Your Questions

Q: Dr. Eppley, One month ago I had an intraoral chin reduction surgery. This consisted of bone burring on the sides because I have a round face and had a somehow wide chin. I like the results of the chin, but can’t realy enjoy it because I am left with an inverted bottom lip! My surgeon says it takes time for the muscles to get used to the new form of the chin, but for me is not a satisfying answer, as my chin muscles move completley fine and also my lip. Also, from my reasearch, inverted lip seems to happen with chin augmentation, not reduction! Chin does not sag so mentalis muscle seems ok. I do have a tight feeling in the chin, When hand pulling lip up it does not strech as it used to. Is this scar tissue issues? contracted mentalis muscle? Did it attached to low? From what I can appreciate the indentation under my lip is at the same height. It just feel like tightness is pulling everything down and my lip responds by going inside. Would steroids injections work? Ultrasound? D o I need a scar revision surgery ( inside mouth scar seem ok ). Is just the muscle still tighten after the trauma?I am very distresed as I had a beautiful mouth and smile and now it looks so tense and unatural. Please consider answering my questions.

A: Thank you for sending all of your pictures. Mentalis muscle dysfunction is very common after intraoral chin procedures as the muscle must be completely detached to do the procedure. Since the muscle is put back together by sutures, there can be a period of tightness/distortion based on how tight it was put back together. While you may think the mentalis muscle fine, that is the main tissue injured during an intraoral approach. Whether it will have a complete recovery on his own can not be predicted. But the protocol for your recovery is as follows:

1) Stretching/massaging the lip and chin is helpful as you have already demonstrated. Such maneuvers should continue for another month.

2) Do NOT inject steroids as they are a destructive chemical that has unpredictable effects in tissues like muscle and fat. It may ultimately cause a worse problem in the long run.

3) If some improvement continues over the next month, then let natural healing takes its course.

4) If there is little to no improvement in another month, fat grafting either by injection or a small dermal-fat graft into the tight area would be the proper treatment.

You have plenty of time to improve as total healing takes up to six months. You have to be patient with this process. Impatience makes people do things that may not be prudent.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in something similar to a mommy makeover – but I”m not a new mother – actually like 53 yrs old. I’m really thin (which I can’t stand), but I have multiple sclerosis. I’m interested in multiple things, but don’t want to ‘piece them’. For example, lip injections, facial fillers, and I really need to do something about my skinny buttox & breasts.I’ve e-mailed before along with my picture, but I was just told to make an appointment. So I was wondering if you have some kind of package (similar to mommy makeover) for older ladies? If so, may you also give me the cost? Thanks.

A: The age of 53 wold not be considered old for any type of plastic surgery procedure(s). Age is not the issue, your medical history may be. With your multiple sclerosis the question is whether you can safely undergo an anesthetic as well as tolerate from whatever surgical procedures you may undergo. The answer to that question would depend on the cur6rent state of your medical condition, what your own doctors say about such surgery and what procedures you may be having. It makes it impossible to answer any surgical cost questions without all of this information since I don’t know what procedures may be appropriate for you. This is why the suggestion about making some form of consultation would be critical in make these determinations.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I came across your practice from RealSelf, and I’m very interested in having some work done on my face.

Basically, I would like to create the male model look facial surgery you talk about in your blog using custom jaw implants and cheekbone implants. I had a few questions, though:

1. At the moment, I’m overweight (225 lbs at 5’9), but I read that the jaw/cheek implants have the desired effect only if the face is thin. So I’m working on dropping about 80 lbs within the next 1.5 years before going ahead with the surgery. My question is, is this okay or even recommended? Will my current body fat skew the implant design in any way? Or can I go ahead and get the implants now, at a high body fat, and then lose the weight: would that have the same effect as losing the weight first and then getting the implants?

2. I’ve attached a front side picture of myself and a jaw x-ray I just had done today while at the dentist (they were looking for wisdom teeth to remove). Is my face structure suited for implants to create the male model look? I know you can’t say for 100% without an in-person consultation, but I thought I’d get an approximate opinion from an expert like yourself.

Also, I know it’s unrealistic to expect to look like someone else, but I’d like to create a facial structure similar to that of young Johnny Depp. How feasible would you say this is? I was thinking of doing jaw/cheekbone work, rhinoplasty, and whatever else is necessary to get the desired look. What do you think/suggest?

Thanks so much!

