Is a Custom Wraparound Jaw Implant the Best Way to Fix My Short Chin?

Q: Dr. Eppley, I would like to know if a custom wraparound jaw implant can address my short chin or it would be better to do a genioplasty and individual jaw implants? I was told by a local Dr that I would need 8mm vertical jaw angle lengthening and 12mm of anterior chin projection but I find your posted results to be superior so I want to know what would you recommend. Thanks.

A: I am not sure where those jaw augmentation estimates are based on as in looking at your face as they seem to be excessive  A horizontal chin augmentation of 8 or 9mms and a vertical jaw angle lengthening of 3 to 5mms is the most you would likely need…although computer imaging would have to be done to determine what you are trying to achieve. A total jawline implant provides the most predictable and connected jawline augmentation method and is always better than three separate unconnected jaw augmentation methods.

Ultimately computer imaging of your face needs to be done to help determine exactly what type and degree of jaw augmentation you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Can Custom Cheek Implants be Designed with Existing Standard Cheek Implants in Place?

Q: Dr. Eppley, I had my cheek implants (Terino malar style 6mm size) placed about 10 years ago. As I get older I realize I look tired because of my under eye bags seemingly created by the forward placement of my implants. I have always wanted a more posterior “high cheekbone” extended arch implant that you describe and have pictures on the website. Is it still possible to replace my off the shelf implants with custom extended implants even though I already have implants in place?

A: There is no problem changing out your current cheek implants with new custom designed cheek implants. In fact over 1/3 of all custom cheek implants are done in patients who have had prior standard cheek implants.

In computer designing cheek implants, any existing cheek implants can be digitally removed to make the new ones. it is also helpful once the new implants have been designed to digitally bring back in the existing implants to compare the two designs in shape and bone surface area coverage. 

Dr. Barry Eppley

Indianapolis, Indiana

Treatment of Iliac-Costal Syndrome with Rib Removal

Q: Dr. Eppley, I am very interested and serious about the procedure.  Although I am not seeking rib modification for cosmetic reasons only. I am an avid walker and cycler. During exercising and movement, my lower ribs touch my hip bones (or something in there!)   It is extremely bothersome and impedes my workout significantly. I realize there can be some risk and residual rib pain. Staying fit and working out is critical to my health. I realize you may not resolve the issue completely, but any relief would be acceptable. I am financially prepared for this and interested in pursuing rib modification.  Thank you Dr Eppley, I know you are highly experienced in this procedure and I greatly appreciate your assistance.

A: What you are describing technically is known as iliac-costal syndrome. Getting rid of the outer half of ribs #s 11 and 12 on the affected side has proven to be vey helpful in symptom relief in this rib-associated syndrome. I have had some patients who have requested removal of rib #10 also but that rib should have no contribution to impingement on the iliac crest given its more horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jaw Angle Implants after Overdone Jaw Angle Reductions

Q: Dr. Eppley, I had cortical jaw reduction done in Asia and unhappy with the results. Do you do custom jaw implants? if so,would PEEK or titanium mandible angle implants be better? Thank you. 

A: I have done hundreds of custom jaw implants out of every available material. Whether the more expensive options of PEEK or titanium are viable options for your jaw restoration would depend on what size of implant is needed and what you are willing to pay for the surgery…as both PEEK and titanium custom jaw angle implants are considerably more expensive than those made out of solid silicone.

Ultimately a 3D CT scan of your jaw is needed to determine what size jaw angle restoration is needed. That may also influence the material choice for the implants.

Dr. Barry Eppley

Indianapolis, Indiana

Orbital Decompression and Custom Orbital Rim Implants for Orbital Proptosis and Psuedoproptosis

Q: Dr. Eppley, I am a 43 yr old female seriously interested in orbital decompression surgery and I believe I may need eyelid retraction surgery as well. I follow Dr.Eppley on Instagram.  He advised me to seek a local oculoplastic surgeon to address my concerns. There are 2 in the city of Memphis, TN.  After consulting one, he admitted he had very limited experience performing the surgery because there isn’t a demand for such a surgery in my city.

I do want to ask some questions, prior to my consultation, if I may? If you can answer any of the following, that will help me to narrow down my questions during my virtual consultation.

I have included pictures to assist you or Dr. Eppley in hopefully answering my questions.

Here are some of my problems with my eyes:

*I have my thyroid tested annually, my last test said all my numbers were in the normal range.

1Bulging – it appears to be getting worse as I age.

2. Excess skin or fat on my lids. Hooded eyes – I do not like it. I do not like it!!

3. Inability to close my eyes fully when I sleep.

4. Asymmetrical eyes – sometimes it is so drastic.

5. Double bags under my eyes when I smile.

6. Eye shape – my down turned eyes ages me, in my opinion. Can an eye shape be changed during surgery?

My goals would be to fix those aforementioned problems.

The questions I have are as follows:

1)Am I candidate for orbital decompression surgery?

2) How long is the recommended stay for out-of-town patients?

3) Does private insurance cover orbital decompression surgery? (I have Cigna, which is out of network).

4) If insurance does not cover any of the costs, how much roughly would it costs for the procedures I have listed and/or any procedures Dr. Eppley deems necessary?

I greatly appreciate your time and consideration.

A: In answer to her questions:

1) I think you ideally need the following combination of procedures:

     a) orbital decompression

     b) upper blepharoplasty

     c) lateral canthoplasties

     d) orbital rim augmentation

    While you may have orbital proptosis, there is also a signficant contribution of infraorbital rim/midface deficiency.

2) Patients usually come home in a few days after the procedure. Recovery is largely about swelling and its resolution.

3) I do not take insurance

4) My assistant Camille will pass along he cost of such surgery.

You would need a 3D CT scan to determine the bone anatomy as well as a preoperative ophthalmology evaluation that determines you do not have a metabolic basis for your orbital proptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jaw Angle Implants Design and Surgical Placement Process

Q: Dr. Eppley, I was reviewing some information with a custom jaw and chin implant that was one piece and appeared to have some soft portions to it.  I don’t believe that I need a chin implant.  I was just checking in regard to the custom jaw implants.  

How long would it take to examine me, design and fabricate the implants?  Approximately how long for surgery?  Would it be better for me to be there in person for you to examine me initially? 

A: I am not sure what information exists that suggests that any custom one piece total jawline implant has some ‘soft portions’ to it. But that is certainly not true. 

To be implant type specific the term ‘jaw implant’ refers to any implant that may be used along the jawline at any location, it is a general term. What you are seeking are ‘jaw angle’ implants, one type of implant that is used for the back end of the jaw.

On average it takes 30 days to design, manufacture and ship for surgery any custom implant…after a 3D CT has been obtained from which the implant is so designed. That would be the shortest possible time.

The surgical time required for removal of your existing jaw angle implants and their replacement with new custom jaw angle implants would be 90 minutes.

Seeing you in person doesn’t really add much to deterring what a new implant design would be. Having existing implants in place is the single most important aid in a custom implant design. Such implants can clearly be seen on the bone in the 3D CT scan. When you know what you have in you doesn’t work well, you have a good guide as to how to improve their design and dimensional requirements.

Dr. Barry Eppley

Indianapolis, Indiana

Submental Chin Reduction for Hyperdynamic Chin Ptosis

Q: Dr. Eppley, I just sent a request for the “Predict my face” on your website. I am scheduled for a submental chin reduction on January 15th. It’s obvious when I’m smiling that my chin needs reducing. This is what motivated me to pursue this procedure. However, when playing around with photo morphs, I came to realize that when I’m not smiling, the chin seems to be in the right place (very slightly protruded). I have a unique profile view because my lower jaw may be slightly receded (although my bite is good, there is a slight overbite). When I reduce my chin in the non-smiling photos, it doesn’t take long before I look like I have a receding chin.

I have attached a video of me progressing from not-smiling to smiling. About how much are you thinking needs to be reduced? I believe that the procedure will still benefit my profile, do you agree?

On another note, I have attempted to get the cone beam x-ray, but places around here will only let me use their machine if I am patient of theirs. I’m not planning on getting it done unless you think it will be helpful in determining the amount to be removed.

A: In answer to your questions:

1) In hyperdynamic chin ptosis , the chin position at rest is often normal. That always poses a dilemma because surgery is done in a static position (at rest) for the treatment of largely a dynamic problem. (in motion) The key is to not overdo the procedure and treat it like it is a large protruding chin at rest.

2) While at rest I would not consider your chin overly protrusive it is still a strong chin in profile that a few millimeters of projection loss would not cause it to become recessive. 

3) The removal of 2mms of bone is merely to allow the soft issue resection to be tucked in to reduce the dynamic protrusion of the soft tissue chin pad. 

4) A preoperative x-ray is not needed since the procedure is not largely based on bone resection as so indicated in #3 above.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant after Sliding Genioplasty

Q: Dr. Eppley, I am interested in getting a bimaxillary advancement in due to sleep apnea and a receded chin/ midface. 

After this i was hoping to get a custom jaw implant from your surgery. Would the sliding genioplasty as part of a maxillary-mandibular advancement effect the ability to design a custom implant? 

Thanks 

A: The simple answer is no. It does not matter what the underlying bone shape is when it comes to computer designing a custom facial implant to lay over it. It is quite common in my experience to do custom jawline implants in patents who have had a prior sliding genioplasty. In fact it is also not rare to do a simultaneous sliding genioplasty with a custom jawline implant overlay.

Dr. Barry Eppley

Indianapolis, Indiana

Can Iliac Crest Reduction Be Done?

Q: Dr. Eppley, I was wondering if there was any type of surgical procedure that would directly involve changing the shape of the pelvis, not through fat transfers or implants, but with a modification of the bone itself. Specifically of the iliac crest, to give a male pelvis less height and more width if that makes sense?

Is there a way to make the male iliac crest more like the female iliac crest, giving a female hip flare to a male pelvis? I’d be very interested to know if this surgery is possible and if so the costs/recovery of such a procedure. If not, I’d very much like to hear alternatives to the procedure to produce wider, feminine hips. 

A: There is no surgical method to change the shape of the bony iliac crest that dimensionally reduces it height and gives it more width without undue scarring, plate fixation, risk of bony non-union and considerable postoperative pain The only treatment option is to augment the sides of the iliac crest with an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Male to Female Transgender Rib Removal Surgery for Waistline Reduction

Q: Dr. Eppley, I have questions about rib removal surgery. I’m a MtF transgender and have a very hard time narrowing my waist. This gives (in my opinion) a very masculine appearance to my body. I was wondering how much a rib removal is, how dramatic you think it can be in a transgender patient, and if it would be enough to give a feminine appearance to the ribcage, or if corsetting would still be required for a “tapered” look. I’m looking for something drastic in my body, but something that still seems natural for a woman if that makes any sense. 

I’d also be interested in any before and after that may be available for transgender patients that have had this procedure, if there are any available! 

A: About 1/3 of the patients in which I perform rib removal for horizontal waistline reduction are MtF transgender patients. They seek the procedure out for the exact same reasons to which you have described. Because of their genetic male ribcage and torso shape there is no other effective alternative. Removal of the lower half of ribs #10, 11 and 12 (as well as a wedge of latissimus dorsi muscle) removes an anatomic barrier for whatever maximal waistline reduction is possible. The degree of such waistline change is open to personal interpretation as to what constitutes ‘drastic’. Noticeable is what I could call it but I would never use the term ’drastic’ as that implies an unrealistic surgical expectation. I have never had a transgender patient, or any rib removal patient for that matter, complain afterwards that the result was inadequate…but I know why. This is all that can be done for waistline narrowing, there no other alternatives so whatever the result is is the best that can be achieved.

A period of postoperative corseting is always helpful as the compression helps with swelling and the shaping of the waistline. But I do not see it as a necessary permanent waistline shaping method to do.

Dr. Barry Eppley

Indianapolis, Indiana