Your Questions
Your Questions
Q: Dr. Eppley, I have had manly broad shoulders my whole life it’s made me quite self conscious wondering if there’s anyway we couldn’t shorten them I’m not sure if this is a thing please let me know I look forward to a response!
A: Shoulder reduction surgery is a real and effective surgery for narrowing one’s shoulders whether it is in a transgender male to female or cis-female patient. I would refer you one of my websites, www.exploreplasticsurgery.com, where you can place in the search box the terms, Shoulder Reduction, Shoulder Narrowing or Clavicle Reduction, where you can read in detail how the surgery is performed as well as the recovery from it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking for a solution to my hollowed out eyes. Or perhaps you would consider them deep-set. In any case, it seems that ocular surgeons are afraid or unwilling to fill the hollows under my eyes, and I can’t understand why. Perhaps you have a different opinion or solution.
A: I fill undereye hollows all the time. If the surgeon is not familiar with the use of custom infraorbital and infraorbital-malar implants then they do not have adequate tools to ideally treat the problem for certain patients…which would explain their hesitancy/inability to do so.
It is not that it can’t be done but you have to have all of the tools/techniques to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an online consultation with you three years ago and you provided me with predictive imaging of the procedures I would be getting. (custom Infraorbital, midface and jawline implants). I had originally planned on getting these procedures done this year but after getting a sleep study and CBCT scan of my airway done, I have come to learn that I will have to undergo double jaw surgery to address these issues. I have also attached updated pictures and a CBCT scan of my skull if it is of any help. Please let me know if I can provide any further information.
1. While double jaw surgery will address my maxilla , lower jaw and chin, I have read that it often will exacerbate an “upper midface” deficiency around my eye area (which I already have). I would like to address this area with custom implants. Is it possible to come up with a surgical plan for this after my orthognathic surgery?
2. What is the approximate cost for custom midface and custom infraorbital implants ? I realize this is a very broad question but was wondering if it would be possible to get a rough range.
3. What is the maximum vertical augmentation possible to get in custom orbital rim/zygomatic implants.
A: In answer to your questions:
1) Bimaxillary advancement surgery will definitely exacerbate an infraorbital-malar skeletal deficiency as it is left behind from what moves forward below it. It is not uncommon to design custom midface implants to treat that issue secondarily.
2) My assistant Camille will provide that cost information.
3) There is no absolute vertical maximum for raising the height of the infraorbital rim, short of staying below the level of the orbicularis muscle below the lashline. I have never seen anyone that needs more than 7 to 8mms. Most patients are in the 3 to 5mm range
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I want to look tall with a head implant. Is that possible? And how many cm will I grow? Minimum how many cm?
A: With a 1st stage scalp tissue expansion one can have a skull implant that adds 3cms…but you have to careful in just adding height as the head may look too ‘skinny’…so it needs to come down over the sides into the temporal region as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my situation is I had a zygomatic sandwich surgery done and now look like a woman. It gave me way to much projection in the lower part of the cheekbones, I have a revision surgery booked for later this month and I will either reverse 100% the zygomatic sandwich surgery and get a implant at a later date, or I will reverse just 50% of my zygomatic surgery… but I still don’t think it will achieve what I want as I am looking for a very high look with projection on the zygomatic arch back to the ear,
This is why I need to talk to you as soon as possible so you can help me decide if I should reverse 100% and get a implant or reverse the surgery just 50%
I have attached three photos, two photos is where the zygomatic arch was done with filler and had the high cheekbone look and the second is with the zygomatic sandwhich surgery. It gave me a chipmunk look. I want permanent projection like I had with the filler.