A: In answer to your questions about male model look facial surgery:

1) You definitely need to be down near you ideal body weight to get the best benefits from Facial Sculptiong/Structural surgery like jaw and cheek implants as well as rhinoplasty (although less so for rhinoplasty)

2) I do not think you will get that close to a Johnny Depp look. He is very thin skinned with low body fat. You have much thicker skin so even a rhinoplasty would not even come close. I am sorry to say that this is not a realistic facial surgery goal for you. I may have a different opinion when you have lost the weight. This is also not to say that the facial procedures you have described would not be beneficial for improved facial aesthetics. It is just that you are not going to get the more sculpted angular facial look like that of Johnny Depp.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had custom jaw angle implants by you last week. I feel at this point that there might be some asymmetry between the two sides. My right side feels like it is not even with the left side. Can we do something about this now?

A: Thank you for the followup. We are now entering the postoperative time period in which the concerns about symmetry in facial implants for most young men occur. So it is important to review some basic points about your specific recovery and the protocol for managing potential facial implant asymmetry concerns:

1) At just two weeks after surgery, only about 50% of the swelling from this type surgery has gone down. But equally relevantly, facial swelling and its subsiding course are never even between the two sides. This would be particularly true in your case where the right jaw angle implant was operated on ‘twice’. As you may recall I shared with you that I closed and then reopened the right side to check and resecure the implant. This is relevant because that means there was twice the trauma to the right and the passage of the screwdriver 6X through the right masseter muscle as opposed to just once on the left masseter muscle. So there is going to be substantial differences in the resolution of the swelling between the two sides of the face as this early postoperative period.

2) That being said, you may well be right about the positioning of the right jaw angle implant…or you could just as equally be wrong. I have seen it occur both ways. There is simply no way to judge as this point by an external evaluation. I can not do it nor can any other surgeon. What I do know about your implants is that they have double screw fixation so the implant can not just be turned our pivoted on itself.

3) Because of this uncertainty it is important then to have a specific postoperative protocol and to understand the wound healing biology and logic behind it.

4) As I said before surgery, one can not get a good feel for the outcome of the surgery including symmetry before 6 to 8 weeks after surgery. This time frame is relevant not only to see what the final outcome of the surgery is but to know how to adjust an implant’s position should that be necessary. If you are going to use an external evaluation to judge how to move an implant then one had better wait to really know where it truly is. But this time frame is also relevant in that re-entry into a surgical wound early on carries with it great risk of secondary wound dehiscence, implant exposure and infection. The tissues are not of good quality until several months after surgery. Re-entry weeks or the first month after surgery places one at great risk for these additional postoperative problems. Patience in surgery truly does have its merits.

5) Whether it is early on or later in one’s postoperative recovery. the best and really only way to know about facial implant positioning is to get a 3D CT scan. This provides an unequivocal picture of the location of the implants. But of equal importance it also tells exactly the type of movements needed to best reposition the asymmetric implant side. Anything short of this information is just guessing in surgery.

In short, my recommendation is to wait until further swelling goes down until at least 6 weeks after surgery. No revisional surgery, if needed, is going to be done before that time period anyway for the reasons previously mentioned. One can get a 3D CT scan now or later but that would not change the time period of management. The 3D CT scan is the better alternative to any other surgeon or even myself making a judgment as to the current state of your jaw angle implants.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, It seems that I developed a cold (stuffy nose with mucus, sore throat) right after my cheek implant procedure. How likely will a common cold like this cause my cheek implants to become infected? I apologize for this inconvenience, but despite my surgeon not being too concerned, I’m still a little worried.

A: My first comment is that if you trusted your surgeon enough to undergo the operation then you should equally trust any answers he or she may provide to you about your after care. You should know that your surgeon is equally interested in a satisfactory and uncomplicated outcome.

There is no known association between the symptoms of a common cold and the development of facial implant infections even in the immediate perioperative period. Viruses are not known to cause bacterial infections. While your immune system may have some temporary ebb in its effectiveness, you should take solace in that you are probably still on antibiotics from the initial surgery as a precaution.

Your concern mah be partially based on that the cheek implants are near your maxillary sinuses. But the implants are on top of the bone and there is no actual communication between the sinuses and the implant pocket.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom skull implant. I have a strange depression across the top and back of my head. Fortunately as a women my hair can hide it. But I do occasionally like wearing my hair short and then it becomes apparent. I have attached pictures with my head nearly shaved so you can see it. Would a custom skull implant work for this type of skull shape problem?

