Q: Dr. Eppley, I have a few questions about mouth widening surgery:

1) How wide can you make a mouth, would it be possible to increase with around 6mm on each side? 

2) How natural would it look after the surgery, would it be lop sided or titled by any chance or would it look like a regular mouth. 

Thank you

A: In answer to your mouth widening questions:

1) The average mouth widening distance increase done surgically is usually 5 to 7mms per side.

2) The postoperative concerns are not whether it will look natural or have asymmetry but how well do the scars do and whether a scar touchup may eventually be needed. In my experience about 50% of patients who have the surgery need  scar revision touchup on at least one side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if hyaluronic acid injectable fillers show up on 3D CT scans? If not, can we work around them? Because I have fillers in place and would really prefer if I don’t dissolve them for the consultation, because of the long wait time between the first consultation and surgery.

A: The only injectable filler seen on 3D CT scan is hydroxyapatite granules (Radiesse) which appears because of the radiographic density due to their calcium phosphate composition. Hyaluronic acid fillers, which are simply sugar molecules, are not dense enough to be seen radiographically.

Even in cases of Radiesse filler being present, the material is digitally removed to do implant designs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Just wanted to check in and Thank You for the Lateral Orbit Rim – Brow Implants, I really enjoy having a broader profile both above and around my eyes! 

I also realized I liked having some of the extra swelling on the sides of my eyes that pushed the lateral rim out even further.  I wasn’t sure if it was possible to try Fillers on top of the lateral rim implant to try making my appearance even wider around the eyes? (pics below better show my idea)  

Is there any concern about infecting the implants when using Injectable Fillers near them? If I did like the temporary Injectable Filler, could Allofill then be used for a semi-permanent effect?  

Thank you for any advice!

A: You can have fillers placed above the lateral orbital rim – brow implants in the subcutaneous tissues. Just be sure the injector knows that there are implants underneath and the injector should not try and place the filler down at the ‘bone level’….which is what they would normally do when trying to augment a skeletal structure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffered from a orbital floor / medial wall fracture 6 months ago and had the fracture repaired with a silicon implant. However, the repair has resulted in vertical dystopia. My injured eye (left) is now noticeably higher, 1-2mm by guessing, than my right eye. I wanted to ask if this is something that you confidently feel could be corrected. Or, if this is something I should just live with. Thank you.

A: Whether your iatrogenic vertical dystopia could be improved by further surgery is not a judgment that can be made by guessing. A 3D CT scan of the orbit should be done to determine the location and thickness of the orbital floor implant and how the level of the floor compares to the opposite uninjured side. If the thickness of the orbital floor implant is the cause then you would know reliably that thinning it out should lower the over elevated eye.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I have breast implants that have likely outlived their shelf life. I got them implanted in 2001 and since has had a child, plus gained weight. I am having back issues and cannot exercise like I used to due to the breast weight. I really need to do something to get my life back and I believe this is likely one of the first steps. I would like to get a consultation either virtually or in person to see what i’m looking at regarding options and costs. Thank you.

A: Certainly removal of the breast implants with a lift is the equivalent of a ‘breast reduction’ effect…which uniformly resolves the musculoskeletal symptoms of larger breasts that have a sag. Removing the implant is the equivalent of removing breast tissue in a traditional breast reduction procedure. And also like a breast reduction a lift will likely need to be incorporated to manage the loose skin that will become greater as the implant volume is removed.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in a custom skull implant. In particular, i’d like occipital augmentation to mitigate the mild flat head appearance that I have. I would like to ask, do you use PEEK as material for this procedure or is it only done with silicone. Also, I am considering getting an FUE hair transplant sometime in the foreseeable future. Would having a skull implant reduce the viability of FUE? Finally, I would like to know rough cost range for custom occiput implants. Thank you in advance.

A: 1) I have no particular preference for the material used in skull implants, But the material chosen will have a major influence on the cost of surgery and how small or large the scalp incision needs to be to get it placed.

2) While having a skull implant does not preclude having an FUE harvest later, given the value and limited supply of donor hair, it can be argued that hair transplantation should be done before skull augmentation. But this was more of an issue when the traditional donor harvest of a strip grafts was done. Today with FUE harvest there is less compelling need for the order of a skull implant and hair transplantation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 27 years old male. One year ago I got 5 mm Medpor jaw angle implants but unfortunately, I think they are not big enough for my face. I talked with my surgeon and he said he could inject fat to provide more projection as a permanent filler. I tried HA filler 3 months ago, while it got absorbed fast in two months, I found the projection it provided to be satisfactory. I got 1.5 ml on each side. 

My question is, would fat provide a projection similar to the ones that fillers did? From what I’ve seen, fat seems unable to make contours, but if the volume required is small, wouldn’t they still be a good alternative? If not, replacing the implants seems to be my only option as I seem to absorb fillers fast.

Thanks for taking the time and read my mail. I’m looking forward to your reply. I’m attaching a picture; no 1 is the current me and no 2 is what I’d like to have ( I used software to create). 

Best regards.

A: While fat injections would be a logical graduation from injectable fillers, it has two aesthetic issues. First fat injection survival in a  young man will likely go just like the fillers…it will be absorbed fast with little to no successful survival. Secondly, even if it survived, it will not create your imaged results. Fat is soft and will not  create sharper angles..it will just be rounder with no sharpness. Implants can only create that result because they have an assured firm push on the overlying soft tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young male patient with a brief question regarding facial implant work. I noticed that on your website, you have articles that refer to customized male model-style cheek implants. If a patient wanted to undergo surgery to have these cheek implants placed, would they need to undergo a 3D CT scan of their skull to have the implants designed? Or are they manufactured in an “off-the-shelf” sense?

A:Ideally true custom cheek implants are manufactured from the patient’s 3D CT scan. There is an option for special design implants (using other patient’s custom facial implant designs) with the understanding that they are like all traditional standard performed implants…they are made for someone else (a patient or a skull model) and their fit may not be exact or the aesthetic outcome may not be ideal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would to inquire about a possible sagittal crest reduction. The top most (crown) part of my skull is slightly raised in comparison to the rest of my skull, and there is a slight dip toward the front of my head which accentuates the crests prominence, giving it a more ‘bump’ or ‘bruise-like’ appearance. 

My questions are: 

1) What are the expected costs associated with this type of procedure?

2) How long am I expected to be in the country should I choose to proceed with this procedure? 

3) How is this procedure actually done? 

I understand this is a lot of questions, although would appreciate a decent answer to each as it is something I am heavily considering following-through with. The severity between the pictures and real life are fairly contrasting, and it may just be that I notice the severity a great deal more than others, although it makes me uncomfortable having it there.

A :In answer to his sagittal crest reduction questions:

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

2) You should be able to return in 48 hours after the surgery.

3) Through a small scalp incision at the back end of the sagittal crest the raised bone height is reduced by high speed burring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you so much for your response. The imaging is definitely an improvement over what I have now. In the model’s picture, the tip of her nose not only projects outward but also somewhat projects a little bit downward so that her nostrils aren’t exposed. Can we achieve this in my case? I also still think that my nostrils look flared (my nostrils look thick) so I am hoping we can do an alar base reduction as well as a weier  resection so that my alar lobules (I think this is what they are called) can be significantly thinned to achieve a further slimming effect. Is there any way we can further slim tip and make it more pointed through removing layers of fibrofatty tissue and then using permanent sutures to retain that refinement? I also think that I’ll require osteotomies for each of the third sections of my nose to bring the bones inward  because my bones are so wide I’ll provide a picture. I also think that my columella is both retracted and wide so that the angle between my lip and the tip of my nose is very wide. I believe this causes my nostrils to be overexposed. Is there any way to bring the collumella forward as well as lengthening my nose so that my nostrils are much less exposed? I would also like to reduce the width of my entire nasal base. Do you think my alar base should be lowered or highered since the base of my nostrils are lower than my collumella? My ultimate goal is to not only decrease the size of my nose but to dramatically alter its shape. I am looking for dramatic results and an overall more graceful, feminine, and balanced look.  

I apologize for all the questions but this surgery means a great deal to me because my nose is the number one feature that detracts from my face. It’s amorphous and I’ve always dreamed of having a nose like that model’s. Here are pictures of the wide nasal bones in the middle of my nose along the nostrils as well as a picture of the scar on my columella which I hope to be fixed. 

A: In answer to your rhinoplasty questions:

1) One of the hardest goals to achieve in rhinoplasty is deprojecting the nose. (making it turn more downward) There are gartfmtung techniques to try and do so but it is still hard to achieve much in that regard.

2) Nostril narrowing/thinning can be done but the results are often more narrowing than thinning.

3) In all revisional secondary surgery I always defat the nasal tip and use an only air closure of surgical with kenalog to try and decrease tip thickening due to scar.

4) The nasal bones are only at the upper third of the nose so osteotomies only affect that region.

5) Your columella is retracted and it will take cartilage grafts to bring it out. That may or may not make it more narrow.

6) There his no good method to reliably raise or lower the alar absence. (attachment of the nostril to the face)

7) As I stated previously, while I can appreciate what your ideal nose reshaping goals are, you have to be realistic with what is possible. Every rhinoplasty maneuver can be done but you are not going to have a ‘model’s thin nose, your natural skin thickness is just not going to allow that to happen. A nose is not like clay where you can just make anything out of it. No matter what is done to the bone and cartilage underneath the eventual result is what the skin that overlies these structures will allow to show through.

Dr. Barry Eppley

Indianapolis, Indiana