Your Questions

Q: Dr. Eppley, Exactly, like if we were to look at each other face to face i don’t want my face horizontally wider.(making me look more masculine) I want the difference when you look at me from the side “vertically” going lower near my back jaw to make everything a little smoother. I’ve gotten my cheeks and chin implants done but am now seeking mandibular (jaw) implants which is why I am looking to you.

A: Thank you for your inquiry and sending your pictures. What you are seeking is vertical lengthening jaw angle implants whose main effect is vertical but, by definition, have to add some width so the implant can attach to the bone. These are a standard type of jaw angle implant whose effect is for patients just like yourself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing regarding your expertise on mentalis resuspensions, chin fat pad resuspensions, interoral shortening vestibuloplasty & sliding genioplasties. 

Two years ago I had a free gingival gum graft performed. The periodontist also did an extensive and complete mandibular vestibuloplasty as part of the gum graft that included the intentional detachment of my mentalis muscles and a full and deep blunt finger dissection of the vestibule from rear molar to rear molar. 

I have now significant discomfort and dysfunction. My lower incisors, all show when I talk or open my mouth. I had immediate speech dysfunction and a pronounced lisp following the vestibular deepening. My lower lip does not close properly. I have to throw my lower lip up to get it to close to the upper lip. I drool constantly and have to suck it back in. The lips both have changed shape completely and sag down noticeably like a very old person in their 80’s, I am half that age. My lower lip has changed color to a darker hue and is very dry looking. I can’t keep food out of the sides of mouth and my tongue can’t clear it. My chin is a completely different shape. It’s flat and a lot tissue has gathered at either lower corner. It’s like my face was cut off and it just sags down. 

Years earlier I had a chin implant put in extraorally from under the chin. I had it removed extraorally as well due to aesthetic concerns as it was far too big and the wrong contour to my face.

I am wondering what, if anything, I can do. In my research it seems I need a mentalis resuspension in combination with one or more other procedures including perhaps a fat pad resuspension, vestibule shortening & a sliding genioplasty, To be honest I would rather not do a sliding genioplasty if possible but most surgeons seem to recommend it to take up loose tissue. A question I do have is – Is it possible to do a mentalis resuspension without doing a sliding genioplasty? 

Any advice would be appreciated.

A: Thank you for your inquiry and detailing your surgical history and current problems to which I can say the following:

1) On a conceptual basis you have to go back and look at the origin of the problem and then adapt a treatment that is focused on reversing it. As you have described with the deepening vestibuloplasty from molar to molar the tissues have indeed been released and lowered. So efforts along the line of a shortening vestibuloplasty would seem appropriate.

2) While it is true that any form of chin augmentation (implant or genioplasty) can help with the success of mentalis resuspension, I wold be cautious about that in your case. Your history would indicate that you should limit the variables in any corrective approach. You have already learned well that not everything always goes according to plan, despite the best intentions, and you certainly don’t need to develop any new complications from a procedure that you do not feel is essential. In other words, you do a chin augmentation IF it remains an unfulfilled aesthetic desire. I cannot pass judgment on that ‘need’ based on a single frontal picture.

3) A mentalis resuspension can be done without a sliding genioplasty and most of the time is done without it. It can be useful to apply a sheet of ePTFE on the front portion of the chin to give the tissues something to grab into to help hold it. But I would certainly not use a sliding genioplasty for that purpose unless that was already desired to be done anyway. (which has you have already stated it is not)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in infraorbital implants with high vertical augmentation (approx. 6mm). I was wondering if that is possible for everyone or if there’s a risk of the implants touching the eyeballs if they implant rim border is too high? 

Many thanks 

A: Thank you for your inquiry and describing your objectives. A 6mm high height on a custom infraorbital implant is not rare in my experience.  At such heights or higher I have not seen the potential problem of touching the eyeball.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom jawline and custom bilateral infraorbital malar implants. How are the implants placed? Would they all be through the inside of the mouth or would the infraorbital implants be done through the lower eyelid? I don’t want my eye shape to change or for there to be an increase in sclera showing – is this something you’re always able to avoid?

Thank you,

A: A custom jawline implant in a male is typically placed using three incisions, two in the back of the mouth and one from outside under the chin. The combined infraorbital-malar implant is typically placed through the lower eyelids…unless it has only a very small infraorbital extension and/or does not saddle the infraorbital rim.