A: Thank you of your inquiry and sending all the well done pictures and videos. It can be seen in the pictures almost the exact outline of a custom skull implant that would be used to augment all of the depressed skull areas. (back of the head, posterior fontanelle dimple and parasagittal areas. While the design and fabrication of such a custom skull implant can be done from a 3D CT scan, we have to consider the following issues in its design:

1) How much back of the head augmentation can be achieved give the amount of scalp stretch that can be achieved in a one-stage procedure. (this is usually in the range of 10 to 12 mm at the central area of greatest project in the back)

2) The incision used to placed the implant. Ideally I usually like to use a low occipital horizontal hairline incision as opposed to anything across the top of the head. This usually allows the incision to be smaller in length also.

3) The location of the incision and its extent plays a role in whether the parietal region can be accessed for reduction. This is really the single greatest issue as providing access to do the parietal reduction may make an incision longer than may be aesthetically tolerable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a male who would like more vertical length to his chin as well as more horizontal length and projection. However, I am a bit hesitant to do a sliding genioplasty. Is it possible to create a custom chin implant that can achieve vertical length as well as horizontal length–basically, an implant that can get the same appearance as a sliding genioplasty can do? I would be greatly interested in this if it were possible. Thanks so much.

A: You are describing exactly why a custom chin implant is occasionally used. It is to either create dimensional changes to the chin that standard chin implants can not….or to replicate what a sliding genioplasty can do for those patients who want to avoid actually cutting and moving the chin bone.  A custom chin implant is made from the patient’s 3D CT scan and can virtually be designed just about any way one wants. What has to be paid attention to is its size and how much horizontal and vertical increases is it being asked to do. One needs to consider the overlying soft tissues and make sure they can adequately stretch to accommodate the size of the implant.

One aesthetic advantage a custom chin implamt has over a sliding genioplasty is that it can be designed to extend further back along the jawline. This allows for a smooth transition from the chin augmentation backwards which in some sliding genioplasties may result in a stepoff or notch deformity behind the bone cut.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get a sliding genioplasty in the near future. I know that both horizontal and vertical expansion can be achieved,and I am looking for both of these (very slight vertical lengthening). However, there are four other things that I am also looking to achieve and my enquiry is as to whether these can be achieved by the same sliding genioplasty procedure.

I want to widen my chin to the same width as my mouth for a masculinising effect (the distance needed is that not that large). I also want to deal with some chin asymmetry that I have. I also want to ameliorate (or at least not make worse) my mentolabial fold. Finally, I have a slightly retrusive lower lip; I was wondering whether the genioplasty would/could have any effect in bringing it forward. I realize a BSSO would be ideal, but I’m not willing to go through that so I’m going down the ‘camouflage’ route.

A: In regards to your four additional effects that you desire from a sliding genioplasty:

1. While a sliding genioplasty can be cut in the middle and widened, this has limited effectiveness and should only be done by this form of bone expansion when minor widening effects are needed. A custom chin implant creates this widening effect much netter and in a more predictable fashion.
2. Whether moving the bone around can improve your asymmetry depends on what type of chin asymmetry one has. You will have to be more specific as any such asymmetry is not evident in your pictures. But if the asymmetry is slight, I would not count any any type of bone movement correcting it. A sliding genioplasty can create its own asymmetries as well.
3. The only way to prevent deepening of the labiomental fold with a sliding genioplasty is to graft the step-off created by the forward bone movement of the downfractured segment.
4. Only a BSSO can move the lip forward since the lower lip is a tooth supported structure and not a bony one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For my forehead augmentation I have been unsure whether I should use bone cement or just do a custom forehead implant as we originally discussed. I would prefer a custom forehead implant, but I know that can’t be done at the exact same time as the orbital rim shaving as it needs to be made custom from the skull model. But rather than do it on two separate occasions, I thought of a possible option… I thought about coming to see you for the orbital bone shaving, temple brow lift, and then immediately after this operation (like the following day) get a CT scan done and then get a custom forehead implant made, and then after a week or two weeks (however long it takes for the implant to be made) then get the forehead implant placed on to the forehead? This would mean I could get both the orbital rim shaved down, making the outer area of the eyes more open, but also get the angularity and shape I hope for with the implant. And do it all in one visit. Also it would mean that the incision wouldn’t have a proper chance to heal so maybe easier to go back into the coronal incision without resulting in much scar tissue or risk for stretching etc (which may happen if done 6 months later for example)? What do you think about that?

A: There are two ways to achieve your forehead goals in a single visit.

1) In designing a custom forehead implant the amount of orbital rim shaving is factored into the design. Since the implant would not be sitting over the orbital rim reduced area this makes it a very viable approach.

2) Use bone cement at the time of orbital rim reduction. This is done under direct vision and it could be shaped based on what is seen.

Either way I see no reason why orbital rim reduction and forehead augmentation would need to be two separate procedures. I have done this combined forehead approach many times.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I’m wondering why “As a single stage procedure you will get closer to the size of the upper lip but not all the way down to match the upper lip size completely.” as mentioned on Real Self.

