Your Questions
Your Questions
Q: Dr. Eppley, I’ve also been looking into custom jaw implants to add some vertical length to my ramus and chin. However I’ve noticed that in the vast majority of these cases the results tend to look unnatural and often times asymmetric. Whilst I was confused about seeing the asymmetry in several of these custom implants (surely the designing process would have attempted to avoid any asymmetry?), this is less of a concern for me as some of the results I have seen are symmetric and thus I think with the right planning that can be avoided. However, what is bugging me is the synthetic ‘afters’ of most of these custom jaw implants. I don’t know how to describe it other than that it sometimes looks very ‘plastic’ which of course it is. Also I’ve noticed that a lot of these cases look very ‘bloated’, almost as if they have bruxism caused masseter hypertrophy. But why do the silicone implants create this unnatural looking effect through soft tissue? Even where augmentation isn’t extreme, the really sharp mandibular border that the implant creates doesn’t seem to look real. Is there anything to be said here about eliminating this effect?
A: Jaw angle asymmetry is the norm in jaw angle implant surgery not the exception. Whether the degree of asymmetry is significant or bothersome to the patient will vary widely. I have seen patients with small amounts of asymmetry have multiple surgeries to try and make it perfect while other patients with larger amounts of asymmetry are perfectly content with it. My experience is that if you are a young male you will fall into the former category and will not rest unless it is near perfect. While making custom jaw angle implants definitely helps decrease the risk of postoperative asymmetry, it does eliminate it completely. There is the implants design and then there is the actual placing the implant. I have an enormous experience with jaw angle implants and even I have a 10% to 20% risk of jaw angle asymmetry particularly when it comes to implants that create any vertical lengthening of the jaw angle.
Most people that seek jaw angle enhancement need vertical lengthening and not just width. All current commercially available jaw angle implants create width only and are inadequately designed in my experience. But that is what is available to almost all surgeons so that is what gets used. This wide rounded angle implant creates a fatter jaw angle not a more defined one in most cases. I am to sure what you refer to as ‘really sharp jaw angle implants’ since no such style of jaw angle implant is currently available to my knowledge. I have my own line of vertical jaw angle implants and often will custom design them to get a sharper and not rounded jaw angle look. That begin said, not every face can end up with a more defined jawline look. The heavy the face or the one with thicker tissues will never get a very defined jawline/jaw angle effect from any type implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Permalip implant removal. I had 4mm Permalip implants put in my upper and lower lips this past year. It has not even been a year but I would like to get the upper implant removed. It causes a crease when I smile and my smile looks restricted and very unnatural. I have been doing a lot of research and you seem to have quite a bit of experience with the Permalip implant.
I had a few questions:
1.) how long would my upper lip be swollen for/how long would it be noticeable.
2.) how quickly could I start again with filler
3.) Will my smile go back to normal or will it stay restricted from the lower implant still being in?
4.) what is the cost of the removal of the upper implant only?
5.) Have you removed quite a few implants and are there ever complications?
Thank you!
A: In regards to Permalip implant removal:
- There should be very minimal swelling…unlike the original placement.
- You may return to getting injectable fillers 6 weeks after the implant is removed.
- I would anticipate that your smile will return to normal. This is a mechanical obstruction issue.
- My assistant will pass along the cost of the procedure to you tomorrow.
- Once the implant is removed I have yet to see any complications that have resulted…other than the lip will become smaller.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull augmentation. I have a depression on the back of my skull which has bothered me for numerous years. I have had it since birth so it has not been caused by an accident. I would be interested in injecting PMMA to fill the area or inserting an implant, however, I am worried about the side effects, especially since it is not a common procedure. I have long hair, will the incision cause a bald spot on my hair line? Is there anyway to make another incision which does not affect the hair? Is PMMA safe or could my body reject the substance? Would an implant stay in place with only soft tissue holding it in place? Is this procedure possible under local anesthesia? The reason I ask is I have a surgery planned for August under general anesthesia, and I am told general anesthesia sessions must be spaced 6 months apart, however I would like this surgery sooner than that. Thank you for your time.
