Your Questions
Your Questions
Q: Dr. Eppley, Questions for Dr. Eppley regarding PMMA bone cement for skull augmentation: is it safe and permanent? Are there long term complications associated with its use? Why isn’t this procedure not commonly performed?
A: While PMMA bone cement for skull augmentation is both safe and permanent, it is an aesthetically inferior technique because of its limitations in volume addition, the need for a long scalp incision for placement and a higher risk of contour irregularities. Custom skull implants are aesthetically superior due to more controlled aesthetic outcomes, less risk of contour irregularities and they are placed through smaller scalp incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had infraorbital implants and lower eyelid spacer grafts with canthopexy of which I am very satisfied as they have made a great improvement. I wonder now of custom infraorbitalmalar implants might provide even further facial improvement. I really don’t want to one up my lower eyelid incisions again since I have had such a good result. What are your thoughts on this potential procedure? I know it create a more compact orbit bit what are the other benefits?
A: As a general statement what I would tell any patient who has undergone an aesthetic procedure which has made a good improvement…be very cautious in trying to take a good result and make it a great one. The reward:risk ratio changes and just because you have had a uncomplicated experience the first time is no assurance it will be so the next time.
That being said it would be fair to say beyond a somewhat more compact orbit it provides an extended high cheek look as well. Based on your one limited side view picture I would not be an advocate of this procedure in your case because of the risk vs reward benefit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a review of my case and photos. Your practice is very appealing to me because you offer a wide array of treatments and surgeries. I want the procedure(s) that give me the BEST chances of reaching my aesthetic goals. I am open to all suggestions. I am specifically interested in learning if I could benefit from facial lipo, kybella, threads and/or facetite OR should I just go straight to a facelift or other surgery. I have attached 5 photos: current frontal, side, 45 degree and smiling pics with areas that bother me marked. I also attached a frontal version photoshopped to show how I’d like my lower face to look. I am not adverse to surgery or down time if the procedure gets me what I want preferably permanently. My only restriction is I want as minimal scars as possible and no silicone facial implants. I am 40 yrs old, 5’2, 123 lbs and have had the following aesthetic procedures done several to many years ago: buccal fat removal of entire pad, open rhinoplasty, upper eyelids, ultherapy of lower face and neck, chin implant and then removal of implant years later. Please let me know if any additional info is needed. Thanks
A: Thank you for your inquiry and sending your pictures. The lower facial slimming effect you are trying to achieve is best obtained by a surgical jowl tuckup procedure. (aka limited lower facelift, mini-facelift etc) All other less invasive procedures you have mentioned are for those that are not ready to jump to a surgical procedure. They do not create the same result but serve as methods to delay a surgical approach until more significant signs of facial aging are present or that their results have proven they are inadequate for the patient’s aesthetic goals.
I have attached an example of such a younger type of limited facelift with a close up of the scars around the ears. (6 weeks postop)
FYI no facial rejuvenation procedure, surgical or otherwise, is permanent. They all degrade over time…it is only a question of how much and over what time does one eventually return to baseline. That would be particularly applicable at a young 40 years old.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am concerned about the asymmetry on my face. My jaw slopes to my right and my right eye, lip, and nostril area are dragged downwards. My right eye is lower than my left, I don’t consider it to be too severe but it is quite noticeable and I would really like to fix it. My right brow, nostril, and lip corner are lower as well. I think an orbital floor augmentation/ implant and any procedures accompanying it would solve my VOD, however I’m not sure if I’m the right candidate. My desire would be for the affected areas on the right to be symmetrical to the left accept for my jaw which I would like address in the future. I am very curious to know your informed opinion and ballpark prices for each of the procedures that would be needed to fix the asymmetries on my right being my lip, nostril, and eye + (brow). A response and price estimation would be greatly appreciated, thank you so much!
A:Thank you for your inquiry and sending your pictures. In the assessment and treatment planning of facial asymmetry it requires a good quality frontal picture (yours does not include the full face, is not current and are very grainy in clarity) and a 3D CT scan of your face to have full knowledge of the underlying facial bone structure.
