Your Questions

Q: Dr. Eppley, I’m from Europe. I had a surgery to enhance my scrotum with two implants but keeping my real testicles. Now my scrotum feels too big and the prothesis are similar in size to my testicles. Due to big scrotum you can see 4 testicles. Prothesis are 5.4cm. I would need new ones that a7cm or even more. What would be the cost? I hope that 7.5cm wasn’t custom implant because i need to go from Europe and the journey is very expensive.

A:All testicle implants over 5 cms need to be custom made. You are correct in that if the goal was to overwhelm in size the existing testicles one needs to be at least 6.5cms if not more. The side by side testicular enlargement technique works because the implants are at least 33% more in size/volume than the natural testicles. (more is even better)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have viewed this from your website and am so grateful to find a surgeon that knows what he’s doing. 

https://exploreplasticsurgery.com/plastic-surgery-case-study-the-submental-approach-to-hyperdynamic-chin-ptosis-correction/?doing_wp_cron=1613839090.8922240734100341796875 

I really wanted to know what was the client chin like after and if any problems has arose from the surgery. 

Has there been more dimples? More of a golf ball look or even created a bigger chin ptosis. Please can you let me know. Been searching for this for weeks and found you.

A: A submental chin reduction does not cause soft tissue pad contour irregularities because it treats the problem from below rather than trying to remove tissue from the chin pad proper. (e.g., liposuction) Because tissue is removed the soft tissue chin pad does not get rounder or develop more ptosis. The only outcome question is in how much improvement is obtained but ti never makes things worse.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi I would like to know price for revision chin ptosis after I removed the implant. Since the first surgery of my chin with implant my lower lip turns more down and shows more of my lower teeth. I think the mentalis muscle must be repositioned as well as the soft tissues.

I send 2 pictures, the first one is after implant removal and second one is before chin implant placement. The problem appeared since I did and removed the chin implant. Now I don’t have the mplant and the problem is still in my chin.

A: Intraoral soft tissue chin pad resuspension for ptosis has a relatively low rate of success even though it theoretically should work. As a result I have learned that it does work better when the soft tissue chin pad has something to adhere to once lifted like a sheet of ePTFE on the bone. This is more effective than just resuspension alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, so I was born with a condition called Cowden’s syndrome, one of the symptoms of which is an unusually large head. It’s not so much wide as it is tall and from my face to the back of my head feel miles apart. Have tried big and tall hats, largely as a joke; got up to 4xxxx not fitting when I gave up.

Anyway, I’ve been self conscious about it my whole life, and am amazed that this type of surgery is possible. Would love to know more info on it.

A:When it comes to skull reduction the question is not whether it can be done but how effective it would be based on the thickness of the skull bone and how much reduction the patient needs to achieve from their perception of an improvement. To make that assessment I would have to see some pictures and do some computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a young male and I’d like to consider getting a procedure done that brings my eyebrows down ever so slightly (2mms or so). It isn’t a drastic change but it would maximize my appeal in eye area. One thing to mention is when I push my eyebrow down slightly 2mms, the skin gets rid of my tiny 1mm upper eyelid exposure too, giving a deep set look which I want (refer to photo). 

I think I would be an ideal candidate to achieve my desired eyebrow look given my good overall eye area base to work with. 

What do you say?

A: What you are asking is not surgically possible to do. Raising eyebrows is one thing, lowering them is another. Botox injections would be the only approach that may work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 24 year old healthy male. Due to my ethnicity, my eyes are more prominent than I would like, and this orbital decompression would be purely cosmetic + I don’t have any health conditions and my eyes operate normally. With this orbital decompression I would like my eye to fall further back in my eye socket like photo.

Is my desired orbital decompression procedure result Possible like photo? I appreciate any response

A: Orbital decompression works by dropping down the anterior orbital floor which makes the globe drop down and back a bit. How significant those changes are and controlling them in a precise way is not an exact science given the variables of how much of the floor is lowered, the size of the orbital contents and that fact that this is a bilateral/paired structure. So applying orbital decompression as an aesthetic procedure where the outcomes are much more highly scrutinized than when done for medical reasons would suggest that your imaged goals may or may not be exactly achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First off I want to say thank you for taking the time to answer my questions, and also that I am aware that these questions may have lots of variables that can make it difficult to produce definitive answers. 

1) I am extremely interested in getting a sliding genioplasty done, as my lower third is just not what I want it to be. How much in total is that procedure with you generally? Also if I was to have horizontal as well as vertical movement would that affect the price depending on how much movement, and why? 

2) When the bone is cut and a gap is left between the cut bone and the remaining lower jaw bone, how do you generally fill that gap (bone graft or calcium based filler)? And can you describe how the bone then heals back into one solid piece? 

3) As a 30 year old healthy male, how long would the recovery be until I was able to eat and speak normally with minimal signs of swelling (best estimate). and how about until the bone is fully healed? 

4) Lastly, I want to pay cash for this procedure. Would it be a problem in any way on your end if I did not have health insurance? I am aware of the risks involved. 