A: Filling in flat spots on the back of the head (skull augmentation) is one of the most common of all aesthetic skull reshaping surgeries. It can be done successfully by either bone cements or implants based on the size of the defect and patient preference. Most patients opt for either custom or semi-custom silicone implants because of their ease of insertion, smaller placement incisions and lower risk of palpable implant edge transitions. The body does not reject such implants although there is a very low risk of infection. The implanted materials doe not affect overlying hair growth. Any potential hair growth alterations lie along the incision line. These type of skull augmentation procedures are best done under general anesthesia not local anesthesia. I am not aware of any medical validity to the need to space a general anesthetic six months or any number of months apart.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip reduction. I had persistent dryness and swelling on my lower lip. A biopsy was performed the report of which is below. Since considerable amount of tissue was removed during biopsy my symptoms have improved somewhat. However the problem is still not resolved completely. My lower lip is still very bulky. So I am thinking if a lip reduction surgery or vermillionectomy of the lower lip would help me.
A: Thank you for sending your pictures and describing your lip symptoms. A lower lip reduction can definitely help the symptoms of cheilitis by removing the abnormal mucosal tissue. The degree of symptom improvement is based on how much of the abnormal (dried) mucosa that can be removed without creating any significant lip distortion.
I would think subtotal lip reduction first before considering a total vermilionectomy which will cause some lower lip color distortions. A vermiollionectomy can always be performed secondarily of the lip reduction does not provide significant symptom improvement.
Reducing the lower lip is often performed under local anesthesia. Resorbable sutures are used to close the incision which take a few weeks to dissolve or fall out on their own.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the temporal artery ligation. I have previously had a treatment for this from a vascular surgeon about 1 month ago and I am not happy with the results. I believe this is because I only had a single point ligation on either side and from reading through it seems this rarely works unless you are lucky.
At the moment the arteries are approx. 50% reduced from before, and don’t seem to bulge up as much when I drin and are much quicker to reduce in size, but I can still feel pulsations so I presume I have some backflow here. Also, the left side seems to snake a bit further across the head all the time now.
Can you let me know if I would be able to have a further ligation done and if this will resolve the issue ? The reason I am contacting you primarily is because your cosmetic background as I understand further cuts would need to be made towards the top of the head where they are more visible. I am concerned about scarring here as from the last operation I was left with scars approx. 2cms long although they don’t bother me very much as they are close to the hairline.
A: Thank you for your inquiry. Please send me some pictures of your temporal regions for my assessment. As you have mentioned it almost always requires more than a single point of ligation in my experience. In fact, I have never done a temporal artery ligation using only a single point ligation. Whether additional points of ligation would be beneficial can only be determined by actually doing it but I would suspect that it would.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had written to you earlier regarding defining my waist (my original email is attached with my pictures below). As you can see from my pictures, my ribcage is quite wide in frontal view. I would like to decrease the width of my ribcage to give more femininity (narrowness) to my upper body, as well as to give some length to my short torso. My protruding ribs don’t bother me, it’s the width that I dislike.
I am 5’3″ and I am 120lbs. I am not overweight and I don’t intend on losing any weight. I’ve always had an athletic body, I am naturally driven to exercise and I have a healthy relationship with food.
I would greatly appreciate your thoughts and advice, as well as what improvements I could achieve with surgery.
I look forward to hearing from you.
A: Thank you for sending your pictures. If I interpret your description and objectives properly, it is the width of the ribcage rather than its anterior protrusion that is your concern. This concern is a bit different than the classic desire for a reduction in the anatomic waistline. (ribs #11 and 12 and sometimes part of #10) or reduction of an anterior lower ribcage protrusion. (ribs # 7,8 and 9) Rather it is a reduction in the width of the ribcage further up at the sides. (ribs # 8,9 and 10) While this technically can be done, this is the area where partial rib removal has the greatest potential for exposure of the pleura (outer lining of the lung) as this is where the lower lobes of the lung exist. So the potential risk of a pneumothorax is greatest in this area. Whether rib removal in this area for aesthetic purposes is worth that risk is an issue up for debate. This area of rib removal is also different in that the incision to access it would be on the sides directly over the area. (which is not necessarily an aesthetic disadvantage)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi there! I have a few questions as I start thinking about the procedures:
1. I want to do back of the head augmentation, top of the head augmentation, and also forehead augmentation – will this make my head too heavy?
2. What are common side effects of the materials used (I will not be opting for implants) – are there natural biomaterials available?
3. How many of these procedures do you do annually? Over the past 2,3 years?
4. I will also be getting other procedures done with other specialists for the eyes and nose – do you recommend coming to you before or after rhinoplasty and how long should I wait in between?