The most common use of lower eyelid incisions by plastic surgeons is in older patient with lower blepharoplasties where tissues are removed of which increased scleral show or lower lid margin rounding is a well known risk and is not a rare postoperative development. It is very different in young people who have stronger tissues and a stout lateral cantonal tendon who get custom implants where no tissues are removed and lower eyelid support is being added. As a result increased scleral show is not an expected problem and often the reverse occurs…an elevated lower eyelid or decreased scleral show. (if it existed beforehand)

Dr. Barry Eppley

Indianapolis, indiana

Q: Dr. Eppley, earlier this year I had a forward-sliding Genioplasty. Myself and the surgeon had agreed on a projection of 8mm, but during the operation the surgeon decided that 6mm would be better. I wasn’t convinced by this decision at the time of leaving the hospital and I’m still not convinced now. 

To be fair, I can see a positive difference which is wonderful! However, I still believe that 8mm would have been the better choice and I’m overall disappointed by what could have been. What do you suggest I do next, if anything at all? I would very much appreciate your professional opinion. Kind Regards, 

A: Thank you for your inquiry and sending your before and after pictures. I can appreciate your sentiment that 8mms was a good choice for advancement given the amount of natural chin recession you had. While not achieving the ideal chin augmentation goal there is some solace when the operation goes on to heal uneventfully. Presuming your interest is in improving the result you have (which is what you are exploring) one ‘advantage’ of the prior surgery is that you have a very clear idea as to what 6mms achieved. That then allows you to re-evaluate the original premise of whether 8mms was the ideal choice or perhaps even more would be better. With the new number in mind your options are obvious to re-do the sliding genioplasty or top it off by adding a small chin implant on the front end of it. I can make arguments either way but at an added augmentation of 2mm to 4mms at most, adding a chin implant on the front of it seems an acceptable choice given the reduced magnitude of the surgery. But I have seen plenty of patients make similar movements by re-doing the sliding genioplasty as they were strongly opposed to an implant. There is no right or wrong about either option, it is all about whatever makes the patient feel most comfortable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a thin/athletic female, but due to very high hip bones have severe hip dips where I essentially have two hip curves. I am aware that there is hip and bbl surgeries, but my worry is that because of my very high hip bones and wide ribcage, I wont have much of a waist if I get implants to help the dip dips; my hips would start directly under my ribcage. I have seen where you do rib removal, but was wondering if he has any experience in hip impingement or bone shaving. I wonder if a combination of high hip bone shaving and then a hip dip procedure could get me the hour glass shape I desire. I’d love to know your thoughts on if this is something even possible, and how realistic it would be.

Thanks!

A: Thank you for your inquiry and detailing your concerns. What you are referring to is reduction of the outer curve of the iliac crest bone leaving intact the anterior and posterior crestal areas. This is known as iliac crest reduction or hip bone shaving. This could be combined with hip dip implants. That is certainly possible even though I have never yet had that specific combination requested yet. Please send me some pictures of your hips form assessment and computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, You said that it was impossible or not recommended to bring the eyes closer in those suffering from hypertelorism 1. But could it be possible to increase the distance between the eyes for those who suffer mild hypotelorism? 

A: Orbital box osteotomies in adults, whether it is to bring the eyes closer together or further apart, are treacherous from an aesthetic standpoint. Numerous aesthetic tradeoffs exist (e.g., long coronal scalp scar, bony irregularities) for which the tradeoffs do not seem worth the benefit. It is not impossible, just not advised.

To illustrate that point I saw a patient recently who had orbital box osteotomies as an adult for mild hypertelorsim. She is now on her 5th revisional surgery to manage the aesthetic tradeoffs. Her eyes are better but…

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, is it possible to eliminate or mitigate scleral show by cheek augmentation and infra orbital rim implants? I would like to avoid eyelid surgery and when I “push up” the soft tissue on my cheeks under my eyes, I achieve the “hunter eyes” look I am after😄 But it seems to me the only way that can be achieved, is by attaching soft tissue to the implants so instead of pulling down the eyelids it pulls up the flesh. Is it possible or is it just crazy talk? Thanks for your time.

