Your Questions

Q: Dr. Eppley, I am interested in jaw angle implants. I’m looking for a small width increase to my ramus/jaw line and possibly a genioplasty. I feel that my chin is under projected for a male but I dont want to overdo anything either as I want it to look natural which is what I’m more interested in bone fusion than implants. In terms of implants, is it a a high risk procedure for the jaw implants? 

A: When it comes to creating width to the jawline, there is no other method than to use implants. Jaw angle implants pose similar risks like that if any other facial implant, they have no additional risks than the standard risks of infection and aesthetic concerns. (asymmetry and size issues) that all facial implants share.

 The one issue that makes the different than some facial implants (nose and chin), although the same for other facial implants (cheeks and temples), is that there are two of them as they are placed in pairs. Thus they have double the potential risks as that of a chin implant for example. This is most notable as it relates ti symmetry between the two implanted sides.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been wanting breast implants for awhile now. My family all have bigger breasts than me and I’m the one with nothing. I don’t want really big breast but big enough for me to have my self esteem high. And I wanna feel good about myself. I’m 19 years old. I am a young mom. I plan to have not in the future. I wanna still be able to breast feed and look natural. Any suggestions will you help me?

A: At 19 years of age you can certainly have breast implants and they can even be silicone  implant if so desired. What determines a natural look is based on the patient’s interpretation of that term but generally that means not too big for your body. What that would be for you I can not say since I don’t know what you look like or what your breast size goals are. I would need to see pictures to help make that determination. And then ideally you should be sized before surgery using volumetric implants sizers.Breast implants, regardless of their size or shape, do not interfere with the ability to breast feed. They are placed under the muscle, way away from the ducts of the nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty. (I think) Please see attached pictures of my frontal and profile view. In the first three pictures, I am pushing my lower jaw out forward, which is normally how I rest my face to create the illusion of a stronger profile/jawline. The next 3 pictures depict what my jawline looks like if I bite down normally. The end look that I desire is a masculine/defined jawline. I wanted your insight on what would be most aesthetic for my face/what would make me look the most ruggedly handsome. I look forward to hearing back from you soon.

A: Thank you for your inquiry. Based on your pictures I would recommend a sliding genioplasty combined with small widening jaw angle implants. That will accomplish what you are showing by thrusting your jaw forward for the chin as well as add some complementary width to the back of the jaw. I would prefer a sliding genioplasty in your case as the chin augmentation increase you are demonstrating by a jaw thrust create both a horizontal and vertical chin change. This is best done by moving the chin bone down and forward. While that does not widen the chin, that does bot appear to be a chin dimension change you are seeking since a jaw thrust does not widen it either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reduction. I wanted to inform if it’s possible to help me with the following. I have a bulged forehead, that looks bigger than the one’s of people I generally see. Maybe it’s scaphocephaly, I’m not sure. I’ve attached a photo. Is it possible to reduce it to a more normal appearance? You mentioned a  ‘conservative change’, would it be possible to go even further? Would an operation cause a large scar? How much recovery time would be neccesary? What would roughly be the costs for such an operation?

Thanks! 

A: Certainly some reduction of the forehead bulge with or without some brow bone reduction can be done. (forehead reduction) I have imaged a conservative change to see if I am going in the right direction. When I do computer imaging I like to demonstrate what I feel is the minimum amount of change that will occur. More may be possible but a patient’s decision for surgery should be based on the least amount of change they can accept.

To do forehead reduction an incision has to be made somewhere and this is actually the biggest decision in the surgery as to where to place it so it the most aesthetically acceptable.

Most of the recovery (swelling) should have resolved by 7 to 10 days after surgery.

My assistant will pass along the cost of the surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have seen before and after of paranasal implants and it seems the goal is to make the face look less flat? I do plan on getting these done. Also I have recessed jaw and my maxilla is basically normal and my bite is fine but I am going to get it checked with an jaw surgeon. So no type of midface implants makes your maxilla look more forward?