But those issues aside, what is equally important is for the patient to make a list of their specific facial asymmetry concerns AND to prioritize them in order of importance. This allows the patient to focus their resources on the procedures that have the greatest value to improvement of their facial asymmetry concerns.
In short a better picture and knowing your priority concerns would allow some more useful information to be provided.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a chin implant which is a medical grade silicone implant by Implantech. Over the last couple years my chin has changed. I think the implant shifted. Recently in the last few months I felt a tearing sensation on the left side, along with pain and itching. Now there’s a little divot along the left side and to me it looks like it shifted up closer to my mouth. I’m concerned that it shifted up or scar tissue tore as well as bone erosion. I want it out my face. I’m concerned about my skin not shrinking back after having it for 20+ years and I’d rather not go back to a recessed chin. My mouth is moving normally and I’m not in pain. It does feel weird compared to the left side. I can almost feel it now being closer to my mouth on that left side.
Questions/ideas:
Can the implant be removed and hydroxyapatite be used to create a chin?
How about a sliding genioplasty without another implant?
A: Normally I would get a 3D CT scan of the lower jaw to fully understand the chin position on the bone and what style/size the chin implant is. But since it is clear that you want it removed and not replaced with another implant then the scan will not be useful. The question then is not whether it needs to be removed but what to replace it with and what should those dimensional changes be.
Hydroxyapatite cement is a theoretical replacement but it is a hard material to control its shape and would only be viable if just a few millimeters of augmentation were needed in the central chin. A more controllable autologous option is a sliding genioplasty. The only question with it is what are the dimensional movements needed. That can be determined by how you feel about current chin look and what contribution the indwelling chin implant is making towards your current chin shape. (which can be accurately determined intraoperatively with its removal) That would then guide the amount of horizontal chin bone advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was born with a large nose and recessed chin and had rhinoplasty and chin implant twenty years ago. The rhinoplasty left me with a bump so I had a revision several years later. During the revision he scooped out my slope and took a chunk of my ear cartilage and put it on the tip, and angled the whole thing up. You can now see inside my nostrils. He also narrowed my left nostril at the base and the right nostril now sticks out and up. The tip is kinda pinched-looking and my slope is gone. It does not fit my face and I can’t breathe properly. After the revision he tried to shrink the tip using a steroid injection called Kenalog (0.1 mL). I think he tried to do the Barbie-style of nose. My left nostril wall is collapsed and I’ve recently found a huge benefit wearing breathe right strips at night. I’m now sleeping through the night and it’s amazing. Several years ago two stitches worked their way out through the tip area on the inside of my nose. That was scary. I feel like the entire nose is unstable. I’ve had a couple consults in my area and they’re not what i need… I need functional and aesthetic rhinoplasty.
A: By your nose surgery and symptom description you have both functional airway and aesthetic nasal shape concerns. Positive improvement with the Breath Right strips demonstrates that there is internal nasal valve collapse +/- weak lower alar cartilage support. This often happens when the structural support of the nose has been over reduced. This is best approached by the combination of middle vault spreader grafts and batten grafts to the lower alar cartilages using septal cartilage grafts. Septum is the best source and it is unknown to me whether your septum has previously been harvested or not. (I suspect it hasn’t given that ear cartilage has been previously used) This functional surgery can be combined with the needed aesthetic changes which appear to be bridge augmentation, columellar support, tip scar removal and right nostril adjustment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have complex muscular issue on the left side of my head and face, impacting the temporalis and masseter muscles. I had this issue for around 3 years and it currently has caused a TMJ issue. My temporalis muscle is very painful and causes a lot of twitch and it becomes very painful when goes by the ear down to cheek bones. There is a severe muscle pressure putting stress on my ear and jaw. This makes it difficult to do daily task as causes it causee much stress on muscles around the body. My upper cheek is bigger, hurt sand puts pressure on cheek bone as well. When moving my face, the pain gets stronger. I cannot wear a splint anymore as it pushes muscle more towards the TMJ bone and ear. TMJ was clean and steroid was injected and the steroid has caused more muscle issue in temporalis then was there before. TMJ specialist define muscle root cause but cannot seems to get any treatment answers. I have seen a few TMJ specialists and plastic surgeons. In addition, I have occipital neuralgia. I had migraine surgery where the greater occipital nerves were decompressed and the arauriculotemporal nerves removed. Based on your experience, I have seen you have worked on the temporalis muscle and was wondering if you would be able to resolve my issue. Botox was used with some relief which was a good indication the root of the issue was there. it feels like I have a knot around that area. MRI of head and TMJ did not indicate anything.