A: Infraorbital rim implants, if they add vertical height, do help push up the level of the lower eyelids. (mitigate scleral show) This effect is also supported at the time by soft tissue cheek suspension to the lower eyelids. It may not be equivalent to the effect created by pushing up on the cheek tissues from below by hand but it definitely helps.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Part of my problem with my profile is my lower lip is too recessed as well.  Can the sliding genioplasty address the lower lip recession as well?  The attached pictures show what could be accomplished with only a modest amount of vertical lengthening.  The lower lip advancement should be considered when deciding how much horizontal projection to give.  I saw this video and the surgeon in this video said the labial mental fold would appear less with sliding genioplasty because you are bringing it forward and down instead of just forward as in a chin implant.  Will the lower lip move forward as well in sliding genioplasty?

I provided a link showing that I would like the osteotomy cut to reach more posteriorly just underneath the nerve to reach farther back to give a more broad appearance.  See 1:19 in the video.  I would also like the cut made in such a way that there is continuity in the bone.  You can also come up more so it’s a few millimeters below the tooth root.     I’m not sure if the bracket’s you ordered are for a specific dimension.  As far as specific dimensions I was thinking 8-9 mm vertical and 7 -8 mm horizontal. 

A:It is clear that you have some basic and common misconceptions about what a sliding genioplasty accomplished. So let me provide you with some basic understanding of what the procedure does and does not do:

1) It will NOT bring the lower lip position forward. Lower Lip position is primarily controlled by the lower teeth. Thus the only procedure that will bring the lower lip forward is a sagittal split mandibular osteotomy (orthognathic surgery) which pulls the whole lower jaw forward with the teeth. A sliding genioplasty is a bone cut beneath the lower teeth which moves the chin bone but does not change the bite relationship or move the lower teeth forward.

2) The depth of the labiomental fold (better described as the labiomental sulcus not a fold) is controlled by the attachment of the mentalis muscle to the bone. Any type of chin augmentation procedure (implant or sliding genioplasty), by definition, moves the bone or soft tissue chin pad below forward BELOW the attachment of the mentalis muscle or below the labiomental sulcus. Thus any form of horizontal chin augmentation is goin to make the labiomental sulcus deeper. That is unavoidable. In the case of a sliding genioplasty which is also providing vertical elongation the deepening of the labiomental sulcus may be mitigated somewhat. (not made appreciably deeper) That being said what is going to happen in your case? Because of the chin bone movements it will probably not get any worse but I would not count on it betting better either.

3) When it comes to the osteotomy cut, I will make it as to what I know is best. Your key misunderstanding on the sliding genioplasty bone cut is that you must stay way below the mental foramen to avoid cutting the intrabony course of the nerve (and resulting in permanent  lower lip numbness) and you must equally stay below the tooth roots enough to avoid creating permanent numbness of the lower front 6 teeth. But no matter how the osteotomy cut is done it will NOT make the chin wider. A sliding genioplasty that brings the chin forward and down will result in the chin becoming more narrow…this is unavoidable.

4) How much the chin bone can come forward and down will not be known until actually doing it in surgery. You have a naturally very small chin and the large chin implant has undoubtably caused some typical loss of 1 to 2mms of bone. While I agree that a total 8 to 9mm forward and perhaps equally vertically downward may be optimal, whether that can be safely achieved in surgery remains to be seen. You can’t just move the chin out in space, part of it must remain in contact with the bone above it to heal and avoid substantial bone resorption.

In conclusion you are under the illusion that a sliding genioplasty can do more that what it can really do. The purpose of the sliding genioplasty in your case, as opposed to going right to the entire custom jawline implant, is to lessen the implant load on the chin with the second stage custom jawline implant. It is not being done necessarily because it will create a better aesthetic result than the one stage custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I am here to see if jaw implants will work to achieve the specified looks I desire. My greatest concern is exactly how I will look like after the surgeries. I am fearful that the implants needed to achieve the ideal looks which I desire will somehow not look proper or good on me after the surgery. Therefore I believe that seeing myself with the implants that I require/desire/request to achieve my desired looks on my face i believe this would eliminate all my concerns. I have provided you with a set of 7 photos, 4 of them show my current state without surgeries, the other 3 show the ideals of mine, that I am seeking to achieve. I believe photoshopping my side profile to the side profile specified by 2 of the photos as well as show how the front of my face will look like after the jaw implants have been done on the sides, so seeing an image of the front of my face as well as side view with implants, would be so so appreciated. thank you again for taking time to hearing my concerns.

A:Thank you for your inquiry and sending your pictures. While the ideal examples you have shown all have different types of jawline shapes, your overall concept is to have more definition to your jawline particularly at the corners. (chin and jaw angles) I have done some initial imaging just looking at one type of potential jawline change for you to ponder. Such a jawline change can be stronger or less defined but for now all we are trying to do is see if any type of jawline change would be aesthetically beneficial.

I would also caution you that computer imaging is not done to show the very exact result that will occur.The purpose of computer imaging is frequently misunderstood by patients. Computer imaging is done to help determine what the patient’s aesthetic goals are. It is a method of visual communication to help your surgeon understand what your specific goals are. It is not necessarily an accurate predictor of the final outcome. It establishes goals to aim for which may or may not be completely achievable based on human tissue responses to surgical intervention that lie beyond that of what computer software can account.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi! I am interested in the 2 step occipital skull augmentation and was wondering if it would be possible to have this procedure done under local/sedation rather than general anesthesia. Thanks!

A: Thank you for your inquiry. Larger skull augmentation procedures are not operations that lend themselves to a pleasant experience or good surgical outcomes when attempted under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two lumps on my forehead for about 7 years now. They don’t bother me on normal lighting but when there’s a bright/sharp lighting, they are very visible. This has really been distressing and I’m very keen to get rid of these. What are the treatment procedures available for them? 

I have attached the pictures as well.

A: Thank you for your inquiry and sending your picture. You have the classic forehead horns or eminences. There are two approaches to elimination them. One approach is to burr down the bony eminences through a small hairline incision. The other approach is to build up the forehead above the brow bones around them with a thin layer of bone cement or a thin custom implant. Which approach is best depends on how you feel about the rest of the shape of your forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi Dr. Eppley, I’m interested in chin implant removal and then a sliding genioplasty. I would like to use a submental incision, and I was wondering if this is possible?

A:Thank you for your inquiry. The question as to whether a sliding genioplasty can be done externally from a below (submental incision) is an interesting one and not the first time I have heard that question. When coming from below there are three technical challenges/problems:

1) degloving of the soft tissues from access (which provides the blood supply for the bone to survive

2) angle of the bone cut

3) application of plate and screw fixation

Having done lots of submental bony chin reductions, I can envision how all three challenges can be overcome as long as the bone movement is not excessive….although I have never yet done the sliding genioplasty operation from this approach myself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had reached out to you awhile ago regarding my chin issues. I have attached an x-ray imagine that I think shows my issues with the drooping chin tissue/ptosis. I’ve previously had some regrettable chin surgeries including a small implant and then the removal of that implant and a sliding genioplasty. If you have the time to give me some advice that would be awesome.  My main concern is that my chin looks too long and droopy when smiling especially. Thank you for your time. 

Kind regards,

A:In theory the sliding genioplasty after the removal of the chin implant was intended to solve the chin ptosis. But the amount of forward chin movement was so modest (albeit appropriate for your face) that I would not have expected that to provide improvement of the chin ptosis unless it was combined with mentalis muscle tightening/lift. (and even then it was not a guaranteed improvement as the bone movement is so small) At this point the only assured improvement of the soft tissue overhang is an excisional submental chin tuck.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fixing the lower part of my face with a corrective chin implant and jawline custom made to obtain masculine appearance.

A:Thank you for your inquiry which your doctor forwarded along to me. In looking at your pictures and the thicker skin you have you are not never going to have exactly the ideal lower jaw shape that you have shown in your examples. But you can make considerable improvement with your naturally shorter chin and jawline. The most effective way to get the best jawline shape and more masculine appearance is a two stage approach. First have a sliding genioplasty done to bring the chin way forward and down. That alone will produce a big improvement and serves as a foundation onto which a second stage custom jawline implant could then be done to wrap around the whole chin/jawline to get the best jawline shape and definition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a primary rhinoplasty in eight years ago in the Middle East. The surgeon straightened out my bridge and tucked in the nostrils a bit. Over time, the tip drooped more than the original nose. The nostrils were still quite wide.