A: The question you may be seeking to answer I can answer right now based on your goals and how the zygomatic sandwich osteotomy (ZSO) procedure works…you need to reverse it 100% and get an implant later. The ZSO procedure does not create a high cheekbone look which is what you are seeking and what your previous filler has created. The ZSO pushes out the main zygomatic body laterally but not the zygomatic arch, creating a wider anterior cheek look. While it is an autologous procedure (avoids an implant) it simply can not create the high cheekbone look and trying to do so with it is a structurally flawed concept.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a mandibular angle implant surgery (on one side only) to correct asymmetry on the lower part of my face. In other words, I am looking to match the side that is flatter to the side that is fuller. I had asymmetry in the mandibular area since birth. It bothered me a bit less since the overall facial volume/baby fat camouflaged the asymmetry somewhat when I was younger. But as I aged and lost facial volume, I started noticing the issue become more apparent to the point where I feel the need to address it. Moreover, the lack of fullness in the mandibular area not only causing visible asymmetry but also does not provide adequate support for the upper face, which exacerbates the sunken/gaunt appearance. I have looked into fillers but I prefer a permanent solution in the form of an implant.
1. Based on the picture, would you recommend “off the shelf” or a custom implant to address the issue? Or any other type of implant?
2. It is also important to me that an implant is made out of silicon and NOT porous polyethylene, as I would not want to have anything in my face that can’t be easily removed if there is an issue down the road. Also, from doing my research about this procedure, I think it is important for a surgeon to secure an implant with screws to avoid any type of implant migration. Do you agree?
3. Also, I would like to know the recovery (how quickly can you return to work, etc.) associated with this type of surgery.
Thank you very much and I look forward to your response.
A:In answer to your jaw angle asymmetry questions:
1 I would never try and use a standard implant to correct jaw angle asymmetry. All that will do is just create a different type of jaw angle asymmetry. These asymmetries may seem ‘simple’ to correct but they are not. It requires implant design precision to do so and only a custom approach gets the best chance to optimize jaw angle asymmetry.
2) Solid silicone is my custom implant material of choice for the very reason you have mentioned. There is no type of jaw angle implant that should be placed without screw fixation.
3) Swelling is the primary recovery issue which will take 2 to 3 weeks to look non-surgical and up to 3 months after surgery to really judge the final aesthetic result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi there! I had a question about facial implants. I had vertical lengthening jaw angle implants about four years ago and I am starting orthodontics for TMJ soon and it will be moving my lower jaw forward just shy of 2mm and moving other teeth etc. I was hoping that my jaw implant won’t be affected by the orthodontics and jaw bite plate that will move my jaw joints?
Thanks so much
A:If you are not having an open surgical procedure on the jaw angles, which it appears you are not, then your jaw angle implants should be unaffected by these orthodontic treatments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am slightly concerned about the eye incision for the infraorbital-malar implants:
- 1) What are the reasons for not inserting them through the mouth?
- 2) What types of patients are more at risk of developing lower lid retraction?
- 3) Are patients with darker skin tones more likely to develop lower lid retraction?
- 4) If lower lid retraction does happen, are there any procedures that can be done in the future to help improve their appearance?
A: In answer to incision questions about the the infraorbital-malar implants:
1) When placing the implants through the mouth the risks of infection, implant malposition and permanent numbnerss of the infraorbital nerve are dramatically increased. Have done that many times and seen all of these issues it is not an approach I will ever use again when the eyelid incision has virtually none of these issues.
2) The risk of lid retraction is very low in this procedure because it is a non-excisional tissue access approach usually done n young people with good lower lid tissues and canthal support…and infraorbital rim support is being added.. This should not be confused (which it often is) with a traditional lower blepharoplasty done in older patients with weaker lid support and where lid tissues are actually removed. The few times I have ever seen any lid retraction is if a postoperative hematoma has occurred or the infraorbital rim is raised excessively high in close proximity to the incision location.
3) Skin pigmentation does not increase the risk of lid retraction or adverse scarring in my experience.
4) The treatment of lid retraction is well established with release, spacer grafts and canthopexy/canthoplasty as effective techniques.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 20 years old and my skull and temples are narrow which makes my face looks bigger is there any other way other than surgery and implants. Can’t you put something on top of the scalp or skin and not inside it. I just want to look normal but I am very scared of surgery especially on my head and temples.