A: The critical question is what part of the temporal muscle is involved….anterior, posterior or both. Temporal pain reduction by surgery only works if it exclusively or primarily involves the posterior portion of the muscle. By your description it appears that the anterior portion of the muscle (ear to cheekbone) is the culprit for which muscle reduction/removal can not be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a mouth widening procedure in the future as my mouth is a bit small for my face. What do the finished results of lateral commissuroplasty look like? There are no photos online showing what post operation heal scarring from commissuroplasty look like. Is the scarring bad? If you were face to face with someone is the scar noticeable from 1 feet distance? Please help me, I would like to know bad the scar from commissurplasty is before I determine whether it is really worth scar or not.
A: In my extensive experience with mouth widening surgery, while it is an effective procedure, scars are a concern and just about 100% of patients undergo secondary scar revisions from it. The corner of the mouth is an exquisitely sensitive area for incisions and scar formation. It is not like the rest of lips due to its location and frequent exposure to stretching forces.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is a jaw implant good if you don’t want fillers but want to build up your jaw line? As you age and your skin thins will you see the implant?
A:Jaw implants are made to fit the bone and look like a natural extension of the bone. No one’s skin can ever thin enough to show the outlines of a jaw implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, you seem very experienced in custom chin implants. My question is if you want to increase vertical chin height using an implant, will the implant blend with the sub mental skin under the chin (neck) perfectly using custom chin implant?
A: I am not sure what you mean by ‘blend with the submental skin under the chin’. The implant blends into the bone as that is what it sits on. But I think you mean will the skin from the bottom of the chin from the vertical lengthening stretch out below the chin and not look indented…and that answer would be yes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in thick skin rhinoplasty. I had a consultation that wasn’t successful as he said he was unsure of how the result would come out due to some thick skin. My nostrils are also small and collapse in when I breathe in deep.
A:There are lots of rhinoplasty patients that have thick skin which does not preclude them from having surgery. One just has to acknowledge that there are limitations as to how much nose reduction/reshaping can occur, that postoperative steroid injections may be needed and that it can take up to a year after surgery to see the very final result. With nostril collapse on inspiration this indicates that your rhinoplasty would need batten cartilages grafts or turnover alar rim grafts to support the lateral ala as part of your procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have always had facial asymmetry and was unhappy with my profile bc I had a weak chin, so I decided to fix the profile issue. It appears the chin implant, though centered, made the asymmetry worse. I’m interested in trying out jaw fillers (potentially cheek as well if necessary) and visiting the option of removing or correcting the chin implant, as I also THINK it might be too low or angled to low since it seems almost alien to my face and interrupts any facial harmony I had before. Granted, the side view is better than before.
A:Thank you for your inquiry. You are correct in all of your assumptions about the chin implant….in the presence of chin/jaw asymmetry a standard chin implant will exaggerate the asymmetry appearance, it is positioned too low because of the backward inclination of your chin bone (creating more of a 45 degree angled augmentation effect) and it is an implant style that is too wide for a female chin. And like many undesired chin implant results in females it offers an improvement in profile but looks worse in every other facial view.