I then had a revision rhinoplasty there years later by another surgeon. The surgeon lifted the tip and reduced the nostrils. It looked quite ok and I felt quite attractive but the nose was still quite long and the nostrils still a bit big. He wanted to shorten the tip and further tuck in the nostrils after 1 year, because he first wanted to check how my nose healed in that year.

I then had a third rhinoplasty with the same surgeon. He shortened the length and further tucked in nostrils. As this has healed, the tip is still overprojecting and now looks bulby. It is also drooping a bit with a fullness (slight hump) which I’m guessing is scar  tissue? This time around, there seems to be an unevenness in my nostrils as well.

Attached are my current pictures. I’d really appreciate a realistic view of what is possible for an improvement.

A: Thank you for sending your pictures and detailing your rhinoplasty history and current concerns. What is most revealing about your 3 rhinoplasty surgeries is what happened from the second to the third one…and this is very common in thick skinned noses where further tip shortening is desired after multiple procedures. Unlike the first two procedures where sequential improvements were obtained, after the third surgery new problems developed that were not present (or recurred) after the first two procedures. What this speaks to is that at some point in any revisional procedure the balance between improvements vs tradeoffs becomes less favorable. In an effort to take the procedure to an even better level (and you can not be faulted for asking to do so) the benefits are just not realized or some form of negative shape changes occur. In the spirit of the old saying..’past history predicts future behavior’…this provides a note of caution about a 4th rhinoplasty endeavor.

Does this mean no improvements in the shape of your nose is not possible? I can not yet say whether I can provide such improvements as I need to know what was done in rhinoplasty 2 and 3. You should be able to get those operative notes from your surgeon for my review.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, There is the area on the back of my head which is a 3 inch by 3 inch indented area. If just that part could be corrected the rest of my skull is all fine. 

A: Thank you for sending your pictures which clearly the indentation on the back of your head. While there areas seems small (3 x 3 inches) it is actually bigger than it seems when trying to build out a skull contour that is smooth and confluent with the rest of the bone around it. While a custom skull implant is the ideal way to build that indented area out for the reason mentioned, its is reasonable to use bone cement to do so for the same of economy. Fortunately I built my experience in skull augmentations using bone cement long before custom implants existed so this is a technique of which I am very familiar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have had a hyaluronan injection (product name: Restylane) in my brow bone a few months ago.

● Do I need to remove the hyaluronan for a 3D CT scan? 

● If it needs to be removed, I will need to ask my doctor to give me a hyaluronidase injection to dissolve hyaluronan before the 3D CT scan.

A: You do not need to worry about the injectable filler in your brow bone areas as that will not interfere with the 3D CT scan imaging. It is a non-radiopaque type filler which is invisible to the scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young caucasian female interested in learning if there are ways to surgically increase the size of the eyes, specifically their width. My eyes currently are very small with a rounded outer edge. I wear winged eyeliner to try to widen the appearance of their size, but I think you will still be able to see in the attached photos their true edge and the “blank space” their small size leaves in my face. There are a few other procedures that I might pursue in the future to remedy that amongst other imperfections (rhinoplasty, lip fillers, potentially methods to widen my mouth and shrink my forehead if possible), but firstly I’d like to know if there are ways to increase the size of the eyes, arguably the most important facial feature. I’ve included photos of myself as well as photos of people with an eye size and shape that I like (large, pointed inner corner and outer edge)– there are a million examples of course of people with large eyes but I thought it might be helpful. My weight varies a bit in the photos but the size and scale of the eyes of course remains the same (I’m usually the middle weight). I also included a digitally altered photo of myself with just the eyes edited a bit wider. This may or may not be helpful because that kind of result might not be possible with surgery, but perhaps you might be able to convey to what extent a result like that would be possible. 

Thank you for your time and assistance.

A:Thank you for your inquiry, sending your pictures and detailing your eye concerns/objectives. While there are many types of eyelid adjustments that can be done, the one dimension that is very refractory to change is lateral eye width. The eye corner can be moved up or down but changing its width has different implications. And there is a good anatomic reason for that being so. There is an intimate relationship between the eyelid and the globe (eyeball) in which the eyelid needs to be tight up against the eyeball at all times. That is to prevent the globe from drying out or developing associated symptoms. (chronic tearing) While the outer part of the eyelid can be surgically lateralized that would likely pull the corner of the eyelid away from the globe particularly if a lateral canthopexy was done. Even if a lateral canthoplasty was performed the bony lateral orbital rim would need to be changed and such a lateral pull would also likely make the eye look more narrow vertically…which is diametric to what you are trying to accomplish overall.

While your request is not uncommon, I do not have a surgical technique to accomplish your goals in a safe and reliably effective manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello. I had a large chin implant placed 4 weeks ago. I believe it is too large/high. I also can not smile. Would you recommend replacing the implant? I included some before pics for reference. The collage are all before pics, just some are from when I was younger. Thank you for your time. I wish I had found you 4 weeks ago! 

A: Thank you for your chin implant replacement inquiry and sending your pictures. While your chin was naturally short/smaller, it is a ‘compressed’ type of short chin which means there is a vertical component to the chin deficiency as well. (as evidenced both by vertical facial third assessment and the deeper labiomental fold) Your chin implant may or may be too high but when just horizontal advancement is done in a chin like yours, the vertical shortness becomes magnified…and you have all of the symptoms that you describe. While chin augmentations do take a full three months to see the true result, I would agree that the symptoms you have now both aesthetically and functionally are not going to substantially improve. You really needed a 45 degree type of chin augmentation in which the vertical lengthening with less horizontal projection is the more appropriate dimensional change. Your current implant relies exclusively in the horizontal projection to achieve its effects…which in many patients is fine but it just doesn’t work well with your chin anatomy.

Your options now are:

1) Remove and replace your chin with a small vertical lengthening style which produces a 45 degree type of projection. (5mms forward and 5mms down)

2) Remove the chin implant and replacement with an opening sliding genioplasty with the same type of dimensional movements as #1 option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orbital rim implants six weeks ago along with a canthoplasty, but I believe they are too big for my very small face, and created a concave shape in my cheeks below the implant. Are there custom implants that would look good on a small face? I am a small built female with a very narrow face.

A: Thank you for your inquiry and detailing your recent surgery. Once of the ‘advantages’ of having implants in place and knowing what you don’t like about them is that it makes designing a new implant that works better much more likely. (i.e., when you know what doesn’t work that helps considerably in figuring out what will work) Beside the size issue one of the disadvantages of preformed implant shapes is they are made for a skull model and not your specific anatomy. This is why the transition between the implant and what lies around or below it is obvious now that the swelling has subsided. Custom implants solve/improve that issue by their design in most cases. A preoperative 3D CT scan nay also reveal any other reasons (e.g., positioning) as to why you see what you see on the outside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your reply!. Alloderm seems to be a great option!. For the measurement of the shoulder atrophy, it’s very asymmetrical and not a perfect round shape. So this area (of skin atrophy / fat atrophy) is around in height 8 – 10cm and in width around 5-6cm (sorry its hard to measure it) It will be so amazing and my dream if i can find a permanent solution, and feel normal…

After alloderm graft, will the result be permanent? Like if for example i lost weight, do sport, or get old?. And I have heard that Alloderm can be resorbed over time, is that true?

Thank you so much for your kindness!

A: Thank you for sending your measurements. The purpose of the measurements is help select what size Alloderm or Strattice sheet (both are tissue bank dermal grafts) is needed or what the dimensions of the implant would be if we where going that route.

My extensive experience with Alloderm in the face as well as the breast is that it is volumetrically persistent. Whether that translates to the shoulder for your type of problem can only be speculated as who has ever done it before? Alloderm is used extensively in breast reconstruction as a lower sling to support an implant and as a reinforcing sling in aesthetic breast surgery for bottomed out breast implants…situations where its persistence is important. Whether the high motion area of the shoulder will share a similar long-term outcome is presumed. While a custom soft silicone implant will undoubtably provide long-term volumetric maintenance my long-term concerns with its use in the shoulder is eventual edging of the implant being seen and/or an unnatural folding of the implant when you raise your arm., Thus it is better to have something that will allow tissue ingrowth and a few less risk of graft edges being visible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, my concerns are a very asymmetrical nose from a prior rhinoplasty. I have been afraid of redoing it through the years and having worse results, but as I age, it becomes more and more obvious to me. I also have concave temples (I once had a blend of heart shaped/oval) but now have a peanut like facial shape, with my left eyebrow sagging worse than my right one. I also notice it increases the sagging of my outer upper eyelids, so when I relax my facial features I look grumpy or unhappy when I’m not at all! 

I would like these two issues for sure. Id like to have more addressed but my nose and my temples are my highest priority, I’d like to find out how expensive they may be, including a generalized idea of How extensive would my nose repair might be? I have hanging columella and alar retraction for sure. I am not looking to have the “perfect nose” but I would like it more symmetrical and when I use my muscles to pinch my nose downward and push up on the columella it looks so much better with allowing my eyes to be more visible (except for the alar retraction is also still visible with pig-like nostrils lol.)

I am a medical professional so I fully admit I’ve researched all the procedures and watched several informative surgical videos of these procedures, as well as multiple reviews of surgeons across the country. So I am most interested in the cost and the potential of how extensive these procedures might be for my situation and how much vacation time off from work I’d be required to have. Thank you so much for your time!

A: Thank you for your inquiry, sending your picture and detailing your concerns. From a primary standpoint the permanent treatment of temporal hollowing are temporal implants. Like many women you need the extended design and the only debate is what thicknesses they should be. (4 and 6mms are the options of which most women usually get 4mms) For your revision rhinoplasty based on your picture and description most if not all of the issues are in the tip area. It appears that it is a combination of hanging columellar correction (caudal septal resection and columellar strut), alar retraction correction (alar rim septal grafts), and tip defatting/scar removal and possibly some tip rotation. My assistant Camille will schedule  a virtual time to discuss further if you would like as well as pass along the cost of such surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve provide the list of items below that are related to the asymmetry of my face:

1) Uneven eyes (Might be worth noting that it seems like the older I get, the worse it gets.)

2) My jawline is uneven.  It might be difficult to tell in the image, but one side of my jaw is not symmetrical to the other side. If I lost about 10 pounds it would be more evident.

3) I’d assume, that if my eyes were to be re-leveled, it might also require some adjustments to my nose since its alignment appears to coincide with the asymmetry of my eyes.

4) Lastly, if I decide to undergo any procedures related to my eyes, then it is probably also worth considering doing something about the bags under my eyes that give the appearance that I am always tired.

If you have any questions or I need to provide further information, please let me know.

A: Thank you for your inquiry and sending your pictures. You have an overall right facial asymmetry in which all the facial features on the right side are different. (smaller/lower) Some are very minuscule but they can be seen when looked for carefully. (which you the patient has) Yours is a superior facial asymmetry where the greatest and most visible difference is at the eye level. (vertical orbital dystopia = VOD) Think of the eyes like a box (hence the name orbital box) where the eyeball is encased in a box of bone. Thus in your right VOD the orbital box is lower. Hence not only is the eye lower but what lies around it is lower as well. (eyebrow, brow bone, upper and lower eyelids, cheek) This is noteworthy when treating VOD as pushing the eye up is one thing but how does that affect the appearance of what surrounds it. (meaning you can’t usually just push the eye up in VOD and get a complete correction)

The first place to start to determine what and how to do it is to get a 3D CT scan for full assessment. I will have my assistant Camille contact you to schedule a virtual to discuss in more detail.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. The main reason is mostly cosmetic so I would also be looking into liposuction in that area as well. I am of a smaller build 5’2” 118 lbs. The asymmetry in my body and lack of waist has significantly impacted my body image so I have been looking at rib removal for years but always thought it was too dangerous or extreme! 

I am curious about how much greater the risks are in regards to the organs once the ribs are removed and with my scoliosis if the risks are higher?

A: The risk of organ damage in general in rib removal surgery is essentially zero. It is a common misconception that is a concern. I would refer to my website, www.exploreplasticsurgery.com where you search under the term RIB REMOVAL and read what I wrote about Rib Removal surgery and organ damage in an article in more detail. This is particularly relevant in your case where taking rib #12 has no aesthetic benefit. You will understand the relevance of that when you read that article. Your scoliosis creates no added risks to the surgery. Its only relevance is that it has shown on one side why taking rib #12 has no benefit to waist reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m on your page now for the surgical reshaping of a flat back of head? I hate the shape of the back of my head and am willing to travel for this. I also saw your comment on a Real Self question & answer forum saying that this procedure can be done non surgically by injection… could I please learn more? Namely how much would these cost? 

