Your Questions

Q: Dr. Eppley, I have very noticeable eye/overall facial asymmetry and have asked a few surgeons about a brow lift + blepharoplasty to address this but it doesn’t seem realistic. Would a custom implant be able to fix this? 

A: Thank you for your inquiry and sending your picture. You are correct in that a browlift and upper blepharoplasty would not only not correct your eye asymmetry but would make it appear worse.

You have to think of vertical orbital dystopia (VOD) as a composite bony and soft tissue box which all must be dealt with as a unit. You can’t just treat one component of the orbital box and have it look right…I wish it was that simple but it is not. While the eye can be raised up considerations have to be given to the brow bone above it as well as the overlying soft tissues (upper and lower eyelids and eyebrow) and how they must be managed to follow and/or drape around the new eyeball position. 

Most VODs of significance, and yours would certainly qualify (greater than a 3mm difference in the horizontal pupillary line), need a complete orbital box management approach. The question then becomes how effective would the surgery be in terms of achieving improved or optimal horizontal pupillary line alignment. This assessment first begins by getting a 3D CT scan of your face to have a complete understanding of the bony differences in shape and position between the two sides. This not only provides valuable diagnostic information but is used for treatment planning as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m highly interested in the custom jaw implant or the standard mandibular and chin implants, respectively. I have a few questions about surgery. 

1) I found prices for the custom jaw implant online (roughly $15,000). What is included in this price? Only the implant(s) and the surgery or also the appointments before surgery? 

2) What is the standard procedure for international patients? Do we have to come for several visits over the course of a couple of months or is there a possibility of a “fast track” for the surgery (meaning that we have several appointments + surgery + check up within a tighter time frame so we don’t need to fly back and forth)? And will I be able to fly home a couple of days after surgery? 

3) What is the general down time after the jaw implant placement? I know that swelling will last for several months but when will I be able to speak / eat again fairly normally? 

4) Due to Covid and travel restrictions, I suppose that it will be unlikely to make an appointment for surgery this year. I am aware that before agreeing to surgery, we will have an online consultation etc.. But I would like to know how long in advance I need to book a surgery date? 

Thanks in advance for your response.

A: Thank you for your inquiry. In answer to your questions:

1) My assistant Camille will pass along the cost of the surgery to you.

2) The entire preoperative consultation/implant design process is done virtually based on a 3D CT scan you can get in your country. You only come over here once, for the surgery, when we meet in person the day before the surgery. All followups are also done virtually. This is how almost all national and international patients perfer to go through the process. But all patients have the option to also proceed in a more traditional face to face manner if their travel schedule so permits.

3) Patients can speak normally immediately after the surgery. One is advised to stay on a liquid/softer diet for the first 30 days after surgery until the intraoral incisions are more fully healed.

4) COVID has not affected our surgery center or patients undergoing surgery. We have been fully operational since May 1, 2020. We do require patients to have a negative COVID test within the week prior to their surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, what’s the typical price range for a combination of infra-malar and brow ridge augmentation? 

And would it be possible to correct a lateral asymmetry of the zygos? Maybe with a bigger implant on the deficient side? My right arch is weaker on one side from an asymmetric mandible/bite force over time. Thanks.

A: Thank you for your inquiry. In answer to your questions:

1) My assistant Camille will pass along the cost of the surgery to you.

2) One of the many advantages of a custom implant design process is the ability to address bony asymmetries between the two sides, just as you have mentioned between your zygomatic arch differences. The computer program will clearly see any asymmetries and will adjust by making the implant thicker on the smaller side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I had a chin implant approx 20yrs ago hard silicone and had a bike accident about 5 yrs after the implant shifted and was removed. I had another one put in intraorally metaphor with no problems but my lower lip was saggy. (lip ptosis) I had a mentalis resuspension with 2 mitek screws. It held up for a long time but iI noticed my lower teeth are starting to show more and more at rest. Would a sliding genioplasty and a mentalis resuspension be a better option for this?

It looks like you have done quite a few and are experienced in this type of specific procedures. 