A: Looking vertically longer is one thing, having more horizontal projection is another. Your original inquiry asked the question of a longer maxilla which is an increase in the vertical dimension…which is not possible. Many types of implants give the midface more horizontal projection or bring it forward. You have been using confusing terms in your descriptions. It is now clear that you mean increased horizontal projection of the midface. This can be done using a variety of midface implants including paranasal implants, maxillary implants, premaxillary implants and combinations of any of these midface implant styles. The best way to bring the midface forward is through the use of a custom midface implant which augments the entire midface bone above the maxillary teeth level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in shoulder width reduction. I wanted to consult you for a surgery which I still do not know anything about and, as much as I researched, I have not found much about it. I am a transgender girl and I have a big complex with respect to my wide shoulders. I have a female body but still my shoulders look broad (not muscular but really broad) and I think it is the part that is disproportionate to my body. I have been researching about surgery to reduce broad shoulders but can’t find any information on it. I heard that you performed a complicated rib reduction intervention on a model and wondered if you could intervene on my bones. But this time on the collarbone to get it to look narrower. Is this surgery possible? Do you know if it is available in America or anywhere else? Here in Europe nothing is known yet. Thank you very much for your attention. 

A: What you are referring to in regards to shoulder width reduction is to shorten the clavicle, the bone that runs between the sternum and the shoulder. By removing a segment of this bone, the shoulders will move in a bit and create more of a rounded shoulder look. This requires an incision over the clavicle on each side and the use of a metal plate to hold the bone back together as it heals. It would also require a prolonged recovery as one might predict considering that it creates a controlled clavicle fracture on each side.

While such a surgery can theoretically be done (it is just a spin off of the treatment of clavicle fracture), I have never performed it nor have I ever heard of it being done anywhere in the world. It would take an extremely motivated patient to undergo his surgery on an aesthetic basis considering the scope of the procedure, the creation of small scars in a visible area and the recovery involved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have the problem of mentalis muscle strain and distortion after a sliding genioplasty advancement. I want to improve it by the mentalis resuspension method but only by an intraoral incision. Because I did the sliding genioplasty surgery my mentalis muscle is strained and looks distorted when I close my mouth or pout my lips and also there is too much ower teeth show. My doctor who performed my surgery will improve my mentalis muscle strain by cutting some muscle at my chin. And then he said that the mentalis muscle resuspension is not suitable for me. Is that true?? When I rest my mouth it’s normal and my lower teeth show but but when I try to close or pout my lips my mentalis muscle strain appears and my chin looks distorted. Which method is suitable for me? Should I allow him cut my muscle?

A; It is correct that a mentalis muscle suspension procedure is not what you need to improve your mentalis muscle strain. Rather you would likely benefit from a mentalis rmuscle elease and dermal-fat grafting procedure to prevent recurrent muscle contarcture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from midfacial hypoplasia. I am currently scheduled to undergo a modified LeFort III and I anticipate undergoing bimaxillary advancement in the future. I am fully aware of the risks associated with the procedure.

I have considered going for the ‘camouflage’ approach, consisting of implantation, and thus I am drawn to you given your experience and presence. What will be crucial in making my decision is whether there is anything that customized implantation can achieve in the upper midface that a modified LeFort III procedure cannot, and vice versa. Initially I was curious as to whether the soft tissue response would be different. Is there anything that you can envisage an osteotomy involving the upper midface achieving that a custom implant cannot?

The main point of my email though is with regard to something more specific. My surgeon informs me that the cut will be made in the lateral orbital wall above the lateral canthus. The lateral orbital wall will be moved forward,along with the lateral canthus. This is important to me because my lateral canthus is very far back relative to my medial canthus and the anterior surface of the eyeball. In fact, this is probably my most pressing aesthetic concern. So my surgeon assures me that it is solveable. However, if there is another way of achieving this aim without undergoing a risky procedure such as a modified LeFort III, I would be eager to undergo it. 

Which brings me onto my question. I know that it is possible to replicate more anterior projection of the lateral orbital rim with implants. What I would love to know is whether the lateral canthus may be brought forward in the way that it would with an osteotomy? Perhaps through disattachment of the lateral canthus and replacement in another part of the newly constructed lateral orbital rim? 

Another brief question that I have is with regards to the appearance of the lateral orbital rim without movement of the lateral canthus. I struggle to envisage how the lateral orbital rim would appear if it is given anterior projection past the position of the lateral canthus. Would the lateral canthus become invisible in this situation or how would it appear?

Thank you for your time.

A: In short, you have correctly surmised that the position of the lateral canthus inside the lateral orbital rim can be repositioned either onto the bone or onto an implant rim. (lateral canthoplasty) One would certainly not choose a modified LeFort III procedure if that issue was the primary objective of the surgery. As there is an easier way to accomplish that goal. 

Be aware that in the execution of any form of a LeFort III ostetotomy the later canthus has to be detached and then reattached once the bone is moved. It does not really ‘move’ with the bone as it comes forward

Whether you should do the LeFort procedure or onlay implants depends on how much forward movement of the midface/rims you need to accomplish your aesthetic goals and what other midface needs are to be addressed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I m interested in migraine surgery. I will try to be brief about my migraine history. Twelve years ago I was in an auto accident. I had/have hereditary stenosis of the C-spine. Things in my neck shifted enough that I needed a vertebra removed. I had a vertebra and disk ripped apart in my lumbar spine. I have mild tingling and numbness in my hands. I have chronic pain in my neck and lumbar that like my head never goes completely away. From the beginning I received epidurals in my lumbar and neck, although the full pain was never covered up. In 2011 I had a new pain management Dr. who had just done a  nerve block in my neck and asked how I felt. I said much better, now if you could get my head to quit hurting… He took my head PAIN seriously. Everyone before thought I just had a headache. He did nerve blocks on the outside of my skull, at the nerves. I almost cried. For 7 years I had… you know what it feels like to smash your thumb? That’s how my entire head felt for 7 years, my knees almost buckled from relief. He learned, on my behalf, how to do Occipital RFA’s.

I’m tired of fighting insurance and government procedures. I hope to have 20 or 30 years left, and I want something more permanent. It not only affects me but everyone around me. My wife deserves better and the best I can be. With blocks and RFA’s the chronic pain becomes less. I would love to be able to get off of the pain meds I’m on. At least reduce the levels. I am tired of being treated like a criminal because some people abuse their drugs and others who suffer from extreme pain are called druggies for over dosing when it’s cleaner than other ways and doesn’t involve others. I don’t like being in pain.

Please consider me for migraine surgery.

A: Thank you for detailing your history. The critical question, as in all chronic migraine patients including occipital neuralgia, is whether occipital nerve decompression would be effective. While you have some suggestion that it may have some benefit (positive response to nerve blocks and RFA), there really is no way to know with any certainty unless some simply does the procedure. The main qualifier for me as to whether one should undergo external occipital nerve decompression surgery is two-fold; 1) the patient accepts the uncertainty of the outcome and 2) Should the procedure not be effective there is nothing else surgically I can do to try and make it work better. In other words I do the maximum extent of the surgery knowing that this is a one time short for relief.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision surgery. A little over a year ago, I had a pilonidal cyst removal surgery and it left me with a disgusting scar in an intimate area. The doctors told me that the scar would no be very noticeable, but it is in fact very noticeable and ugly. This has really hurt my self-esteem and made me feel disfigured. I would like to see if making it less noticeable is an option. Please let me know if you think there is anything you could do.

A: Thank you for sending your picture for consideration for intergluteal scar revision surgery. Your intergluteal scar can be improved and will require complete excision of the scar and the recreation of the sacral cutaneous ligament. (this is what creates the intergluteal crease) Such surgery is very familiar to me since this is the exact approach that is used to place buttock implants and is how the intergluteal crease must be put back together.

This scar revision procedure can be done under general anesthesia as an outpatient surgery. It ail likely not widen again after this type of scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about bimaxillary surgery.  I’m very confused on what the answer is. I have a recessed lower jaw but my bite is fine. So I was thinking about getting bimaxillary surgery for my maxilla as well. 

However here is what I’m inquiring about. I have prominent/wide cheekbones that protrude laterally. I notice though my cheeks look a little sunken in from the front anterior wise. I have those nasolabial folds. This is something I find a rare problem. I don’t see many people who have this issue when their cheekbones are prominent wide. 

So basically will advancing my maxilla through bimaxillary surgery help with this? Are there any implants that would help with making your maxilla look more forward? If I’m getting jaw surgery anyway should I skip the implants? Thank you

A: The answer to your concerns is very straightforward and not confusing. While you can do bimaxillary surgery with a good bite relastionship this would be uncommon. Such surgery, short of sleep apnea treatment, is done when the bite is off. But if both the upper and lower jaw is horizontally short, then skeletal correction keeping the same bite would be fine.

Bimaxillary surgery will not help with wide cheeks. The bone cut at the LeFort 1 level is done below the cheeks so it does not affect their appearance in the long run. (when the swelling resolves)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may be interested in getting a tip rhinoplasty. Should I consider just getting a tip refinement? I’m not really happy with the “box-like” bulbous tip I have naturally. However, if surgery wouldn’t offer me a great advantage, then I wouldn’t risk it. I don’t mind the the rest of my nose. I do like my profile very much. I’m insecure when people see my face front-on due to the width of my nose. I have more photos to send if you would like.

A: What you have is an isolated boxy nasal tip due to the size and separation of the domes of your lower alar cartilages. Your nasal tip could be nicely reshaped through an isolated open tip rhinoplasty. That would solve your nose appearance concerns on a permanent basis.Whether you would consider this type of nose change offers a ‘great advantage’ remains to be determined by you. Based on your stated concerns I would think it would. I will have my assistant pass along the cost of that type of rhinoplasty surgery to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old and am interested in chin scar revision. When I was a child I slipped and fell on my chin resulting in one big visible white scar on my chin and two small ones, and another one on the bottom of the inside of my my mouth in front of the teeth. The cut inside my mouth healed absolutely perfect without even using stitches but the same can’t be said about the scars on my chin. Now eight years later I really want to get something done to minimize the white scars, as it really affects my confidence and my ability to be happy with my appearance immensely. 

The medical report from the incident reads as follows: “Cut on inside of mouth (1 cm deep) that seems to be connected to external scar on chin. It was judged that it didn’t need to be sutured but the chin is taped up and back. The tape will sit until it falls of. On the chin (external injury) scar that is 1.5 cm long and relatively deep; local anesthesia with carbocaine-adrenalin. Sutured with single sutures 5-0 Ethilon, which are to be removed in 6 days time. Otherwise there are some excoriations on the lower lip but no other cuts.”

Now the texture of the skin beneath is kinda hard and it feels like the area is slightly raised. I also think that as a result of the trauma the surrounding skin changed texture to become more bumpy and depressed in some areas. Can something also be done about the lack of hair growth in the scars? I am open to anything that can be done and I’m price insensitive as long as an improvement can be achieved.

A: What you have is a typical white scar line that runs perpendicular to the relaxed skin tension lines of the chin. Given where it is oriented it has healed better than one might have anticipated. But that being said it is still noticeable and it has a residual appearance that bothers you. It can be improved through a chin scar revision procedure where the scar is completely cut out and then closed in a geometric pattern to break up the straight scar line. I would use Acell particles to plant into the car to help lessen how much scar would form the second time around. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead injectable fillers. I had a PMMA forehead implant placed last year, but I’m not entirely satisfied with the results. The biggest issue is that the implant doesn’t extend all the way to my hairline, and there is a slight notch near the top of my forehead where the implant ends. Moreover, the implant did not adequately augment the central brow region.

Hence, my questions are:

1) Can filler be used to augment the areas circled in the picture?

2) I’ve read about necrosis and blindness, which is the main concern I have. Would it be safe to inject fillers into these areas?

Thank you!

A: I would definitely not put injectable fillers down by the brow area. This is a danger zone in injectable fillers whose risk may be increased with a forehead augmentation underneath it. I think the upper forehead region is safer as it is not near the vascular pedicles that exist down at the level of the brow bones.

While you could do forehead injectabale fillers, it is safer and more effective long term to have your forehead implant modified or replaced. Your existing PMMA forehead implant can be supplemented to improve your aesthetic concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is outer corticotomy method for jaw angle reduction? Is it just cutting the jaw slightly from the front view? Another thing I don’t necessarily want is screws to hold bones together. 

Also, what is muscle reduction by electrocautery? Isn’t that dangerous to the muscles? Wouldn’t cutting a part if the muscle be more effective?

For my chin, I had attached 2 more pictures. One with Botox into the jaw with NO filler to the chin and another with both Botox and filler. The one you saw before in the first email was without any procedures done. I just want the sides of my chin narrowed not necessarily broken and attached back together with screws if that makes sense. 

Anyway we can cut the muscle and jaw and narrow the chin without any screws and long terms affects? Thank you!

A: The outer corticotomy jaw angle reduction method removes the outer cortex of the jaw angle.  It leaves the shape of the jaw angle but makes it thinner. This is in sharp contrast to the more traditional full-thickness amputation method of jaw angle reduction.This creates the appearance in the front view of some slight narrowing. It does not require plates or screws as the bone is removed.

You never want to cut on or try to take out portions of the masseter muscle as this will lead to visible irregularities on the outside. In addition it can result in both intraoprtstivr anf postoperative bleeding. Electrocautery more uniformly shrinks the muscle and has no risk of bleeding.

The sides of the chin can be narrowed through an intraoral approach by just removing portions of the sides of the chin.  (known as lateral tubercle ostectomies) Like the jaw angles it is done by removing the outer layer of the bone and does not require any plates or screws.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the look from V line jaw surgery. I currently receive Botox injections into my jawline to narrow my face and I have a filler for my chin. I am of Asian decent but I find that some surgeons in Korea overdue it and some faces look too overdone and I want a more natural look.

I want the look that I currently have. I am looking for a more permanent solution. I would prefer not to have my jaw shaved since I’m satisfied with the look I have now with just having my masseter muscle reduced from Botox.

Since I have success with the Botox into the massetter muscle would you be able to reduce that muscle permanently without complications later on? My filler will also be gone soon, would you be able to narrow the sides of my chin because I don’t want an implant.

How long until I will be presentable to go back to work? How long do I have to stay in the area? Can’t wait to hear from you soon. Thank you.

A: The reason you don’t like Korean jaw angle reduction results is because they amputate (cut off) the entire jaw angle in most cases. While that can have a radical effect on facial width in the front view, it artificially raises the jaw angle and thus can look overdone. (because part of the jaw is missing) That is just one way to do jaw angle reduction. The other way, and the more common and better method that I use on many non-Asians, is the outer corticotomy method. This preserves the jaw angle shape and just makes it thinner. The width reduction may not be as dramatic as the amputation method but it looks more natural (not overdone) and keeps the shape of the existing haw angle which prevents complete soft tissue collapse inward. This form of bony jaw angle reduction is what would be appropriate for you along with some muscle reduction as well. This might be something to consider as muscle reduction by electrocautery usually doesn’t produce as much reduction as Botox does.

For your chin I am assuming you added filler to the central part of the chin to give it projection and make the chin appear more narrow or v-shaped. Thus the bony reshaping method would be an intraoral t-shaped chin osteotomy technique. This narrows the chin in width and also give it some slightly increased projection.

Having both of these surgeries, you could go home in a day or two. Be aware these type of jaw surgeries cause considerable swelling and would take 10 to 14 days before you look presentable for work. (although what defines presentable will vary from person to person)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve talked to one plastic surgeon about doing a lower facelift, but cost and time make that impossible for now. I’ve been reading about fat transferring and it sounds less invasive and as I understand there is less downtime.  Also, I’m not quite ready emotionally for a facelift if it can be put off for now.

I’ve considered having injectables, but too often see unnatural looking results and do not like the idea of having to do it every 6 months or so.

Thanks in advance for your consideration.

A: Thank you for sending your pictures. While trying to circumvent a facelift, or delaying to for awhile, is understandable, no non-facelift procedure is going to produce the imaged results that you have provided. I assume that you recognize that issue since only more aggressive skin removal can create that degree of jawline and neck definition.

That being said, there are more limited procedure with less recovery that can be beneficial. Fat injections to the cheeks/midface as well as sub mental/neck /jowl liposuction would provide some aesthetic benefit and would help defer a more formal facelifting procedureuntil a later time. At the least it would be far better than using injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about Occipital Bun Removal. How much does the surgery costs; what is the recovery time; how prominent is the residual scar; how long before I can return to work? I am bald. Additionally, what are the risk of the surgery itself? Thank you.

A: I will have my assistant pass along the general cost of the procedure to you on Monday for Occipital Bun Removal. I would need to see a picture of it to have her provide a confirmed cost of the surgery. This procedure is done through a 3 to 4 cm long fine line incision either right over the knob or in a skin crease (if it exists) above or below the knob. How the scar looks would be the only risk of the surgery. All such scars in my experience heal really well and I have yet been asked to ever perform a scar revision procedure on it. One could return to work within a few days after the surgery. There has never been a problem with getting the bump of bone completely reduced to be level with the surrounding skull bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in the early stages of investigating my abdominal liposuction options for reducing my stomach fat. I sent pictures to you as well and then discussions could continue as needed. 

I have attached 3 photos for review. A little background: I am 58, 5’8″, 160 lbs. I work out 5-6 days a week with both weights and cardio but I can not get rid of the so called “stubborn” fat around my mid-section. I am open to different procedures and I have investigated Cool Sculpting with mixed thoughts to that procedure. 

Thanks again and I will wait for reply.

A: You have the classic male distribution of fat in the abdomen and flank/waistline areas. You would not be able to loose that on your own unless you dropped your weight to about 140lbs, which is not a sustainable weight for you. You are an ideal candidate for liposuction as this is the most effective and efficient method of reducing it. Non-invasive methods such as Cool Sculpting, at best, will create only about 1/3 as good of a result over a long protracted time with multiple treatments. Most men are not very tolerant of a slow and incomplete treatment process for fat reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am touching base to let you know your response in dealing with my pectoral implants assisted me being successful in making a date to change my pectoral implants later this year. As you are aware I would like to get this right. However based on what has happened I wanted to run by what is going on. As you know I have had the Powerflex 1 271cc pectoral implants placed in my chest which has a projection of  3cm. What my doctor and I discussed is that we would like to change to the Powerflex 2 style implant in the 293cc volume which is the largest of the 3 sizes in a slightly lower projection of 2.5cm.  However these ones as you are aware are more spread out which will give me a more medial augmentation towards the sternum.

What I was wondering if you could help me with is that I noticed some surgeons place pectoral implants vertically and horizontally. i wanted to know what looks these two options give and the benefits they have. Secondly my concern now is that I am torn between the choice of using the 293 cc with a 2.5cm projecion or going lower at 203cc volume with a projection of 2.1cm.  I do trust my doctor but I don’t feel he has come across a patient like me. My aesthetic goals are to have a noticeable pectoral muscle but with more of a definition of muscle rather than a “busty” “booby”  body builder look. I  don’t wish to become a bodybuilder. I actually like being a slim and toned male but with muscles similar to when someone shreds or reduces their body fat . 

In saying that I might add that I personally find the Powerflex 2 style pectoral implants to look more natural over the anatomical ones. I don’t know if I’m saying that due to my ones being on the larger size but another key point in my current implant is that my implants don’t softely taper off into my real chest like a natural pec muscle would. That is why I am stuck between these two sizes as I want bulk in the lower area of the pectoral muscle and on the top area I would like the implants to taper off into my normal chest area without looking like two big solid implants glued to my chest.

A: Since you are having the original surgeon do your pectoral implant revision, then these are discussions you need to have with him/her. That is your responsibility as well as that of surgeon. Asking other surgeons to try and guide you as to the proper implant selection is both unfair to whom you ask as well as to yourself. Only your surgeon knows what you look like and has a vested interest in your outcome. You either trust your surgeon or you don’t. If you don’t then find another surgeon that you do. Standard pectoral implants come in certain sizes and the results they create are limited and do not work ideally for everyone. When one is seeking very specific results after a first set of pectoral implants have been placed, one should strongly consider having custom pectoral implants made. This will remove all doubt about size and shape concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal. I’m a thin girl, and I was considering removing four ribs to get a smaller waist. My plastic surgeon in my hometown said he punctured a lung while performing this surgery before and therefore does not do this procedure anymore. Is there anyway to eliminate this risk? Any other major risks and complications with this surgery? Can it be done under local with IV sedation instead of general anesthesia? Thank you for your time.

A: The best way to avoid such a complication as you have described for rib removal surgery is to have someone do it that knows what they are doing. That should be a complication that is easily avoided in experienced hands, particularly down as low as ribs #11 and #12 where the base of the lung does not extend that low. This is a procedure that can only be done under general anesthesia. It is performed in the prone position (with the patient face down) and Exparel long-acting local anesthetic is used for nerve blocks once the rib portions are removed. This is a very safe procedure when down by a surgeon with experience doing it.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Do you offer scrotal lift and penis webbing removal? I plan to fly over just to have this done. 

If you do offer this,

1. What technique is being used to fix it?

2. How long does the procedure take?

3. Can I expect little to no scarring?

Thank you!

A: Such scrotal and penile procedures as you have described are commonly performed in my practice. While I don’t have any visual assessment of your specific penoscrotal anatomic derangements, I can provide some general answers to your questions:

1) Most scrotal lifts are performed by a midline reaction along the raphe. The treatment of penile webbing depends on its location. (e.g., penoscrotal band, glans-shaft webbing etc)

2) Each The procedure takes around one hour to perform under general anesthesia.

3) Most scrotal lifts have very minimal visible. Penile webbing correction may be different as some of the scar lines will likely end up on the penile shaft, which does not scar as well as that of the scrotum.