A: Unfortunately the very thing you fear is the only way to make any difference for a narrow head shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am just over 3 weeks out from having double jaw surgery (3 piece lefort 1 w/BSSO). I also had cheek implants added because of deficient mid face growth. Lastly I had a mandibular jaw angle implant on one side only… reason was that the other side has a little bump that jetted out and the implant was to make both sides symmetrical. However, swelling/ that side of my face where the angle implant was placed is way bigger than the other side. I got steroid shots but no improvement. My doctor said the swelling is preventing the jaw to set properly in the joint on that one side which makes it look worse. Two other things he noted: location for that implant requires much more than just reposition the jaw like the other side…he said it requires positioning it under the back muscle which requires work that induces note swelling.
I noticed the structure itself compared to the other side was not symmetrical when putting my finger to both and using my ears to gauge. He said not to use that because the tissue on one said was thicker than the other so he accounted for that so you can go off bone because it will even out when settled in which could be 7-9 months.
Would like to get someone else to look at it to be sure it’s not the implant size that’s incorrect and too big. Pretty sure it was a Medpor implant…. 12 months from now could make it hard to replace.
However, if this is all normal and you’ve seen similar instances turn out well given time to heal, I wouldn’t mind that and happy to wait… just want a good outcome.
Thank you for your time!!
A:I do not comment on any surgical result while under the active care of their primary surgeon. That is both inappropriate and a disservice to both the patient and the surgeon. What I can say as a general statement is that when the positioning of any facial implant is in question, whether it is 3 weeks, 3 months or 3 years, you don’t guess by external look or feel. You get a 3D CT scan which can show the exact position of where the implant is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I have a few additional questions about the secondary t-shaped genioplasty procedure.
I would be interested in a small amount (2-3mm) of additional narrowing at the same time as my projection is restored. Would this be possible given that I had a t-cut osteotomy as part of my original genioplasty in November, or would the risks of shattering/unwanted fracturing be too high? How much time passage between my original surgery and the revision would allow this cut to be done safely (or would it never be possible)?
Additionally, part of the reason I’m interested in restoring my projection is to address soft tissue laxity in the submental region and ptosis of the chin pad that has come from the horizontal reduction. If I were to have a few millimeters of narrowing, would that fully or partially negate the benefits of restoring the projection horizontally? What are the risks of ptosis from narrowing genioplasty vs from horizontal reduction?
A: In answer to your secondary bony genioplasty questions:
1) I would not advise doing a secondary narrowing of a t-shaped sliding genioplasty for a few extra millimeters of narrowing. That bony union is often incomplete and it never heals in a completely normal shape. Doing it a second time may risk further incomplete healing. Point being is that it is not worth it for that small amount of difference.
2) Any loss of bone support, regardless of the dimension, is another factor that either creates more or risks optimal improvement in the chin ptosis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In 2017 I had double jaw surgery, bottom was moved backwards and top moved forward. After time has passed my cheeks have gotten really saggy and my midface is unbalanced. I am wondering if maybe cheek inplants can sort of give me more fullness in the mid face and also add structure, to kind of lift my saggy cheeks.
A: One of the well known adverse effects of a LeFort osteotomy can be loss of cheek fullness and/or the development of excessive persistent fullness in the lower cheek area. (due to the wide subperiosteal tissue release needed to perform the procedure) Such effects can become more apparent also based on the type of upper jaw movement, particularly in larger forward advancements. Increasing the bony support of the cheekbones can help but the key to doing so is to get the right style and size of cheek implants in place. What you really lack is a combination of undereye and high cheekbone structural defieciency. This is where a custom infraorbital-malar cheek implant style works best. Standard cheek implants do not have the ability to provide this type of bony footprint coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I underwent a buccal lipectomy about a year and a half ago and I was very dissatisfied with the result. Searching for a solution to my problem, I recently read your article on buccal lipectomy reversal with dermal-fat grafts and was interested. I would like to know if you did more cases similar to the one reported in the article and if you had good results. In addition, I would like to know the chances of graft necrosis in the procedure.
