Rhinoplasty, Vermiion Advancement, Cheek Implants, Sliding Genioplasty and Jaw Angle Implant Facial Reshaping Options?

Q: Dr. Eppley, Thank you for responding so quickly! I would like your opinion on what could make my face look more symmetric and give it more definition, if possible. Basically, I would like to look like I have good bone structure. I’m not trying to look like any particular celebrity, but I’ll use their pictures to show what I like. I have several facial reshaping procedures in mind, but perhaps you will suggest something different.

I’m 27 years old, female, had braces to correct an overbite over 10 years ago, a primary closed rhinoplasty and a subnasal lip lift last ye5ar. I’ve tried lip fillers both before the lip lift and after.

Overall, I think my nose is better, but I’m not completely happy with it. As far as my lips go, I like the view from the side much better now, but the front still bothers me. Fillers never did much for me in my opinion.

I think I look drastically different bare-faced. Makeup helps me create some definition and angularity in my face, larger upper lip and a more symmetric nose. Of course, makeup can only do so much. I’d rather get more significant and lasting changes.

Here are my specific questions. I’ll start with what had already been operated on and then get to facial implants.

NOSE

I still have a remaining bump that is visible from certain angles. I wanted a more concave bridge and a tip that’s rotated a bit up to create an effect of a slightly shorter nose. I also think it lacks symmetry from the front and even with makeup I have difficulty making it look straight. My original nose had a bump and a bulbous tip, but didn’t seem crooked to me. My breathing was great before surgery, now it’s a bit worse, but not to the point where it bothers me.

Do you think it would be worth it to operate on it again?

LIPS

I just want my top lip to be close in shape and size to the bottom lip. Unfortunately, the lip lift didn’t give me a top lip. And I don’t like what fillers do to me (too puffy, not enough vertical red lip). So I feel stuck. The surgeon who performed my lip lift told me multiple times that both vermilion advancement and V-to-Y would look horrible because there would be no white roll and my lip would look pasted on, but I just don’t see what other options I have. The only thing he suggested was Botox lip flip to prevent the top lip from curling inwards when I smile and more filler. I am not happy at all with the current state of my lips – still very thin top lip when I look straight on, nonexistent on the sides unless I overline significantly, plus now if I close my mouth completely there’s a visible strain in my chin, that’s why I mostly keep the mouth slightly open – if I close it, my chin flattens.I don’t like how (in my opinion) it makes me look sad or angry.

What can I do?

CHEEKS

I’m interested in a custom model implant that extends all the way back. I’d like the effect of very prominent cheekbones, but I know there are limitations.

Do you think that’s achievable for me?

CHIN/JAW

My goals are: shorter, more protruding chin, and a defined jaw. I’ve always felt my chin is a little too long vertically, but in addition to that after a lip lift when I close my mouth my chin looks recessed. I also carry some fat around my jaw even when my weight fluctuates lower. It’s just never been really defined. I’ve had one surgeon recommend a neck lift, but I don’t know if that will be enough – I’m not sure how good my underlying structure is. I think my face always looked soft.

What would be a good solution here? Sliding genioplasty and a custom jaw implant? Something else?

A: Thank you for sending all of your pictures and detailing your concerns. You are correct in that makeup can make a person look completely different. But it is also helpful because it shows what the patient is trying to achieve.

As I understand it your prior surgeries have included a closed rhinoplasty and subnasal lip lift. Your goals now are to basically have a more defined facial structure and fuller lips. In essence this comes down to the following facial reshaping options:

NOSE  While your initial rhinoplasty provided improvement (reduced the hump) it reflects the more modest changes that typically occur from a closed rhinoplasty and largely left the tip relatively unchanged. You are probably seeking a more complete rhinoplasty to lower the bridge further, reduce tip projection and provide some tip rotation This is the way you are going to get a somewhat smaller and more shapely feminine nose.

CHEEKS You need some defatting underneath them from buccal lipectomies and perioral liposuction to create less fullness between the cheekbones and the jawline. This will also create a bit of a cheek augmentation effect. A custom heel-arch style always provide the best definition .

LIPS. When women draw their lips on and they look better they are basically adjusting the position of the vermilion. While a subnasal lip lift creates more central upper lip fullness it does not address the sides of your lip which is why you like it from the side view but not so much from the front view. This can only be addressed by a vermilion advancement.

CHIN-JAW. Your chin needs to come forward and be narrowed (sliding genioplasty) and some small jaw implants that help create a more visible angle to the back would create a more total jawline effect with the chin.

These are my initial thoughts,

Dr. Barry Eppley

Indianapolis, Indiana

Can Custom Infrarbital Rim Implants Be Made Out Of Titanium?