The question is not whether you are going to remove the chin implant but what are you going to replace it with that would be better. Of that the options are between a custom chin implant vs a sliding genioplasty, each with their own advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty procedure. Since the sliding genioplasty is usually done through a diagonal cut as I have seen on the internet, I am interested in knowing if every horizontal advancement always has some degree of vertical shortening? Is it possible to advance the chin just horizontally without changing the vertical dimension? If so, how does the cut look then? I am scared that the side effect of advancing the chin forward might be some vertical reduction.
Thank you very much for your time.
A:In answer to your insightful sliding genioplasty question, control of the vertical dimension of the chin is affected by the following:
1) Even if not change is done to the vertical dimension with a sliding genioplasty it will usually look a bit longer as it is advanced due to the changes in the overlying soft tissue chin pad. (this is similarly true with implants)
2) The risk of vertical shortening is sliding genioplasty is related to the bone fixation method used. With a diagonal bone cut, if wire fixation or bicortical screws are used (neither of which I use) then vertical shortening can happen as these are bone compression techniques. And by definition almost always happens) If plate fixation is used the vertical dimension is controlled much better because there remains a bone cap with the advanced chin bone segment as the plate allows the chin bone movement due to be done in any horizontal or vertical dimension. (in essence it is a bone suspension method
As you can see this is a geometric function of the bone fixation method used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, hi I was wondering whether if not satisfied with your head shape after removal of the muscle in posterior temporal head reduction (temporal reduction surgery) are you able to have another consultation regarding bone structure or is their certain risks.
A: The posterior temporal bone is quite thin and only a few millimeters can be removed….which makes for a negligible reductive change. It is the muscle removal that makes the major difference. But it can be done but it will not make for any further major head width change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Looking to improve the rounded appearance/protrusion to the chin on the side profile. On the front view I would like to achieve a slightly shorter and more rounded/feminine look to the chin. I also have a chin dimple that I have corrected with filler but it is still slightly visible in certain lighting and I would like to have that resolved.
A: Thank you for your inquiry and sending your pictures. It appears that much of your chin excess is from the soft tissue pad which will take a submental approach and some bone removal as well to adequately reshape it smaller. Fat injections would be the logical approach to the chin dimple which could be performed at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Interested in rib removal. I have a very big thorax for my body size. Is it possible to reduce the scope of the thorax?
A: No it is not. You can’t reduce rib protrusions that high up on the chest wall. This is a common question but is beyond what rib removal surgery can do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, when my face is expressionless, I don’t have any visible eye bags, it’s quite youthful. But.. when I smile the fat on my face pushes up and gives me eye bags. I think everyone has them, but for me, I feel these smile eye bags make me look worse. They give off a strong dark shadow when in darker/certain lighting and I really don’t like it.
Is there a specific/custom midface/orbital implant that can completely eliminate my undereye smile bags? Refer to my photos to see what I mean.
If there is such a procedure that can completely fix my insecurity?
A: Thank you for your inquiry and sending your pictures. What you referring to is what is known as a dynamic problem for which any surgical approach is a static one….meaning static procedures will not fix a dynamic problem. Surgery is basically done an expressionless faces for which it is designed to treat a problem that is seen in these circumstances. While the concept of building up the infraorbital rim may have some theoretical merit in your situation it is not a procedure I have ever done for this issue, thus I can not speak for its potential effectiveness. But it would seem that further underlying support would not diminish the bulge of undereye tissues that occur when you smile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there typically issues with a jaw implant as one the jaw bone ages and you lose fat and elasticity? Can you see the implant? And do they need replacement?
A: The answer would be no and no. The implant would never need to be replaced because of device failure. And as you age the soft tissue support provided by the implant is beneficial rather than a detriment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple follow up questions regarding both the picture and the operations itself.
1) I’m a little confused by these pictures without labels, is the first one the 8mm advancement and the 2nd one the 12mm? The one that was sent over last thursday was for the 10mm? If that is the case, can I have the front view for the 10mm as Dr. Eppley only did a side view for me for that one.
2) Dr. Eppley mentioned that I have deficient lower jaw growth, which leads me to think that jaw surgery may be an option. I currently do not have any severe jaw related problems (sleep apnea etc. though I do snore quite loud sometimes). What is the aesthetic difference between the jaw surgery and the sliding genioplasty that he recommended? My logic goes like this: If there is indeed no aesthetic difference between the two, then why waste the time and effort to go through Jaw surgery? Are there any additional benefits for me to go consult with a jaw surgeon rather than go through with the sliding genioplasty, with the latter being much more cost effective. What are your thoughts for my case?
3) Given my deficient lower jaw, will the sliding genioplasty accentuate that? In other words, will the lack of a lower jaw become more pronounced after the surgery?
A: In answer to your questions:
1) the pictures are label as pred 1, 2 and 3 in their tags which signify roughly 8, 10 and 12mm horizontal movements.
2) Unlike the profile view, front view imaging can not be predicted based on millimeter movements.
3) Whether orthognathic surgery is an option depends on the state of your occlusion. (bite) If there is no functional bite issues or the bite discrepancy is slight/modest, then orthognathic surgery is probably not an option. But without x-rays, a bite analysis and an orthodontic evaluation the merits or lack of merit to orthognathic surgery can not be precisely known based on external facial pictures. The only definitive way to address this issue, one way or the other, is to get a formal evaluation/workup for it.
4) I would go by what the pictures show you and the effects of the chin augmentation change about its effect on the rest of the lower face/jaw.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Last year I had a tear trough implant placed with the SOOF lifted over it, combined with lateral canthoplasty and lower lid retraction surgery. I didn’t like the outcome of the surgery and had to receive revision surgery a few months ago. This included removal of the implant, restoration of the canthal angles to a more natural position by using drillhole fixation, and a short horizontal lengthening of the eyelid. The SOOF was also raised again to address any any potential hollowness. I had told the Doctor prior to surgery that I did not want the SOOF raised and wanted it to be back in its original position, and he agreed, but unfortunately did the opposite during surgery. The revision surgery was a huge improvement, however I believe that the SOOF lift has left my undereye/midface area looking bloated and fat. Additionally, the creases under my lower lids have disappeared and so have my love bands. I was wondering if it was surgically possible to return the SOOF to its original position without cutting into the canthal incision site where I had surgery before? Could the SOOF be lowered by a lower eyelid incision? Is the SOOF’s fixation to its new, lifted position permanent?
A: That is an interesting question and the first I have ever heard of a patient requesting SOOF lowering. In theory that should be possible with wide subperiosteal release and letting it just drop. That normally would work in the previously unoperated patient but in the situation where it has been deliberately raised it would have somewhere ‘normal’ to go. But having never done such a SOOF lowering procedure my answer is theoretical and not based on any actual clinical experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering what cosmetic surgeries would be needed to achieve this look. I edited the photo on the left to balance the facial features to appear far more graceful from the side:
Substantial reduction of the nose bridge and depreciation of nasal tip. I realize the reduction shown is drastic and apparent, however I feel that my nose is far too large from the side and this is the best correction. In addition, correct misalignment and deviated septum to improve overall breathing as well.
Slight chin augmentation to gain slightly more pronounced and remove the “tucked” in profile.
Straightening of the jawline. Vertical shortening of the jaw bone to obtain the “straight” profile rather than the rounded profile( seen in the pictures). Note: This is the one that is troubling me the most. I am not sure what needs to be done for the jaw in combination with the chin. Some surgeons have commented that jaw shaving is an option. Some have said that fat grafting is the way to go as well but I am having my doubts about this one. Would appreciate your help and thoughts. Thanks:).
A: Thank you for your inquiry and sending your morphed images to which I can make the following comments:
1) As you have suspected that degree of nose reduction is not possible. The large skin envelope controls how much size reduction is possible. Even if it were possible you would likely not be able to breathe through it. A more realistic outcome is halfway between the size of the nose you have now and the unachievable small nose size you have imaged.
2) The modest chin augmentation effect is certainly able to be obtained.
3) Your jawline straightening effect is achieved by an inferior border removal between the jaw angle and chin. That is a very difficult operation to do intraorally and places the mental nerve both in the bone and at its mental foramen exit at some risk. A 3D CT scan would be needed to look at the jaw anatomy and determine exactly where the nerve runs through the bone and see how that correlates to the amount vertical bone reduction that needs to be done.
4) The alternative approach to the jawline, and one with far less risk, is to augment the jaw angle to eliminate the prominent antegonial notch which is the cause of your non-straight jawline in profile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently removed a mandible angle implant and had a retraction in the masseter, I would like to know about the effectiveness of the masseter muscle reattachment surgery.
A: Reattachment of the masseter muscle, once it has been lifted off the bone and retracted, is very difficult with a low rate of success in my experience. A camouflage approach by building up the soft tissue deficit is more effective, again in my experience..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to know what the options are regarding shortening the nose and midface. I have yet to see actual nasal shortening described anywhere, rather people focus on tip manipulation for the illusory appearance of a truncated nose, or altering radix position. Post-op from a lefort 1 with counter clockwise rotation or impaction (during which the skeletal housing for the nose would be shortened which begs the question, what happens to the cartilage afterwards?) could a “slice” of the soft tissue nose be excised? Skin, cartilage, and septum. Following this, the nose is then simply adjusted up (the entire structure would slide up) and sutured back together. If there was no excessive gum show prior to the Lefort 1, this would accomplish shortening the nose and midface without inducing any inappropriate levels of tooth/gum exposure. Patient would be left with a small external scar across their nose.
If this cannot be done, may I ask why? I can only imagine the limiting factor to be blood supply and not wanting a major risk of necrosis, but could the entry point be strategically placed to avoid this? Or perhaps lifting or stretching the artery to gain access without traumatizing it?
Any help is greatly appreciated.
A: You are asking a classic midface shortening question for which, short of a LeFort I impaction in vertically maxillary excess (which really only shortens tooth show) or a subnasal lip lift (which only shortens the upper lip), there are no other effective procedures for doing so. You are understandably viewing external midface shortening as a structural/geometric exercise…which it is not. The midface soft tissues are not going to shrink or become less so with any underlying vertical structural reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 32 year old female and I have a short and chubby face. I’m considering a custom jaw implant primarily for vertical face lengthening but also a defined jaw line. Attached is a pic of my profile and another pic of someone with the jaw appearance I would like. I would appreciate your expert opinion. Thank you!
A: Thank you for your inquiry and sending your pictures. You are spot on with your diagnosis of a vertically short lower face. While your thicker facial tissues are never going to be as defined as the ideal picture you have shown no matter what you do, vertical jawline lengthening with facial defatting (buccal lipectomies and perioral liposuction) will produce the most effective result in that regard. Elongating the skeletal structure of the lower face and defatting what lies above it is the most you can anatomically change. (technically you can also do high horizontal cheek-arch augmentation as well to create a skeletal line above it)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a more enhanced, attractive and masculine face.This also goes beyond just the custom jaw wrap around implant that I first enquired about. I am interested and willing to consider other potential enhancements to the face such as in the zygomatic areas – cheek bone implants and other possible recommendations. In short, I want a rather significant makeover to maximize my full potential.
This issue is I have is that I put on a significant amount of weight within the last two years due to some negative personal incidents in my life – leading to the neglect my health and well being. However 2021 is a new year, and it is time to focus on my health, appearance and happiness. I have a BMI of around 35 and an estimated body fat level of 40% – classifying me as obese.
My plan over the next 8 months is to lose about 35 – 40 kilos. And attain a body fat % level of at least around 15%. This should provide a more reasonable analysis of my “natural facial” features.
My question is, should I do my consultation now – However – significant fat and bloat are covering my facial features – which may impair any analysis and influence any potential recommendations.
Or
I have attached four photos to this email. Would you recommend any orthognathic surgeries. I know this is extremely difficult to assess just from a few random photos but an initial opinion would be appreciated ) However I would rather prefer implants or other corrective options if it could be an effective alternative.
I look forward to hearing your feedback and suggestions.
A: Thank you for your inquiry and sending your pictures. Given that weight loss would be of tremendous benefit and I need to see what the ‘real’ facial shape is when it comes time to plan and undergo male facial masculinization implant surgery, it would be better to wait until you have achieved at least 75% of your weight loss goals. At that time better facial assessment, imaging and treatment planning can then be done.
Based on the pictures provided, I do not see any indication of the need for orthognathic surgery. But that is said with the caveat that an informed opinion in that regard requires x-rays and a dental/occlusal assessment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have unique problem perhaps you can help fix.I had silicone injection in my chin many years ago and had them removed last year. It was a ball of scar tissue. After the removal my lower lip has fallen due to loss of support. I’ve had two previous failed surgeries where Drs tried to re-suspend the mentalis muscle. But the mentalis muscle seems to be intact and surgeries to re-suspend it higher have not worked.
Have you ever encountered a similar problem and been able to fix it I would like an appt. I presently have a chin implant but that has not helped. Perhaps something higher might fill in the gap and add support. I am a 60 yr old transgender women and in my youth silicone injection were quite common.
A: Thank you for your inquiry and sending your pictures. You have to go back to what caused the lip to look like it does now….excision of soft tissue (scar and silicone mass). This is a soft tissue volume deficiency problem with subsequent tissue contraction into the removed tissue area which will pull the lip down. This is not a mentalis muscle problem or a skeletal chin deficiency.
Thus to any chance of reversing it you have to add soft tissue back in through a release and dermal-fat graft….as you have suggested.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The top of my skull is completely flat and from a side view it looks really bad like if looking at a nail. I have a lot of hair, so you can’t really tell the shape of my head from a photo, but I found 2 pictures that would give a good representation of what I have going on. I was teased a lot as a child and am deathly terrified of going bald. It’s had a huge impact on my life and I just want to know if it’s possible to fix so that I can be confident in how I look and greatly decrease my social anxiety.
A: Thank you for your inquiry and sending your representative pictures of the flat top of your head. It appears that you would like to have the top of your head augmented to a more convex shape rather than flat. That is best done by a custom skull implant which can be placed on a one hour surgery with a remarkably short recovery period.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have vertical orbital dystopia. My left eye sits lower than my right. I was hoping you could teach me more about what sort of procedures I would need to correct it.
A: Thank you for your inquiry and sending your picture. Like in all cases of vertical orbital dystopia (VOD) it is important to recognize that as the eyeball is raised what lies around it must be changed as well, particularly the position of the eyelids which will not move up with the eyeball as they have separate attachments. Thus most VOD cases consist of a custom orbital floor-rim cheek implant (made from a 3D CT scan) and upper lid lifting (ptosis repair) and lower eyelid raising. (lateral canthoplasty with spacer graft)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello I was just wondering if you can have fillers on the temporal muscles as implants seem risky. I was checking if there are any non surgery ways of doing this I will attach a photo of the temporal muscles.
A: Temporary injectable filler or fat injections can be used for temporal augmentation and is good starting point to see the effects. Ultimately temporal implants offer the only permanent augmentation method and are actually the safest method as they sit in either a submuscular or subfascial position depending upon what temporal area is being augmented.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I did surgery after suffering a brain aneurysm. After the swelling had gone down I noticed this indentation in left temple. How can this be improved?
A: The indentation you have is due to loss of the temporal muscle volume as it retracted from the craniotomy procedure. Since it is a soft tissue issue it should be replaced by soft tissue. Fat grafting for your temporal augmentation would be the logical choice. While the fate of injected fat can never be accurately predicted, and it may require more than one session for the best result, it is a good approach. The other option would be to place layered ePTFE sheeting to build up the temporal depression which would be placed through your existing craniotomy incision line.
Dr. Barry Eppley
Indianapolis, Indiana