Thanks again for your time and I look forward to hearing from you!

A:Thank you for your inquiry on sliding genioplasty to which I can say the following:

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

2) While the anterior step and the posterior inferior border stepoffs are grafted with tissuej bone chips, I should assume that some bony deformity will persist at these areas whose magnitide is affected by how large a bony movement that is done.

3) Speaking is not affected at all, eating is only affected by the limitation of biting off foods in the first weeks after surgery. (due to the incision location) Posterior molar chewing is unaffected.

4) This is a question for my assistant Camille.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello! I am a young  male looking for a way to reduce the horizontal width of my hips in the nearby future. Narrow hips and a wide chest are seen as more masculine, I’m sure you know, but my body currently resembles a slightly more feminine figure (unfortunately). I hope the photos are sufficient for visual aid, but I can always send more; the photo with my phone in the frame is with fully inflated lungs, the other is without. After much time spent photoshopping various pictures to understand what would make my body more masculine, I discovered that widening my rib cage to achieve a masculine “V-taper” results in a unpleasantly wide chest (nor is it possible, as far as I know). Narrowing the hips even slightly, on the other hand, produces a sublime result. I am unsure what the limitations are for such a procedure—or if it is even possible—but I do understand that there are many ligaments and such attached to the hip bones. Is it possible to reduce the hip bones while leaving the muscles be? Or, could the muscles/other attachments be partially reduced to make reduction of the hips possible? If it means anything, I assure you that the loss of some tissue mass in this area is easily a worthwhile sacrifice (perhaps even ideal) if it means the hips can be narrowed.

A: I will assume that when you speak of more narrow hips that you are referring to reduction of the iliac crest, specifically the most lateral craved wing of the iliac crest. While there are important soft tissue attachments to the iliac crest (TFL) it is only the middle third or so of the crest which would be reduced. This still preserves most of its attachments and those released are also sutured back. 

From my perspective the question is not whether it can be done but whether the tradeoffs n doing so are worth it. The obvious one is whether the scar placed over it would be acceptable. But actually the appearance of the scar is not what would concern me, it would be whether it would be a potential source of chronic pain. It most certainly would be in the short term but what happens in the long term is not precisely known since this is a procedure done for aesthetic purposes that has very little actual clinical experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, for a custom jawline implant, can the chin implant component be placed submentally?

I ask because I have slight chin ptosis / excess tissue from a previously removed chin implant and would like a submental tuck done at the same time.

A: In most men a custom jawline implant is placed through a three incisional technique, one of which is the external submental incision through which the entire implant is inserted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a transgender man interested in achieving a more masculine facial aesthetic. I really want the male model look and the procedures I am interested in are buccal fat removal/liposuction and jaw/chin implant. However, since I am not a surgeon I would like to know what procedures you think would be best for me to achieve my desired look. 

My main concerns regarding my face are asymmetry ( I generally like the left side of my face but I think the right side is droopy and unsightly), the large space between my eyes and my eyebrows (which I perceive as feminine), the fat on my cheeks, and the lack of protrusion in my jaw and chin. I’ve added photos of six angles of my face as well as AI-generated renderings of my face as more masculine to show you the ideal look I would like to achieve. I realize that when it comes to things like AI they are not completely realistic but I thought I would add a few photos in to show you my ideal results. Thank you.

A: Thank you for your inquiry and sending all of your pictures. While you may not be a surgeon you do know what you like and don’t like about your face so that is what largely guides me in each patient. Your own morphings show a subtle chin/jawline change which is very achievable and I might make that effect just a bit stronger. (see attached) Otherwise you could make an argument for brow bone augmentation but if you have not pointed it out then I would say it is of low importance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a pronounced forehead bone and its not equal. What are the different options to do about it? Can I work with fillers or the scalp need to be made equal? Thanks for the advise! Kind regards

A: That set of raised paired forehead prominences are your brow bones caused by overpneumatization of the frontal sinuses. They are often not equal in appearance as one frontal sinus is usually bigger than the other one. The definitive approach to treating it is brow bone reduction surgery

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need Head Augmentation. Backside of my head looks flat that’s why I need skull enlargement plastic operation. How much it will cost and what is recovery period? 

Thanks for your prompt response. 

A: When considering a skull implant of that size, it would take a two stage skull augmentation to achieve it. The scalp does not have the ability to stretch over an implant on its own all at one time. 

The recovery from any form of skull augmentation surgery, particularly the back of the head, is remarkably quick. Since it causes no swelling in the face and there are no physical restrictions afterwards one will find the recovery period to be fairly brief.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the cost of skull reshaping surgery?

A: Thank you for your inquiry about skull reshaping surgery. This is a specialized type of plastic surgery that is associated with dozens of different procedures based on the many skull shape abnormalities that are seen. To provide you with specific answers to your skull reshaping request, I would need a description of your head shape concerns with pictures so I can first determine what type pf skull reshaping surgery you need. Then the details of that type of skull reshaping surgery can be provided including its cost.

Dr. Barry Eppley

Indianapolis, Indiana

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