Q: Dr. Eppley, I had a Mittleman chin implant three weeks ago via a submental incision. It initially looked to me despite the swelling and had no sigs of infection. I had some lip numbness on both sides and occasional shooting/electric shots on the chin during the second week after surgery. But all of his has been improving but I am still having pain in the right lower lip as if the “lip is split vertically. I also have some occasional drooling from the right from the right corner of my mouth. Pain is worse when I open my mouth. 

Do you ever find a CT helpful to confirm good implant placement without nerve impingement? I am willing to wait a little longer but if these symptoms do not improve I would consider removal of  the implant, possibly shaving down the right wing to make it more narrow and make sure to free any potential nerve impingement. This could just be a nerve traction injury resolving, but I don’t want to miss true nerve impingement if that needs to be addressed given the asymmetry in symptoms at this point.

Have you experienced this before and how have you handled this?

Thanks for your help and guidance!

A: I believe you have already answered your own question…remove any doubt about the position of the chin implant and get a 3D CT scan. That will unequivocally answer the question of potential implant impingement on the nerve. A Cone Beam scan (CBCT) of the mandible can be obtained at a local dental or oral surgery office (just search under Cone Beam scan and you find where to have it done locally) for less than $200. Such a scan will put both you and the surgeon at ease with whatever the management strategy is determined to be. (time vs implant adjustment)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After my 2nd open heart surgery my sternum never healed. It’s been almost 3 years since my surgery and I’m still in pain. I had my wires removed in 2017, that didn’t resolve my issues. Is the sternal plate rigid fixation something that could help me? My pain management doctor said he doesn’t think it’s nerve related.

A:The critical question is what is the source of pain. If the pain is a result of mobility between the two sternal segments, and a CT scan so demonstrates that such sternal non-union exists, then rigid sternal fixation would seem like a logical treatment choice. If there is no mobility then we would have to assume that it is more related to the overall trauma of the ‘chest splitting ‘ process for which there is no good treatment for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jawline reduction surgery five years ago, but I think the surgeon may have trimmed the bone a lot. I don’t like the looks that the jawline is very high on the angle now. I want to have an implant that brings the jawline down just a little but without looking too masculine. I also don’t like bulky jaw angle. I want to have feminine jawline look. I’d like to know what are my options?

I would like to consult with you in detail. I have attached a photo of me and pointed out some problems that I would to fix. Both sides of my jawline are not even. When I had a chin implant, my left jaw always showed more depression then my right side (see the pic). Would the custom jawline make the jawline even again like the photo I photoshopped next to it? I would like to achieve that result. 

Some of the questions I would also like to know. 

1) what are the risks associated with the custom jawline? What is the longevity of the implant? What happens when I get old and my jawbone shrink, would the implant still be in place?

2) cost. When can I expect the implant be ready?

3) Recovery time

4) can I fly back home after the surgery?

5) how is the procedure performed?

6) is the implant reversible?

A: A 3D CT scan of your face will provide the definitive answer as to whether what you see on the outside corresponds to what the bone looks like on the inside. For the sake of this preliminary discussion we will assume that there are underling bony asymmetries/deformities and that their correction will create the improvements you seek. In answer to your questions:

1) A custom jawline implant is permanent and can not be come displaced from the bone with age. Its risks are the same as any other implant went placed in the body. (infection, asymmetry of placement, over/under correction)

2) It takes 30 days after the CT is received to have the implant ready for surgery. My assistant Camille will pass along the cost of the surgery to you later today.

3) Recovery is one you already know. It would be the same as the recovery from your jawline reduction surgery.

4) Most patients fly home 2 to 4 days after the surgery.

5) The implant is placed through incisions inside the mouth (at least in your case)

6) The implant is easily reversible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, A couple of months ago, I had my masseter muscle trimmed which I totally regretted. Now I have depression on both sides where the muscle was trimmed. I see that the skin is going in a little. How do I fix this problem? Would fat transfer work? 

A: In answer to your masseter muscle problem, trimming the masseter muscle is always a bad idea as it leaves soft tissue depressions over the angle. This issue would become magnified of a custom jawline implant is placed to partially restore the jaw angles. Fat injections would be a one reasonable approach to treat it

The restoration of lost volume from a change in the shape of the masseter muscle is not an aesthetic problem that is easily remedied. Whether it is the result of disruption of the pteryomassteric sling (masseter muscle retraction) or masseter muscle reduction restoring its shape can be attempted by various soft tissue strategies. Fat injections is the obvious choice but not the only one. Dermal-fat grafts, allogeneic dermal sheets and even ultrasoft silicone implants can be used. I have done all of these strategies and each had their own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m contacting your office hoping to set up some sort of consultation for a Chin Augmentation procedure. I’m aware you do quick 10-minute pre-consultations over Skype, so perhaps that would be a starting point? However, I’m more than willing to move forward with a regular consultation if that would be most appropriate. What would you need from me to set up a consultation?

Beyond that, if this initial email might also be used as a launchpad for questions, I’ll include some of the ones I have regarding your office.

1How does your office handle the payments? (Lump/Monthly/ect…)

2What is generally the recovery time for the procedures? 

3How bad is the scarring from these procedures?

4Are the implants chosen from a stock set of preexisting implants or are they gathered by some other means?

5Certainly nothing meant against neither you, but I was told to inquire about this–how often do you preform these procedures?

6Are you or can you request to be put under for these procedures? Call me timid, but I’m not exactly experienced going under the knife.

7Kind of a silly question, but from your previous patients, how would you rate the pain before, during, and after?

8I most definitely wish to come in for a consultation fairly soon, how much would that visit cost?

9How far out are appointments made for chin augmentation procedures with your office?

Thank you for your time and I hope to hear back from you soon.

A: Thank you for your inquiry. I will have my assistant Camille contact you today to schedule a virtual or actual consultation time. She can also answer all logistical questions as they relate to your questions #1, 7 and 8. Int answer to the other questions:

2) Recovery is largely about swelling which takes about 3 weeks for most of that to subside. Although it really takes up to 3 months to see all of the details of the final outcome.

3) Submental skin scarring is minimal.

4) The type of chin implant chosen, standard vs custom, depends on the patient’s aesthetic needs and goals.

5) Chin and jawline procedures are performed every week multiple times.

6) Chin implant surgeries are done under general anesthesia.

7) Pain is not a big issue for patients after chin augmentation surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you analyze a patients soft tissue during a consult to tell them if they can achieve the angularity they hope for with facial implants?

A genioplasty and chin implant will have the same amount of angularity then, I suppose, right?

Also, does material matter? Do harder materials like PEEK or more brittle ones like medpor have any benefit?

A: In answer to your questions:

1) There is no preoperative test or method of evaluation that can predict how any patient’s soft tissues will respond to what is changed underneath it.

2) A sliding genioplasty and chin implant will have slightly different aesthetic effects because their resultant shapes are different. But both stretch out the soft tissues.

3) It is a myth that that any of the implant  materials used will have an influence on the overlying soft tissue effect. There is no biologic basis for that common misconception.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When it comes to the “short face syndrome” characterized with a shorter lower third compared to middle and upper third, this is often present without any problems in chewing or overbite / upperbite.

In my case, my maxilla is very forward (almost as forward as the likes of Jordan Barrett) but my jaw is small. It is not micrognathic nor retrognathic but just slightly smaller than average. I mean to say that it is short, narrow, and lacks forward projection (lines up with the hollow of the nose but not further than the lips). My bite is okay (class 1 with one or two crooked teeth) as is my breathing etc my only concern is aesthetic

Would your advice to someone who wants peak esthetic modification to be made to their jaw be to have the orthognatic surgery (cosmetic only, and expensive as hell) to fix this JAW OR

Just be to opt for either a simple osteotomy like a genioplasty, or implants like your big ones that fill up around the jaw and chin.

The other reason I am not too certain on the implant route is because they give a “bloated” look in a lot of cases, although I would not be surprised if it turns out that an orthognathic surgery would do the same thing.

I am curious what makes this procedure look so angular and sharp:

https://exploreplasticsurgery.com/wp-content/uploads/2016/02/Custom-Jawline-Implant-result-frofnt-view-Dr-Barry-Eppley-Indianapolis.jpg

When these ones were still effective but you can see they look a bit “bulkier” and less angular:

http://www.customfacialimplants.com/photos/custom-implants/customimplants36.jpg

https://exploreplasticsurgery.com/wp-content/uploads/2017/01/Custom-Jawline-Implant-Replacement-of-Medpor-Implant-result-front-view-Dr-Barry-Eppley-Indianapolis.jpg

One user on a board I frequent (and if you know the website Lookism, you know it’s filled with nonsense) theorized this is because of the material of the implant and that silicone gets “squished” by the tautness of the soft tissue. Others theorized it’s because of the masseter muscle.

What made the implants that I linked in that picture so effective when the others looked “bulky”?

Thanks so much for your time.

A:There are many variables that go into what happens with the external facial appearance after any underlying implant or bone moving procedure. But the most important one is the patient’s natural soft tissue thickness. In short, angular faces end up with greater defined results. Fuller faces do not usually get angular just bigger and fuller. The best analogy I know is lip augmentation. Full lips get nicely fuller with any form of augmentation. Thin lips never get nicely fuller no matter what is stuck in them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty where they lowered my columella and used a premaxillary implant at the base of my nose where the incision was in my upper gum line similar to the way you insert them.

I didn’t care for the premaxillary implant and had it removed. I now notice my upper lip is longer and the red part of my upper lip hangs down lower. 

Is this because the premaxillary implant stretched the muscle and skin in my upper lip area? 

What can be done to bring my upper lip position back to where it used to be? 

Would a lip lift work and if so, doesn’t this only address the skin and not the muscle that was also stretched? 

A: Like the method that stretched out the upper lip, you have to do the same to restore it….an intraoral lip tuck to shorten the vermilion and a subnasal lip lift to shorten the vertical distance between the nose and the upper lip. This dual approach would be the most effective approach in lifting the lower lip back up after premaxillary implant removal..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21year-old male. I had my brow bone shaved because it looked like a Neanderthal. Although my surgeon shaved it too much and now it looks too feminine.My question is can fat grafting make my brow ridge more masculine and how masculine can I achieve? Since I don’t want to have an invasive procedure again.

A: Given your own restrictions (no surgery) you are left only with the options of injectable fat for fillers. How aesthetically successful they can be can not be predicted beforehand. But suffice it to say that ‘soft’ materials like fillers and fat do not create the same effect as stronger augmentation materials like bone cements or implants. While I see little harm in doing injectable fillers, which are reversible, I would try that first before doing fat injections. Perhaps for just a little bit of indistinct brow bone augmentation these softer materials may be effective for your brow bone aesthetic needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you with my concerns as I have seen you respond to Real Self posts concerning similar issues. 

About two years ago I have v-line jaw reduction done (I am transgender and currently 30 years old). I had a fairly broad jaw before surgery. The surgery was fairly good and I’m mostly satisfied with the bone work, but I find I have too much soft tissue now which makes my face appear bottom heavy. I have very very subtle signs of jowls and do have pre-jowl indents. My skin is in excellent shape. I would like to improve my jawline and I’m not sure if some sort of mini lower lift or lipo would be the way to go here. I’d like to hear your opinion.

A: Just by your general description and having seen a lot of patients with your exact soft tissue issue after V-line jaw reduction surgery, only a limited form of a lower facelift can address the now lax tissues which have resulted due to the removal of bone support. This so called ‘tuckup’ lower facelift produces skin tightening right over the jaw angle area which is most affected by the prior jaw reduction surgery.

Dr. Barry Eppley

Indianapolis, Indiana