I have seen your work which is great, and shows drastic results compared to other surgeons and pictures. Could it be that other surgeons are not experienced, or perhaps they don’t remove enough from the lips for drastic results to be seen.

The only major difference has been on people with double lips, but your work shows amazing results on people with normal lips.

A: The lip is comprised of the more visible dry vermilion with the wet vermilion and mucosa making up the invisible part of it. The dry vermilion is not stretchable while the wet vermilion and mucosa are much more elastic. Thus when doing a lip reduction the tissues that needs to be removed is the dry vermilion as it is what is externally seen. Removing any portion of the wet lip tissues will not cause any lip reduction effect to be seen. The dry vermilion, however, will only permit a certain amount to be removed in a single setting without causing a visible distortion to the lip. Knowing how much to remove and here to place the excision closure line is the key to a successful lip reduction result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting permanent augmentation to my lateral orbital rims. My lateral orbital rims are virtually invisible, and this gives me eyes a very retrusive look from the sides. I’m aware that augmentation with implants in this area is rarely ever done, however I have seen lateral orbital rim implants offered online. If this is currently in achievable, do you think this sort of custom lateral orbital rim augmentation has a role in the future with 3D printing of facial implants?

A: There is nothing unique or unusual about augmenting the lateral orbital rims or lateral orbital rim augmentation. It is like augmenting any other orbital rim area. It is only unique because it it is very rarely requested and there is no really effective standard shaped implant available to do it. As a result there is no question that the only way to do it well is with the use of 3D custom implant designing. The fit over the lateral orbital rim must be precise and how it blends into the upper and lower orbital rims is key for a successful aesthetic outcome. Failure to do so can result in both visible and palpable implant step off edges.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions regarding head width reduction. I’m reading on your webpage that this is achieved by removing a part of the temporal muscle. Is it just a part of it kind of like cutting half of it or is it this half the exterior part of it like slicing the exterior part of the muscle? Do you also do some bone reduction or not ? Because i think mine could be more bone than muscle. Is there any downtime for this type of surgery ? How risky is it? I would like to have done to reduce the width of my head but I’m worried about possible complications or permanent damage because of having this surger. Will you have like diminished power on your bite after the surgery permanently or something like?

A: The most effective method of head width reduction above the ears in my experience is removal of the posterior temporal muscle. It is far more effective than bone removal because the muscle makes up a significant part (50%) of the width of the side of the head at the ear level. The entire posterior temporal muscle is removed which, surprisingly, causes no after surgery weakness in chewing or biting down. (because the anterior portion of the temporalis muscle which is left alone makes up about 75% of the total temporal muscle volume. The surgery is usually done from an incision behind the ear so it is ‘scarless’. If one wants to remove bone as well the incision would have to be changed to in the hairline at the side of the head. The only real risk with this surgery is in how effective it may be. Although in my experience it produces an immediate and noticeable difference in each patient in whom I have performed the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin reduction question. You stated that how the soft tissues behave after the surgery in the healing process is not under surgical control which is understandable. I’ve read that sometimes the muscle and tissues once they’re stripped from the bone and put back might not adhere as firmly as before and result in poor facial and chin aesthetics. Is that more the case than not in your experience? Also, is there anything that I can do or avoid doing post-op specific to this surgery to foster better outcomes? Thanks!

A: To clarify your concerns, the reason you have a redundant soft tissue pad of the chin is because you had a bony chin reduction only. You were counting on the soft tissues of the chin shrinking down and sticking back to the bone in a tight manner…which obviously did not happen. This was completely predictable and is common after an intraoral bony chin reduction. That was a flawed surgical plan for your chin and is not a reflection of anything you could have done after surgery to prevent it.

A submental soft tissue chin reduction avoids this problem because it removes the excess soft tissue and reattaches it back to the bone. Thus it it a soft tissue tightening procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am interested in skull reshaping surgery. I try to hide my head shape as best as I can. It’s almost as if I have bumps on each side right above my ears that end right after my ears going back that make dents toward the upper back of my head that make the top of my head look even pointier than it already is when facing me from the front.  It is much more evident when my hair is shaved even lower than these pictures which I try to avoid.

A: By the front view pictures that you have attached, you have a peaked head shape probably due to a congenital microform sagittal craniosynostosis. The midline sagittal area is very high while the parasagittal regions are very sloped down into the temporal areas. This makes the top of the head very peaked with the sides being narrow…very much like that of a roof. Ideally you need a combination of sagittal ridge reduction and parasagittal augmentation. This is best done using a custom skull implant to build up the sides (parasagittal/temporal areas) and to burr down the sagittal ridge at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rhinoplasty surgery. I was in a car accident a few years ago in which I was told I had a very small fracture on my nose. I assume significant scar tissue grew on the fracture which ended up making my nose look crooked and to the side as well as a huge bump on the right side (which just so happens to be the same side that one of my protruding ears sticks out farther than the other making that entire side of my face look lopsided and HIGHLY unsymmetrical) 

A: By your history you had a displaced nasal fracture which made your nose visibly deviated. Scar tissue growth does not make a nose crooked, displaced bone and cartilage fractures do. The indentation of the nasal bones on one side and the bump on the other side is indicative of bilateral nasal fractures and displacement. Unfortunately your facial pictures are not clear enough and with good lighting to really show the nose shape. For now I will assume, at the least, that your rhinoplasty would require breaking and repositioning of the nasal bones. Whether any other parts of the nose may need changes can not be determined from the pictures you sent.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an otoplasty procedure. I have always had protruding ears but it was much more manageable before I began losing my hair as the hair would make it much less noticeable. My right ear sticks out significantly further than the left one but they are both protruding.

A: The good news is that protruding ears can be very effectively reshaped into a more normal and less obvious position on the side of the head with traditional otoplasty surgery. Done through an incision on the back of the ears, the antihelical fold and conchal cartilage of the ears are reshaped using permanent suture techniques. Both the position and the asymmetry of the ears can be improved with otoplasty surgery.

Protruding ears and ear asymmetry are very common with many skull shape deformities. In occipital plagiocephaly, for example, the ear on the side of the head where the occipital skull is flatter is always pushed further forward and sticks out more than the other ear. Otoplasty and skull reshaping surgery is often done together for a more complete craniofacial makeover and due to the convenience of surgical access in the sam region.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have hyperpigmentation and a loss of facial tissue on my left chin from scleroderma. I’ve been looking at achieving asymmetry through fat grafting and remove overlying dark scar tissue which looks like a birthmark. I have attached my chin pictures for your review.

A: Thank you for sending your linear scleroderma chin pictures. Your scleroderma chin defect is very common as well as the hyperpigmentation that goes with it. You have two treatment options. It can be treated by injectable far grafting to improve the contour. This will not remove the hyperpigmentation and may require multiple fat grafting sessions to get the best contour. But it is a ‘scarless’ approach to your linear scleroderma. The second option is to complete cut out the hyperpigmented skin and close over the contour defect with a dermal-fat graft. This is the only method to eliminate the hyperpigmentation and is a one-step approach to create the most filled in contour. But it will result in a vertical fine line scar down the side of the chin and may or may not require a scar revision based on how it heals and how wide the scar mat become.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty done about 2 weeks back to correct a receding chin. My face is always slightly chubby so I never though that a thin face would be a problem for me. Now that most of the swelling is down and I can feel the bone underneath my chin I know that this is what is going to be the height of my face. Although I will wait the entire month mark to make up my mind about a revision, my question is, if I do go through a partial revision and restore the height back to its original while keeping the advancement will my face still be thin? What causes the thin face? Is it the advancement or the heightening? Or is it better to just restore everything to original? And if I do will I ever go back to looking like I did?

A: Any change in facial fullness after a sliding genioplasty is a function of both horizontal advancement and vertical lengthening. The face above the chin did not really get any thinner but it looks that way as the front part of the lower face is pulled down and out.Without knowing what exact dimensional changes were done with your siding genioplasty I can not say what would happen with a partial or complete reversal of the chin bone position.

What I do know is that at just two weeks from surgery, all of your chin swelling is not gone and you have yet to truly see the final result or have accommodated to this facial structural change.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I have orbital dystopia where my left eye sits further and lower than my right eye. My question is will the placement of orbital floor implants correct the misalignment and depth of my left eyeball?

A: Correction of orbital dystopia is very challenging for a variety of reasons. First one can not just move the eyeball anywhere one wants by changing the volume inside the orbit because of the optic nerve. Care must be taken to not put too much pressure on the eye as the low but real risk of visual loss is ever present. Secondly, the increase in interorbital volume is always multifactorial and changing the size of the interorbital space through implant augmentation affects just one of these factors. Lastly, there is no scientific method to know exactly how much to augment the orbital floor and where. All that can be done is to take measurements and make a 3D implant from them to match the other side.

It is best to think about improvement in the position of the eye rather than absolute correction. Raising the eye is one challenge but bringing the eye forward is even more so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few things I’d like to have addressed for some facial reshaping. My temporal region is a bit sunken in and causes a roundness to my face. I’m not sure if using fat grafts or a filler such as pmma is more suitable. As far as my lower third: I think it’s short and usually keep my mouth partially open to “elongate” my face to give more definition to my cheeks and jaw. My chin projection is good but it’s just short and a bit round which I’d like to square off. Also my jaw angles are high and ill defined which i’d like to correct. My cheeks have a bit of a chipmunk thing going on which I believe vertical lengthening of my lower third will help, but I believe a Buccal lipectomy will help definition substantially. I’ve attached a few pictures. Let me know what route you think would be best for what I’m trying to achieve. Any opinion on what would help give more definition and angularity to my face is more than welcome. 

A:  In answer to your specific facial reshaping concerns:

1) The treatment for temporal hollowing are temporal implants. They are easily placed on top of the muscle and are permanent. A second choice would be fat injections although their survival is far from assured.

2) Lengthening the entire jawline is best done by a custom jawline implant that adds vertical length from the jaw angles to the chin.

3) A buccal lipectomy will help create some submalar hollowing but will not create a complete improvement of the so called ‘chipmunk cheek’ problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had a breast augmentation about 5 years ago but one of my implants has deflated. I have insurance on them through Mentor. Not sure how to go about figuring that out but obviously I am doing research to find a plastic surgeon to get it repaired. But also since I’ll have to go under again there are a few other procedures I am interested in having done at the same time. Any info would be helpful. Thank you.

A: In regards to breast implants what every patient that has breast augmentation receives is a breast implant warranty from the manufacturer. The warranty entails a lifelong implant replacement (for the type of implant that was originally placed) and a maximum amount to be applied toward the cost of the breast implant replacement surgery. What that was five years ago from Mentor I can not say for sure but that number was probably in the $2400 range. (or more) That information can be determined from the manufacturer.

The way the warranty works is that it is between the patient and manufacturer, not between the surgeon and the patient. (even if it is the plastic surgeon who did the original breast augmentation) The warranty is also ‘backended’ so to speak. This means the patient must pay all the expenses for the breast implant replacement surgery up front. (minus the cost of the new implants) Once the ruptured implant is removed it is then sent to the manufacturer for their evaluation. Thereafter the manufacturer reimburses the patient  to the limits of the warranty in force at the time of the original breast augmentation surgery. This is a process that usually takes about 3 to 4 months to complete.

In regards to your breast implant surgery, you have to decide if you want to stay with saline implants or switch to silicone implants. If switching to silicone implants, you would have to pay the difference between the current cost of saline vs silicone implants as per the original warranty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read as you get older cheek implants can start to look unnatural due to loss of facial fat etc, this is something I don’t have much off! and also would you have any idea how implants will effect my smile given it is quite a large change I am seeking?
A: In answer to your cheek implants questions:

1) Whether facial thinning will eventually cause an unnatural show of the implants depends on one’s facial tissue makeup and how they age. This is most relevant to young very thin females who have little facial fat now and will have none much later in life. Such thin tissues may eventually allow for the cheek implants ti reveal themselves through the tissues. This is rarely an issue for most men. But the reality is that most of today’s cheek implant styles are broader with thinner edges so this may not even be an issue for older females with  low facial fat volumes.

2) Since cheek implants are placed through the mouth and up and under the lip, the swelling will cause some temporary disruption of full smile animation for a few weeks. But cheek implants, small or big, are placed under the periosteum below all muscles and nerves that work the smile. Thus they should have no long-term disruption of facial expression.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I am interested in fat injections for my buttock problem. I had silicone butt injections when I was younger. It was a poor decision. And now I am trying to right my wrong. I have severe discoloration on my hip area and leg. I am unsure if it is from the after effect of the silicone shots. I found you on Real Self and wanted to speak with someone in reference to getting this procedure done. But wanted to know if the discoloration is a problem or a health issue.

A: The discoloration (hyper pigmentation) is a direct result of the silicone injections. It is how the body responds to foreign materials, particularly that of liquids. It is interesting that the injections were into the buttocks but yet the discoloration is in the hips and legs. That is probably to it being in the lymphatic system. It is stabilized and I don’t think presents any heath risks. Fat injections can be therapeutic for silicone oil in the tissues because it breaks it up and introduces healthier cells around the silicone granulomas. While the fat injections will not get rid of the silicone oil, they can break up hard lumps and can make the overall buttocks softer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. I would like to remove as many ribs possible to get a smaller waist. I also wanted to know if I could get the tummy tuck procedure separately with another doctor. I have attached some pictures of my waistline for your review.

A: Thank you for sending your pictures. I really do not see you as a great candidate for rib removal surgery. Tummy tuck surgery with liposuction should be done first to see how much improvement could be done from those more traditional waistline reduction procedures. Only after that has ‘proven’ that inadequate waistline reduction can not be obtained would rib removal be considered. Right now your waistline tissues are toot thick to justify a rib removal procedure.

Rib removal surgery is most effective is patients that are fairly lean and need a structural waistline change to help make more of a difference. It should be considered a last stage procedure to help achieve a waistline reduction that could not be obtained by more conventional waistline reshaping procedures. (liposuction, tummy tuck) While effective, such waistline surgery is for the most motivated of patients who can aesthetically tolerate a small scar on their backs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Since you’re a maxillofacial surgeon, you know about the LeFort III Osteotomy that is done in cases of severe midfacial hypoplasia where the patient usually suffers from a syndrome like Crouzon’s. 

However, many say that such a procedure,although extremely invasive and dangerous in some cases, could theoretically improve the appearance of a non-deformed patient dramatically. 

Since almost no maxillofacial surgeons would perform this osteotomy on patients that have no bite or jaw problems, are there any cosmetic operations that can be done on a non-syndrome patient and replicate the aesthetic outcomes of a Lefort III osteotomy?

A: The effects of a LeFort III osteotomy are to bring forth the lower orbital rim, nose bridge and base and maxilla. This type of change can be replicated by a custom only implant placed over the exact same facial areas. While previously not possible, the use of custom implant design from a 3D CT scan make possible a midface implant that can essentially replicate what a LeFort III osteotomy can do. (minus the occlusal changes) I have made several of these midface implant designs recently and they are inserted through an intraoral incisional approach. Only the augmentation of the nose needs to be done separately through a closed rhinoplasty approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I do not like the indent on my hips and would like hip augmentation which is my main concern. Perhaps a fat transfer would be necessary but you would know best as you are the expert. With the fat transfer from my stomach my waist will become even smaller giving me an illusion of bigger hips but I am not so sure that the indent will be gone. I am concerned about scarring; I have a keloid on my left buttock and I would hate to have anymore scarring. 

A: For the treatment of hip indentations, there is no question that fat injections are the best treatment provided one has enough fat to harvest. I have no concerns about adverse scarring from the injection or the harvest sites. While the take of fat grafts is always unpredictable, it always preferable to the use of an implant for hip augmentation regardless of its percent of take.

While hip implants do exist they are reserved for discrete hip indentations in patients that do not have enough fat to harvest. Since they require an incision for placement, one had to accept a small scar at the top of the hip. Fat injections allow for better blending of the augmentation into the more posterior buttock region.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in endoscopic/minimally invasive forehead contouring or implant. My concerns are twofold: the “dented” look of my forehead in the area above the brow ridge (more prominent on the right side), and the “sharp” point in the middle of my forehead where the bossing ends. I am aware of the challenges that hair loss poses for surgical options but I wanted to stress that I am open to any and all options available to improve the appearance of my forehead in overhead and other unflattering lighting.

A: Thank you for sending your pictures and excellent diagrams of your concerns. The fundamental cause of your forehead concerns is the sharp contract between the amount of brow bone bossing (frontal sinus hypertrophy) and the shape of the forehead above it. In an ideal world the combination of brow bone reduction and augmentation of the forehead above it would be done. But your frontal hairline location and lack of hair density, as you have stated, create considerable aesthetic scar issues with the traditional approach to it of a hairline or scalp incisional approaches. It impossible to do such a technique through a mid-forehead incision in a horizontal wrinkle line, and I have done so numerous times in men, but I still remain hesitant in doing so.

The most limited scar approach to your forehead contouring is to accept the brow bone position and augment the near circular areas above it that create the very obvious forehead indentations. This could be done through either the application of bone cements or small custom implants placed through an ‘endoscopic’ or limited scalp or forehead incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently mulled the idea of having plastic surgery over, but am unsure if I should follow through with it due to a couple reasons. For starters though I am a 19 year old male, and am looking for a manlier, more defined face if that makes sense? My chin and cheek bones seem to have no contour or shape. In addition to this, I broke my nose a few years back and wanted to see about having it realigned and thinned out. I had surgery on it when it first happened, but the doctor said he was limited by my age and the need for my face to continue to develop. The injury left my nose kind of puffier and with a hump too.

So my first worry is I am not sure what to expect results-wise, and paying thousands for something that I am a) unhappy with and b) would cost me thousands more to fix is unsettling. Secondly, I have an overbite because of how my teeth grew in, and my dad couldn’t afford braces, so I still have the ongoing problem.(you can probably tell in the pictures I upload). I am thinking it would be best to get my teeth fixed first now that I can afford it, and then see how that fixes my jawline and go from there.

My third worry is how an implant or reshaping would effect my voice, laugh, etc. I read some reviews where some patients said they couldn’t even smile the same or weren’t able to at all. Obviously that wouldn’t be good.

I had another one but can’t think of it. I can try and give you a picture of what I would like my face to look closer to in terms of chin, cheeks, etc, so let me know if that would help. I am just trying to gauge if I should bother with this type of surgery, and what the results may be in addition to if I should get my teeth fixed first, then focus on the rest.

Hopefully this all makes sense, I wanted to keep it short but that didn’t happen unfortunately.

Let me know what your advice is, and thanks a lot! I’ve done a bit of research but the Internet can be hard to trust at times.

A: Thank you for your inquiry. My advice is that if you have high worries that you will be unhappy with facial reshaping surgery….you will. Young male patients have a very high rate of revision with any form of facial reshaping surgery because they don’t have realistic expectation of either the process or the results. At least you recognize this up front.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m not sure if you remember me…I originally enquired about coming to see you for a forehead implant a few years ago. After a lot of consideration, I decided to just do forehead shaving in my own country (mainly due to cost factors and work schedules), and to see how I felt about that result. I am relatively happy with the result however the the bone has been shaved unevenly and I feel one side is more protruding than the other more flatter (preferred) orbital rim area. Also there is some bumpiness in the middle part of the forehead.

I would like to do a slight refinement of this area and make the orbital rim smoother and less deep set. And at the same time to do a lateral brow lift to raise the outer corners of my brows. 

I mainly wanted to know if it would be possible to do the slight forehead shaving revision using the same incision used for the lateral brow lift? I like the technique where the lateral brow lift incision is just in the hairline at the temples, thus it being skin which is removed in the brow lift, rather than hair bearing scalp, and then possibly getting a few grafts to cover the incision after it has healed. Is it possible to use some sort of long shaving device (ie an endoscopic shaving tool) from the lateral brow lift temple incision and shave down the slightly protruding orbital areas?

I don’t want to risk potentially making my current coronal incision scar wider by going in again and know I want to get a lateral brow lift for an exaggerated cat like/ eyebrow extending up and out type appearance, so I thought this would be a good potential method. What do you think?

Below would be the position I was thinking about the scar to be. Allowing the skin and outer portion of eye to be pulled upwards without any raising of the hairline, while at the same time being relatively close to the eye for easy access to the orbital bone area.

A: Good to hear from you again and I do remember you. It is not possible to effectively shave any portion of the forehead or orbital region through a temporal/lateral brow lift incision. It is simply too far away and the access is too limited to effecttively work through. Any attempt to use the temporal approach for forehead contouring is likely to cause as many irregularities as it is intended to solve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to ask you about the possibilities of lowering my eyebrow arch and straightening my eyebrow out entirely, and adding more protrusion through the use of a custom brow bone implant. I want to make it clear that I’m not looking to lower my entire eyebrow itself, just the arch. Increasing the protrusion for a more masculine “deep set” eye appearance. I see at least the protrusion is possible on your website. My eyebrows aren’t that straight. Could I do this and also straighten my actual eyebrows themselves out?  Minimize my eyebrow arch and then heighten the tips at the end that come close to the temples like I did in the picture I attached? 

I really want to get rid of this arch and have a straighter brow, would the custom brow bone implant help with this seeing as how it will be custom implant? Could a custom brow ridge implant ‘lift’ the outer edges of my brows(near temples) to look look straighter and more masculine and less arched? Along with the added protrusion?

In effect I really just want my actual eyebrows straightened out with added projection for deeper set eyes. I would also consider an eyebrow hair transplant to add to this effect if you deem it appropriate. Also I have a slight asymmetry that I’ve observed in pictures where my right eyebrow seems to sit a tad bit higher than my left, could this be evened out during this procedure?

A: A custom brow bone implant will improve the projection of the brow bone based on how it is designed.  This will, by definition, make the eyes appear a bit more deep set. What the overlying eyebrow will do, however, may or may not follow how the brow bone shape changes underneath it. That is an unknown variable and many of your objectives with the eyebrow shape are asking too much of any brow bone augmentation procedure. You only do a custom brow bone implant with the expectation of altering the protrusion of the brow…anything that happens favorably with the eyebrow should be viewed as a bonus.

Dr. Barry Eppley

Indianapolis, Indiana