A: To clarify on augmentation of the back of the head, the superior method aesthetically is a custom skull implant. For smaller skull shape defects PMMA bone cement can be used through a very small incision with introduction with a funnel…but that is not a ‘non-surgical method by injection” It is still a surgical procedure that requires the same dissection under general anesthesia as placing a custom skull implant. It also does not produce as good an aesthetic result. You are over interpreting what you have read.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could suggest me what you would do to improve my appearance. I have an asymmetrical jawline, which is more visible when I smile or talk, but at the same time I feel like my face could benefit from other surgeries as well. (my forehead is prominent, my eyes are sunken) I do not know which surgery I would benefit the most from. I am only 26 years old and I feel like I look older, and I would like to go and correct what could cause me to perceive myself that way.

 I would really appreciate your feedback.

A: Thank you for your inquiry and sending your pictures. The one surgery that would benefit you the most is the one that treats the single feature that bothers you the most…which only you can say. You have listed high forehead, sunken eyes and asymmetrical jawline. The reason you look older has to do with your sunken eye appearance with a touch of upper eyelid ptosis. Unfortunately that is also the one facial feature that is the most difficult to improve and even more difficult to try and image the change on your picture. For the sake of discussion I have imaged hairline advancement, rhinoplasty and left chin-jawline augmentation. Then in a second image I added some slight volume to the inferior brow bone/upper eyelid area and even that small amount to ma made a big difference in improving that facial issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached a few photos. Looking to advance the chin a bit, remove some of the fat surrounding the neck and perhaps have implants or filler to give the lower mandible some form. My under eyes are also quite hollow so I would be interested in looking at solutions for that. 

A:Thank you for your inquiry and sending your pictures. I did some initial imaging on the side view one which is the best place to start with an initial assessment from which I can make the following comments:

1) With your thicker facial and neck tissue, and naturally shorter lower jaw, what I would recommend is that you first work on the chin-neck relationship  and gets some positive changes there. With your shorter neck and thicker tissues a sliding genioplasty is a better chin procedure for you as moving the chin bone forward pulls the neck muscle out which is a big help in the thicker neck patient with an obtuse cervicomental angle. This can be combined with a submentoplasty procedure to remove neck fat and tighten the platysma muscle to really help your cervicomental angle. These two combined procedures will do the most for your chin projection and neck reshaping and then you can see about any further work on the rest of the jawline later.

2) Your undereye hollowing could be done with the chin-neck work and is going to require a custom infraorbital-malar implant to give the undereye area the added volume that it needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How much vertical chin reduction can be achieved in my case by the intraoral wedge removal genioplasty?

A:Thank you for sending your chin pictures. While I haven’t yet seen a panorex x-ray to yet determine how much chin bone can be safely removed, I can predict at last 1 cm of vertical bone height would be reduced in the center. (which by definition has to taper out to the sides) But the real limiting factor in how much vertical chin reduction is seen on the outside is the overlying soft tissue which is obviously not removed. It can be compressed somewhat as the chin bone is vertically shortened but not in a 1:1 relationship to that of the bone removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant revision surgery 6 months ago. During the recovery, the nerve reaction on the right side is slightly weaker, causes no problem. I believe there should not be any nerve injury during the procedure. 

However, intermittent numbness and pain become more severe in the latest month. The implant was perfectly screwed and didn’t shift. I found one possible reason is that one side of the incision (denoted in green color in the attached photo) is close to the mental foramen. As the underlying scar grows, it may compress the mental nerve, which causes the pain and numbness (sometimes an itchy feeling). These feelings become stronger if I pressed the skin above the mental foramen. 

Could this develop into chronic pain? Is that possible to deal with this by nerve decompression surgery someday later? 

I’m looking forward to your reply!

A:It would be impossible to predict how the affected mental nerve may react as its distances itself from the date of the surgery. But at 6 months out from the surgery it would seem not very likely to develop into chronic pain if it has not done so already since the scar tissue has fully formed at this point.

Dr. Barry Eppley

Indianapolis, Indiana