Q: Dr. Eppley, I have a deformed forehead. My brow bones are sticking out and the bulge is very prominent.I am hereby sharing the photographs 

I would like to know if it is possible to shave the brow bone partially through incision below the brows as I don’t want to go for scalp incision due to receding hair line and possible scar formation post surgery

My expectation from this surgery is reduction in the deformity and not to get a perfect look. Also, the bulge above left brow is more prominent  than right which looks even worse. I would like to know if that can be shaved off to bring down to the size of right bone.

A: Thank you for your inquiry and sending your pictures. You have major brow bone protrusion. An effective reduction can not be done by just shaving the bone (it is too thin), it will require bone flap removal and setback. The more pertinent question,  however, is the surgical access to it if any scalp incision is eliminated as an option. An incision would to be made at the eyebrow level. Whether that is made just at the hairline at the bottom or top edge of the brow bone can be debated but I would prefer the bottom edge of the eyebrow hairs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have differences in the shape of my buttocks with the left being lower than the right. I was told that a buttock lift would be need to improve the asymmetry at the bottom.

How familiar are you with the procedure? I’ve read that trying to fix something like my case is 85% more likely to make the problem worse due to fat distribution. I would just like your professional reassurance as to how you would avoid making the problem worse. Thank you.

A: Your right buttock has a lower infragluteal fold than that of the left. Thus a left infragluteal or lower buttock lift is needed to raise the lower side to match better with the higher right side. 

I have performed lower buttock lift surgery for almost 30 years. In so doing I have never seen or would understand how it is likely to create an ‘85% risk of making the problem worse’. That is not a pertinent question or a relevant likely outcome. The real question is whether the fine line scar along the new raised infragluteal crease is a worthy tradeoff in the correction of your buttock asymmetry. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know you’re one of the top surgeons in the USA for revision. I had my nose job (primary) about 1.5 years ago. I’m satisfied however I notice a bump – ball lump like feeling on the side of my nose tip. I do not know if this is common. I read that it isn’t cartilage coming out as usually does shows after 3-6 weeks post op and not 1 year post up and plus. Do your patients usually get these or have these and is it due to maybe an acne or thick pore build up? What’s the resolution that you would do for this. If I took a photo you wouldn’t see it as when I put my finger on the side of my nose tip I can feel like a small ball. I attached a photo to show the area. 

However I’m thinking it could be a epidermoid cyst tip of nose. How do you remove these without any scarring?

A: Just based on this one picture it is more likely that you are seeing the cartilage underneath the skin. It can 1 or 2 years sometimes for the fine details of the shrink wrap effect of the the tissues to reveal the underlying osteocartilaginous anatomy particularly in the tip area. It would be very unlikely that a dermoid cyst could occur from an open rhinoplasty….not impossible but I have never seen it or heard of it occurring. Undermining the skin would not be a mechanism for its occurrence. Until proven otherwise I would assume this is due to the same of the underlying lower alar cartilage.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Thank you for the quick turnaround and spending the time to morph my pictures, much appreciated. Some feedback and follow-up questions:

1) I agree with the chin, I definitely wanted more projection both vertically and horizontally, and your initial morph there I think is very close to what I would like (I might have to play with it myself a bit to allow my mind to adjust to the drastic change haha). My questions here:

     a) Do you know about how many millimeters of a movement that would predicted to be?

     b) Is the width of the chin also changing here or just a chin movement? This questions is mostly to understand if the body of the chin needs to be change as I know I have some asymmetry there.

2) I think the cheekbones are a little trickier. I would like them a slimmer, but I also would like to maintain the current natural “curve” of the zygomatic body and arch I currently have. I am not intimately familiar with all the various cheekbone osteotomy procedures, but I know the ones popularized in Korea are the L and U shaped oseoteomies. I have also attached photos of people I think who have gotten such reductions that reflect the results I would like to achieve. I think my overarching goal there being to maintain the natural “curve” and protrusion of the cheekbones despite the reduction. My questions here:

    a) Which variation of cheekbone osteotomy (name in the literature) would you recommend so I can do more research? Pointers to any publications would be appreciated!

    b) Would your recommended procedure also affect my anterior cheekbone projection?

    c) Is there imaging and preplanning here to plan the cuts as to  protect the facial nerve?

3) As for risk factors: I know genioplasty is a relatively more common and well-practiced/studied procedure. It is also performed rarely, especially here in the states, as the procedure seems more nuanced. In my research, the main complications seem to be facial sagging and bone integrity issues (non-union) after cheekbone osteotomy. So my questions here are:

    a) As compared to genioplasty, how often do you perform of cheekbone osteotomies? 

    b) What is the relative complication/satisfaction rate for each?

    c) Has the technique for cheekbone osteotomy been changing recently or has it been the same technique used for a number of years? Based on the literature, it seems cheekbone osteotomy is a relatively recent technique that’s constantly undergoing new innovations, which makes me concerned about the stability of the outcomes.

Sorry for all the questions, and thanks again for the time!

A: In answer to your questions:

1) I would estimate the chin movements as 7mm horizontal and 5mms vertical.

2) Chin width never increases with sliding genioplasty. If anything it may  become slightly more narrow.

3) In cheekbone reduction osteotomies you never lose the natural curve of the zygomatic arch as the osteotomies are done in front of and behind the curve of the arch.