Q: Dr. Eppley, I was wondering if it would be possible to design custom infraorbital rim implants for the under eye out of titanium? I understand that it would be more expensive and that you are usually not a fan of using non-pliable materials for implants. But, since my only concern is under eye hollowing, I would assume for the results I want, the implant would be small. And also what would the price be of the same orbital rim implants made out of silicone? 

Thank You

A: I actually have no strong predilection about implant materials, it just comes down to their cost and whether their construct allows them to be placed through aesthetically acceptable incisions.

You are correct in that because a very rigid implant like titanium for the orbital rim would be small, it could be placed through a lower eyelid incision.

I will have my assistant Camille pass along the cost of both materials for custom infraorbital implants.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Cost Of A Facelift?

Q: Dr. Eppley, My question is the one to which every patient needs an answer and most doctors hesitate to give: cost. I need to know as funds are limited. Its nasal labial and marionette lines, plus overall tightening of sag and increasing luminosity of skin. Thanks. I’ve been reading about Bellafill and other flllers, but they are costly and may have unpredictable and very short lasting outcomes considering cost. Thanks. P.S. At some point, maybe they’ll make some implantable bone to restore lost bone volume in faces. That and a fat transfer may do nicely then. Anyway, can you give me and idea of your facelift cost – spec. marionette and NL folds.

A:I have no hesitation about giving costs as long as I know exactly what one is being quoted for. In facelift surgery there are three different types which vary in extent and cost and that choice is based on the patient’s anatomic needs. Not knowing your exact needs makes it a guess but I have no problem doing so, I will have my assistant Camille pass along what I would guess is the type of facelift you need. Beyond that I can make the following two comments:

1) While a lower facelift can improve marionette lines, its effects on the nasiolabial folds is limited to the lower end of that fold.

2) A facelift should be be confused with other forms of facial voluminization procedures such as injectable fillers, fat or even injectable bone substitutes. Their resultant aesthetic effects are not comparable and are used for different indications.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Custom Jawline Implant Make My Male Face More Handsome?

Q: Dr. Eppley, My goal is simply to become more handsome and aesthetic. Ideally, I would like to like to acquire typical male model aesthetics, i.e. strong chin and jawline with high cheekbones and low facial fat. Although, I know there are limits to what surgery can do, so I’m trying to keep my expectations in check.

I was assuming that the ideal chin width would be relative to the rest of my face. That’s why I was considering jaw and cheeks implants at the same. I suppose I’m a little concerned about changing my chin to match the current dimensions of my face, then changing other parts of my face at a later stage.

I have considered starting by fixing the chin, then using fillers to enhance the cheeks and jawline to get an idea of what my face will look like with additional implants.

Based on your experience working on male faces, what would you recommend to approach the typical features of a handsome male face?

Thanks,

A: I would agree that if you just change the chin it doesn’t really match the rest of your jawline. The typical approach most patients take is to the whole jawline (chin and jaw angles) with a custom jawline implant and then see how they feel about the cheeks later. Although I have just as many patients, if not more, that just jump in and do it all at once. It is really a question of comfort as to a staged vs a total facial reshaping effort. There is no right or wrong way, it is based on the patient’s comfort level.

Dr. Barry Eppley

Indianapolis, Indiana

How Long After Surgery Takes It Takes To See The Results from Skull Reduction and Temporalis Muscle Removal?

Q: Dr. Eppley, I am interested in doing a combined large skull reduction and removal of temporalis muscle. 

I was wondering though, as I have read that there is some swelling after, and that it would take time before the result is apparent. Could you give a “timeline” of how much of the result is achieved percentwise, say 2,4,6,8 and 12 weeks after surgery? I suppose the swelling from the temporalis reduction is milder than that of the skull reduction?

A: As you have mentioned there will be swelling afterward of which the worst will be in the first 10 days at which point one is more publicly presentable. Finer details of the result take 8 to 12 weeks after surgery to fully appreciate.

You are correct in that the swelling from temporal reduction would be somewhat less than that if it was combined with skull reduction.

Dr. Barry Eppley

Indianapolis, Indiana

How Soon Can I Have My Sliding Genioplasty Revised?

Q: Dr. Eppley, I’d like to ask you this question since I read your answer on Real Self regarding a revisional genioplasty immediately post op. 

I had my genioplasty 3 days ago – even at the peak of my swelling I feel I was not advanced enough. My surgeon agreed to advance me more horizontally and vertically in 2 days if I wanted it.

He told me the procedure would be straightforward since the suture has not healed fully, scar tissue has not formed, and the bone does not have to be recut.

My main concern is additional nerve damage – I already have numbness in my bottom teeth post op which I heard is normal. Would a second procedure so soon increase the chances of the nerves not recovering? Also, when he stitches the sutures back up a second time, could this cause issues perhaps?

