Q: Dr. Eppley, I had Medpor jaw angle implants placed (medium design onlays) However I am not completely satisfied as it was the RZ mandibular angle implants I thought I was getting but I thought I’ll give it time to see the results. But they have added absolutely zero vertical length at my angle and are too small. 

I am looking for a revision jaw angle implant surgery and I want it done with best chance of success and it’s your name I’m constantly hearing of . I am wanting these removed and replaced with the large RZ implants.  I’m hoping for a good bit of flare along with a drop down at the angle also. What would be the start in getting a rough cost and the getting the process started with yourself. 

A: Thank you for your inquiry and detailing your jaw angle implant surgery history. Whether your goal of achieving ‘a good bit of flare with a drop down at the angle’ with standard jaw angle implants remains unknown to me at present. Until I know exactly where your current implants are positioned, how they compare to that of the dimensions of RZ implants, and what you look like before, now as well as what your computer imaged goals are, I do not yet have confidence that such a standard implant exchange can be aesthetically successful for you. 

It becomes critical to determine before another surgery that it can truly be successful. Given the challenge that removing Medpor jaw angle implants poses, you would want to have a high level of confidence that it will work.

The first step is to get a 3D CT scan of the lower jaw (CBCT or cone beam scan) to see the current location of your implants.

Dr. Barry Eppley

Inianapolis, Indiana

Q: Dr. Eppley, I am 72 years old and am only interested in getting rid of my turkey waddle with a direct necklift. Surgeons here in New York  do not want to do this surgery because it is an older technique. I have had a consult with a surgeon here in New York but his cost was well  over 10k for this simple surgery. 

A: Thank you for your inquiry. The reason surgeons are hesitant to do this surgery (direct necklift) is because of the scar that runs down the middle of the neck….which in women is much more of a concern that it is in men who have beard skin which heals better than non-hair bearing skin.

While a direct necklift is less invasive surgery with a quicker recovery than a traditional lower facelift, I would not call it ‘simple’ surgery. It still requires time and good technique to adequately get rid of the turkey waddle while creating a fine line scar in a visible area of the neck. 

I will have my assistant Camille pass along the cost of the surgery to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have numerous lower third facial reshaping questions:

1. Based on the “wish-pics” I shared with you, do you think it would be possible to get favorable results with just a well defined custom chin implant, micro-liposuction to the jawline, and buccal fat removal? or are the jaw-implants needed as well? I’m afraid I may look too masculine or the angle may look unnatural.
2. Will I still have a continuous look to my jawline if I get the 3 custom pieces instead of the wraparound or will there be noticeable gaps in between?
3. Do I need a custom chin implant for the look I want to achieve (less recessed more prominent harmonious chin) or will an out-the-box chin implant do? 
4. Do you have any pictures you can share with me of similar cases of female jawline augmentation? I found only a few on  your website.
5. What % of your jaw implants are female?
6. What % of your patients get revisions after a jawline procedure? 
7. What % get infections from the implants?
8. What other surgeries would you recommend to improve my facial profile to look more balanced?

A:Thanks for resending the email and providing all of your pictures. The answers to your questions are as follows and are abde done your pictures and the effect of a ‘jaw thrusting’ maneuver:

1) Such a jaw thrusting maneuver always bring chin forward and at a 45 degree angle. This also tends to thin out the face from under the cheeks back to almost the jaw angle area. No where in this maneuver does it necessarily make the jaw angles wider or more square.  Thus it seems appropriate that the right design of a chin implant and buccal lipectomies and perioral and jawline liposuction would be appropriate.

2) As in #1 I question the values of any jaw angle augmentation at this point. I would rather do first what is described in #1.

3) A standard chin implant will not work as it can not create the important 45 degree lengthening needed. It is either a custom chin implant or a sliding genioplasty. I personally prefer the latter as it is better for the neck as it pulls the neck muscles forward as the chin bone comes forward. 

4) Whatever pictures have been approved by patients to post (and most don’t) is available on www.exploreplasticsurgery.com and you can  look under different procedures in the search box.