Thank you very much!
A: Thank you for your skull augmentation inquiry. In answer to your questions:
1) Any material added to the head, implant or otherwise, is not going to make your head feel heavier.
2) If you eliminate all synthetic materials then the only natural biomaterial would be your own fat. Its well known side effects is resorption and lack of permanence.
3) I perform 50 to 75 aesthetic skull reshaping surgeries per year…and each year the number is increasing.
4) I would wait either three months before or three months after this type of surgery before doing other aesthetic procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask you a question about a transgender patient that I have scheduled for a rhinoplasty and chin reshaping. She would like a more rounded anterior chin to give a more feminine appearance. I was planning to make a submental incision and just drill down the parasymphyseal inferior edge to reduce the square appearance to a more rounded appearance. I know you do quite a bit of facial contouring and I would love your thoughts on this case please. I have attached planned areas to show where I plan to reduce.Thank you so much!!!
A: There are two chin reshaping approaches to changing the genetic male chin from square to a more feminine tapered look:
1) Inferior border osteotomies (use a saw not a burr as you need to take a lot more bone than you think) I This is not actually the best approach because it does not narrow the chin that much. But you can up the aesthetics of the result by placing a small central chin button style implant (3/4mms) which helps create an overall more tapered appearance. (the ying and the yang effect so to speak)
or
2) T-design intraoral osteotomy (midline resection) This is the best method that will instantly change a flat square chin into a more tapered chin in a ‘scarless’ fashion.
I done a lot of both and either one is better than what she has now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an injectable rhinoplasty procedure. I’ve been researching injectable fillers and I constantly see them being advertised as being able to last up to a certain number of months. From what I’ve read though, these fillers are resorbed over time. If I get 1 syringe of Radiesse, how much of filler can I expect to remain after 6 months? Or, more importantly, when would I need to do a repeat injection to maintain a good aesthetic result?
Anyway, I’m hoping to get fillers to raise my radix and provide a smoother transition between my nose and brow ridge (the area just above the nose bridge and between the eyebrows). Based off your experience, which filler be the best for such an augmentation?
A: While it is trie that almost all injectable fillers have a limited duration, some do have documentation of lasting longer than others. The longer lasting ones are the particulated fillers, such as Radiesse, whose duration should be a year or even longer. In the radix of the nose, which has little motion, one should anticipate that duration which is confirmed by my clinical experience. I think Radiesse is a very good filler for the radix and would be my first choice for this form of injectable rhinoplasty
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom cheek implants. Last year I got a custom wrap around jaw implant which produced a nice flare towards the back part of the jaw. I like the beefed up jaw, but now feel my cheekbones could be a little wider to balance my face out a bit. As a trial, I had the cheek area filler injected to try out the look (a total of 2 cc’s of Juvederm). It was a step in the right direction, but I thought for the long term it might be better to go with implants (perhaps custom) and that I could get a little more projection than I got from the filler. Do you think cheekbone implants might be a good idea and should I be concerned that the implants might show themselves through the skin down the road? I have attached a Photoshop rendering of me with larger cheekbones. What do you think?
Also Do you think a buccal fat removal procedure would help with the excess jowl tissue?
A: It is not rare that after a jawline implant, where the lower face has gotten wider, that one notices that other parts of the face are out of balance a bit. As a general aesthetic rule, the width of the jaw angles should not be greater than the width of the cheeks/zygomatic arches. This has clearly happened in you and is the genesis of your inquiry. You have proven by both injectable filler and computer imaging that cheek augmentation would be beneficial. To get the best fit to the bone and have the least risk of implant show, custom cheek implants would be preferred. This is particularly true in what you are showing in your imaging as this is a high cheek look. Most standard cheek implants are made for women and they highlight the lower apple cheek area primarily.
Jowling will not be improved by a buccal lipectomy. The buccal fat pad is situated much higher than the jowls. Jowling has to be treated by either direct liposuction or smoothing out the jawline from a small lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having a large skull reduction done, running from all the way back to midfront and all between the temporal lines. I know that this sd a rather large area. How long time does it take before the final result is apparent? I guess that depends on how much bone thickness is removed? And is it possible to harm the result in the recovery phase by being hit or bumping the head? I occasionally play contact sports, and work as a laborer.
A: Regardless of the skull surface area involved, it takes a full three months to see the absolute final result from a skull reduction procedure. Generally about 50% is apparent by 3 weeks after surgery and 80% is apparent by 6 weeks after surgery. But it takes a full three months for the last bits of swelling to goal away and the scalp tissues to shrink back down. As a skull reduction only removes the outer cortical layer, there is plenty of inner cortical bone left for support. Thus this does not place your skull at any increased risk of injury from light or occasional trauma events…and probably not even from more severe impacts as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants placed last year and it has given the region much needed volume. However, I still notice that there’s still some mid-face sag that I would like to correct. I’ve researched various options like mid-face lifts, but the one thing that really intrigued me was thread lifting. Can I just check if you’re family with such a procedure, and if so, could it be used to adequately address a mild amount of mid-face sag?
Thank you!
A: I am very familiar with the threadlift procedure and the devices to do it. It has always been and continues to be intriguing to many potential patients because of its minimally invasive nature. It will always be compared to what are perceived analogues to it including a lower facelift and a cheeklift.
While it can create a very mild cheek lifting effect, the duration of this effect is very temporary and does not provide much of a sustained result. Simply pulling up on the tissues is not a good substitute for actual deeper tissue support and/or skin excision. This has proven to be certainly true for the many versions of thread lifts that have been promoted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My main discomfort right now after my rhinoplasty is a frontal headache. It is quite severe and persistent since I got out of surgery. Do you think it would be relieved by taking off my nose guard? Is this common following rhinoplasty? Thanks for any thoughts you have.
A: Having a frontal headache is not a postoperative symptom that is common after rhinoplasty surgery. While you have had multiple facial procedures (chin, cheek and jaw angle implants) as well as a rhinoplasty it could be related to any or all of them. But rhinoplasty would be the potential culprit by anatomic proximity. I could only envision that the rhinoplasty with the nasal bone osteotomies could be the source. Fracturing the nasal bones so close to the forehead certainly sounds like it would give one a headache. Other aspects of your surgery could also create a headache due to the congestion caused by a septoplasty and inferior turbinate reductions.
Whether removing the splint would be a solution I do not know although there is only one way to answer that question. I hate to do it because it will cause more swelling but if your symptoms do not have improvement in another day that is what we should probably do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I would like your opinion on what procedures might help me achieve a more chiseled, rugged and defined face. (aka facial masculinization) I have chubby cheeks, my chin I feel is weak, and I would like more definition in my jaw. In my picture I have had filler inserted into my chin about a month ago, however it hasn’t had made the difference I’d hoped for. Overall I’d like to ditch the round, baby faced look in hopes of a more handsome and masculine look. The second picture is an idea of the look I’d like to work towards. Any advice is much appreciated.
A: Thank you for your inquiry and sending your pictures regarding facial masculinization. The first insight that I can provide is that you are never going to achieve the facial look as you have demonstrated in your ideal male face image. You don’t have the right soft tissue overlay (thin fat layer) over your facial skeleton. Your facial soft tissues are thicker and thus they will never look as defined as the male model’s face.
That being said there are some realistic improvements that can be obtained and the approach to do it is based on a combination of the 5 male skeletal highlights and fat reduction surgery. The use of cheek, chin and jaw angle implants combined with buccal lipectomies and perioral and neck/jawline liposuction is the maximum aesthetic facial changes that can be done with the goal of sculpting the young malke face that is softer, rounder and less defined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to create the male model cheekbone look, and I know that cheek implants would be the best way of doing this. However, as I understand it, an overly large facial implant can tend to look unnatural. My thoughts here are in terms of increasing the lateral projection of the cheekbones with a zygomatic sandwich osteotomy (ZSO) and then sculpting the actual cheekbone shape with a custom made implant. Do you share my view that this is the best way to go about creating prominent, male model like cheekbones without making them look unnatural?
A: When using the term male model cheekbone look, this usually implies a high cheek prominence marked by a prominence zygomatic arch prominence which extends back towards the ear. While I would agree that moving the zygomatic arch outward by osteotomy with an anterior implant (in front of the osteotomy) is one way to create that type of cheek augmentation, that is the ‘hard’ way to do it. It is easier and equally if not more effective to use a custom cheek implant design to create that type of zygomatic/zygomatic arch augmentation. Then the arch can be augmented in a tapering fashion back to the ear without any risks of an edge transition between the implant and the osteotomy location in the combined osteotomy-implant method.
