Your Questions

Q: Dr. Eppley, I have a question about your stance on the ability of infraorbital rim implants to marginally effect scleral show on the lower lids. 

I’ve researched this topic quite a lot, and your name always pops up within discussions surrounding it. I’m a bit confused, though, as in some posts — whether it be on your blog or realself.com— you suggest that if orbital implants have enough vertical height, they can help drive up the eyelid slightly and reduce scleral show. However, it seems you also commonly suggest these days that any sort of vertical pushing from beneath is a flawed concept so far as changing lower eyelid position. 

Is it the case that sometimes it can work and sometimes it doesn’t? Is it that when it does work, the effect is very marginal and so wouldn’t be very perceptible? 

Interested in your insight on this topic. Many thanks!

A: CUSTOM infraorbital rim implants that saddle the rim and add vertical height can have a modest effect on reducing scleral show as there is a relationship between the bony infraorbital rim and the lower eyelid position. If a modest reduction in scleral show is all that is needed (1 to 2mms) then the implant alone may suffice. But in significan sclerla show with rounded lower eyelids and/or downturned outer eye corners, the implant will need to be supplemented with soft tissue management as well (spacer lower eyelid grafts and lateral canthoplasty) to have a very visible and sustained lower eyelid uplifting effect.

It is not a question of whether it sometimes works and sometimes doesn’t. You have to match the anatomic problem the patient has with the correct solution to treat it. All three techniques mentioned are tools to be used of which some lower eyelid reshaping needs only requires one while others requires all three.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a MTF transgender. I wish to reduce my underbust measurement through modifying my rib cage. I just read a post here https://exploreplasticsurgery.com/case-study-transgender-rib-removal-surgery-body-contouring/?doing_wp_cron=1619818519.8208200931549072265625 and I realised it is possible to modify the ribs to reduce waist size. I’d like to ask if it is possible to modify the ribs to reduce my underbust size? Can I also achieve this goal through a corset?

A:The portion of the ribcage to which you refer (underbust) is the fixed portion of he ribcage over the bottom portion of the lungs which can not be surgically reduced. It is also a ribcage area that is unlikely to be modified by corseting due to the fixed nature of the ribs.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have an initial video consultation scheduled with you already. My question is, can all the procedures I am wanting be performed on a single day? Tentatively, I am planning to get infraorbital-malar implants, nasal tip rhinoplasty, buccal lipectomy, and sliding genioplasty (bilateral where applicable). Of course, I won’t finalize plans for any specific procedure until I get your ultimate recommendation at the consultation, but, for scheduling purposes, I am wondering if it is possible to perform all of these in one operation. In particular, I would like to know whether it is safe to be under anesthesia for the duration of these procedures. Thanks, looking forward to speaking with you.

A: It is very common to perform many facial procedures at the same time. So the combination of IOM implants, tip rhinoplasty, buccal lipectomies and sliding genioplasty do not pose any medical risks or any undue physiologic stress on the patient through both the surgery and the healing process.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a few of questions regarding infraorbital implants, which I am considering potentially having (I am right now trying to choose between fillers or implants) and would really appreciate some expertise help choosing. 

My first question is, how long do they last, exactly? 

I know they are said to be permanent, but is that figuratively or literally? For instance, would it be possible to actually have them your whole life, or would you have to change them eventually? Given that they are after all of silicone, and that you have to change silicone breast implants each ten years, I mean? 

2) Would it be possible to insert them from the inside of the lower eyelid, or can they only be inserted from the outside? 

3) Finally, I understand that they are attached to the bone with metal screws? Does that mean that if I am passing through the metal detector at an airport that the screws would make the alarm go off? 

And in case I would ever for some reason need to do an MRI, how would that affect the screws? Would it pull them out?

A:In regards to your questions about infraorbital rim implants I can provide the following answers:

1) All forms of aesthetic craniofacial implants are of a solid composition so the materials are structurally stable. They can never degrade or breakdown resulting in the need for eventua replacement. Solid silicone facial implants should not be confused with gel-filled breast implants which do have a limited lifespan.

2) While smaller standard infraorbital rim implants can be placed through a transconjunctival approach (inner eyelid), larger custom infraorbital rim implants can not. How this may apply to you I do not yet know.

