Your Questions

Q: Dr. Eppley, I initially had a very broad, and blunted rectangular face. I desired a more oval face and thus pursued surgery in South Korea. My chin tip was narrowed by 7mm, my jaw angles were amputated and the outer layer of my mandible was also shaven off. 

My face is definitely thinner and longer now, but it’s not the shape I had been hoping for. My face shape went from broad and rectangular, to a heart shaped face. My chin tapers in slightly when I rest my face with no expression, instead of the oval U shaped curve I was wanting. 

What bothers me most now is when I smile. My surgeon failed to alert me that the shape of my smile would be so drastically affected with these surgeries.

Prior to surgery, my face was very round and full when I smiled. Now, when I smile with teeth showing, from the ears down, it is an upside down triangle. The chin is extremely tapered in and I just feel it doesn’t look natural at all. The chin tip is also extremely small and its width is probably less than 3cm wide. 

I really hope you will answer my enquiries because I really don’t know where to start to rebuild my face to what I wanted it to be.

(1) I am looking into chin widening surgery. How much can the chin tip be widened with an interpositional bone graft before a step off is visibly noticeable when smiling/tissues stretched back on the bone? Would this surgery keep the curve to the chin or make it more square (ideally not square.) If I were to reinsert a 6mm bone graft, that would logically create an excess of 3mm on the sides of the chin that do not blend into the jaw line. Would 3mm create a visible dent or step off in the face line when I smile?

(2) Is the extreme tapered-ness of my chin when I smile with teeth from the outer layer shaving of the mandible or from the amputation of the jaw angles?

(3) To be quite honest, I like that my jaw angle now starts from below the ear and do not wish to add any vertical length here. Therefore, what area would I need to augment in order to get a more rounded face when I smile? Would I need to augment the back jaw angle in order to get the oval face shape I desire when I smile?

(4) I said in my previous email that I would ideally like to steer clear of silicone, ideally medphor as well. If nothing else can be used then I would need more time to wrap my head around it and get over these feelings. Can whatever augmentation materials I need be pre-formed implants using acrylic PMMA or hydroxyapatite or any more biocompatible materials?

Attached is a photo of my smile.

A: In answer to your chin widening surgery questions:

1) A 6mm interpositonal graft should not make the chin look too square. If any step-offs occurred to the side of the chin they could be shaved down at the same time.

2) The extreme tapering of your chin when you smile is from the loss of bone from the sides of the chin primarily. There is not enough support for the soft tissues as they retracted upward from smiling.

3) Getting a more rounded face now has nothing to do with the jaw angles. It is what is done to the chin and the bone right behind it.

4) Trying to make bone cements to work for the chin/anterior jaw widening effect is not going to work as well as preformed implants. But the use of hydroxyapatite cements is a possibility. It is not ideally made for this type of onlay facial bone application but an experienced user can do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  My doctor confirmed that i was experiencing chin ptosis as a result of poor attachment of the mentalist muscle. He said that there was no tightness in the scar from the intra-oral incision. The problem stems entirely from the suspension of the mentalis muscle.This doctor does not perform the corrective surgery i require and i am still interested in moving forward with yourself. 

However it would be great to know a little more about mentalis muscle resuspension and your experience with this particular surgery. 

1) Can mentalis muscle resuspension be performed with permanent results or does the muscle return to its original position eventually?

2) How many resuspension have you performed thus far?

3) Of the patients you have treated, how many patients have experienced sustained results?

I look forward to your answers.

A: The questions you are asking about chin ptosis repair are not about the sustained ability of the muscle resuspension…as that always stays where it is put. What you are really asking is how well does resuspendinjg the muscle work at fixing the chin ptosis and improving the lower lip position. While the two are related. it is not a 1:1 correlation. All successful mentalis muscle resuspensions do not always effective solve those two issues completely. Having done lots of them I can say that it is about a 50% improvements in the associated lip and chin issues with the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 55 years old and in excellent health. Over the years my testicles have shrunken and I would like to enlarge them back to where they use to be. Specifically I mean that I wan t enlarge the size of the testicles I have. How can this be done? Thanks.

A: Testicular enlargement surgery is done by creating custom testicle implants that are larger in diameter than your existing testicles. (based on how much size increase you want) What is unique about them for this purpose is that they have a hollow center which is an approximate size of your existing testicles. In surgery such implants are bivalved (cut in half) and then used to encase your testicles and put back together. A hole remains on one end for the vascular pedicle/vas deferens to exit.

The other implant option is to use standard testicle implants and hollow them out during the surgery. This is obviously far more tedious but avoids the custom implant route.