A: As you may know the most common treatment for any form of facial fat loss/atrophy would be fat injections. But in the handful of cases where patients have specifically requested non-injectable dermal-fat graft for buccal fat restoration have done well and have not suffered fat loss/necrosis. That is not a surprise to me as the typical size of the buccal fat pad is in the 3ccs range, which translates into a small dermal-fat graft, which usually does well anywhere on the face when implanted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would be interested in finding out about fixing the shape of my skull (a bit pointy towards the top and flat on the back). See the pictures attached. I just found out about Dr. Eppley’s work here online and am impressed by the results from the photos I saw. Please contact me and let me know.
A: Thank you for your inquiry and sending your picture. From the front view reduction of the pointy head is usually done by reducing the height of the sagittal crest. (point) The flat back of the head (which I know by your description but have not seen a picture of it, is usually treated by a custom skull implant.
Both the posterior sagittal crest reduction and the augmentation of the flat upper back of the head can be done through the same small incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The back left side of my head is a little smaller than the right side and I never really realized there was a difference until now. I’m now 25 years old and I’m extremely self conscious about it. It’s extremely noticeable when I turn my head to the side, my whole left side of my face looks smaller because of this. I believe it’s called plagiocephaly but I have never talked to a Dr about it. At my age is it too late to have a surgery because I know you’re supposed to catch this early on?
A: Treating adult plagiocephaly head shape concerns with a custom skull implant can be done at anytime in an adult’s life. You are referring to non-surgical helmet therapy for head reshaping which must be done in the 24 months after birth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m curious about your testicular implant surgeries. I have used metal testicle stretchers (1-10 lbs at a time), and have done saline infusions into my scrotum (up to 2.5L of 5% dextrose saline) and have learned about your surgeries recently. I know of people that inject silicone into their scrotum, but the danger and permanence of silicone injection in that area has turned me away. Hearing about your work with silicone implants, that can ‘wrap’ around the existing testicles has piqued my curiosity, so I figured I’d reach out with some questions. On the page you describe the implant process, you mention the largest implants you’ve done have been 7cm in length. Doing some rudimentary measurements, one of my testicles is about 2 inches, and the other is about 1.5. Pulling my scrotal skin outwards, and measuring from the base of my scrotum the measurement is a bit over 8inches, and pulling apart the skin to the sides reads a bit over 7 inches. I was curious whether you considered doing larger testicular implants, and whether with large amount of ‘space’ I have what size I might be able to accommodate. I’m also curious about how many of these types of procedures (or similar) you’ve done. I know there’s not really such thing as a ‘safe’ surgery, but I was also curious what the risks of something like this may be.
Thanks for taking the time to read this, and for any information you may have for me,
A: In answer to your testicle implant questions:
1) Whether you can safely handle an implant size greater than 7 cms I can not say. It may be so. But external measurements by stretching scrotal skin do not really tell what the displacement effects may be with an internally spaced volume, particularly when there are two implants. But with your history of stretching and saline infusions it may be possible. In this situations/requests I have to be prepared for what happens if the size chosen (let’s say 8 cms) does not fit in surgery. Thus a backup smaller implant size must be available.
2) When it comes to specifically wrap around testicle implants the only complications I have ever seen in when the testicle slips out of the implant after surgery. (which has occurred twice and occurs early before encapsulation occurs) What I have learned from that experience is to place a suture between the closed end of the implant up through the bottom end of the testicular capsule and used that pull it into the implant and then tie it down. That will prevent that potential displacement issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just had a quick question regarding surgeries you preform. Is it possible to get both clavicle reduction surgery, and rib removal surgery for a smaller waist, at the same time? Additionally, does liposuction of the waist work to get a smaller waist measurement for patients who are skinny or normal weight, and how much does it tend to reduce the waist by?
A: Typically shoulder reduction and rib removal surgery is not performed at the same time. That is a difficult recovery that few people would be advised to undergo. In exceptional circumstances if the patient has accompanying support it may be possible in selected patients.
Liposuction of the waistline alone in skinny patients would not be expected have any real reduction effect of the waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My face is severely lopsided and my lower jaw does not sit exactly in place. It is very noticeable when looking in the mirror or inverted photos of myself. One of my eyes is also larger than the other and one of my cheeks has much more skin/fat than the other as well.