4) I will have my assistant pass along the cost of the procedure (scrotal lift) to you tomorrow. I would need more information about the penile webbing before a quote can be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One is I feel I have significant facial asymmetry. Everyone tells me it is not but for some reason I feel like it is. Another problem that I have is that I do not feel like my face is lean enough. I am very skinny but I still feel like my face is not lean. I think one reason may be that my cheekbones are not very prominent. I feel like surgery should be a very last resort since I am only 19 years old but I was wondering if there was anything I could do to make my cheekbones more prominent such as exercises or something. People tell me that I already have a good jawline but I just don’t know what to do. If you could please answer me, it would be much appreciated. I have seen pictures of your work and I think it is just wonderful. That is another question. If I have the cheekbone surgery or any surgery, I am afraid that I will look fake or like plastic. I know that sounds rude or disrespectful and I’m sorry but looking real or fake scares me. Thank you for taking the time to answer my questions. I look forward to hearing from you.

A:Thank you for sending your pictures. I think what creates your face asymmetry is that your left eye has a lower eyelid position and has more scleral show.

I would agree that to make your face appear more lean that cheek implants would be helpful. You can not exercise your cheeks to make them bigger. The key to achieving a natural look is to have cheek implants that are more modest in size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. My first rhinoplasty was two years ago and the I had a revision a year later. I have difficulty breathing through my nose. Attached are many photos of my nose as well as two pictures of men – I find their noses especially attractive. I would ask for a nose with similar features. Other surgeons have told me that I have the following problems:

1.) dorsal hump

2.) tip reconstruction to have better tip shape and projection

3.) internal valve collapse – both nostrils are collapsed (seen in

nostril picture)

4.) nostril shape asymmetry – alar notching deformity on the left

side. To fix with alar cartilage graft

5.) deviated septum/nose not on my face straight

6.) My own opinion – nose is too over-rotated. Would like it titled down so that nostrils and tip are more in alignment – making a straight line expression – NOT tilted toward the ceiling.

Very difficult problems. Essentially, all across the board, I have been told that I will need rib cartilage to rebuild my nose as it is horribly damaged. Overall, I would want a more functional, symmetrical and more proportional nose to my face. Again, some cosmetic and functional issues.

A: In regards to your nose and revision rhinoplasty, suffice it to say that it is a difficult challenge. While there are many technical maneuvers in your revision rhinoplasty, the key is adequate cartilage grafts to be able to achieve just about any of them. Your nose is completely collapsed and needs to be rebuilt using cartilage grafts. How successful that can be done depends on the stretch of the scarred nasal skin as it must expand to the underlying rebuilt nasal framework. Without question a rib graft would be needed to supply the graft material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am still interested in this procedure. I feel like my whole face is wide and really would like a more narrow appearance from looking straight on as well as the sides. I feel like if only the jaw angle is cut and chin is lengthened, I would still have a wide face. Is the jaw bone between the angle and chin able to be cut? Also, my chin seems a bit wide. I personally like the whole V-line jaw surgery that is done in Korea. I will attach more pictures here. 

A: Let me demystify for you what V-Line Jaw Surgery really is. It is the combination of chin and jaw angle narrowing/reshaping. The intervening bone between the two, known as the body of the mandible, can be changed in any significant way way due to the location of the nerve that runs through it and the proximity of the tooth roots. In some cases the bottom of the body of the mandible may be removed but the width of the bone in this area can not reduced. 

The combination of jaw angle reduction and chin surgery that has been previously discussed in prior emails is, in fact, V-Line Jaw Surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask how the soft tissue of the face responds to implantation v. osteotomy. I am currently deciding whether to go ahead with zygomatic sandwich osteotomy for lateral projection of the cheekbones, or whether to achieve this change with implants. My decision mostly hinges on the soft tissue response. I want the augmentation to ‘stretch’ the soft tissue as much a possible. Am I right in saying that an cheek osteotomy will achieve this goal better? I say this because its true that a sliding genioplasty will mobilise the submental soft tissue more than a chin implant will (given equal amounts of augmentation). I have thin skin and low bodyfat, I just lack projection meaning that my soft tissue does not appear to wrap around the bone well.

A: If you want to stretch the cheek tissues as much as possible, an implant achieves that better than a zygomatic sandwich osteotomy. This is because by virtue of the implant placement the soft tissues must be elevated off of the bone first and then the implant placed. That does not occur in an osteotomy where more tissue adherence remains. Such a cheek effect from implants or an an osteotomy is not analogous to the chin where the submental area improves from a sliding genioplasty because of the attached muscle stretch not that of the overlying soft tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know it is still early my custom jawline implant recovery process and I will wait for more of the swelling to subside in the next couple months but I am concerned that the implant may be too wide for my face. Potentially, I think the size of my masseter muscle and the size of the implant may have been too aggressive, combined. You can see in the picture that it actually the widest part of my head now. I know it is a bit pre-mature and I will wait and see if the result changes, but is there a process where you could potentially modify the current implant and make it smaller if need be? Thank you.

A: Thank you for the very early followup and I certainly appreciate your concerns. I have seen and heard it from just about every patient whether it is from a custom jawline implant or just isolated jaw angle implants. When one looks like Quagmire  (American Dad), it is very understandable that one thinks the implant may be too wide. (big) And while that may eventually be proven to be true in your ultimate aesthetic judgment, I can offer you the following insightful commentary.

At less than 10 days from surgery, you have not even had 50% of the swelling to go down. The swelling over the jaw angles is always the largest because the thickest of the masseter muscles allows for a large amount of swelling to develop that is very facially distorting. This is very evident in the classic very round appearance to the back of the lower jaw. There is considerable swelling to go down at this point and most people don’t start to feel better about the result until about 3 weeks from surgery. (when about two-thirds of the swelling has gone down) At this point the face starts to assume a more normal shape, albeit still bigger than the implant has actually created, as the final swelling and tissue wrapping down and around the implant has yet to occur.

I would highly doubt that you will see that the implant is too wide by 2 months or so after surgery. But in the advent that you feel that it is, the current implant can be  modified to be smaller. (less wide)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the chin wing procedure and from the looks of it it doesn’t enhance the jaw but so I would like to get implants for my jaw. 

I have a question about the procedure, I understand it uses bone grafts but can it be used to bring up a weak chin and change the shape of a chin? Like I want to know if it can change the shape of a chin from a round one to square one all using your own bone. 

I plan on getting jaw implants but I really want to use the chin wing to change my chin shape with my own bone, thank you.

A: The chin wing is procedure that moves the chin and a long extended limb of bone back to the jaw angles forward and usually down. (vertically longer) It is NOT a procedure that uses bone grafts to achieve its effects. It is an osteotomy that cuts and moves a vascularized inferior border mandibular bone flap.  It will not change the shape of the chin from round to square. It merely takes the chin you have and gives it more projection and vertical length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to retain your expertise as a Consultant as a facial implant designer and then to have the mid-face lift done with you after having the implants replaced with your design here in my country?

I am informed that my insurance fund in my country would actually pay for the replacement of my current implants and thus it makes it more feasible for me to have them replaced here.

My only concern with the local option was the design of the implants (aesthetically). It is manifest that you have more experience with implants and are thus familiar with the most aesthetically suitable design for my facial structure.

Your reply in this regard would be greatly appreciated.

A:I have been asked that question to be a facial implant designer many times but that is not something that I will do. The surgeon should be the same person who both designs and places them. This gives the patient and the surgeon the best chance to get properly placed what has been actually designed. Asking a surgeon to place an implant design that he/she has never done before is a recipe for an adverse outcome.

Dr. Barry Eppley
Indianapolis, Indiana

Dr. Eppley, I am disappointed that I can not have the breast lift and the breast implants done at the same time.  I am looking at a size D cup or C cup at the smallest.  I guess I am confused that if I just did the lift I thought I would need to do the implant as well or I would look funny.  If I need to do them separately, how long in between would I have to wait? Thank you for your time.

A: What is important to realize is that a lift and implant operations fundamentally fight against each other, one uplifts and tightens the breast mound while the implant expands and pushes out on the breast mound. It is easy too see how these two forces may be competing and cause both aesthetic (inadequate lift, inadequate volume) and medical (wound dehiscence, infection, loss of the nipple due to circulation impairment) complications in certain patients. Whether one is at risk for these potential issues depends on two factors; 1) the extent of the breast lift and 2) the size of breast implants desired. Many women do have a combined breast lift-implant operation but they are able to do that because either the extent of the beast lift they need is more limited and/or the size of the breast implant they aesthetically require is not large. Burt when you combine a full breast lift with larger breast implants, this is a surgical combination that at best will lead to unaesthetic result or at worst a major complication.

The interval between a full breast lift and breast implant placement would be three months.

Dr. Barry Eppley
Indianapolis, Indiana