4) The L-shaped anterior cheek bone reduction osteotomy is the most common osteotomy pattern used.

5) I have performed many cheekbone reduction osteotomy surgeries in both Asian and Non-Asian patients. But by comparison chin osteotomies are more commonly requested and performed.

6) While there are many subtle variations in technique whose clinical relevance can be debated, the fundamental concepts of anterior zygomatic body and posterior arch osteotomies with plate fixation has remained the same.

7) A preoperative 3D CT scan is required before any form of facial bone surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First off, thank you for all your posts and answers which have put out for free on the web. I have found them to be an invaluable source of information. 

I am a 25-year-old male looking for some advice. I am grateful to have been blessed with a decent facial bone structure but I am looking to take things to the next level aesthetically. While my jaw is quite strong and wide, I feel I have a relatively flat mid-face. I would like to augment and strengthen this feature, particularly my zygomatic arches, for that hollow, chiseled male model look you have written about so extensively. As I understand it, this would also serve as a preventative measure against mid-face sagging as I age, while also providing under-eye support. 

What do you think of this plan? And if possible, could you also provide a rough estimate of the anterior and lateral projection that would suit my particular case?

In addition, to achieve a significant outcome in my case, would fillers be sufficient? Or would I need to go with customized silicone cheek implants? Finally, would you recommend any augmentation to the lower third, such as the chin to balance everything out?

Thank you for time. 

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

1) In looking at your pictures, you do have a lean/thin face which is always the most favorable to create definition from any form of facial implant augmentation…which is particularly important in trying to achieve the type of midface look you have described.

2) I can not provide numerical estimates for infraorbital-malar implies just based on pictures and an email response.

3) You can certainly try fillers but they an not create the same effect. Fillers are like injecting jello which is adequate to create indistinct volume but is not the same as putting a firmer material that pushes off of the bone. The latter can create an angular skeletal look was opposed to the former which creates an indistinct mass effect.

4) I could see the benefits of chin augmentation in the spirit of some additional facial masculinization effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to ask if can enhance and get sharp, well defined jaw while I have some asymmetry there? I mean if its possible with custom implants or something else would be needed? 

Best wishes.

A: A custom jawline implant is always the best approach for maximizing the effect and improving any bony asymmetries of the lower third of your face. Whether you would be able to see the type of result you desire is affected by one other factor…the overlying soft tissue and its thickness. Patients who get the best results have the thinnest tissues and leaner faces which enables whatever is put beneath them to show through the best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the maximum scalp expansion possible? I think I would like to spend at least 4 months and maximum of 5 months in the first stage scalp expansion. This is because i would need a pretty big augmentation, and my case is a bit of an outlier. Perhaps something similar to this photo. Is it possible? I have the time to spare.

A: Based on the picture you are showing no form of skull augmentation would require a scalp expansion to that degree. That is from a reconstruction case due to scalp loss and the scalp flap would be covering normal vascularized tissue one the tissue expander was removed not an implant.

But I am all for a nice slow scalp expansion in which more could be achieved than in the typical six week period commonly used in most two-stage skull augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was interested in the perioral and buccal lipectomies as well as a revision sliding genioplasty to add just a tiny bit more projection (3mm or so), as well as a platysmaplasty to refine the jawline. I was wondering if the chin were to be advanced more, could we fill in part of the labiomental fold with HA paste to prevent a deep crease there? Thanks!

A:Typically I would fill in the step of a sliding genioplasty with allogeneic bone particles which will ultimately become ingrown with bone. HA paste, an older form of bony augmentation which is synthetic, has largely been relegated to historical significance given the lack of manufacturers who make the particles. HA bone cements are also an option but due their high cost and lack of bony ingrowth would be inferior in my opinion to allogeneic (tissue bank) bone particles.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I have noticed patients gaining shoulder width on each shoulder by 3cm using implants.

1) Do the implants stay in place during your entire life?

2) what happens when you gwt the implants done and then start exercising afterwards and start gaining muscle on the deltoids? will that not arise problems?

A: You are referring to deltoid implants, also known as shoulder widening implants, of which the most common widths are 1.5 cms or less per side. In answer to your questions:

1) Like all implants placed in the body, deltoid implants become surrounded by scar tissue (encapsulated) which holds the implant in position lifelong.

2) Like all muscle implants, most of which sit on top of the muscle and under its fascia, they are carried outward in an uncomplicated fashion with any increase in the size of the muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have make bimaxillary and sliding genioplasty orthognathic surgery and you can see in the photo the final result. 

When mouth is closed I can accept it, when I open the mouth and the TMJ work its like I don’t like my surgery result as it immediately appears with a  double chin, superior lip have problem specially in the attachment with the nose, inferior lips don t have the necessary bone support and give me stupid expression, finally even the cheeks are floppy.

Thank you.

A: Thank you for sending your pictures and x-rays. As best as I can tell from them and reading your concerns, you have aesthetic satisfaction with the mouth closed but not with opening.This is completely normal as orthognathic surgery is done for the static closed mouth position as this helps set the jaws in alignment. Surgery is not done for how it may look in opening as the facial soft tissue changes with that movement. This is not abnormal nor is there anything wrong. You may benefit by other soft tissue procedures which were not meant to be done at they same time as your orthognathic surgery.

Dr. Barry Eppley

Indianapolis, Indiana