Your Questions

Q: Dr. Eppley, I have read from some sources that orbital box osteotomies is an extremely risky procedure, but have read elsewhere that the risks are over exaggerated. Can I please ask for your opinion of the risks involved? Also, are there any alternatives that you know of that can increase interpupillary distance?

A: From a medical standpoint I would not consider orbital box osteotomies as particularly risky, although it does require a frontal craniotomy to perform. From an aesthetic standpoint, however, there are going to be some tradeoffs. (bony irregularities, long coronal scalp scar) And 100% of orbital box osteotomy patients (children, teens and adults) are going to need revisional surgery to improve any of the aesthetic tradeoffs. Thus like all aesthetic surgery, which always trading one problem for others, the decision for surgery is balancing the benefits vs the risks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have a flat crown/flat back of skull. I figure I would need about an 1 1/2 inches of added depth to the top and back of skull to provide my ideal skull shape. Please advise if this can be attained realistically. Thanks.

A: Thank you for your inquiry and sending your pictures. Crown of skull/back of heads are commonly done using a custom skull implant. However the stretch of the scalp always a controlling factor in how much augmentation can be achieved in a single surgery. While I would question the number of an ‘inch and a half’ or 37mms of augmentation that is actually needed (most people way overestimate their augmentation needs as they do not appreciate the effects that come with the large surface area effect of changing a convex surface), suffice it to say that your optimal augmentation needs could only met with a two stage approach. Such a two stage approach uses either a first stage scalp expansion followed by placement of the definitive implant or designing a two piece implant and placing the layered implants in two stages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had sliding genioplasty about an year ago. I am not happy with the results as the previous surgeon extended my chin downward by 5mm, but I had asked for an extension around 9-10mm. Is it possible to perform a revision on the prior surgery to give me the desired chin extension?

A: If I understand your sliding genioplasty concerns, you desired a 10mm bony vertical lengthening but ended up with only 5mms. The prior surgery can be repeated to add further desired vertical lengthening. The bone will heal just fine and I always add tissue bank corticocancellous chips to it to ensure healing and fill in any bony gaps.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Im interested in temporal lift to elevate my brows laterally only (not interested in endoscopic or coronal brow lift) including elevating my upper cheek lift, with the same temporal incision .. Will you be so kind to let me know the price for this procedure and what is your technique? Are you going to just remove a little bit of skin and then suture? Or are you going to dissect the whole tissue? 

A: While temporal or lateral brow lifts can be done by several techniques, your interest by your own description is in what is known as a more direct or excisional approach. This requires the placement of an incision either right at the hairline or back in the temporal scalp. Either approach requires some tissue dissection and excision for its effect.

Trying to get the more distant cheek tissue lifted through the same identical incision is more challenging because it is an area further away than that of the brows. This falls into the basic principle of the further away the pull area is from the target the less effective it is. Unless a hairline incision is used that extends low in the temporal area concomitant cheek lifting will require use of additional dissection techniques in the subtemporal or lower eyelid areas.

I would need to see pictures of you to better determine how temporal/cheek lifting would be done and what type of result you is seeking….before a cost of the surgery can be provided. There are too many variables here just to just guess.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 5 months ago I had jaw implants. I feel that the jaw muscles are a bit bulky and I’d like to get Botox to make them slimmer and more chiseled. Is there a legitimate risk of the Botox infecting the implants? I read one of your recent articles regarding placing filler on cheek implants and you recommended that a cannula be used to avoid injecting into the implant pocket. Are there any similar guidelines for infecting Botox into the jaw muscles?

A: Any time you place a needle through the skin and inject anything near an implant that is always some risk of causing an infection.  Botox nor jaw implants makes that any different. While the risk is probably low, it can never be zero. Unlike injectable fillers Botox injections have to be done by a needle not a cannula.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Two months ago I had infraorbital rim implants that extended into the mid face/cheek. The augmentation was only about 1.5-2mm for most of the cheek and about 3mm for the under eye area. I’m not happy with them and intend to get them removed. 

Beside for not liking how they look, there are two other issues I have: 

1) my smile looks distorted. The upper lateral areas near my eyes seem pretty expressionless, and my lower cheeks look off from a 45 degree angle (almost like a little ball sticking out) 

2) my midface just feels stiff. Especially the upper area, it just feels like my facial muscles aren’t as soft/versatile as before. 

So my questions are: 

1) are my above concerns valid? Essentially, have you ever seen them? 

2) after getting the implants removed, will my smile return to the way it was before? 

3) is it possible for there to be cheek sagging even with the implants in place? The logic in thinking is because the soft tissue is separated from the bone, perhaps it doesn’t always reattach properly even when the implants are there? Especially because silicone implants are slippery and maybe the soft tissue won’t adhere to them the same way it adheres to bone? 

4) considering I’m in my mid twenties and only had around 2 mm of augmentation of the implants will only be in place a few months before removal, would you anticipate I will avoid complications associated with implant removal? 

A: In answer to your infraorbital-malar implant postoperative questions:

1) Cheek implants are well known to cause the temporary midface stiffness and smile distortions that you have described when put in through the mouth. Infraorbital-malar implants placed through lower eyelid incisions, however, do not in my extensive experience.

2) If the implants are the cause of the smile distortion then removing them, presumably, would be the solution.

3) The elevated cheek soft tissues never reattach as they can’t to a smooth surfaced implant. They are merely held there by the implant’s volumetric displacement. This is the concept of ‘soft tissue float’ in implants.

4) Regardless of the thickness of augmentation the detachment of the soft tissues and the implant’s footprint are the same. You are hoping that a thinner implant has a lower risk of cheek sagging after removal than a thicker one….which is a hope that does not have a sound biologic basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw an article on your website wherein you discuss an orbital floor implant of hydroxyapatite cement. I was wondering if this is something you still do.

I ask because I initially underwent a bridge-of-bone canthopexy with a lower lid skin pinch blepharoplasty. In other words: the canthus of both eyes was secured subperiosteally through a drill hole in the lateral orbital rim. Unfortunately the canthus of each eye was mispositioned thereafter.As a result I underwent a revision bridge-of-bone canthopexy but the  

lateral canthus of each eye still seems to be mispositioned. The canthus is placed so lateral that it is removed from the eyeball and there is a gap in between the eyeball and the lower eyelid . In addition the lower lashline seems to be too long vertically (there is a horizontal enlargement of the palpebral fissure), and thus the lower eyelids are a bit droopy. As a result I suffer from dryness and itching eyes. Frankly the result looks rather unnatural to me also.

I was recommended an orbital floor implant since my eyes are deep set, and it was thought an orbital floor implant could resolve some of my issues at the canthal area. After seeing your article about an hydroxyapatite orbital floor implant this raised my interest. Is this something you still perform, and if so, would you potentially consider me a candidate for such bilateral surgery or not?

A: Thank you for your inquiry, sending your picture and detailing your surgical history and current lower eyelid concerns. While I perform a wide variety of orbital procedures, including orbital floor augmentation with hydroxyapatite and custom made implants, these procedures do not seem to be appropriate to improving your lower eyelid malposition in which the lower eyelids lack good apposition against the eyeball due to vertical lower lid shortness and outer corner malposition. While I don’t know exactly how your prior canthoplasty procedures were performed (I know what you said they did) or whom recommended an orbital floor implant for your lower eyelid concerns, trying to bring your eyeball up and forward a bit, in and of itself, would exacerbate your current problems. Orbital floor augmentation may or may not be part of the solution but, more importantly, lower eyelid lengthening with spacer grafts (particularly in the right eye) and better position of the eye corner would be what would be the standard and accepted approach to get your eyelids up and in better position back against the eyeball. That is the key in relieving your eye symptoms and appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know if I were to get a hair transplant in the same month as these skull and facial surgeries we were planning, would it be better to get that before or after these other surgeries? Or does it not matter? I figured the incisions would be in mostly different places but I wanted to make sure.

A: When it comes to hair transplantation, that causes by itself a lot of facial swelling and the nature of the hair rafts are tenuous early after the procedure. Thus the prudent approach is to separate these procedures by three months apart of which I would do the hair transplants as the second stage to ensure they are to disrupted by anything from the facial and temporal procedures. They definitely should not be done so close together…that is not good for the best results of either procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, About two months ago I had infraorbital-malar implants. It seems most of the swelling is gone (80% or so), but I’m not happy with the results. My doctor tells me recovery takes a full year, but quite frankly I just don’t believe that, and I’ve lost faith that it’ll get better with time and I want to have them removed as soon as possible. Regardless, gambling with a year of my life is harder done than said. I saw a post of yours on Realself where you write that if patients aren’t happy after 6 weeks it’s unlikely their concerns will be resolved with time, and I agree with that. 

My main questions are as follows: 

1) can the implants be removed after 2 months? The implants were silicone 

2) From your experience does the face normally return at least closely to its original state? 

3) does removing them early (2-4 months post op) make it more likely for the face to return to its previous state? Because I feel waiting one year as the doctor wants me to may end up distorting my face for good. 

4) is there a legitimate concern for facial sagging? I’m concerned that the implant pocket will cause sagging (I’m 26 if it’s relevant). What about scar tissue? Is that likely to change the face? 

5) about how long does recovery take for implant removal? 

6) how long after removal can I get facial fillers in that area? 

7) if my doctor refuses to remove them before a year, can I go to a different doctor? 

8) is the cost for removal cheaper than the cost for placing them? 

Thanks in advance for the help,

A: In answer to your questions:

1) I think it is a fair statement to say that if patients are unhappy with the outcomes of their facial implants by 6 weeks after surgery, their concerns are rarely resolved by time along and some form of surgery is needed. This is a general statement based one my extensive experience but each case must be assessed individually.

2) Whether the face returns to its original anatomic state, I think that does not occur at the 100% level. The real question is not whether it returns to normal but how come to that can it occur. That is affected by many factors most prominently the size of the implant, how long it has been in and its material composition is.

3) As a general rule removing implants sooner rather than later (as long as one is 100% certain that want them removed), in theory is better for returning the tissues back to normal. But most of the issues that relate to the tissues returning to normal (disruption of osteocutaneous ligaments for their placement and tissue stretch) has already been done by the initial surgery.

4) Sagging is always a concern from any midface implant removal. The best way to prevent such sagging is to performed a cheek lift/fresuspension at the same time as their removal.

5) Implant removal would have a faster recovery than their initial placement.

6) Six months

7) A patient can choose to go to any doctor at any time.

8) Not knowing what your original surgical fee were, I can not say. But since the implant fabrication cost is not needed for their removal that may be less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am scheduled this summer for a procedure for the removal of an occipital knob on the back side of my skull. Before fully committing to the procedure, I wanted to ask a few questions pertaining to concerns that I have about the operation. 

From our consultation and the case studies that you published online, I understand that this is a fairly low-risk procedure. Are there any potential serious implications that could arise from this surgery? I am also concerned about the size of the scar for this operation. I plan on fully shaving my head after the surgery; in your estimation, will the scar be detectable from a few feet away? I understand that the scar size can be variable, but will it appear to be a hairline incision and will it be any wider than two inches? I attached photos of the occipital knob to this message if they may be helpful in gauging the potential size of the scar. 

Any information would be greatly appreciated, thank you. 

A: In answer to your occipital knob skull reduction questions:

1) The occipital knob is a very thick protrusion of bone which means reducing it entirely still leaves a lot of bone for protection. While I could not imagine it not being very thick bone, the way to absolutely determine if it is indeed as thick as I think it is is to get a 2D CT scan and make measurements.

2) The scalp scar is in the range of 5 cms length and it does heal very well. It is placed in a horizontal skin crease if one exists which in your case would be at the bottom of the knob. I can not say whether it will heal so well that it would be undetectable from a few feet away. But I have yet to have a male patient comment on that they found the scar unacceptable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have been looking to have chin surgery for a while now. My chin is my biggest insecurity. I never smile due to the way my chin pulls down when I smile. I also dislike the dimple in my chin and how wide my chin looks when I smile.

A: Thank you for your inquiry, sending your pictures and detailing your concerns. You have two specific soft tissue chin concerns, 1) hyperdynamic chin ptosis and 2) a vertical chin cleft. They may be anatomically related as a vertical chin cleft occurs due to a midline soft tissue deficiency. For improvement/correction a submental approaches needed as the size of the chin pad must b reduced and the chin cleft managed by a muscle repair in your case. Such soft tissue chin repairs, while not technically challenging to perform, are difficult to predict the outcomes since surgery is done in a static setting while your chin issues mainly appear with dynamic motion. (smiling)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a big complex with my head shape because my head is too wide. When I go a Korean plastic surgery hospital the doctor said most part of side head is bone, there is very slim muscle over the ear. Is that true that there is 7mm to 9mms tmuscle hickness above the ear??

A: In my extensive experience with temporal reduction surgery, most men particularly Asian males, have very thick temporalis muscle in the location above the ears. It is usually in the 7 to 9mm thickness range and sometimes even thicker. However the best way to determine the muscle:bone composition ratio of the side of the head is a CT scan. By looking at how much the thickness of the muscle makes up the sides of the head this will help you to determine if temporal reduction surgery is worth it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would this mess on the side of my mouth be correctable without a facelift? Just an incision beside mouth? I had filler placed there over a year ago and ever since it looks terrible. I have also had the area melted with devices and I am left like this. I’d take a scar any day over this mess. Thank you.

A: Thank you for your inquiry and sending your picture. With the development of perioral folds I would expect any treatment that involved adding volume (fillers) or skin tightening/fat reduction efforts to merely exaggerate the problem. This is a surgical issue that requires either direct or indirect tissue excision/rearrangement. Even though it is an indirect approach, there is no doubt that a lower facelift is the superior approach to trying to smooth out this area by distant tissue excision and skin pull and is also scar free by the mouth area. However there is a direct approach which is an elliptical tissue excision placed above the perioral folds along the line of the nasolabial fold. (see attached image) It typically is reserved for much older patients who have a very deep nasolabial fold anyway which is the equivalent of a pre-existing scar. Bit it can be done on anyone if they are motivated enough to want to avoid a facelift and can accept the scars.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Greetings, do you by any chance offer cranioynostosis treatment in adults, 19 years old to be specific. I have lived with sagittal craniosynostosis my whole life and I want to get it treated.Please refer me to someone that can perform this procedure if it is not in your field.

A: Almost 100% of the time cranial vault surgery is not done in adults due to the increased thickness of the bone and the magnitude of the surgery. Young children have thin pliable bone and a growing brain to help shape it. In adults we greet the effects of sagittal synostosis used on the aesthetics of it not through craniotomies.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need this procedure. Can a custom skull  implant be made that creates a square shape without increasing the height of the head? 

A: Creating a more square-shaped head requires a custom skull implant that elevated the lateral bony temporal line. While such an implant will cross the sagittal midline of the head it would do so by only adding about 2 to 3mms of height in the middle…which I would call not really substantially increasing the height of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Please find attached photos of my face at anterior, oblique and profile angles.

I’m interested in custom paranasal silicone implants to address retrusion in the Lefort 2 area and general lack of definition in my midface. I’m hoping to achieve 5-6mm with paranasal implants.

I’ll be looking into dental veneers down the road to project the teeth out as much as possible as well.

I’m aware that down the road I’ll need implants to address retrusion in the tear trough area too, and other work, but would like to start with the paranasals for now.

I’ve also attached photos of my “ideal” female faces where the mid and lower face areas are very well projected (even though I am aware my lower face is structured very differently to theirs.)

Could you please advise on what the cost of custom paranasal implants, including all surgical costs, would be?

Many thanks.

A: Thank you for your inquiry and sending all of your pictures. The best way to think about your implant design is to look at a typical Asian midface implant that addresses the whole midface retrusion issue and then decide how to reduce it if so desired. I have outlined with the purple lines what would be considered the footprint off the premaxillary-paranasal component of it. Assuming that is the basic design of what you need/desire, my assistant Camille will pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Vertical Orbital Dystopia surgery obj my right eye. However, there is concern involved, as I have to put in eye drops. Here are the names of the drops:

Vital Tears Eye Drops

AzaSite Eye Drops

Xiidra Eye Drops

Retaine Eye Drops.

These are all for dry eye purposes.

A:Those eye drops are all used to treat dry eye syndrome (keratoconjunctivitis sicca) which I assume this is present in both eyes and not just the vertical orbital dystopia side. But even so that does present some concerns about aggravating that condition with any type of procedure on the eyelids in which their position up against the eyeball is surgically manipulated. I would have to have some input from your ophthalmologist who put you on these medications to better determine the risk of symptomatic aggravation with any orbital surgery.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, One thing that bothers me is the fact that I don’t have hollow cheeks like a lot of models do. Why is this, and how could I get that as well as just get a more angular facial structure overall? I have heard that thick skin tissue plays a part, not sure if that is the case for me?

Best regards.

A: Thank you for sending your pictures. While thicker skin does play a major role in how well the facial bones are seen, you still have some room for improvement in changing some of your facial structure. The two areas that strike me as the most important for you are buccal lipectomies (for hollow cheeks) and jaw angle augmentation. (for more angular facial structure) n This would enhance the already largely good facial bone structure you already have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I asked you the other day if the chin can, in a safe and natural manner, be vertically lengthened up to 15-20mm and you answered as follows:

“Getting the chin vertically increased to 15 to 20mms is best done by a staged vertical lengthening bony genioplasty. In the first stage the bone is lengthen by 10mms and then six months later add the additional vertical length required. No form of an implant does this very well became the soft tissue chin pad will not redrape up over the implant properly once it is detached for implant placement. It works in a genioplasty because the soft tissue chin pad at the bottom is never detached thus always follows the bone vertically down in a natural fashion.”

With regards to this I just had a follow-up question:

Is it possible to split the two stages into a genioplasty and then a custom chin implant? So for example in the first stage the chin will be vertically lengthened via a genioplasty, say, 10mm. And then in the second stage (4-6 months later) the chin will be further vertically lengthened via a custom chin implant, say, 5-6mm. Might that work?

A:Your supposition is correct. That would be an effective technique as long as the bulk of the ertucaly lengthenign effect is done by the bony genioplasty. (10 to 12mm bine first stage, 5mm implant second stage)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding custom forehead implants. I’m a saturation diver which basically means we live in hyperbaric chambers for a month at a time at depths at up to -300metres. We breath helium so we saturate our bodies in helium/oxygen. Would these implants be ok absorbing helium and decompressing as such. Would there be any complications?  Obviously if the implants holds any gas on the way up to the surface there’s going to be huge complications.  Have you ever had experience with saturation divers and implants in the past. Just want to make sure it is indeed safe.

A: Good question… that is a new one although not the first diver who has had a skull/forehead implant in my practice. Solid silicone is a highly-cross linked polymer which would not absorb any gases that are circulating in your blood stream. That is not possible from a material and soluble gases standpoint. 

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I have a question regarding paranasal implants. Could they be used in a way to bring the alar base upwards? The reason I’m asking is because this would enable a long nose to appear shorten, since if there was a way to bring the alar base forward and up (through means of a well placed implant), one could then shave the collumela and present with a shortened nose (the entire base of the nose would move up, including the alar base). 

Thank you in advance!

A:Thank you for your inquiry. No form of midface augmentation is going to rotate the alar base upwards in any significant way. The effects of paranasal implants are primarily in the horizontal or forward direction…at least by conventional design. I could envision shaping the patronal implant design a certain way to try and create that upward movement but I could not tell you whether that would be effective for that type of nasal base change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in learning more about a surgical knee lift. I have very bad rolls of wrinkles from suntanning in my youth. I may need a calf lift too. I have sagging there also. I would love to see some pictures of any knee lift procedures. Thank you

A: Thank you for our inquiry and sending your pictures. A knee lift is similar to a few other body contouring procedures (e.g. armlift) in that a visible scar results that is not hidden. (unlike breast lift or tummy tuck for example) Thus the decision for such surgeries is more aesthetically difficult because one doesn’t have the luxury of a surgical result that does not have its own aesthetic downside. Thus, It is always a question of which is better from the patient’s perspective…the scar from a knee lift or the wrinkles above the knee. each patient is going to interpret that differently. The only thing that matters is to avoid trading off one problem for another problem that one dislikes just as much. With this premise in mind the patient who feels the knee lift scar better than their wrinkles is a good candidate for the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in undereye-cheek implants. I prefer custom implants to be able to individualize the shape of the implants to suit my face, but on the other hand I’m worried that the costs will be much higher. Please inform me on the cost difference between custom and conventional implants and maybe on some other (dis-)advantages of either procedure.

A: Your assumption is correct in that custom undereye cheek implants is always going to cost more than the use of standard implants. But beyond cost the reason a patient would  choose a custom implant approach in almost all cases is because they offer implant designs and augmentation results that are not available with the use of standard facial implant designs. Such is the case with infraorbital-malar implants (aka custom undereye cheek implants0 as no such standard implant design exists to replicate what this custom approach to the undereye area does. One could try and combine standard infraorbital and cheek implants but they would be a relatively poor substitute as they are not only not connected but don’t create the same effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions concerning the eyelids.  When I met with you concerning my hooded lids he asked how I felt regarding my brows.  At the time, I said that I was good with my brows.  I have since given it some more thought and wonder if a brow lift in conjunction with an eyelid lift might be the best option to address my concerns regarding my heavy lids.

– Is it possible to do a brow lift in conjunction with the eyelid lift?

– What types of brow lifts do you recommend? Essentially, where are the incisions?

A:  In answer to your browlift questions:

1) A browlift and upper blepharoplasties are commonly done together and is a more complete form of eye rejuvenation if there is ay brow sagging present.

2) For determining the type of browlift, for which there are five (5)  different types, the key determinant is the length of the forehead. (how long is the distance between the eyebrows and the hairline. If the forehead is not long, an endoscopic browlift technique is done. If the patient has a long forehead of which there is concern about it getting any longer, a pretrichial or hairline type of browlift is done.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Dr. Eppley, I had saline breast implants placed five years ago through armpit incisions. The left breast implant has always been too high but I let it go at that time. I now want to change my implants to silicone, increase my breast size and get the two breasts looking more similar. (attached are my current pictures) Do you think I would need to come in in person to discuss the breast operation and be examined? I know there are different types and shapes of silicone implants and so I want to ensure that we choose the correct implant. I prefer them to sit a little lower because I think it looks more natural. Basically I’d be happy if both my implants looked like my “good” implant, the one that was placed correctly. Also, I don’t think adding 75 CCs is a huge jump but if this greatly increases my chances of rippling or other issues, I’d like to weigh that in my decision. I’m really happy with the look and feel of my breasts, they feel natural and there is no rippling double bubble etc. So I am trying to avoid any of those issues in round two and honestly that’s kind of been my hesitation in getting them fixed, but the asymmetry does really bother me. 

A: In answer to your breast implant replacement questions:

1) I do not consider a before consultation (coming in way ahead of surgery) to be essential. There will be one the day before surgery anyway. Your pictures show a left breast with a highly positioned implant with the associated higher inframammary fold level as well. This is not rare in the transaxillary approach for breast implants, particularly on the non-dominant side of the surgeon. (right handed surgeon often does not do an adequate inferior dissection on the left side of the patient) This is best treated by a small inframammary incision where the lower end of the pocket can be adequately released with the implant exchange. The implant size increase is already known (+75ccs) and there are only available smooth silicone implants today of which high profile projection is probably what you are seeking. (all textured/shaped implants have been removed from clinical use or should not be used due to the risk/concerns of ALCL) Your goal, besides volumetric breast size increase, is to have the left implant position look like the right…that is a given.

2) A 75cc implant increase is really minimal so don’t let the number fool you. As a general rule one needs at least a 30% implant volume increase to even see any change on the outside. For example, if one has 350cc one really need at least 450ccs (+100ccs) to tell any difference at all.

3) The size of a breast implant has no correlation with the occurrence of ripping. That is caused by different issues.

4) When in doubt about the increasing the size of the breast implants, you can always just adjust the left implant down as that addresses the most important concern to you

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to do a combination of sliding genioplasty for vertical and horizontal chin increases while also doing jaw implants to maintain the optimal jawline proportions and angles? Can both procedures be done in the same surgery?

Is a wrap around vertically lengthening implant the better alternative or is this a case by case assessment? 

A: Thank you for your inquiry. It is very common in my practice to combine a sliding genioplasty for the chin and a custom jawline implants for the rest of the jawline.

Whether a total custom jawline implant would be better or even a good alternative depends on the horizontal and vertical dimensional changes needed for the chin augmentation part of the jaw. If the additive numbers of the horizontal and vertical chin movement is 12 or less a custom jawline implant can be done. But if those combined numbers are greater than 12, a sliding genioplasty is needed for the chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding the forehead implant and size…How large do these implants go? Can they be made quite substantial or is there there a limit to the depth and size etc…My forehead is quite sloping you see and small….So I’d like to go substantially larger if possible. Nothing ridiculous but as long as it looks adequate.    Not happy with it right now at all.

A: Technically a custom forehead implant can be made to any size in the design process.The ‘limitation’ is in how much the forehead skin can stretch to accommodate what is placed behind it. While that is a practical consideration, the reality is that I have not yet seen someone whose tissues could not stretch to accommodate any implant that has been designed.

One of the keys in custom forehead implant designing is the balance between how much the slope should be corrected in the side profile vs how much width to provide in the front view to keep it looking natural and that it look like it belongs there. The latter is trickier to figure out then how much to change the slope.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 24 years old and I had regrettable cheekbone reduction surgery in Korea sic months ago and I am devastated by the results. I am hoping to reverse the changes made and was wondering if you could help with some questions. 

I think the doctor fractured the zygomatic bone then pushed and rotated it inwards. If no bone was removed, is it possible to push and rotate it back outwards? Is a bone graft still necessary in this case? 

Many thanks for your help. 

A: I am very sorry to hear of your unsatisfactory aesthetic results. Cheekbone reduction osteotomies can be reversed and, in most cases, a bone graft is required. That determination however requires a 3D CT scan to look at the osteotomy pattern and the current healing of the zygomatic osteotomy site. That is a scan you can get where you live and we can order it for you to have it done.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I have a question about the shoulder reduction treatment, I am wondering what the costs of this treatment would be?

I am emailing as I wish to reduce my shoulder width length. My shoulder width length is very problematic to me as I am a woman but my shoulders are so wide it gives me a very manly figure (see image). I have discovered about this surgery from an online forum from a patient who underwent treatment with Dr Eppley. I am curious as to how much the total procedure would cost, the recovery time and bone healing time.

Kind regards,

A: Thank you for our inquiry and sending your pictures. Your bideltoid width appears to be greater than 50cms which would more masculine than feminine. Thus you would be a good candidate for shoulder reduction surgery. I will have my assistant Camille pass along the cost of the surgery to you later today. The total recovery time is six weeks which mainly relates to how long full range of motion of both shoulders is normalized. It is a progressive range of motion of the shoulders which begins at two weeks after surgery.

Dr Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need a custom skull implant procedure. Can such an implant be made that creates a square shape without increasing the height of the head? 

A: Creating a more square-shaped head requires a custom skull implant that elevates the lateral bony temporal line. While such an implant will cross the sagittal midline of the head it would do so by only adding about 2 to 3mms of height in the middle…which I would call not really substantially increasing the height of the head.

Dr. Barry Eppley

Indianapolis, Indiana