primarily affects epithelial and dermal healing of which is most relevant to facial laser skin resurfacing. Its negative effects on deeper tissue healing is less certain. But that being said, it is still best to not undergo elective surgery for six months after it has been stopped.
2) Hair transplants have no known association with causing facial implant infections.
3) The timing of a revision rhinoplasty is one of convenience. It can be done in conjunction with other facial implant surgeries or done in isolation. This is not a medical decision.
4) The revision rhinoplasty, as indicated in answer #3, can be paired with any other aesthetic facial procedure. There would be no reason to have the remaining good jaw angle implant removed first before placing another one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been looking at getting some work done on my lower third for a few months now. After doing some research, I’ve heard I would best benefit from different two things, and I’m not sure which I would benefit more from:
1. Bimaxillary Osteotomies (Lefort 1+ BSSO) with CCW rotation and sliding genioplasty. This was due to both a recessed mandible as well as maxilla? I can’t tell whether my maxilla is recessed, although from my profile shots, my whole face just looks flat or potato like.
2. Facial Implants. Probably a full custom wraparound. For the chin, an emphasis on increasing width, height, and projection, and a more square shape.
So I’m at a huge crossroads here. I’m torn on whether I’d be better off with implants vs jaw surgery.
A: The fundamental answer to your question is that you are trying to compare apples to oranges. Orthognathic surgery and facial implants are not comparative procedures, they are done for different reasons with different outcomes. Orthognathic surgery is largely a functional operation whose main goal is to improve your bite. There may be aesthetic benefits to it but they will not remotely compare to what a custom jawline implant will do. Conversely a custom jawline implant is a completely aesthetic operation with no functional benefits. You have to prioritize as of what your primary goal is….then that decision becomes much easier.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like hip implants. I made a huge mistake and had silicone injected by a unlicensed injector several years ago that caused a bad reaction in my body. My hips turned black and became hard as a rock. Fast forward to last year where I had the material, hardness and discoloration removed. I had a BBL earlier this year to replace the large dips I had in my hips from the removal surgery. A lot of the fat died so I’m thinking due to me having the silicone in my hips for so long maybe fat will not survive in that area. Right now I have dips in my hips that I would like fixed. I would like to have silicone hip implants placed to build them out.
A: It is important to realize that placing implants anywhere in the human body requires normal healthy tissue around them to avoid infection and other implant problems. If fat has trouble surviving in the hip area due to the tissue quality this bodes very poorly for any attempt at implant placement. At the least further fat injections may be needed to improve the tissue quality of the hips before implants may be placed. The hip areas must feel soft and not hard to rigid if implants are even to be considered. I would need to see pictures of your hips to determine what this area looks like
Dr. Barry Eppley
Indianapolis, Indiana