I think he did a great job otherwise, I just didn’t fully communicate my goals.

Thanks for your expertise.

A: What your surgeon is telling you is accurate in that an immediate secondary genioplasty is a lot easier to perform now than when you are fully healed. This will not increase the risk of the nerve recovery not proceeding like it would have after the first surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Safely Have Hairline Lowering After a Coronal Incision From Prior Skull Surgery?

Q: Dr. Eppley, I’ve had several scalp contouring surgeries done with you (6 or 7 coronal scar “openings” in total if I remember correctly). I wonder if it’s safe for me to have a hairline lowering surgery done, if it’s over 1 year post op since the last head surgery, or is there a risk of skin necrosis between the coronal scar and new scar from the hairline lowering then? I’ve heard it should be safe 1 year post op, since the head grows new arteries and blood vessels, but I wonder if this is the same case with me since I’ve had so many scalp surgeries done…? 

A: Good to hear from you again. If I understand what you wanting to do, you want to move the entire scalp (which is what a hairline advancement is) which would necessitate undermining well past the coronal scar. And the pertinent question would be whether the intervening scalp between these two incisions (new frontal hairline one and the old coronal one) would survive? That is obviously a very good question and I have not seen a similar case of hairline advancement. It is possible the scalp will survive without any problem, but if it does not….

All I can say about that question is when in doubt….do a delayed approach. You make the hairline incision needed down to bone and then simply suture it closed. Then 4 weeks later perform the actual hair advancement. This is what is called a true ‘delayed flap’ approach and has been used for skin flap surgery for one hundred years. In this way you ensure that new blood vessels find they way into the narrow island of skin between the two incisions from each side.

Dr. Barry Eppley

Indianapolis, Indiana

Is Fat Grafting A Treatment Option for Cutis Verticis Gyrata (CVG)?

Q: Dr. Eppley, I saw a response that you wrote on Is There Surgery For Cutis Verticis Gyrata? at https://www.eppleyplasticsurgery.com/is-there-surgery-for-cutis-verticis-gyrata/

I was wondering .. how does the fat injections you spoke of work and or is surgery a better option now? 

And do you do both?

A: I don’t think trying to cut out the areas, as has been historically done, is a very effective approach and has a risk of just making them worse. Fat injections tend to make them less deep, and while not a ‘miracle cure’ for them. is a less risky treatment option.

Dr. Barry Eppley

Indianapolis, Indiana

Am I A Good Candidate Injectable Fat Grafting for Shoulder Augmentation?

Q: Dr. Eppley, I had my pectoral implants replaced last year. If the photo looks familiar, Implantech has posted it on its website. I am very happy with how they turned out. I am now planning on ab etching of the waist, lower back, and flanks. I have read on your site that you have experience with fat transfer to the shoulders. My ideal would be to harvest as much fat as possible and transfer to areas where it would most successful. I am thin 5’10 and 155lbs and 56 years old. From first glance, do you think I would be a candidate for fat transfer to the shoulders? 

A: In answer to your question, you are a good candidate for far transfer to the shoulder IF your primary motivation for the surgery is the liposuction/etching etc. The reason I make that statement is because in that scenario you have nothing to lose by taking the harvested fat and transferring it to the shoulders. The worst that can happen is that the fat doesn’t survive. But even if that occurs it prepares the shoulder tissues for the placement of deltoid implants if you are so motivated. (the definitive shoulder augmentation procedure)

You have to recognize that at your age and low body weight, fat transfer to any face or body area is far from assured in terms of volume retention. The reality is that fat is more likely to survive at a very low percentage than a higher one.

Dr. Barry Eppley

Indianapolis, Indiana

Is 18Years Old Too Young for a Custom Jawline Implant?

Q: Dr. Eppley, I do apologize if this is not the correct way to contact you but i recently saw your Youtube video about custom jaw implants.

I was just wondering a few things. 

I am from the UK and was wondering if you are able to complete surgeries on someone out of the with US? 

I also am going to start saving soon for the cosmetic work I wish to have done and was wondering if there was any chance you had a rough cost so iIknew what i was looking to save ?

I do not want to waste you time by asking for a full consultation as I may not have the money for a few months and I fully understand costs may vary greatly depending on the patient, but just a ballpark figure would be fantastic.

Im 18 also and wonder also if it would be advised to wait until I was a little order or if i can get the procedure soon ?

Thank you so much and sorry for any inconvenience this may cause you.

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

1) The vast majority of patients for custom jaw implant comes from may different places all over the world. So it is common that patients travel in for the surgery.

2) My assistant Camille will pass along the cost of the surgery to you on Monday.

3) At age 18 your lower jaw is adequately developed to have the surgery.

Dr. Barry Eppley

Indianapolis, Indiana