But if done well, both types of cheek augmentation approaches can help achieve the male model cheekbone look in the patient with the right type of facial anatomy (thinner face)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had always assumed that nothing could be done to fix my lazy eye/ptosis by recently I was googling around and found that their was plastic surgery for this as well. I’m the guy who was interested in a bunch of procedures last month, including a custom implant for forehead augmentation to add to my brow ridge/eye brow protrusion for deeper set eyes, and I’m still interested in having that done. albeit I don’t want to add too much protrusion as I have some already.
Regardless I was curious to know if it was possible to get an asymmetrical eyelid ptosis fixed at the same time as the custom forehead implant?
Baring in mind the ptosis is mild-moderate, however isn’t caused by orbital dystopia(my pupils appear to be in the same horizontal plane in the vast majority of my pictures), and I’ve also noticed my eyebrow seems to sit a tad bit higher on the eye with the ptosis, could you in anyway lower the brow a bit to offset this and even it out while placing the forehead implant?
If you cannot do anything about the eyebrow being a bit higher that’s fine because I also wanted to do an eyebrow hair transplant combined with a temporal browlift to get rid of my eyebrow arches. After reading up on the two procedures it seems to me like they would allow me to trim my eyebrows to appear even, given I get enough grafts put in.
Is this realistic with an eyebrow hair transplant and temporal browlift?
Could these two procedures be done in conjunction with the ptosis surgery and forehead implant? Would it be better for me to have these done separately?
A: It is always best to do eyelid ptosis repair in an adult as a separate procedure. This is procedure where fractions of a millimeter count and doing it under local anesthesia so the surgeon can see the position of the eyelid as the sutures are placed is critical. So I do not recommend eyelid ptosis repair at the time of forehead augmentation.
It is not possible to lower an eyebrow or really adjust eyebrow levels when doing forehead augmentation. As the forehead and brow tissues are being expanded it becomes impossible to make adjustments to the eyebrows, whether it is lifting or hair transplants, at the same time and be effective in doing so. To make an analogy this is a little like trying to put the roof on a house where the foundation and the sides walls are not completely erected. Thus the finishing procedures of brow lifts and hair transplants should be deferred to a second stage after the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am planning to get custom chin and jaw angle implants and I have some queries regarding flying in from overseas.Firstly, typically how long does it take from the initial consultation to get scheduled in for surgery? I’m hoping to fly in around mid January, so I am wondering what the deadline would be to make my first consultation in order to get scheduled in at this time. Secondly, how long should I plan my stay for recovery? I plan to travel by myself and I’m assuming I will be fine to manage myself post surgery?
Thank you.
A: To get custom chin and jaw angle implants made for surgery, that is a process that typically takes 3 to 4 weeks after receiving the patient’s 3D CT scan. This is why almost every such patient gets their 3D CT scan where they live and the sends it to me to get the implants designed and made for surgery.
Having a large international practice, just about every patient that comes from afar does so by themselves. So your situation would be common. For custom chin and jaw implants surgery I would advise an overnight stay in the surgical facility so you can return to your hotel room by yourself the morning after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Pursuant to my previous questions on a sliding genioplasty, I have come to the realization that horizontal chin advancement will probably not improve the aesthetics of my profile without concurrent movement of the lower lip and the mentolabial fold. On the face of it, a small BSSO seems like the best bet. However, I’m really reluctant to go ahead with the BSSO due to the issues with repositioning of my bite and the wearing of braces. I really feel at a loss as to what to do in reducing the retrusive appearance of my lower jaw without going ahead with the BSSO. I know that the mentolabial fold can be improved with an implant or fat grafting, and obviously the chin can be improved but I’ve made a morph of my profile with just those changes but I feel like my retrusive lower lip is still pretty glaring. Is there anything you can suggest at all in doing a full BSSO camouflage procedure involving the chin, lower lip and mentolabial fold? Is there any scope for an implant to push the lower lip forward like there is with the upper lip? Also, is there any way for a genioplasty to actually lessen the mentolabial fold if it’s done with that in mind? If there’s anything else that you can suggest, please do so.
