Can My Uneven Brow Bones Be Reshaped?

Q: Dr. Eppley, I have an uneven brow ridge with uneven eyebrows (one is flat while one is pexed, makes me look constantly expressive). I want to know if it’s possible to correct the asymmetry of my brows and adjust their position so that they are both closer to my eyes, giving more hooding if possible. I have produced a (poorly edited) morph of the look I would like to achieve. How realistic are my goals? Can it be done with implants/ a solution other than fillers and Botox? Thanks.

A: I find that your eyebrow shape goals are only partially realistic. The first question is about the asymmetry…why does it exist? If it is bone based, as the eyebrows often follow the shape of the bone, then a custom brow bone implant for brow bone reshaping can be done which may also help lower them a bit. If the eyebrow asymmetry is soft tissue based this is more problematic as then only temporary Botox injections can be done. Bit either way it is to possible to move the eyebrows inward or any closer as there is not treatment, non-surgical to surgical that can do so.

Dr. Barry Eppley

Indianapolis, Indiana

Can Facial Implants Be Seen On Dental X-Rays?

Q: Dr. Eppley, I wanted to ask a question regarding jaw and cheek implant. Are facial implants such as these visible in dental x-rays? I am strongly considering this procedure but feel somewhat insecure about someone seeing them in x-rays. Is there anywhere I can see how the look on an x=ray? 

A: Non-metallic implants are not seen in a dental x-ray which would be that of a panorex. However any screws used for the implant’s fixation would be.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Chin Implant Lessen The Labiomental Fold?

Q: Dr. Eppley,  I have had a prior sliding genioplasty but want more of a result with further horizontal augmentation. But  I’d like to avoid a revision genioplasty. I was wondering if you think it would be possible/advisable to get advancement of the chin and labiomental fold area with a combination of chin implant (I think wraparound would make sense if I’m already having the jaw implants) and some soft tissue procedure to reduce the fold (filler possibly?). I attached a morph of my goal and a superimposition.

A: The amount of horizontal chin advancement you have shown is achievable with an implant. However filling in the labiomental fold can not be done with any form of an implant as that area reflects the attachment of the mentalis muscle which sits above where any implant can be extended. That is an area which can only be augmented by fat grafting. But that part of your imaging is not achievable in the magnitude you have shown.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Get Botox For Masseter Muscle Swelling After Mandibular Implants?

Q: Dr. Eppley, A week ago I had mandibular implants placed. My jaw muscles are not extremely large and bloated. Is getting Botox so soon after surgery an option? Would that compromise the result or healing, or would it have any negative effect on the implant? 

Thanks 

A: While your questions are more appropriate for the surgeon who did the procedure and that is really his/her responsibility to answer them, I will do you the courtesy of providing an answer.

Aesthetic recovery from jaw angle implants takes a full three months to see the final result. It would be completely expected to have swollen jaw angle tissues at this early point after surgery. The use of Botox injections would be both biologically and medically the wrong thing to do and could well end up infecting the implants. Time is the answer to your facial swelling issues and there is no easy and simple method to expedite that process.

Dr. Barry Eppley

Indianapolis, Indiana

Can Orbital Box Osteotomies Be Done To Increase Intercanthal Distance?

Q: Dr. Eppley, I have an aesthetic eye spacing concern. I believe my eyes are positioned too close together in proportion to the rest of my face. It is something that has bothered me for a very long time and I am willing to do whatever it takes to find a solution.

Through my own research I have realized that increasing intercanthal or interorbital distance can seemingly only be achieved through highly invasive and expensive craniofacial procedure that would undoubtedly have many aesthetic trade offs of its own. Widening of the nose bridge, full coronal scar and bony step offs seem to be the most significant. Even in consideration of these trade offs, I still feel as though I could benefit from this procedure.

I would first like to know whether it is even possible to achieve such a movement of the orbits (3-6mm) with a high enough degree of accuracy and predictability? If so, is it plausible that a cosmetic patient could undergo the procedure if they were both well informed and highly motivated? I can send pictures for evaluation if it would be helpful.

I just find it very hard to accept that my biggest and most detrimental perceived flaw seems to be one of the only things that does not have an easy cosmetic fix.

Thanks

A: The issue is not whether orbital box osteotomies can be performed to increase intercanthal  distance by 3 to 6mms, because you can, but whether the aesthetic tradeoffs you have mentioned and the magnitude of the procedure (a frontal craniotomy is needed) and its cost could be justified for that type of aesthetic eye change. It would be hard for me to imagine that it would.

Dr. Barry Eppley

Indianapolis, Indiana

Can Infraorbital-Malar Augmentation Be Done By Osteotomies and Bone Grafting?

Q: Dr. Eppley, I have a fairly recessed midface and orbital area. This is noticeable from profile and indicated by my negative orbital vector. It also results in the appearance of dark tear troughs under my eyes. I would like to fix this through any means possible. My problem is that I have a great aversion to implants. It is not that I doubt their effectiveness, I am just irrationally uncomfortable with the idea of having them in my face. Though I realize I may have no other choice than to ultimately go with implants… But in any case, my question to you is this: Could you perform any sort of osteotomy that would advance the infraorbital rims as well as possibly the malar-zygomatic complex? If so, I’m guessing it would be a lot more complicated and perhaps risky than simply getting implants, but I’d be very interested to hear about it and understand all my options. Thanks in advance.

A: As you have correctly surmised trying to achieve infraorbital-malar augmentation by osteotomies and/or bone grafting is fraught with many issues such as bony step-offs and  irregularities to name the most prominent of them. But their main aesthetic drawback is that moving the bone fails to raise the infraorbital rim which is a key augmentation dimensiona change needed in addition to moving to forward. in short trying to move the bone is both an inadequate solution as well as one that creates its own aesthetic issues.

Dr. Barry Eppley

Indianapolis, Indiana

Can Rib Removal Be Done Right Under The Breast?

Q: Dr. Eppley, Can the costal margin directly under the breast be shaved/reshaped/removed? Or is that not possible due to it be so close to the chest? Most people I’ve seen with costal margin protrusion are usually lower and not directly under the breast like mine(i have an extremely short torso).

A: The costal margin under the inframammary crease of the breast can be reduced or removed and is a common rib graft harvest site in nose and jaw surgery. The question is not whether it can be done but whether it can achieve the contouring effect that you desire. It is not clear to me yet how rib reduction in that area will improve a short torso.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Get Scapular Reduction, Rib Removal and Clavicle Reduction All Done During The Same Surgery?

Q: Dr. Eppley, In addition to my previous email, I’ve become intrigued by a recent post you put up on IG regarding clavicle reduction. I’m interested in doing somewhat of an “upper body feminization” if you will. I’m transgender (MTF) and am interested in learning more about whether there would be any significant benefits to such a process. I was thinking of a combination of clavicle reduction, scapula reduction and rib removal. 

I understand the rib removal process since it’s relatively straight forward. However, I’m interested to know about the other two procedures and so I have the following questions;

1- in terms of diameter, how much reduction can generally be achieved with clavicle reduction?

2- If scapula reduction can be performed, how big of a scar would result and where would the incisions be placed? 

3- Can all three surgeries be accomplished at the same time?

Aside to the aforementioned questions, I’d also like to get a quote from your office regarding the above procedures. 

I have attached the photos originally requested and an attempt of clavicle photos, please let me know if further photos are needed. 

A: I think it is important to review the anatomy of the scapula which is the best way to determine the implications of its reduction besides the scar. By your pictures the most prominent part of the scapula is its inferior angle. This bony portion of the scapula is the origin of the terms major muscle which has a role in arm movement. Between the scar and the loss of teres major muscle attachment I would be very cautious about considering this type of back contouring procedure. Its is not a question of whether it can be done but whether its tradeoffs are worthwhile. I would be more enthusiastic about it if the inferior angle was shaved rather than completely removed, thus keeping some of the muscle attachments.

In answer to your other questions:

1) For the clavicular reduction procedure, I would refer to one of my websites, www.exploreplasticsurgery.com, where you can search under Shoulder Width Reduction. There you will find detailed answers to your questions as to how the procedure is done with clear pictures of it.

2) I think that putting together all three body contouring procedures together, even if scapular reduction is advised, is too much  from a recovery standpoint,. Even any two of them would be difficult.

Dr. Barry Eppley

Indianapolis, Indiana

Will Custom Facial Implants Looks More Chiseled Than Injectable Fillers?

Q: Dr. Eppley, I’d like to ask 2 questions to Dr. Eppley regarding my future procedures I’m going to get from him 

1) If I get a custom jawline implant and infra-orbital-malar implant, will they always look “sharp / chiselled” or does that depend on bodyfat percentage, and if someone stores a lot of fat on his face then the implant will look “bulky” instead of “sharp/defined/chiselled” (especially the jaw and zygos)? 

2) Why do fillers (Juvederm Voluma in the jaw and chin) lose their sharpness in the first month and instead become “bulky”? Is there a scientific explanation for this? 

Thank you.

A: In answer two your custom facial implants questions:

1) The creation and persistent of any facial angularity done by custom implants depends highly on facial fat content…both initially and long-term.

2) Injectable fillers are soft gels int which the tissues pull back quickly and distort their shape to relieve the pressure they exert. The firmness of implants prevents that effect from happening.

Dr. Barry Eppley

Indianapolis, Indiana

Does Orbital Decompression Affect Horizontal Palpebral Length?

Q: Dr. Eppley, how would orbital decompression effect palpebral fissure length? I have rather wide set eyes, albeit shallow set ones, and anything that would make my eyes seem horizontally shorter would be sub optimal.

A: The orbital decompression procedure is not known to necessarily affect horizontal palpebral length. Theoretically it may as the eye settles back in but that is not an assured aesthetic effect and most likely would not do so. This aesthetic issue is not a reason to do the procedure or avoid it either.

Dr. Barry Eppley

Indianapolis, Indiana