The surgical approach is a through a midline incision on the raphe of the scrotum. This allows the testicies to be dissected out  and delivered through the incision with its pedicle oriented inward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an extra large Implantech conform chin implant put in last year and then got a revision to up the size to an extra large Implantech Terino 1 square chin implant. 

However, with the increased size in implant, a few additional issues have arisen. 

1) I am still unsatisfied with my profile view – my chin still looks slightly recessed. I am interested in a sliding genioplasty to further augment my chin. 

2) The larger implant size has made the pre-existing asymmetry in my chin more evident. If I were to undergo any sort of sliding genioplasty procedure, I would want to have the asymmetry corrected in terms of removing the excess bone growth on the right side of my chin. 

3) The dip/groove between my lower lip and chin has deepened. It is a horizontal line (not sure if it’s the labiomental groove or not) and has become more prominent with the implants. Not sure what would be done to fix this. 

In summary, there’s an array of things I’d like to do to my chin area – would this all be possible while still maintaining the chin implant? As in, either leaving it in during the procedure or temporarily removing it and placing it back in in order to maintain the increased projection. 

Thanks for your time! 

A: Thank you for your inquiry and detailing your chin surgery issues as well as objectives. In answer to your questions:

1) If the chin implant is in the proper position, (low on the chin bone), then a sliding genioplasty can be done with the chin implant in place.

2) It is not clear to me just yet whether/how the chin asymmetry can be improved. It may be best done by making a change in the movement of the sliding geniopalsty from side to side as it comes forward. It may be difficult to remove bone from the chin with the chin implant in place. But just based on a description I can not yet say how it might be done.

3) Deepening of the labiomental groove is always to be expected as the chin comes forward albeit with an implant or a sliding genioplasty. Further forward movement can be expected to even worsen its depth. With a sliding genioplasty the management strategy can be to fill in the bony step-off with cadaveric bone chips/graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Recently, I’ve been reading your patient questions on chin widening – a procedure I am very much interested in. 

One year ago I had a sliding genioplasty to push my chin forward. Without discussion, my surgeon also burred it down on the sides. I had asked for harmonious facial features but burring my chin down to make it narrower was out of line. While the sliding genioplasty itself did improve the side profile of my face, it and the burring has narrowed my chin from the front view and has feminized my face. My surgeon appreciates the look – I do not.

Like some people, I am hesitant on implants and I understand it may be the easiest option to achieve my desired outcome. But i am just not comfortable with the idea of an implant.

1. Is a chin widening osteotomy possible in my case or does the pushed forward chin bone from the sliding genioplasty make it more difficult?

2. I’ve read in one of your responses that this type of osteotomy can create a step off in the chin to jawline area. Is there a limit to which the chin can be widened with a t-shaped osteotomy before it is visibly noticeable in the smile? I’m only interested in adding 4mm or 5mm of width. I’m alright with being able to feel the bone but visibility may be a problem.

3. If a step off deformity is a problem, is there a reason why the step offs can’t be shaved down to meet the edge of the jawline?

4. Is a bone graft necessary for a gap of 4mm or 5mm. If a bone graft is not placed, will the gap stay hollow and eventually fill out or create a bum chin look?

Thank you for your time.

A: In answer to your chin widening osteotomy questions:

1) A widening chin technique can be done in a chin that has already had a horizontal sliding genioplasty.

2) At 4 to 5mms expansion this should not create a lateral step off. Such a step off can be avoided by placed a ‘keystone-shaped interpositional graft and make the separation in the middle osteotomy (without a graft) like a keystone shape.

3) Shaving the pushed out lateral wing if it is present is also a technique to eliminate any lateral protrusion.

4) With a small 4 or 5mm defect an autologous bone graft is not necessary. It is nice to use a small cadaveric bone graft or hydroxyapatite wedge for both stabiity and to ensure complete bony healing.

Dr. Barry Eppley

Indianapols, Indiana

Q: Dr.  Eppley, I am interested in a rhinoplasty and otoplasty revision. I had a rhinoplasty and otoplasty two years ago when I was 18 years old.I believe the surgery did not go as expected because of healing and post-care reasons (wrapping and such). Maybe even due to my young age.

I am now 20 years old and am not thrilled with the outcome of these procedures. I can say that I am much happier with how I looked after then I did before, but I definitely believe he could have done better.I am not looking for perfection but I believe as humans we all enjoy the idea of becoming photogenic and being rather more symmetrical.

I will attach pictures before and after the surgery.

In regards to the otoplasty and rhinoplasty. The problem is the left ear, but I only want to fix it if you think it is possible to be perfect and make appear a but more natural. As for the right ear, I am extremely unhappy with. It looks like a cauliflower ear and mildly deformed.

I am mildly content with the shape when looking at my entire front facial profile, but the side profile bothers me, I am sure you will agree.

As for the rhinoplasty, I am mildly content with the side profile. However I would have liked a stronger profile, and not so much of a dip. As for front forward, it is crooked towards the tip. It is almost as if it looks like the right of my nose lacks cartilage due to the crookedness.

Ultimately looking to straighten, strengthen the bridge, and fill my nose with this revision (I want a more masculine/strong nose)

If you believe that you are not capable of making this my first and last revision, please let me know, with either surgery. If that is whether you believe there is another surgeon who may be able to better assist me or you believe I should seek a revision from my original surgeon, please be honest.

I initially came to you in hopes of jaw implants. I know that underlying, I have a nice base jaw structure, but I only want to improve it and strengthen its appearance in seek of a more masculine, well defined face, with sharp jaw edges.

I stumbled upon your YouTube videos and those results are priceless. There is no other doctor I would trust after seeing your work.

Looking at my pictures, what do you think? What do you recommend? 

A: Thank you for sending all of your pictures and detailing your concerns. In answer to your rhinoplasty and otoplasty revision questions:

EARS. There is definite cartilaginous deformity of the upper antihelix/scaphal areas. This is undoubtedly caused by the way the sutures were placed to fold the ear back. There is also a bit of overcorrection of the middle third of the ear compared to the upper third and the earlobe. On the left ear it is also as you have aptly described a cauliflower ear deformity which is a result of the how the cartilage was folded and healed. While this is the ‘easiest’ problem that you have to treat, it also the most unpredictable of whether it can be improved. I would have to unfold the cartilage from the back side and see if the fold can be recreated in a more natural way. The middle third need to be brought out a bit and the upper third and earlobe to be move in a bit. None of this is technically hard to do but how the scarred ear cartilage will respond now can not be precisely predicted.

NOSE What you have is a lower middle third of the bridge with an overprojected and crooked tip. This creates the dip in your nose which is not the look most men want… a straighter dorsum/bridge is more desired. The tip needs to be shortened and straightened and the bridge built up. This requires cartilage grafts  and I will assume that your septum was not touched during your initial rhinoplasty procedure. This would be critical to know as that would the first donor site chosen given the proximity and its straightness.

It goes without saying that it is always best, if you have confidence in him, to return to the surgeon who performed the original surgeries for your rhinoplasty and otoplasty revision as that would be your most economical approach. But revision ear and nose surgeries like yours requires an advanced level of expertise and experience for improvement…scarred tissues are never as responsive as before they ever had any surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had submental liposuction done last year for my double chin but I am unhappy because the results are so small. I still have a double chin. I went to two doctors and they both advised chin augmentation and liposuction but I didn’t want the former. My double chin is hereditary and I thought I would see a change. Would a submentoplasty have been better? I also got no jawline contour at all. I’ve seen that with Precision TX and incisions by the ear and under chin, there are nice results with contouring. I’m confused and don’t trust anymore. Can you please help me? What do you suggest?

A: Thank you for sending your pictures. The fundamental problem with your double chin is the your chin is short and your hyoid bone is high. Unless the submental area is stretched out (move the chin bone forward by a  sliding genioplasty) and the neck muscle tightened with direct defatting (submentoplasty), there is no further improvement possible.  Isolated procedures like a submentoplasty with a jowl lift can also be helpful. But short of these, everything else will be a waste of effort and esources.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have two questions about what is possible with surgery. I had a lip lift a long time ago and it was brought up a lot so now it always looks like my lips are pouting like I’m sad. Is it possible to make the lips go out laterally to make the corners look like they are higher and outward a good amount like you’re smiling instead pouting. I know it can be done externally but that will leave a noticeable scar. Can it be done internally somehow? The other question I have is I have done work with you on my eyes which made them more open and I’m happy with it but I wanted to know is it possible to make eyes go out laterally as well? To make them wider? My eyes are round but very little in length.

A:  In answer to your corner mouth lift and eye widening questions:

1) The corners of the mouth and the side of the upper lip can only be moved through an external approach, not an internal one.

2) Stretching out the outer corner of the eyes through a lateral canthopexy (eye widening) can be done but it is notoriously unstable with a high rate of relapse. The eye is very sensitive to have good contact with the eyelid and if they are separated the body works really hard to bring it back in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am not sure how common this eye reshaping question is. I was wondering about how far a plastic surgeon can go to alter the shape of someone’s eyes. My eyes are pretty standard Caucasian, round, double lids, no epicanthal folds, non-hooded, etc. But I wanted to change a number of things about my eyes. First off, when relaxed my eyes are round, really open-looking, and sort of just dull. That’s why I have a habit of squinting them to make them appear narrower, and I know that’s probably not good for them, but that’s besides the point. I was wondering if there is a surgery, (or probably a number of surgeries in my case) that can be done for the following: In the inner corners of my eyes, there are just normal looking open tear ducts. But I was wondering if there is anything that can be done to “hood them” or give them the slightest epicanthal folds, not enough that they look Asian, but just enough so that they look exotic and sharp and not as much “open.” Jennifer Lawrence’s eyes are sort of like that. The second thing I was looking into was having the lower eyelids lifted so that my eyes have more of a narrower shape so that I don’t have to squint them. The third thing is something that I have no idea is possible or not, but I was wondering if you can get the middle of your upper eyelids hooded? Not the outer parts of the top eyelids, just the middle so that they’d gradually fan out from sharp, exotic tear ducts, then to a hooded upper eyelid right at the arch of the lid, and then into nice, open outer lids. The fourth thing I was considering was I believe called a canthoplasty, and I’m looking to have the outer corners of my eyes raised slightly so that they have an upwards slant and look more exotic. Sorry this was so long! I just know that the eyes are the most noticeable/memorable feature of someone and I would kill for nice eyes.

A: Thank you for your inquiry. In answer to your eye reshaping questions, which are not uncommon:

1) For the inner corners of the eye, it is possible to close them down a bit for more coverage of the lacrimal lake. But that does not usually create a true epicanthal fold appearance.

2) The lower eyelid can be raised by the placement of an interpositional mucosal graft combined with a lateral canthopexy. Raising the horizontal level of the eyelid requires more tissue,  not just being ‘pulled  up’.

3) A hood can not be created in the upper eyelids as that would require more skin…and a skin graft would create a patchy unnatural appearance.

4) The outer corners of the eyes can be raised, but as discussed in #2, this requires an interpositional graft to maintain it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am attaching pics of my face (front and sides) for facial reshaping surgery. I have had these genetic fat deposits all around my mouth (corners and nasolabial folds) jowls, low cheeks and under my chin since I was very young. The results I would like to achieve is an overall more slimmed down and chiseled look in my lower face, in particular definition along my jawline, eliminate the perioral mounds, and the fat in my chin  

What would you suggest would be the best surgery procedures to achieve what I desire?  

How effective it would be in my case?

A: Thank you for your inquiry and sending your pictures. In short I think what you are trying to ideally achieve is not going to happen the way you want it to be. You already have a fairly thin face (albeit thick skin) and using the criteria of bending your head down and creating skin folds is not going to respond to any type of fat removal treatments. While liposuction can be done in the perioral mounds/lower cheeks and under the chin and along the jawline, its results will be very modest and will not create a very slimmed down or chiseled lower face/jawline appearance.

While a facial defatting procedure will provide some benefits, it will just not be at the level of facial reshaping that you appear to desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been following your website for some while now and was wondering if I could get some answers on cheek resuspension.I had zygoma reduction surgery last year and was interested in this procedure. Specifically I am interested in your preferred method of cranial cheek resuspension.

(1) I am 21 years old and of asian descent. Zygoma reduction has given me slightly lowered cheeks when I smile and puffy nasolabial lines. Would this cheek resuspension technique fix my problems?

(2) Is my age and race a problem with this type of surgery?

(3) Is there hair loss associated with the incision?

(4) How long would it take for swelling to go down and for people around me to not notice that I have swelling?

(5) Is this procedure the same thing as a cheek lift?

(6) Can this resuspension be done to look natural? I do not want to have chipmunk cheeks afterwards and think I only need a slight lift of the cheek tissues.

A: In answer to your post zygomatic reduction cheek suspension questions:

1) Cheek soft tissue resuspension would be the only treatment option for sagging cheeks after zygoma reduction surgery.

2) Your age range and race is the most common patient for cheek suspension after cheek reduction osteotomies.

3) No hair loss is associated with any scalp or temporal incisions.

4) Two weeks would be the maximal recovery for swelling.

5) Cheek suspension and cheek lifts are interchangeable terms.

6) A goal of a slight lift is good as that is what would usually be achieved and/or needed.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

Can hydroxyapatite cement be used to build out this area?

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

Thank you so much for your time.

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

I APPRECIATE YOUR ANSWERS

A: In answer to your hip implant questions:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

A: In answer to your cheekbone reduction surgery questions:

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

A: In answer to your forehead reduction questions:

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

Thanks! 

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana