Your Questions
Your Questions
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
Q: Dr. Eppley, After a lot of research on the Internet (your blog has been an amazing source of useful information for me) I’ve concluded that I should consider the following to improve my eye area: probably /infraorbital-malar implants, maybe a brow ridge implant, fillers or fat graft for my eyelids, and canthopexy to give the eyes an aesthetic eye shape and reduce scleral show.
In looking at various picturess of my face, some of which make my eyes look neutral (neither good or bad) according to my opinion. Just check the labels I’ve put above each image. I’ve also included some photos of my face’s lateral view, so you can evaluate if I really need implants. (At this point, I would like to point out that because of some dental problems I havecrooked teeth and since my mandible and upper jaw (generally my midface) are slightly recessed , I want to ask if you think I might be a candidate for double jaw surgery, which as I’ve read, can improve the appearance of the midface and therefore the eyes) .I’ve included some close up of my eyes with different expressions and finally some photos of eye areas I really admire and would like you to tell me if I can achieve an eye look close to these.
I would to ask you something more general at this point : I know that canthopexy is an operation that is done to change the position of the outer canthus of the eye. Is there a safe way to change the position of the inner canthus as well? Can it be done for purely cosmetic reasons?
Finally, my other questions are
1. What makes my eyes look boring, spaced out,asymmetrical?
2. What procedures can make my eyes look as good and aesthetic as possible?
3. Are my expectations realistic taking into consideration the photos I have included?
A: In answer to your eye appearance concerns, certainly you have some degree of orbital rim skeletal deficiency which presents with lower eyelid sag and increased scleral show. This is anatomic reason for why your eyes looks as they do. I see benefits for infraorbital-malar implants combined with a lateral canthoplasty and possible fat grafts to the upper eyelids. The inner canthus of the eye can not be effectively changed. Whether such changes will make your eyes look more attractive or ‘interesting’ I can not say. This is a matter of personal opinion. These type of orbital procedures help correct volume deficiencies. I never find it realistic to look at someone’s else facial features and think they can be replicated in them…because they can’t. All you can do is work with what you have and make the best out of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read some of your posts pertaining to hardware removal for a sliding genioplasty and couldn’t help but wonder what the difference between removing hardware after a genioplasty and wearing a retainer post orthodontic treatment would be. My dentist has me wear a retainer to maintain the orthodontic treatment induced position of my teeth to help prevent shifting. Wouldn’t the chin need to rely on a similar form of permanent fixation?
A: The stability of orthodontically moved teeth is very different than that of a chin bone osteotomy. (sliding genioplasty) Retainers are needed in orthodontics because teeth that have been moved through bone have ‘memory’ since they have been pushed through bone. (a bone remodeling process) Such a bone process is very different biologically from that of any facial osteotomy. A sliding genioplasty cuts the bone and moves the inferior segment into a new forward position where the bone then heals. Once the bone is healed, it has no memory. This is why plates and screws used to initially hold the bone in its new position are no longer needed after the bone healing process. This is essentially like comparing osseous distraction to that of bone osteotomies…two very different craniofacial procedures and healing processes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is perioral mounds liposuction a high-risk procedure? It seems the procedure is such a rarity that I seldom receive any insight pertaining to the matter. Would this procedure help me with the downturned corners of my lips? I’ve been told Botox and fillers could help, but I am seeking a more permanent solution.
A: Perioral mound liposuction is a very safe facial contouring procedure that I perform regularly. It is done using an incision from inside the corner of the mouth and removes at the subcutaneous level of the face in the area between the cheeks and the jawline. This is a perfectly safe procedure because there are no facial nerves in this area unlike the rest of the face. It provides a mild slimming effect to the lower cheeks next to the mouth.
Perioral mound liposuction will not change the corners of the mouth. It is a fat reduction contouring procedure, it does not have a tissue lifting . A corner of the mouth lift is a small procedure where a ‘pennant’ of skin removed above the mouth corners and the position of the corner vermilion is moved upward, this correcting a downturned or frowning mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead/brow bone augmentation. I’m an Asian male, living in Korea. Like many Asian males, the prominence of my forehead and brow bone is very slight. So the appearance of my face is too flat.
Thus, I’m considering the forehead and brow bone augmentation.For years, I have searched for a hospital who does forehead “including brow bone” augmentation surgery However, Even though many Asians are not satisfied with their forehead and brow bone, all hospitals in Korea say it’s dangerous to use any implants on the brow bone, because there are much important nerve on brow bone region.So I had almost given up, and just at that time, I found your website on Google. So I wonder whether this surgery is really dangerous or not. If not, I wonder why Korean doctors do not operate on the brow bone.
A: It is common, in my experience, to perform brow bone augmentation along with forehead augmentation in many patients particularly that of the Asian male. Whether this is done with bone cements, custom forehead/brow implants or performed brow bone implants, the brow bone can be successfully and safely augmented. The only nerves that exit from the brow bones are the sensory supraorbital and supratrochlear nerves. These nerves supply feeling to the forehead and anterior scalp. They are not motor nerves that cause the forehead to move or the brows to animate. These nerves are at risk in any type of brow surgery whether it is a cosmetic brow lift or any type of brow bone reduction or brow bone augmentation procedure. The risk of injury to these nerves at that of numbness or partial loss of feeling. In rare cases, some pinpoint discomfort may occur from compression of an implant. This is why any forehead implant takes into consideration the location of the supraorbital nerve and makes a relief on its design. This is also why the implant should be designed too aggressively to hang too low over the brow bone.
Having said that, I can not give you a reason why brow bone augmentation, based on your research, can not be found in Korea. It is certainly not a dangerous procedure. I have designed and performed numerous forehead/brow bone augmentation procedures without the nerve complications that you have described.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in infraorbital malar implants. I have no support under my eyes and have a lack of malar development. Although I have high cheek bones…they just aren’t developed and don’t project! This lack of anterior midface and malar lateral projection gives me a very soft, undefined face. And the lack of orbital support gives me a very round eye, innocent look that makes me look really young and immature. This is my assessment anyway. I’d like to know what you think and give me you thoughts and recommendations
Essentially I want to look more chiseled and defined in my cheeks, more masculine and have some angles to my face at least. Also I’d like to have orbital support to make it so my eyes look smaller and don’t have the tear troughs or dark circles.
I will attach some pictures so you can see what I’m talking about. I can only attach two pictures for some reason, but if I push up under my eyes with my fingers…as if I had more orbital support, I look much older and mature, with more definition. I know most people want to look younger with plastic surgery….but I want to look older!! I look way younger than my age.
A: Your facial skeletal assessment is correct in that you have an infraorbital malar deficiency. Correction requires a specialized type of facial implant known as an infraorbital-malar or cheek-infraorbital implant. Such a facial implant does not exist as a standard or preformed style.
There are two method to acquiring infraorbital malar implants, a custom or semi-custom method. A custom approach uses a 3D CT scan of the patient and the implant is designed off of it. A semi-custom approach allows me to select an infraorbital-malar implant from a variety of custom ones that have been made for other patients. Given the shape of this area of the facial skeleton a semi-custom implant can be a more cost-effective methid that fits fairly well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an otoplasty revision and Macrotia reduction surgery. I did an otoplasty to pin back my massive protruding ears some ten years ago but have never been happy with the results. I’m a perfectionist and considering a revision surgery that would reduce the size of my big ears and lobes greatly and more setback – making them closer to the head and ear reshaping too, so quite a complex surgery. Please review my photos and let me know if you can kindly help me. Thanks.
A: Thank you for your inquiry and sending your pictures. Your otoplasty result shows substantial room for improvement and your congenital macrotia was never addressed. Your ears are not set back quite far enough and both the earlobes and the superior third of the ear are too vertically long. So I don’t think you are a ‘perfectionist’ per se about your otoplasty result.
An otoplasty revision can be done to bring your ears closer to the side of your head. They still remain too far away with an enlarged auriculocephalic angle. Your macrotia reduction can be done by a combiantion of a helical rim earlobe reduction with a scaphal flap reduction superiorluy.All of those ear reshaping changes can be combined in one single procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reshaping. I am self conscious about the overall shape of my forehead and the width of my frontal bone. I would like to obtain a symmetrical, square like forehead by widening the brow and frontal/temporal region. I would also like to fill in the central frontal depression. Would you recommend bone cement or a computer generated implant for this procedure?
A: What makes your forehead look like it does in the frontal view is the anterior temporal lines which flare outward as they go back into the frontal hairline at the top sides of the head. Rather than having a straight vertical temporal line which would give the forehead a more square symmetrical shape. The question is whether it is best to increase the width at the bottom of the temporal lines to that of the top or to being in the temporal lines at the top to match that near the bottom of them. Either one will help achieve a more square look. Based on your own description it appears that the former would be how to change the width of your forehead. When you add in the need for central forehead augmentation it then become a clear choice of a computer designed custom forehead implant for your forehead reshaping surgery. These are a lot of precise changes to be made and it is far better to make that precision effort on the computer than leave it up to the surgeon to artistically make it during surgery using bone cements. Also the use of a custom forehead implant allows a smaller scalp incision to be made with less overall tissue trauma.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I need to create width in my face, especially the lower half (in my opinion). Please let me know what you think I would most benefit from. I have attached pictures of my face for your review.
A: Thank you for sending all of your pictures. I have taken a careful look at them and have done some computer imaging to detriment what type of facial reshaping surgery might be best for you.. As you know you have a long thin (skeletonized) type face due to low facial fat volume. But you also have a high mandibular plane angle with vertically short jaw angles. All of this put together gives a long thin face with little facial width. I can see the benefits of vertical lengthening jaw angle implants that add some width as well as submalar cheek implants to fill out the buccal/submalar hollows. This is clearly seen in the attached computer imaging.
I do not see the need for any chin augmentation as your chin width and projection looks adequate. (and does not look better when I image chin augmentation on you with the other changes)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get cheekbone implants done and possible cheekbone reduction. Is it possible to get them done together?What are the recovery times (as in minimal swelling left) for each, and would that be prolonged if I got them done together?Let me know, thank you!
A: Cheekbone reduction and cheek implants can be done at the same time. When these two procedures are put together it is because one wants the width of the zygomatic arch narrowed but the anterior cheek projection increased. In these cases, the cheekbone reduction osteotomies are done right behind where the cheek implant would be placed. The anterior surgical approach (intraoral maxillary vestibular incision) would be the same for both procedures.
I think it would be true that combining these cheek reshaping procedures will create greater facial swelling after surgery. But in the case of cheekbone reduction and cheek implants, the greatest amount of swelling is going to come from the cheekbone reduction osteotomies. The cheek implants will add a very small amount to the overall facial swelling that will occur.
Thye swelling from this type of cheek reshaping procedures will follow a classic cessation over time of 50% gone by 10 days, 75% by three weeks and 95%$ by six weeks after surgery. Probably what will look as minimal swelling to you will be about three weeks into the recovery phase.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have orbital dystopia with my left eye being lower than my right. Will the placements of orbital floor implants correct the misalignment and depth of 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. There is also the issues of how the overlying eyelids (upper and lower) adapt to an elevated eyeball. Usually adjustments of eyelid position are also needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in implants for a frontonasal augmentation effect. Would it be possible to place a nose bridge implant so that it extends onto the forehead and fans out, so that it kind of gives the effects of a forehead augmentation as well? I am look to create the look of deeper set eyes. Also, how much for each of those procedures? Thanks.
A: I suspect you are referring to augmentation of the glabellar region of the forehead just above the nose. While both areas can be augmented concurrently (frontonasal augmentation), they can not be done using a single implant or through the same incisional approach. While such an implant can be custom designed, one has to consider the logistics of it surgical placement. Such a frontonasal implant would be too big to pass it into the forehead through an open rhinoplasty approach. Conversely an adequate nasal pocket could not be made from any type of superior or scalp incisional approach unless it was an complete corral scalp incision. These are general statements and I would have to know more about the exact forehead and nasal areas you want to augment to determine their applicability to your aesthetic facial needs.
Dr. Barry Eppley
Indianapolis, Indiana