Thank you

A: Changing out a Medpor chin implant with mentalis suspension for a sliding genioplasty with suspension would certainly not be a sure thing when it comes to correction of lip ptosis. in addition the shape of your chin would be more narrow in the front view…which may or may not be considered an aesthetic disadvantage.

This answer may become more qualified if it was known how substantial the chin bone movement would be. In larger bone movements the potential for lip ptosis improvement increases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in an umbilicoplasty to improve the shape of my bellybutton. I want it to be more elongated and vertical. I have been told by other surgeons that not much can be done. I’m wondering if you have any suggestions.

A: What you currently have is a horizontally oriented belly button which is wide and hooded…which is not necessarily abnormal. By your described goals you desire a more vertically oriented belly button shape which could be done by removing the hooding (overhang) with a triangular excision pattern to create a more vertical shape. This will not, however, make the belly button more narrow in width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 33-year old male and have recessed cheeks in all directions. I have been considering getting custom cheek implants for some time now. I’m interested in something like the following patient of yours: https://exploreplasticsurgery.com/plastic-surgery-case-study-large-custom-infraorbital-malar-implants-in-a-male/?doing_wp_cron=1614419247.3002281188964843750000 

I do not have scleral show and my eyes are positively canted but I do have negative orbital vector. Please see attached photo of my eye area. 

My doubts are these: 

— If I have a similar surgery like the patient in the link above; that is, around 7mm elevation of the infraorbital rims with cheek projection of 6mm would my tissues support such volumes given that tissue-wise I’m not that receded? Or would I have to also undergo canthoplasty? I would rather avoid it if possible. 

— With a 7mm elevation of the infraorbital rims wouldn’t this cause problems to my vision? Potentially covering my pupils? Would it make it difficult for me to look down at stuff? Or would I have to move my entire head downwards to look at stuff below my eye level? 

— Would it be possible to augment the infraorbital rim region anteriorly a little more than this patient so that the implant doesn’t scoop inwards as much in this area? I imagine if there’s more volume here this would result in more deep-set eyes which is what I want.

A: Thank you for your inquiry and sending your pictures. In answer to your custm infraorbital-malar implant questions:

I am not sure where you can up with the need for a 7mm height of the infraorbital rim component of the implant. That amount of height increase is only done when one has a congenital rim deficiency, lower eyelid sag, and/or a negative orbital vector….none of which you appear to have. Based on very preliminary information (one picture and your description I see only a minimal need for infraorbital rim height increase…only enough (2mms) to support the desired horizontal rim augmentation. Thus no lateral canthoplasty would be needed either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m severely distressed by my orbital asymmetry and would like to inquire about corrective surgery (based on your “Case Study: Correction of Eye/Orbital Asymmetry with Hydroxyapatite Cement” page). I understand some of the risks of surgery like this, but would love to know more, and to discuss any possibility of me being a candidate for this treatment. 

Thank you

A: Thank you for your inquiry and sending your pictures. In all cases of eye/orbital asymmetry the key question is which is the preferred side. In most patients it is usually higher side and the lower side is at fault…but not always. in rare cases some may find that they prefer the lower side and the higher side is at fault. You did not state which is your preferred side. But in either case a 3D CT facial scan is needed for treatment planning. This is the first place to begin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering implants for both the chin and the angle. However my biggest fear is their displacement and extrusion. I read on your site that they tend to come up at the site of the intraoral excision. That being said, I was wondering if the chances of both extrusion and displacement are less if they are placed from near the ear or neck. If they are displaced, it’d mean another surgery to get them fixed or removed, and that’s something anyone would like to avoid. Also you stated silicone has less tendency to integrate with soft tissue and thus making it more likely for them to be displaced. I wouldn’t mind surgery scars near ear or neck as much as a secondary surgery to get them fixed again. If there is any way to make the displacement less likely, please let me know.

A: The most common complications with jaw angle implants are infection and implant asymmetry….not displacement or extrusion. Because jaw angle implants are screwed into position this negates any risks of displacement or extrusion. (just because I screw them in doesn’t mean all surgeons do) So if the goal is to avoid displacement/extrusion then the intraoral approach is irrelevant in that regard.