A: The simple answer is that without a BSSO you are not going to improve the horizontal position of the lower lip. The horizontal position of the lip is largely based on tooth position. Thus only moving the teeth forward (as in a BSSO) will achieve the ideal morph you have shown. You are in a classic conundrum where you can not get what you want the way you want it. You will have to accept some compromise….get the ideal result with the surgery you would not prefer to go through or get the lesser surgery and accept a lesser result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pediatric skull augmentation. I have a 2 year old son with untreated brachcephaly and plagiocephaly (assymetric brachcephaly). What are the possible side effects of bone cement or a custom implant? Have you done skull reshaping on any children? If so, how many? What age would be ideal for this surgery and how will the cement or implant adjust/effect him as he grows? Finally what is an estimated general cost of this procedure and what is the recovery time? Also I would be extremely concerned about anesthesia for him at a young age. Would you bring in a pediatric anesthesiologist? Thank you for your time.
A: I have done numerous cases of pediatric skull augmentation (onlay cranioplasties) for occipital skull deformations. The use of hydroxyapatite bone cements seems the most appropriate at this young age since the bone will grow into and around it and it will grow proportionately with the surrounding skull bone. I see no reason to perform his skull augmentation surgery until 4 or 5 years of age when the child is older and the skull is more fully formed. This surgery should be done in a pediatric facility (Children’s Hospital) under the management of a pediatric anesthesiologist. Because of the expenses involved this should be a procedure that is done through insurance which requires a predetermination process for approval.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am ready to move forward with my infraorbital/malar implants, but I have a few questions to make sure I understand the difference between custom and semi-custom facial implants. I am familiar with fully custom because that is what we did with my jawline.
So semi-custom does not use my CT scan, but you still design the implants to fit my face based on a design from someone with similar bone structure? Will I still receive the mock-ups and be able to talk to you about revisions?
Does it matter that one of my eye sockets is lower than the other? (AND can that be fixed?)
As always, Thank for your time,
A: The difference between custom vs semi-custom facial implants is the following:
1) A custom implant is made directly off the patient’s 3D CT scan, the semi-custom is using another patient’s implant design off of their scan.
2) The semi-custom implant almost will always require some intraoperative adjustments for fit.
3) The semi-custom approach works better for some facial areas than others. For example, the infraorbital-malar is really not all that different amongst bony deficient patients so It can work satisfactorily in some cases. A semi-custom implant approach, for example, does not work all for a total jawline implant.
4) The only review of the implant design would be by looking at the other patient’s design file. Samples could be made for review but the company will have a charge for them.
5) If you have any significant facial asymmetry a custom implant approach would probably be better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 33 years old and am interested in occipital reduction. I feel self-conscious for years due to the shape of my head. The occipital part of my head is elongated. I have seen on your website the results of skull reshaping operations. I would like to know the risks of this type of operation. I would also like to know whether the skull after the operation is weaker or at risk of suffering a fracture. Thank you for your attention.
A: Occipital reduction is a very safe surgery that is performed by burring reduction of the bony protrusion. How effective it would be is a function of the thickness of the occipital bone and the patient’s desired objective. The bone be reduced as much as the outer cortical bone thickness will allow. The bone can be reduced until the diploic space is encountered. This allows the inner cortical layer to be maintained and this does not weaker the skull bone to any degree. Occipital reduction needs to be down through a low horizontal scalp incision usually placed over the center of the occipital prominence. Its length will be anywhere from 8 to 12 cms in length.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Lately I have been following your articles and blogs specifically for jaw chin and cheek implants, and have noticed that the custom facial implants can be made to any size but it is the skin stretch that limits the size one can get. My question is, if the skin can stretch a lot when someone gains weight, then can the skin also be “pre-stretched” to prepare for substantially large facial implants of a size that you would not normally want to insert without having the skin gained some laxity?
A: The issue with soft tissue stretch in custom facial implants is one that is exclusively limited to that of the chin area, specifically the dimensions of vertical and horizontal increases. This is not an issue back along the jawline or along the jaw angle area where the tissues have substantially more laxity. I have learned that when the chin is significantly vertically lengthened (10 to 15mms) the soft tissue chin pad may ‘ride up’ in front of the implant rather than staying at the very bottom where the maximal chin projection should be. It is also theoretically possible that such large vertical chin increases could contribute to lower lip incompetence. This situation is very rare, however, as very few patients would ever need to have this degree of dimensional change in the chin.