A: Thank you for your inquiry and sending your pictures. What you have is a right facial asymmetry, which affects the entire right side of your face, but in which the greatest asymmetry is inferior or lower. Your chin/jaw deviation is the most severe component of your facial asymmetry which becomes less so as it proceeds superiorly. (mouth corner is lower, nostril is lower and wider, cheek is fuller, upper and lower eye corners are lower with upper lid ptosis)
All of the issues above the jawline can be improved by soft tissue procedures which can be determined by what is seen externally. The chin/jawline, however, has undoubtably a major bony component to it. This will need to be assessed and treatment planed by first getting a 3D CT scan of your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have several questions about sagittal ridge reduction surgery:
– Is a CT scan required if only burring will be performed (e.g., no implant)?
– Do all sagittal ridge reductions require placement of a drain? If possible, I would like to avoid a second scar from the drain tube, even if it means a slightly longer recovery.
– What determines the length of the incision? Is it the amount of distance you need to sweep the burr left-to-right (laterally)? The length of the ridge (posterior-anterior)? The curvature of the skull? The tightness of the scalp?
– What determines the shape of the incision? For posterior ridge reduction, I noticed that some of your incisions have more of an arc (u-shape), while others are closer to a straight line. Why the difference, and does the patient have a choice of incision shape?
– Are dissolving sutures used, or does the patient need to return to your clinic to have the sutures removed?
– Will hair grow through the scar tissue?
– For those who do opt for an implant, how often does the implant’s edge become visible once the swelling resolves? For horseshoe-shaped implants, I assume that it’s difficult to get the prefabricated implant to transition seamlessly into the burred crown region.
– Have you done any off-label testing of verteporfin to minimize scar formation? This could be a game changer if it’s effective!
A: In answer to your sagittal ridge skull reduction questions:
1) A preoperative CT scan is not usually needed if no implant is required.
2) All sagittal ridge skull reductions require a drain which is removed in 24 hours and leaves no visible scar when healed.
3) The length of the scalp incision is based on how much access is needed to properly do the reduction. I always start out very small and then enlarge as needed.
4) The shape of the incision largely follows the hair pattern. I have no preference if it is straight or curved. It heals very well either way.
5) Small dissolvable sutures are used which don’t need to be removed.
6) Hair rarely if ever grows through a scar. The real question is whether the hair will grow right up against the edge of the pencil thin scar…which it usually does.
7) Generally implant edging is either non-existant or very minimal…as has been revealed many times in the patient that provides the most severe test of that effect…the male who shaves his head. It is usually not a problem because I lok for it and adjust the implant edges as needed.
8) I would not use Verterporfin in humans based purely on studies performed in mice. How that translates to humans is not yet known…not so much in regards to its benefits but rather what the adverse side effects with its use may be. Why take an operation which typically has superb scars and risk it for a very minimal benefit. I shall await what incisions in humans reveal with its use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,
•Is the Rhinoplasty with an open or closed scar? My previous surgery was closed and would really prefer not having another scar if possible.
•How far into the sides of my head is the incision for the forehead advancement? Also does the “zig-zag incision effect the shape of the hairline result or does it just mask the scar slightly.
A: 1) Any efforts at a secondary rhinoplasty require an open approach due to altered anatomy and scar. But that answer depends on what exact further nose changes you are seeking.
2) The hairline advancement goes into the upper temporal region. The zigzag portion is along the frontal hairline part, once into the temporal region it becomes straightline The role of the zigzag incision is for the frontal hairline where a straightline scar looks more unnatural.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a Zygomantic Sandwich Osteotomy 1 year ago. I want to reverse it and not do anything else. My face became somehow “bloated” and I don’t like it. I also had SARPE. I know, that a genioplasty would also improve my face, but that is not a concern at this moment.
A: Bone rarely grows over the ZSO osteotomy fixation site. And whatever bone growth around the plates and screws that is going to occur has already occurred by now. Reversal of ZSO involves cutting out the healed bone graftand putting the cheekbone back from whence it came.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For the pectoral implants, I have a question. I still have fatty tissue and glandular tissue on my male breast. It must first be removed before the pectoral inplants is inserted?