If the goal is to lower the potential risks of infection and implant placement asymmetry then an external transcutaneous approach does help mitigate those risks compared to an intraoral placement approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, in 2015 I had a double jaw operation and also my chin is done. I am really dissapointed off the results I lost my ‘ jaw angle’ is it possible to get it back I don’t want a square face. but this really does not look good. 

Hope to hear if something is possible. 

Thx in advance. 

A: It is certainly possible to restore your lost jaw angles. But your picture comparison  the dimensions of the augmentation needed appears to be primarily in width. Given your prior orthognathic surgery and the inevitable bony changes/asymmetry of your jaw angles, this would be best done by custom jaw angle implant designs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a big fan of your work. I am from UK and for the kind of treatment I need my options here are quite limited. Very few surgeons are experienced in implants here in Europe. 

I am contemplating doing something to get my jaws wider and more defined. I do not have any overbite as confirmed from dentists, and my chin is also not poor. The only thing I lack is width in jaw. My cheekbones which seem comparatively wider and this makes the face looks too lean. I want to get the implants only at the angle as I feel they would be sufficient for me. And they seem a perfect solution. 

But I have some major concerns. I have come across many stories where people had to remove implants within a few years of having them. It was either because of infection or because of muscle disruption. (There may be some other causes but I know only these two) 

Therefore I want to ask you if you suggest to place implants from outside, rather than through an intraoral excision. (I am okay with marks, but I don’t want infection and subsequent removal of implants). Are there still chances of infection despite placing them for outside? Do you personally place them for outside for some patients? 

Also, in case of muscle disruption I want to know if it will occur even if I go for the smallest implant size, cause I most probably will, as the difference I need in my case is very subtle. Also in case muscle disruption still occurs, what are the options I have. And what are the chances of muscle disruption in small standard implants.

A: You are correct in that the transcutaneous approach for jaw angle implant placement would provide the best mitigation of the risks of infection or masseter muscle dehiscence. Small standard jaw angle implants are ideally suited for this placement approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 33 year old female. As a teenager 4 of my premolars were extracted for braces, and later 4 wisdom teeth. My facial profile is very flat with no frontal projection of the cheekbones as a result (I lost several mm of volume in my face). I tried to have my upper and lower palette expanded with removable appliances with a dentist at age 32 but my mandible was left retruded. 

I have UARS and struggle with choking, asthma chronic fatigue syndrome, and flimsy nostrils. Both both my nose and throat are obstructed. I’m suppose to get surgery on my nostrils to breathe better, but I know real problem is that the entire nose lacks support both from the loss of cheekbone fullness to support the nostrils and a retruded maxilla. 

I’m in the early stages of looking for a jaw surgeon to correct my airway issues but I know that no amount of surgery can bring back fullness to my cheekbones and upper alveolar process because of the bone loss from so many dental extractions and retraction from braces. 

I was curious if you ever work closely with a maxillofacial surgeon to address some of these aesthetic concerns while they address functional ones? I’m hoping to find a surgeon who is able to do a counterclockwise rotation. 

Ideally I’d love if these procedures can be completed before 9/17/22 because I’m suppose to be married on that date. 

I’ve included multiple photos to show my face and jawline from the side, front, and at various focal points. (The ones not taken in doctors offices were from this year, and I included several from various doctors to account for any discrepancies in focal point, etc., of the photos) 

I think a lot of these issues have to do with my upper palette growing more narrow as a child and preventing proper tongue posture/jawbone growth resulting in a subtle lengthening of the entire face over time, exacerbated by braces and extractions. This lengthening is best shown in side photos of my gonal angle, and the resulting lack of projection in the lower 1/3rd of the face. This elongating also effects my eyes, which are a few milimeters closer together than they were before braces/extractions at age 16 and my nose, which appears larger as a result of the set back maxilla and mandible.

A:Thank you for your detailed inquiry and sending your pictures. My interpretation of your current facial issues are that you may need bimaxillary orthognathic surgery (double jaw surgery) for opening up your airway but, as you have acknowledged, such surgery will not likely adequately address your aesthetic issues. (and may create some new ones as well) While some form of facial augmentations may eventually be of benefit, such aesthetic facial implant surgeries are never performed at the same time as the orthognathic surgery. This is due to not only an increased risk of infection but also because the true aesthetic needs can not be accurately determined. Thes two surgeries are separated by at least six months and also requires an after orthognathic surgery 3D CT scan for treatment planning and implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a punch to my face almost 4 years ago and now have a dimple in my cheek. It is not painful but I do not like how it looks. If I smile to much, to hard, or to long it does feel somewhat odd and looks like a big ball on my cheek. I’m wondering what I would need to have done to correct this and get it back to normal? 

A: That soft tissue indentation (dimple) is undoubtably caused by far atrophy/contracture secondary to the original trauma and subsequent subcutaneous tissue loss due to hematoma/bruising resolution. The best way treat it is a release/fat injection method. Whether you can ever get back to the pre-injury cheek shape is unknown but this approach will offer some improvement in the indentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Over the years I have lost fat above my left eyebrow that is causing a very noticeable shadow in different lights. The shadow/dent makes it seem I am angry all the time even when my face is at rest. It is causing me to be very insecure with my appearance. I have heard that fillers can be used to fill this area, however, have heard that it is a very high risk area to treat due to the arteries around. Can you provide any recommendations on potential treatments that may work to lessen the appearance? I have provided a picture to this message as well.

I appreciate your time so much.

A:Injectable fillers would be an appropriate place to initially treat this left eyebrow subcutaneous fat atrophy problem. The key is to use a cannula injection technique rather than a needle approach as this reduces the risk of any inadvertent arterial injection. There are obviously bone augmentation implants/techniques to use as well but the use of injectable fillers and fat would seem to be the best initial approach to it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to shorten my midface to bring it into better facial balance. I think a LeFort I impaction osteotomy will work, what do you think? I have attached another surgeon’s result from a similar procedure which is why I ask.

A: Thank you for your inquiry and sending your picture. In answer to your midface shortening question:

No matter what you do to the midface bone in terms of bone shortening or rotation the external midface is not going to get look shorter which I assume is your goal. Everyone forgets about the soft tissue part of the midface which can not be removed or tightened unlike the upper and lower facial thirds. Midface augmentation techniques that improve its projection will help with the illusion that it is shorter..which is done by different forms of maxillary-infraorbital-cheek implants. Otherwise I would ignore that before and after LeFort1 osteotomy example as that is a very misleading result because it is early postop, is deliberately tilted downward and the patient has had a rhinoplasty that has rotated the tip upward. All of this makes it looks like the LeFort osteotomy has shortened the midface when in fact it has not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my chin soft tissue is really just sitting on top of the bone and does not feel super attached. I just would like to know if you believe that a vertical lengthening bony genioplasty will cause it to move down as well.

Thank you so much for your time. 

A:Whether the soft tissue is super-attached or not it it still going to be dragged down to some degree as the chin bone is vertically lengthened. (vertical lengthening genioplasty)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello I would like to know if I’m candidate for bone cement….I would like to reshape my head….I have attached 2 photos one is the actual shape of my head and the other one is my desire how I would like to be shaped. 

A:Thank you for your inquiry and sending your imaged result. Whether such a skull augmentation outcome is achievable, it is not going to be able to be done by any form of bone cement. This requires a custom skull implant approach to do so in which 75% of that result is achievable with the immediate insertion of such an implant and 100% or more is achievable with a two stage custom skull augmentation approach. The one factor patients fail to factor into these types of changes is the limitation of the stretch of the overlying scalp to accommodate the added volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My sliding geniopasty surgery was in early September.  I recently had a panoramic dental x-ray and noticed that the line of bone where it was cut for the genioplasty is dark – doesn’t look like there is mineralization there yet.  Is that normal or anything to be concerned about?  I would imagine that malunion would be very rare, but apparently rare things do happen.  Maybe it just takes longer?  It’s been about 6 months now…  I am getting Invisalign to straighten my bottom teeth and thought this could help a bit if they could sink my bottom teeth in a tiny bit so that even less would show above my bottom lip.  I have been considering the second surgery we talked about, but am leaning against it.  I worry about possible complications and probably at this point, things are good enough.  While not perfect, after the surgery you did, things are very much improved.  I do still hold my lip up a bit and have a constant awareness of this part of my body, but it is easier to manage.  I hope you are well.  And thank you again.

A: Mineralization of bone, as seen in x-rays for facial osteotomies of any type, is very delayed by radiographic assessment compared to what actually happens in the body. And it may never have the same density as the chin bone did before because the bone along the osteotomy line is thinner. (less bone thickness from front to back) But I have yet to see a chin osteotomy that did not go on to full bony healing. (it would be interesting for me to see a picture of that panorex x-ray)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello i have scar left from the upper lip lift with corner lip lift. From that my mouth can’t open wide even can’t see a dentist, corner of my mouth become so tight and short. I have concerned it so much and seeking for help if it can be fixed.

Thank you so much

A:While the scars can be excised (cut out) and resutured, which may improve their appearance, it is uncertain as to whether that would actually make your mouth corners less tight. Perhaps a small fat graft placed into the mouth corners at the time of the scar revision may help those contracture symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in getting standard mandibular widening jaw implants and custom cheek implants (For the male model look). After extensive research on these procedures, you seem to be the best surgeon to perform this so I plan on seeing you in the near future! I have a few questions I would appreciate if you could answer for me. 

1) Right now I am 18 years old, and I was wondering what age I would be eligible for this procedure. If it makes a difference I had a hand scan 3 months ago, and it showed my growth plates are fused so I believe I am done growing but correct me if I’m wrong. 

2) I heard that you make computerized imaging of what the post-op could look like is this true? If this is true would I be able to see some computerized post-op images of previous patients to get an idea of how I’ll look compared to my computerized image? (I know with privacy policies that might not be possible) 

3) If in the future I decided to remove the implants how would that work? My understanding is that there would just be some loose skin, and if that’s the case would I be able to fix that with a facelift or a less invasive procedure? 

4) Since our facial structures naturally fade as we age due to bone loss how would that affect the implants over time? 

5) I added some photos of my face and I believe that I would benefit better from mandibular widening jaw implants rather than lateral. I also believe that custom implants would help me achieve the male model look, but based on my face is it possible standard cheek implants could too? I understand these photos aren’t enough to come to a conclusion on what would work for my case, but I would appreciate your thoughts!

A: Thank you for your inquiry and sending your pictures. In answer to your questions:

1) At 18 years of age you can have such surgery anytime as ongoing facial growth at this point is negligible.

2) Computer imaging is always done in any of form of facial reshaping…whose purpose is to determine what type of changes you are seeking. They help establish the aesthetic target. They are NOT done to show you what you will look like exactly…no one can accurately predict any such facial changes.

3) Such facial implants are always reversible. Whether you would have a minor amount of loose skin or not with implant removal can not be known but never enough to warrant any surgical skin tightening procedures.

4) Bone-based implants support the effects of facial aging better than if there were not there.

5) I think you are seeking the differences between standard widening (lateral) vs vertical lengthening jaw angle implants. (that is illustrated in the attached imaging)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the average cost of a forehead horn reduction surgery and can it be combined with a hairline lowering procedure?

A:It would be very common as well as convenient to put upper forehead bony reduction surgery with a frontal hairline advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, after sliding genioplasty, when the bone is healed, what will be the shape of mandible? will it be moulded in the natural shape or will it be in form of as placed postoperatively? another quere is is afterward that mandible will be weak and more prone to fractures?

A:If you place tissue bank bone chips into the bony stepoff at the completion of the sliding genioplasty the shape of the anterior mandible will heal in a more normal convex profile shape. The chin bone after a sliding genioplasty is not known to be more weak or prone to fracture after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have another question for you regarding jumping genioplasty. If the midline of the jumped chin segment were cut and a cadaver bone block were placed and the sides of the chin pushed out, would the step offs be hidden as illustrated in the attached images? Also, do the tongue muscles remain attached to the jumped chin segment? Sorry for all the questions, there is very little information about the procedure online. 

Best regards 

A:Unfortunately the perception of drawings/diagrams makes certain maneuvers seem feasible…while working inside a narrow space with the proximity of the mental nerve is quite a different reality. If you make a midline cut and place a bone block which pushes the sides of the bone out you are going to make the lateral stepoffs much worse….and there is no way technically to place grafts to camouflage the lateral wing stepoffs.

The geniohyoid muscle remains attached to the bone segment, not the genioglossus muscle in any form of a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a big head. Is there surgical procedure to reduce forehead and back of head size?

A:Like all skull reduction procedures the question is not whether it can be reduced but whether the amount of reduction possible is enough to aesthetically satisfy the patient. That has to be determined on an individual basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I am interested in getting a reduction of the zygomatic arch and an occipital reduction. But after getting these procedures will I still be able to play contact sports like rugby? Will I be more at risk of a skull fracture or brain injury in the future after these procedures?

A: Neither cheekbone reduction osteotomies or occipital skull reduction will prohibit you from playing contact sports or increase risk of skull fracture/brain injury afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If I were to do jumping genioplasty instead of sliding genioplasty would you still use bone chips to fill the ‘dead space’ and would the step-offs become less noticeable as the bone remodels? And could the bone cut be made low to keep the vertical shortening in the 2-4mm range? 

Just curious because I like that jumping genioplasty maintains chin width and decreases height at the same time while using your own bone.

A: By definition a jumping genioplasty takes the whole chin bone and sticks it on the front edge of the bone above it. This creates two adverse effects…1) the bony stepoff becomes greater (more severe) and the space between it and the incision prevents any contouring with bone chips and 2) the amount of vertical shortening becomes much greater which is basically the height of the bone below the bone cut. (10mms or more) While the bone cut can be made a bit lower it would not be in the 2 to 4mm range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am aware that your office performs rib removal for body contouring purposes. After doing some research into rib removal and other methods of waistline reduction I have come across the Kudzaev method of waist narrowing[1]. This procedure is currently only popular and performed in eastern Europe and involves performing a partial osteotomy on the floating ribs and then using a corset tightened with a belt on top for 3 months during the healing process where the modified ribs heal and get affixed into their new position. Reading the patent of this method it seems like the incisions that are performed are also smaller (2-3cm) than what is normally done for removal. Additionally, it is claimed that this procedure has little pain compared to removal and can be done under local anesthesia.

A recent academic paper Aesthetic Contouring of the Chest wall with Rib Resection claims that the Kudzaev method doesn’t have clinical trials. “On the other hand, Kudzaev patented a method of narrowing the waist, in 2017, in which the author performs osteotomies on the 11th and 12th ribs by small skin incisions. Thus, he promotes costal fracture, and complements the narrowing of the waist by the use of a corset. In this way, costal resection and its complications are avoided and waist narrowing occurs. However, there is no publication of clinical trials with this approach.”

However, this method seems to have been used frequently in the past with little side effects pertaining to rib contouring when performing extrapleural thoracoplasty for tuberculosis so this technique doesn’t seem particularly new or experimental. It’s only novelty is being used for aesthetic purposes.

Despite the patent saying that only the floating 11-12 ribs can be reshaped, I have talked with a couple Russian plastic surgeons and they claim that the 10th ribs are also able to be narrowed with this method after analyzing a CT scan. Looking at results on Instagram for the surgeons that are performing this, it seems like they are reshaping the 10th rib many other examples I can provide].

I am wondering if you are aware of this method and what your thoughts of it are. Many of the plastic surgeons that perform this operation claim it’s a much safer operation than removal long term as you retain your ribs. I am also interested if you would be able to perform this operation since I have considered flying to Russia but I would very much prefer to stay in the US for something like this.

A: Thank you for your inquiry and detailing the osteotomy method for waistline narrowing of which I am well aware. Having removed hundreds of ribs for waistline narrowing, and never yet see a single complication or any negative after effects of removing the outer half of ribs #10,11 and 12, I can not speak for whether rib osteotomies vs rib removal is safer, has a quicker recovery or produces comparative results. What I can say is the following:

1) The skin incisions needed to perform either technique would be similar. I use a 4.5cm single incision per side which can not be made smaller no matter method is used.

2) No form of multiple rib manipulations should be attempted to be performed under local anesthesia. There is no benefit for the patient or the outcome in doing so and may well make the whole experience far less pleasant and even less successful for the patient.

3) The key to the technique is obviously the patient’s compliance with the corseting.

4) One of the key components of waistline narrowing is the reduction of the thickness of the lateral border of the latissimus dorsi muscle. This soft tissue reduction provides as much waistline narrowing as that of the rib bone changes.

5) Rib removal has surprisingly less pain afterwards than one would think because there is no bone to heal, it is just a muscle recovery. Whether leaving the ‘fractured’ ribs in place will lead to more postoperative or even long-term rib pain I can not say.

That being said I believe rib osteotomies are a valid method for waistline narrowing….which is probably better called ‘rib osteotomy-assisted corseting’. In the properly motivated patient it is a useful technique  But whether it produces similar results to rib removal surgery no one can yet say. They are both similarly safe but one is not safer than the other.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if it is possible to reduce the volume of the greater trochanter bone ? Because for me, it sticks out a lot and makes my silhouette look very weird. My greater trochanter isn’t in the continuity of my hips and it causes me a great pain (impossible to dress) and I cannot accept it. It looks very ugly. 

Furthermore since the greater is that big, it causes me a lateral pain (on both sides). I would be very grateful if you helped me.

Thank you for your answer.

A:While the greater trochanteric bone can create an unaesthetic bulge in some people, it is important to recognize that it is there for a purpose. It is a bony prominence onto which multiple muscles attach (gluteus minimus, piriformis, TFL) with an associated bursa. Besides the potential functional effects from muscle stripping to get to the trochanteric head there is also the risk of creating bursitis and chronic pain. It is for these reasons that trochanteric bone reduction is not done for aesthetic purposes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I have a natural narrow mouth in neutral position. I am considering a lateral commissuroplasty to make my mouth in neutral position a little bit wider and model look. (2mms each side). However, when I smile my mouth is wide, so by getting this lateral commissuroplasty, while my smile get wider? I don’t want my smile wider, just my mouth when it’s in a neutral/expressionless position.

A: By definition if you make your mouth width greater at rest it will become greater when you smile. That is the aesthetic tradeoff.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi I am considering lateral commissuroplasty of increased outer mouth width (1-2mms) equally. Will the scarring be bad? I know the area around mouth is sensible and easily scar-able. But how bad is it? Can the scars be seen from face to face distance or do you have to really look at your face in closeup to see the scars. I will attach my photos of my desired outcome. Do you think my mouth result is achievable with scars that can’t be seen when talking face to face to someone ? (1-3 feet away)

A: The scars from mouth widening surgery is highly influenced by the amount of lateral movement. The usual amount of mouth widening is in the 5 to 7mms range. When it comes to a 1 to 2mm increase, in which I have never done that small amount, it would certainly create the most favorable scar lines.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a gynecomastia surgery in two years ago. The result looked very good in the first month, but after removing the compression strap a scarred tissue lump appeared on both nipples and the skin was also flabby. Six months later my doctor injected steroids and I didn’t like the result, the nipple became very flaccid and came out, especially when they get cold and the nipple become more prominent and areola appears to have deformities, worse than before the steroid. (dexamethasone)

 The ultrasounds say I have the remains of a gland. The doctor who operated on me says it is better not to move anymore, but I can’t live like this. I feel that I have a lot more breasts than before the surgery. I would like to have your opinion of my situation and how I can improve my case to get on with my life. I can’t wear a t-shirt because the nipples are very marked. Thank you.

A:Thank you for your inquiry and sending all of your pictures. The situation you have now is a tough problem and I would be very cautious about deciding what to do since it is very possible to make it worse. The safest thing to do is to break up the scar tissue and remove a little more tissue on the chest wall with liposuction combined with a nipple reduction. Open excision is very likely to make it worse as you already have some contour irregularities.

Dr. Barry Eppley

Indianapolis, Indiana