In these rare patients, pre-stretching the chin tissues would be accomplished by either placing an initial chin implant or, preferably, doing a sliding genioplasty first to set the stage for the eventual larger implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Pursuant to our presurgical conversion about a custom skull implant, I just had two questions.
I still play hockey, ride bikes etc. How long will it take before the skull implant becomes attached so it can’t move because of wearing a helmet and bouncing around ?
The other thing is more a potentially irrational concern but if there is any question about how much bone to remove I’d error on the side of less bone even if it doesn’t go completely flat. I say that because I’m envisioning a hard crash into the board some day in hockey (albeit I’m pretty slow anymore so probably not a hard crash…) and nervous about having a weak spot.
I am looking forward to having the procedure regardless.
A: The skull implant becomes attached quite quickly. But to be safe I would give it a good six weeks and then you can return to all activities regardless of their rigor. Like I said in the office this is like putting a bumper on your head so it adds protection to the skull and does not makes it more vulnerable to injury or fracture from trauma.
Also the amount of bone removed in a sagittal crest skull reduction is not enough to make the skull more prone to fracture afterwards.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get a rhinoplasty with you. I want to ask first though is it possible to change the nostril shape only? I want to show more of an upturned nose but I don’t want to make my nose length shorter. I just want my nostrils to have the more open look from the side. Can anything be done to make the nostrils from this closed in first pic to open in the second pic.My nose is same as first pic and does not show much nostril from the side. I want my nostrils to look like the bottom picture.I not want any different in my nose shape but only nostrils more open from side like this. What method can be done to do this? All my thanks.
A: The answer to your rhinoplasty questions comes from understanding the anatomy of the tip of the nose and specifically that of the nostril rims. The location and shape of the nostril rims is a direct reflection of the location of the caudal edge of the lower alar cartilages. (and to some degree the thickness of the nasal tip skin as well) This is well known by how the reverse is created from what you want…a lowering of the nostril rim which is done by cartilage grafting. Thus alar rim retraction, or upward rim repositioning, can be created by a resection of a part of the caudal rim of the lower alar cartilages. This can be done through a closed approach with incisions inside the edge of he nostril rims. This would not change the shape of your nose in any other way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I would like your opinion on what procedures might help me achieve a more chiseled, rugged and defined face. I have chubby cheeks, my chin I feel is weak, and I would like more definition in my jaw. In my picture I have had filler inserted into my chin about a month ago, however it hasn’t had made the difference I’d hoped for. Overall I’d like to ditch the round, baby faced look in hopes of a more handsome and masculine look. The second picture is an idea of the look I’d like to work towards. Any advice is much appreciated.
A: Thank you for your inquiry and sending your pictures. The first insight that I can provide is that you are never going to achieve the facial look as you have demonstrated in your ideal male face image. You don’t have the right soft tissue overlay (thin fat layer) over your facial skeleton. Your facial soft tissues are thicker and thus they will never look as defined as the male model’s face.
That being said there are some realistic improvements that can be obtained and the approach to do it is based on a combination of the 5 male skeletal highlights and fat reduction surgery. The use of cheek, chin and jaw angle implants combined with buccal lipectomies and perioral and neck/jawline liposuction is the maximum aesthetic facial changes that can be done with the goal of sculpting the young male face that is softer, rounder and less defined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been looking into the aesthetics of the eye area in males and what gives them attractive eyes. I have noticed that there are two trends that male models seem to collectively share.
The first is a high palpebral fissure width-to-height ratio, in other words the width of the eyes is large in comparison to their height.
The second trend is the tendency of male models to have a prominent positive medial canthal tilt (a ‘teardrop’ shaped medial canthus). Bashour and Geist published a study (‘Is medial canthal tilt a powerful cue for facial attractiveness?’) in 2007 in which the eye with such a teardrop shaped medial canthus was preferred 93% of the time in female subjects. Anecdotally the same seems to apply to males given the quantity of male models with the feature.
My questions are twofold:
1) Whether you have any thoughts on the contribution of each feature towards eye aesthetics, and any thoughts on whether the two are at all related?
2) Whether the two features can be worked towards via surgery; and if not, what is the reason behind this?
A: While I would not disagree with the two attractive eyes characteristics that you have cited as being attractive for either men or women, neither feature of the eye can be surgically changed. The width of the eye can not be altered as that is controlled by the dimensions of the orbital bones. The medial canthus is a fixed tendon of the eye whose position and angulation on the inner eye bone can not be surgically altered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very much interested in getting a skull reshaping procedure done under you. I’ve always been conscious of my head (shape wise) growing up. I’ve noticed I have two flat areas of my skull which is the back and the sides. I’ve done many research on skull reshaping and landed on your website. I have the following questions:
1. What is the cost of the procedure? Is it more expensive to do a custom graft or use bone cement? Can you give me a price quote based on my pictures attached (the images on the right (front view)t/below(side view) is photoshopped to give you sort of an ideal results I’d like to have)
2.Do I get the custom graft via CT scan done same day as when I get the procedure done? How does that work since I’m coming from out of state?
3.What is the downtime for the procedure? When can I go back to work?
Hoping for a timely response. Thank you for answering my questions.
A: Thank you for your inquiry. Based on your pictures and description, I see that your two issues need an occipital augmentation (for back of the head projection) and posterior temporal muscle reduction. (for side of the head reduction above the ears) Your imaging results are right on for the side of the head reduction and about 75% obtainable in the back of the projection increase. A custom occipital implant is always the best approach to the back of the head because it can be placed through the smallest incision low in the occipital hairline. The use of bone cements, which are intraoperatively applied and shaped, requires a ,much longer incision placed across the top of the head. I barely use this approach anymore. The posterior temporal reduction is done from an incision behind the ear.
A custom skull implant is made from a 3D CT scan which the patient can get where they live and then they send it to me. It takes about three weeks to have the implant designed and made.
You should be able to return to work in about one week after the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a brow bone implant. My objective is to create a more deep set/ masculine appearance. One of your before/after galleries shows a young man that had this surgery and looks great-naturally. I also wanted pursue improved symmetry even though I realize not everyone is perfectly symmetric. Would having a previous endo browlift have any effect on the coronal approach for this brow bone implant surgery?
A: With a custom brow bone implant I usually place it endoscopically through the same size incisions and locations that the endo browlift was done. A custom implant can also be placed through upper blepharoplasty incisions. Only the use of bone cement necessitates a coronal incisional approach. The relevance of a prior endo browlift is that it creates more scar and tissue tightness over the brow bone regions so a good release is necessary. But it certainly does not preclude the placement of a brow bone implant.
When it comes to brow bone implants, they can be made custom from a 3D CT scan or a preformed implant can be chosen based on custom designs from other male patients. Because it is preformed this permits it to be inserted through small scalp incisions under endoscopic visualization.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in V-Line jaw reversal surgery. I was transitioning to become a female and had v-line mandible contouring surgery where my jaw was was cut up to my ear and removed. I am now de-transitioning after I realize it is not who I thought I was. Is it possible to attach implants if a lot of the jaw bone is gone? I worry too much bone now is gone so is it impossible to attach implant to jaw now? Can it be done? Please help I want it to be square and manly again.
A: It is no problem to do a v-line jaw reversal surgery. I have done about a half dozen several mandibular contouring or v-line reversal surgeries with custom jawline implants just this year. The custom design process allows the jawline to be restored and the existing scar from the previous surgery is not a problem to release and make the pocket for jawline implant insertion. You have more than adequate bone to attach the implant.
The key question in the custom jawline implant design is what the exact dimensions are to bring you back to your original jawline shape or even make it stronger or even more defined than it originally was.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow implants to create a more deep set masculine look. I would first like to trial it with filler. I certainly would need to find an injector who has experience with this as it is not a common request for filler. Is this something you do? Where would the actual filler be introduced. I realize it would take a fair amount. Do you have experience with this procedure? Thank you for your time.
A: I have done brow bone augmentations using injectable fillers, fat injections, bone cements and actual brow bone implants. You are correct in that it takes a fair amount of filler to create a visible brow bone augmentation effect depending upon the filler used, the current size of your brow bones and the amount of brow bone augmentation you desire to achieve.
It is very reasonable to first do a test with injectable fillers. While the result may not exactly replicate the effect of a brow bone implant, it will provide a fairy good idea of what you can expect. I would use a hyaluronic-acid based filler, like Voluma, to get a good push on the brow soft tissues. The filler is placed down at the bone level across both brow bones.
Dr. Barry Eppley
Indianapolis, Indiana