5) For any form of chin/jawline augmentations about 20% are females. Males dominate this type of facial procedure.

6) The very specific type of jawline augmentation needs to be identified as they can be very different. A  jawline augmentation procedure that relies on a sliding genioplasty would have revision rates less than 5%. Those that involves  a custom chin implant around 10% or less.

7) Chin implant infections, of any size or shape,  are in the range of 1% to 2%.

8) I think your primary focus in the lower third of your face seems appropriate. That is the most ‘out of balance’ facial feature you have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Lately the shape of my skull has been bugging me and I wanted to get a professional opinion on it. I have a dip/ridge at the center top of my skull. At times when I’m taking to people are work I can see their eyes dart over to the abnormalities in my skull. Naturally this stings the confidence a little bit. 

With your years of expertise, would you deem the shape of my skull as misshapen enough it needs corrective surgery? 

Would my skull require alot of corrective material? What kind of cost am I looking at? The recovery process? 

I have so many questions and don’t know if I’m asking the right ones.

A: Thank you for your inquiry and sending your pictures. A shaved head makes for a complete reveal of anyone’s head shape and I can clearly the dip to which you refer which is a transverse indentation along the original coronal suture lines. That is ideally treated by filling in the skull dip which is best done through a less than one inch incision placed in the middle of it which will heal imperceptibly. The augmentative material would be a custom implant design from your 3D CT scan.. It would really be like a thin strip of material which you can almost envision from the outside.

Whether this should be treated I can not say since this is a cosmetic issue of which only you can make that determination. I can only tell you how it would be done should you choose to do so..

I will have my assistant Camille pass along the cost of the procedure to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I previously had a BSSO/Lefort I to open up my severely restricted airway and address sleep apnea. While I did receive some relief from the apnea (about 50% improvement in nighttime breathing), the aesthetic result has been a huge problem for me. I had delicate features going into the surgery and the effect of advancing both the upper and lower jaws threw my overall facial balance and harmony out of whack. I have never become accustomed to my new look. This has upset me greatly since the surgery – especially the look of the upper jaw. I look odd and unnatural. A year after the surgery I had cheekbone implants to create greater balance by addressing my midface deficiency. I also had a genioplasty to address my concerns with the chin and jaw that I felt were too strong for my delicate features. But obviously neither one of those procedures are going to address the impact on my appearance caused by the maxillary advancement – and my chin and mandibular still remain too strong in appearance, overwhelming my other features. I fear this imbalance is only going to get worse with age. Can a BSSO/Lefort I ever be set back a bit, or essentially reversed? Does it involve major surgery and a long recovery like the original BSSO/Lefort I? Can you help me? Thank you for your time.

A: Thank you for your inquiry and detailing your history. A maxillomandibular advancement can be reversed in most cases of which the surgery and the recovery would be identical to the first time as it is the same operation just a different direction of movement. As a result this gives one some serious consideration between balancing the aesthetic tradeoffs and the functional improvements gained from the first procedure. Whether are other alternatives to that approach I can say without comparing your before and after surgery pictures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about the zygomatic process of the temporal bone (I believe that’s what it’s called—I’m referring to the bone on the side of the head that connects the ear to the cheekbone). For me, my face is asymmetrical in that it’s wider on the right side of my face than my left. I was wondering if there’s any procedure to thin the bone a few mm and improve symmetry. I have read several posts by you and I believe it is called a posterior zygomatic arch osteotomy.

Thank you.

A:Thank you for your inquiry. You can reduce the prominence of the temporal process of the zygomatic arch. (or the zygomatic process of the temporal bone….depending upon how one chooses to call it) I have done so many times. This is technically called a posterior zygomatic arch osteotomy. This is done by an angled osteotomy with plate and screw fixation to hold the cut bone inward. This is done through a small vertical skin incision at the back end of the sideburn hair in front of the ear.

A very relevant question is whether this is the actual bony reason you perceive an external facial asymmetry. Ideally a 3D CT scan would be needed to confirm the diagnosis before one should do the surgery. The differences in the two sides of the face at the posterior zygomatic arch area will be clearly revealed by such a scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have quite a few questions about sagittal ridge skull reduction surgery. 