A: Gynecomastia reduction surgery can be performed concurrently with pectoral implant placement if the patient so desires.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, So I would like to place custom medpor cheek implants because I have read that over time it will adhere to the bone but I have also read that the risk of infection is higher than with silicone implants but I also read that silicone implants can cause bone erosion over time and that they were more likely to move, so I would like to know according to you which material is best for long term cheek augmentation without surgery revision and without the implant moving (for example for 60 years).
A: In answer to your custom cheek implant questions:
1) Every implant material has their own advantages and disadvantages, there is no one best material.
2) While Medpor does allow tissue ingrowth, it is considerably more expensive than silicone, does have a higher infection rate and is more difficult to revise/modify/remove.
3) Solid silicone remains the primary material I use for any custom facial implant as it is more economical, has a lower infection risk and is much easer to revise/modify/remove should that be necessary.
4) It is a myth that silicone facial implants can move or migrate after they are healed in place. It is true that if you don’t screw them into place during surgery the size of the pocket needed to place any implant can allow them move then due to one slippery surface on another. (but not once healed) Thus the value of immediate screw fixation.
5) It is not realistic to believe that any implant placed in the face or body will never have a risk of revision. The most common reason for revision are aesthetic in nature not due to infection or ‘migration’. There is no guarantee that someone will like the aesthetic result or may feel the need to make some change in their size or shape, whether that is 60 days or 60 years after their placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I might need to have a dental implant in the future. Will the jawline implants make this more complicated/impossible?
My reasoning for wanting a sliding genioplasty in addition to implants is that in case my implants get infected and have to be removed, at least I would have improvement from the sliding genioplasty. I think during our Skype consultation, you mentioned I wouldn’t get any width increase from the genioplasty. I did however stumble across the article below where you mention it is possible. Can you please explain why you believe I wouldn’t not be able to get width increase? (https://exploreplasticsurgery.com/the-step-off-deformity-in-a-sliding-genioplasty/?doing_wp_cron=1618182204.5073790550231933593750)
Would the sliding genioplasty create visible irregularities/ step-off? If so, is there anything that can be done in the future to improve this?
A: In answer to your dental implant and sliding genioplasty questions:
1) The concern with dental implants is not the implants themselves but with the local anesthesia used to perform them. The implantologist needs to know the jawline implant is there so they do not inadvertently inject into the implant space and cause an infection of it.
2) If you are combining custom jaw angles that are designed to merge into the sliding genioplasty, this is how you add width to the chin.
3) Like #2 that is the value of the custom jaw angle/line implants to also cover over the stepoffs from the sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a closed rhinoplasty in 2015. The surgeon did a good job but its not perfect. My columella is cooked and my nasal tip points down. My facial muscles are also very strong and make my nose very wide when I smile. I am hoping this can all be repaired with a premaxillary implant.
Please review the attached pictures and let me know what you think.
A: Thank you for your inquiry and sending your pictures to which I can say:
1) The purpose of a premaxillary implant is to bring forward the recessed lower pyrifom aperture area which your pictures show would be of benefit as evidenced by your less than 90 degree nasolabial angle.
2) Such a midface implant would work in conjunction with a secondary tip rhinoplasty to bring increased tip rotation through caudal septal resection, lateral crural spanning sutures and infratip cartilage resection. Straightening of the crooked columella along with augmentation of the collapsed right alar rim requires a septal graft harvest for the cartilage needed to do so.
3) The dynamic nasal flare that occurs with smiling is not the purpose of the premaxillary implant nor will it address that issue by itself. The placement of bi-alar spanning suture between nostril bases MAY provide some improvement in that regard. The other option is to place a microscrew in the lateral aspect of the premaxillary implant and place a permanent suture between it and the nostril base above.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to reach out given your extensive experience with lip surgery and see if I would be a good candidate for a procedure that I have had in mind for a while. I have a thin upper lift with a bit of a blurry vermillion border, which makes the lift procedure a bit tricky because I would not want to necessarily have more volume in my upper lift, just to lift it a bit since I feel it is too low. I also have something that I would like to ask you regarding my lower lift, I had a chin implant put a couple years ago and I believe that because of the projection of the implant, that pushed my lower lip upwards a bit, so bringing it down a little could also be good not only from an aesthetic point of view but as a functional improvement as well since I feel that I have to force it down a bit when I open my mouth. Thank you!
A: If I understand your inquiry and goal explanations correctly….the lower lip lift (vermilion advancement) is straightforward as that is the only way to lower the vermilion border on the lower lip. For the upper lip the options are either a subnasal lip lift (under the nose) or a vermilion advancement. (at the vermilion-skin border) By definition both lip procedures will create more vermilion show. So to determine which upper lip procedure is best for you I would need to know more specifics about your exact upper lip reshaping goals. I suspect the vermilion advancement is the better procedure. But that depends on whether you want to affect part or all of the upper lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m becoming concerned about the muscle reattachment after the bony chin reduction and if it will cause any types of anomalies such as the chin muscle “balling up”, the bottom lip becoming lax or the chin muscles just simply not returning to their normal function. I do feel I have an overactive muscle in my chin based on dimpling when I contract the muscle and I’m wondering if this will increase my risk for postoperative issues. Could you tell me what I should reasonably expect in terms of these complications? I would just like to make sure I’m managing my exceptions and weighing the risks appropriately.
A: The mentalis muscle is always reattached so postoperative phenomenon such as ‘balling up’, lower lip laxity or other chin muscles not working are not issues I have ever seen after chin reduction surgery. Any preoperatve chin dimpling/overactive mentalis muscle is probably not going to change for better or worse.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will intraoral chin resuspension work for the loose chin tissue that I now have after mini V line surgery?
A: You suffer now from chin pad ptosis/’extra’ tissue from the loss of bone support and the wide stripping off of tissues to perform the chin osteotomy. Simply put you have too much soft tissue for the bone volume underneath it. Intraoral chin suspension is not going to be effective alone and one is certainly not going to perform an external wedge excision of redundant soft tissue chin pad tissues due to the scar. Unless you are prepared to put back the lost bone support, which would be the antithesis of what your original aesthetic goals were, I do not believe anything is going to be effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How accurate is computer imaging of the face in regards to the final outcomes achieved?
A: The role of computer imaging in facial surgery is frequently misunderstood by patients. Computer imaging is done to help determine what the patient’s aesthetic goals are. It is a method of interactive visual communication to help your surgeon understand what your specific facial reshaping goals are. It is not necessarily a completely accurate predictor of the final outcome nor is it intended to be. In facial structural (bone) surgery it is a critical part of the preoperative workup because the patient is going to a look that they have never had and I have to know what exact look they are trying to achieve. Conversely In facial rejuvenative (soft tissue) surgery, computer imaging is less frequently done or of great value because the patient’s goals are well known as they are just trying to go back to achieve a look they are already know. (look younger) In addition such soft tissue facial imaging is prone to shape and shadowing distortions that introduce limitations to any visual value that it has.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I do have a couple of follow up questions for you in regards to the total jawline augmentation that we discussed
- 1) Are you able to combine a sliding genioplasty with a single piece custom jaw wrap around implant or can it only be combined with 2 lateral custom jaw angle implants?
- 2) If the first instance is possible, how will the design process of the implant happen given that a CT scan of what my chin will be like wouldn’t exist yet?
- 3) I am also considering hd liposuction (not facial or neck related) with another doctor, and I am wondering how far apart should the surgeries be. If I were to do the lipo first, how long would I need to wait before you would want to operate on me?
A :In answer to his jawline augmentation questions:
1) A sliding genioplasty can be combined with a single piece custom jawline implant.
2) You make the exact movements of the chin on the scan and then design a jawline implant around it. It is a not uncommon combination.
3) I would separate them by at least 6 weeks.
Dr. Barry Eppley
Indianapolis, Indiana