3) The ultra small titanium screws that I use for most infraorbital rim implants (the same size as the screws in a pair of eyeglasses) are not going to make any metal detector go off and are compatible with MRIs. (titanium is a non–ferrromagnetic metal)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’d just like to say that this case study is incredibly valuable and the results visually look excellent – very natural and impossible to detect that work was done. I think 15mm is ideal in that regard. 

I have a question about the method of surgery. When you do clavicle reduction, you obviously have segments of bone that you remove. It is possible to then remove the bone marrow from these/clean it and then use them as exogenous bone grafts for other patients? Would there be any benefit to having an entire piece of bone like this filling the gap of an osteotomy during lengthening, as opposed to doing a sagittal split osteotomy? 

Secondly, how do you ensure that the clavicles are lengthened in the correct plane when you pull them apart? ie laterally in line with the existing shape of the clavicle.

A: In answer to your questions:

1) While the clavicle has an inner cancellous space that is not bone marrow.

2) While a fibular bone graft can be used for clavicle lengthening that is going to have the patient recovering from two ‘broken’ shoulders as well as a ‘broken’ leg. That is going to make the recovery process extremely difficult. Not to mention a much longer time of limited arm motion given how long it takes a bone graft to heal vs an osteotomy.

3) When doing a sagittal split the alignment of the bone can be seen as the outer segment slides away from the inner segment.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Good Morning! I have a general question. Is it possible to have a shoulder width reduction surgery and rib removal waist line reduction at the same time? Or do they have to be performed separately?

A:It is not uncommon, in the properly qualified patient, to do shoulder and waistline reduction during the same surgery. The properly qualified patient is typically one that brings someone with them to assist in their early recovery phase after they return to the hotel the morning after surgery. This combination body contouring surgery is very difficult to take on alone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I underwent V-line surgery and zygoma reduction surgery nine months ago. But I’m still unhappy with my face width/size. I’m wondering if it’s possible I still have any swelling in my face? I know it’s been 9 months but I’m wondering if it’s possible I still have residual swelling. Maybe not, but I think people experience swelling slightly differently? 

I have attached a post op pic of myself. Please let me know what you think,

A:It would be safe to assume that you have 95% (probably more) resolution of any swelling. With your thicker facial tissues you were never at risk of having too narrow or an overly oval shaped face. (overcorrection) Your aesthetic risk of the surgery is exactly what you are experiencing now…a result that is less than the desired amount of change. (undercorrection)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve wanted to decrease the convexity of my forehead for about 15 years, I don’t like the bulk/bulbous look it has. I didn’t know it was possible to do until a few years ago I saw your patient results. I do not want my hairline lowered, and worry if the scar will show if my hairline recedes. I’m currently 28. Thank you in advance for your time, I appreciate any information.

A: Thank you for your inquiry and sending your pictures. The best approach to reducing your forehead convexity is through a small frontal hairline incision. It can also be put behind the hairline but that scar placement requires a much longer scalp incisions as it lies behind the convexity of the forehead.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello I am considering having chin burring with buccal and cheek and perioral lipo. My question is isn’t there a danger of damaging the facial retaining ligaments when performing cheek liposuction?

A: Like liposuction anywhere, blood vessels, serves and ligamentous attachments are maintained.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had facial feminization surgery 2 years ago and a type 3 forehead contouring which I regret doing and I’d like to have a bigger brow ridge so I am looking into forehead contouring using bone cement.

A: With a brow bone flap setback technique there is very likely some non-healed areas (bone gaps) along the margins of the flap. While these are not a problem now raising the forehead flap for access will expose them so a bone cement approach is the way to go for any form of brow bone augmentation. But the type of bone cement is critically important which is why HA (hydroxyapatite) is preferred over PMMA (acrylic) HA can tolerate exposure to the frontal sinus since it was originally developed for frontal sinus obliteration. Conversely PMMA does very poorly when exposed to any sinus bacteria and often ends up infected as a a a result.

Since most type III forehead contouring procedures often overlook the tail or outer aspect of the brow bone I will assume that the augmentation needed is mainly over the more central bone flap region

Dr. Barry Eppley

World-Renowned Plastic SurgeonCan I

Q: Dr. Eppley, I would ike hip and butt implants. I have a pretty boxy figure, I work out alot and don’t have enough fat for a BBL and would like curves to feel more womanly. 

A: Thank you for your inquiry and sending your pictures. The success of buttock and hip implants is highly dependent on their pocket location and implant size, all of which is dependent on the patient’s goals. (yet to be determined in your case) Intramuscular buttock implants have the lowest rate of complications but that pocket location controls implant size. Hip implants have the highest complication rates of all body implants but can be successful if the implant size stays limited. (relegated to the hip dent areas)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, For a long time Ive been thinking about improving the profile of my face by adding some projection to the mandible. 

Doctor, you are renowned Plastic Surgeon, I observe your results and you are a surgeon of my choice. 

Do you do online consultations based on sent photos and CT-scan? 

I’m wondering what would work better for me: chin implant or sliding genioplasty.

A: Thank you for your inquiry and sending all of your pictures. Based on some preliminary imaging (see attached) your chin augmentation needs are in the 8mm range for which both an implant and a sliding genioplasty can accomplish.The key aesthetic difference between these two chin augmentation procedures at this normal range of horizontal augmentation is how they differ in chin width and what your feeling is for that chin shape consideration.  A chin implant can make it wider or more square while a sliding genioplasty will either keep its same shape or make a bit more narrow.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley ,Some 30 years ago I had cheek implants and I always thought they were a little to big for my face. Fast forward to present day and I had Juva \derm Voluma done to fill out some hollows mid cheek. I believe the person that did the injecting did it too high. It was also my bad for not stating up front I had implants. It never crossed my mind this would even be an issue all these years later. Could this have displaced the implant? Same thing was done the other side and its fine. Can you also advise what types of implants were used back then and can they be removed without a lot of hassle and the cost of removal? Answers aren’t readily available because of age of implants. I’d really appreciate any help you can give me.

A:Thank you for your inquiry and sending your picture. Undoubtably your cheek implants are silicone in composition and can be removed by the route in which they were placed. (intraoral) Because deflating the cheeks by implant removal will have a facial changing effect i would leave the filler alone for now and see how it looks afterwards.

Injectable fillers can never displace cheek implants, particularly ones that are as old as yours are. They are very likely surrounded by calcifications which is very common in ‘ancient’ cheek implants.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am emailing to enquire about reshaping of the skull. This has always been a massive insecurity of mine and it’s become even more prominent in my every day confidence. The back of my head is wider and that is my main concern. I have included a medical letter from a doctor I’ve already seen. I would love to reshape my skull to create an overall more symmetrical appearance. I would appreciate any advice, support or procedure that could be suggested.

A: Thank you for your inquiry and sending your pictures. As your attached letter implies, while parietal eminence reductions scan be done, will it make a significant visible difference externally? In my experience it does because the actual removal involves both bone and a portion of the posterior temporal muscle. Technically what you need is better described as reduction of the posterior temporal lines of the skull. Referring to it as just parietal eminences is a very limited approach and understanding of the actual problem.

A preoperative 2D CT scan to look at the thickness of these tissues in this area would be needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am currently 26 years old with a standard chin implant in. I am interested in a custom chin implant and I was wondering what the price was. 

I am currently trying to decide between a vertical lengthening sliding genioplasty or a custom vertical lengthening chin implant. 

I have included the implant in an attached photo. I want to know if the implant in the photo is considered just a chin implant (though it extends into the lateral mandible) or if it is considered a wraparound implant.

A: You are referring to an extended custom chin implant which costs the same whether the extended wings are there or not.

FYI such an implant design and a vertical lengthening bony genioplasty do not create the same aesthetic effects. While both add vertical length (the bony genioplasty greater than the implant) only the implant adds width to the chin and creates a seamless transition back along the jawline. In other words you are not comparing apples to apples so to speak.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I got a sliding genioplasty last year and my bottom lip is still tight. The area under my lip feels stiff and or like its being pulled. My lips close fine, although my bottom lip appears a little smaller now. I have read a lot of your posts and it seems like the intraoral release with fat filler is something that you often  recommend for this. I spoke to my surgeon about it and I was told that a V-Y procedure is something that she offers. Is that similar to what you do? Is it as effective? I am worried that this might make it worse. thank you!

A:Tissue tightness indicates scar contracture which ultimately means there is a tissue deficiency. Tissue deficiency issues are improved by a release, creation of a new dead space (tissue expansion) and filled in with a tissue replacement. (aka fat graft) In other words you solve tissue tightness by adding more tissue, not by simply moving what is already deficient around. (e.g., V – Y advancement) You have justifiable concern that a tissue rearrangement approach would not make it better and may make it worse. (more scar)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a custom wraparound jaw implant placed about a year ago. I have some significant asymmetry, with my right side jawline being smaller and not as sharp. What options would I have in regards of symmetry by augmenting the right side without a total replacement. Could I have a goretex strip overlay? Could I just have the right side of a one piece wraparound replaced without damaging the chin and left side?

A: When one has asymmetry of a custom jawline implant the first question is whether this is the result of implant placement, implant design or some differences in the thickness of the soft tissues. Knowing that most custom facial implants are designed with mirroring software, asymmetries due to design are very uncommon. The most common cause of jawline asymmetries, by far, is placement. Even slight asymmetries in position along one side of the jawline can make for a very visible external appearance change between the two sides. Thus you never consider a revision until you know exactly why it looks the way it does with a postop 3D CT scan. Such scans are tremendously revealing and will help make the choice whether it is to adjust the implant position or perform an overly implant for the smaller less defined side.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a full jaw implant three years ago by a surgeon in Europe. My jaw wraparound implant got infected a few months ago somehow and formed two fistulas on either corners of chin. I took antibiotics and so far no more problems thank god. But the muscle when I smile looks botched as it curves up then straight down giving me a witches chin as I smile. Are you able to fix the fistula holes and the irregular chin muscle ? My worry is if I try fixing anything the infection may return hence causing me to lose the entire implant. 

A: That is certainly unusual to have an infection years later. But the fact that it occurred in a such a delayed fashion and is on both sides of the chin suggests to me that this is where screws may be located and are the source of the fistulas. That aside a fistula represents an area of scar contracture and soft tissue deficiency. Thus they are acting as scar anchors that cause distortion when the chin pad moves. (smiling) They would need to be excised, a dermal-fat graft placed and then closed primarily. What effect that may have on recurrent infection is unknown since we don’t fully understand why it occurred so late after the initial surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Im interested in finding a way to reduce my skull and came across your site. I have a very large, elongated cranium that has bothered me my whole life. It has a circumference of 64,5 cm. Since I guess its not possible to change or replace parts of the cranium itself, maybe the burring approach could help reducing the circumference and the overall appearance. See attached images (I have a full CT scan). In my case I would like to reduce both the back of the head and the front to “shrink” the elongated look and maybe get some headwear to fit. Questions: What is the estimate cost for a procendure like this? I am living in Norway so its a long way. Are there any partners in Europe that offers the same type of surgery? How long do I have to stay away from work?

A:You are correct in that burring reduction is the only approach in an adult to reduce an elongated skull. As a general rule half of the skull’s thickness can be reduced by burring. If we move beyond whether the scar to access these to do the surgery is a potential issue, the question then becomes whether that amount of skull length reduction is worthy of the effort. Ultimately the best way to answer that question is by taking a side view picture and doing some computer imaging of the potential change.

I am not aware of any other surgeons in the world that do this type of surgery although there may be.

I don’t know what type of work you do but it should be no more than 10 days at most.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have my initial virtual consultation with you in a couple months, all of which so far are regarding various face concerns. I am now wondering about your custom biceps implant. Personally, I am satisfied with the anterior projection of my biceps muscle. However, I do wish for the lateral and medial sides of my arm to be larger if possible. I have not worked out in awhile right now in these pictures, but even after months of strenuous lifting exercises in the past. I had still found the sides of my arms to not be sufficiently pronounced (mainly the anterior and posterior arm become more muscular). I am wondering if you could design a custom implant to make as minimal as possible augmentation to the anterior arms but rather would fill out my arms’ medial and lateral sides, perhaps fill out the hollowness that is visible at certain angles. I have a few questions though. What is the chance of long-term motor or sensory issues? What are the risks in general of this procedure? Would a triceps implant be better for this? Would this be able to be done at the same time as face surgeries (such as with a combination infraorbital implant, rhinoplasty, and genioplasty)? Thanks so much, Dr. Eppley!

A:Thank you for sending your pictures. Because bicep implants either go under the muscle fascia or under the muscle they can only provide anterior projection that parallels the bulk of the muscle mass. What you are asking is not a function of having an implant being designed to do the job but the anatomic limitations of whether such implants can be placed.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, For orbital rims if you are on a lower budget is fat grafting better then non custom implants? I have a flat face and am worried fat grafting won’t make much difference.

A:You are correct that in your face with very significant midfacial flatness fat grafting would be a wasted surgical effort.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am a big fan of your work. I was wondering if you would perform a medial lacrimalplasty, z-plasty, whatever you would like to coin the term since this surgery probably hasn’t been performed for superficial aesthetic reasons. Ideally I would like to extend the medial canthi vertically downwards, I know it can affect the lubrication of the eye, tear troughs, it carries the lacrimal fluid, and it is one of the most insane eye surgeries hypothetically speaking besides orbital box osteotomy. Are you capable of extending the palpebral fissure length of the eye medially? My optometrist measured my palpebral fissure length, and interpupillary distance and said I have 66.5 mm IPD, and 34mm PFL which is way above average, but ideally I would like 2.5mm+ of PFL.

A: Based on your pictures and description you are inquiring about a Y-V advancement of the lacrimal lake region of the inner eye. This has nothing to do with the inner canthi which, unliket he lateral canthi, can not very easily be moved short of more extensive exposure. (e.g., orbital box osteotomies) This would create some increased palpebral length since the skin-mucosal junction is moved more medially. A Z-plasty is used when the angle of the inner eye is needed to be lower…a shape that you already have.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am considering a revision sliding genioplasty as I had a 4mm advancement which made my chin overprojected (this was two years ago). I have a mild tightness and altered sensation on the right side of my chin which is only in a small area. I read here that this might have something to do with soft tissue entering the ‘dead space’. If I were to have a revision genioplasty to put my chin back 2-3mm, is there anything that can be done to alleviate this tightness/altered sensation.

A: You would probably benefit by he placement of a small fat graft at the same time to add soft tissue fill.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I have an virtual appointment with you this December. I plan to get custom facial implants, probably some time Summer or Fall next year. What is the timeline for when you get the CT and also how long before does the final implant design need to be finalized? Isn’t it a good idea to get the CT as close to the surgery as possible since there may be some minor bone changes just from aging?

A:It is generally a 3 month process from getting the CT scan to having the implant ready for surgery. It does not matter when the CT scan is done barring any surgery in the area of potential implantation. Some patibnts use scans that are years old for their custom facial implant designs. Contrary to popular perception there are only very minor bone changes that occur with aging, barring loss of one’s teeth, which do not affect implant designing and implant fit. Almost all custom facial implants are done in patients 59 years or younger where any bone changes due to aging are very minor and irrelevant.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in cheek implant removal and willing to fly over to USA for it. But I have 2 questions 

1) WIll cheek go back to normal after removal of small implants, it has only been in for 1 year and its silicone based implantech 

2) Are any ligaments cut during placement and removal of an implant like osteocutaneous ligaments? 

As some doctors here claim ligaments are NOT cut? Is it possible?

A:By definition placing a cheek implant requires the release of osteocutaneous ligaments. Thus when removing cheek implants there will be some soft tissue sag. The only question is whether it will be particularly noticeable or not.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I hope you’re well. I have midface hypoplasia and want to correct this. The problem is I believe the recession is too great for just implants. Would getting a malar osteotomy first be ideal? Here is my lateral ceph. Thank you. 

A:Thank you for your inquiry to which I can say:

1) What is your anatomic basis for saying that your midface hypoplasia is too great for implant augmentation? What is reasoning behind make that conclusion? I see nothing in your x-ray that would lead me to believe that is true.

2) Malar osteotomies create lateral width not forward projection.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am a 28 year old male writing to you because of my aesthetic concerns about my wide head. I am interested in your skull reshaping surgery because I have a wide head and it has always bothered me psychologically and I have always wanted to reduce its width. 

My current head width from side to side is a little over 6 inches and I find my skull to be wider than almost everyone I encounter. I also work in construction and the fact that my hardhat needs to be set to almost the most loose setting makes me feel more conscious about my head size and makes me look more bulky. I get comments about how I look like an “overgrown baby” because my large head combined with relatively narrow shoulders creates a very neotenous look. 

I have read through your aesthetic skull reshaping content on your website and I know you explained that a good amount of temple width comes from muscle and not bone but what I wanted to know was if it was possible to actually reduce the bone width as well because I would like a significant reduction in skull width. For example, if we could reduce or take out the muscle width by 9mm on each side and then remove another 9 to 10mm of bone per side I believe that could be a significant change and very strong improvement for me. I know that removing the muscle alone will result in some degree of change but I really desire the maximum reduction in head width because my starting point is very wide. This is my biggest concern about my face and I know that you are more willing to make significant changes surgically to achieve stronger results so I hope you can facilitate this request. My current head width from temple to temple is a little over 6 inches and the more reduction I can achieve the better and this would really improve my confidence and I would really like a narrower head. I would really appreciate your time for a virtual consultation so that we can discuss how to plan this surgery. Thank you so much for your time and I look forward to hearing from you. 

A: To answer the question as to whether removing any temporal bone will add to the reduction benefits that the must provides, as well as makes the additional scar length on the side of the head worthwhile, a CT scan is needed to make that determination.

As a conjecture I would imagine that at least the reduction of the parietal bony eminences would be beneficial.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I don’t like the shape of my chin, how there’s a sharp dip from my lip to my chin, and my cleft. I am a very serious patient. I have spent a lot of time researching surgeons and when I came across Dr. Eppley’s before and after photos I was really amazed. 

A:Thank you for your inquiry and sending your pictures. You have a classic horizontal bony chin excess which is why your labiomental fold is so deep. This requires a submental chin reduction approach to remove both excessive bone and soft tissue. (see attached imaging prediction of a potential submental chin reduction change)

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I had a chin implant placed in the fall of 2019. It was placed crookedly, and in my opinion too high. Although I voiced these concern’s to my surgeon, he would ultimately tell me each time that the implant was placed perfectly and I looked great. Even if this was the case, and I did look great, I didn’t feel great, and the chin implant was mightily uncomfortable. My lower lip didn’t have the depression most lips do when you smile, talk, or make general facial expressions. Each time I brought up these concerns, he would say it “takes time”. I am aware of the time it takes for the body to heal, but also aware that it should be at least close to normal after a year, but, it was not. The lip was stiff and seemingly stifled in the middle and the sides. I gave up and gave in, tried to live with it for awhile, but four years is all I could take until I needed to seek help. Finally, I went to another surgeon and got the implant removed in the spring of 2021. When I showed him the implant he was appalled at the placement, and said it was heavily mal-positioned. I hoped that removal would help my lip mobility and tightness, and I wouldn’t say post removal has been net zero, I don’t think it’s even fifty percent better. My question is if anything could be done to improve, my feeling and lip mobility? The feeling is like a chin strap, and shape of the implant still lingers. In a perfect world I would go back to my original chin, but the world is not perfect. Oh well. What is your opinion?

A: While you did not say what route the chin implant was placed (submental vs intraoral) this sounds like a classic post intraoral chin implant placement issues. Usually tightness does not occur from a submental approach. Thus this is scar contracture which really means a soft tissue deficiency. In this situations I usually do an intraoral release and fat graft to relieve the tightness.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I underwent chin implantation (extended anatomical chin, large) 2 years ago, with postop course c/b persistent right lower lip numbness. We later found the right wing of the implant was malpositioned superiorly and could be clearly palpated externally and intraorally. Aesthetically, the malposition isn’t very noticeable. Right lower lip sensation is currently 85% of normal 

In a few weeks I’m tentatively scheduled for revision since my projection was insufficient (pictures attached, before implant and after). My surgeon plans to place silicone (cut from a block) behind the implant for more projection. But he said that he wouldn’t feel comfortable revising the implant wing since it could cause more trauma to the mental nerve and risk recurrent or worsened numbness. I’m concerned adding silicone behind the implant may make any minor asymmetric aesthetic differences more noticeable 

Is trauma to the mental nerve typical with revisions like these, or would I be better served by obtaining a formal second opinion/consult with you or another surgeon?

A: By your original preoperative picture and the type of chin deficiency you had a chin implant was not the best chin augmentation procedure for you. When the chin excess exceeds 10mms and the chin is vertically long a sliding genioplasty is the best approach. The chin can be moved significantly forward and vertically shortened. (see attached imaging) It is important to remember that chin implants worjk best for modest to mdoerate chin deficiencies not signifincant or major chin deficiences. 

Stacking silicone chin implants is rarely a good idea. (if you need that much projection and want to use an implant make a custom one as one piece) There is no biologic validity that removing your silicone implant is going to cause increased mental nerve damage. Furthermore why would you try and stack another implant behind a chin implant that is obviously malpositioned??

I assume you have a 3D CT scan which confirms the exact implant positioning on the bone and where the implant is believed to be sitting is not based on external assessment alone.

Dr. Barry Eppley

World Renowned Plastic Surgeon