What does the procedure actually entail? I have a pretty decent idea from researching a few surgeries that you have already performed like this. 

What is the downtime after this kind of procedure? I can’t take a ton of time off work. 

What is the post surgery scarring like? 

Finally, do you think I would be a good candidate for this procedure? I have a less prominent saggital problem than some other I’ve seen on your site, but more than one I’ve seen. 

I have questions about cost and financing as well, but I’m sure those can wait until we discuss more. Pics below, but I can take better ones if needed.

A:Thank you for sending your pictures which chooses a classic posterior sagittal ridge skull shape. In answer to your sagittal ridge skull reduction surgery questions:

1) The procedure involves a burring (shaving) reduction of the raised ridge through a small scalp incision (3.5 ms) behind it.

2) .The recovery is very quick, no more than a few days other than some mild scalp swelling.

3) Such scalp incisions heal very well. No patient has ever requested a scar revision or had any issues with the scar.

4) Your candidacy for the procedure is based on how much it bothers you and what you want to put yourself through for its reduction.

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

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an issue where my right eye is lower than my left eye. I also have an issue that my eyes are droopy looking from one side which is my left. So I decided that I wanted a cat eye surgery to help me to be confident. I am going to Iran in a couple weeks time & I am going to get the corner of my eyes drilled for the cat eye. However I know that my eye is still going to be vertically not aligned. I messaged another doctor and they said there could possibly be a risk if they perform the procedure on me to get it to be vertically aligned. In real life you can’t tell unless you stare at my eyes. most people do not even know that they are like this. but in pictures it always comes out 10x worse and it just makes me feel insecure. is there any way to fix this problem ? Sorry for the long message and thank you doctor.

A: In vertical orbital dystopia (VOD) the eye is lower because the bone underneath it (orbital floor and orbital rim) are lower than the other side. This may also affect the cheek as well. A 3D CT scan would be needed to determine the exact shape of the bone underneath it to best determine how ti build up the bone to raise the eye. The upper and lower eyelids are also lower so that has to be addressed as part of the surgery as well. The two eyes are never going to be perfectly symmetric but significant improvements can be obtained.

Whether you elect to treat your VOD has an impact on Cat Eye surgery. If you are going to treat the VOD, Cat Eye surgery should be done after.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Firstly, I would like to say it’s great to get in touch with you. I wanted to ask a question about fillers. I like the the idea of custom wraparound jaw implant and custom Malar-zygo implant, but I wanted to ask if you could do a filler that would emulate the look of those two implants? I feel that it would be a good try on for the look, and if i like it, I could get implants down the road later. My goal is just to add get a decent result without too much deviation. Would fillers be able to let’s say add mass in the jaw and make zygos look more projected? Do you have fillers for this option? 

A: The simple answer is injectable fillers are not going to replicate what implants do, particularly of the jawline and along the infraorbital area. They are materials that have rvery different chemical structures and degrees of hardness/softness and are placed at different tissue levels. Fillers produce indistinct amorphous voluminization while implants produce a more distinct and defined look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, On my question on Real Self, you answered me that chin, jaw and Infraorbital-malar augmentation would be of my benefit. 

I know Infraorbital-malar augmentation can be achieved by a custom made implant only. 

But what about the chin and jaw augmentation? Do you think it could also be achieved by standard implants in my case? Or do you recommend to get a custom wrap around implant to augment my jaw and chin, and make it more symmetrical? 

Also, I know it’s not easy to answer questions on the price, because it’s very specific for each individual, but could you maybe tell me something more about the price-range for both a custom jawline implant and a custom Infraorbital-malar implant? 

My goal is to get a more masculine look, and make my face more symmetrical and balanced, and get the high cheekbone look. 

I will provide the same pictures I posted on Real Self.

A: The short answer is if one is getting one set of custom implants (Infraorbital-malar) it would sense to do a second custom at the same time (jawline) sine the manufacturer offers a significant discount for designing and making of two custom implants using the same design sessions.

My assistant Camille will pass along the cost of such procedures to you by tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana