Your Questions

Q: Dr. Eppley, I am interested in learning more about jawline augmentation by the wrap around implants, I don’t think I need customs ones however so are there any that have been premade? I currently have a triangular face but aiming for a more U shaped, masculine shape, will this be possible? also what is the cost, i have attached picture of what I currently look like, and another of what results I am aiming for.

A: Thank you for your inquiry and sending your imaged pictures which shows a smooth confluent jawline augmentation effect back to the jaw angle areas. It would require other facial views of imaging to see the full 3D jawline effect that you seek. One view alone does not provide all the information needed. 

While your jawline augmentation needs are modest by my standards, that does not mean it is easy to achieve. Getting such a smooth and even effect is always most assured by a custom jawline implant made from the patient’s 3D CT scan. Only by creating an implant that naturally expands the shape of the jaw can such a smooth effect be seen in my experience. Standard chin and jaw angles implants are what is known as spot augmentations which are fine if just the chin and/or jaw angle area needs a specific augmentation. But smooth and confluent jawline augmentation effects do not come from the use of standard implants not specifically made for the patient.

I will have my assistant Camille pass along the cost of the surgery to you on this coming Tuesday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having an otoplasty on my left ear. While I did not find many of these types of surgeries during my research, I would like to ask you a few questions.Have you performed similar surgeries in the past, and if so, could you please send me some before and after photos?

What type of method do you plan to apply for this type of surgery and where will the scars be located? Will I have a small scar on the helix of my ear?

I was thinking about a reconstruction from the upper middle up to the top of the ear with the use of a cartilage graft for support, as I saw in one of your surgeries. Do you think that is the best technique to apply on my ear?

A: Thank you for your inquiry and seeding your pictures. You have a form of a constricted ear as seen by the folded over helix from the middle of the ear (3:00 position) up to the center of the top of the ear. (12:00 position) While some may refer to it as a Stahl’s ear, because of its pointed appearance, it does not have a third crus so it is not a classic case of it. The helix is also setback behind the antihelical fold as part of the overall hypoplasia. Interestingly some helical cartilage can be seen protruding from behind the helical skin almost as if the cartilage is adequate by the skin is deficient.

But I do think that the skin needs more helical cartilage support to both pull the helical rim skin back over it as well as provide some more projection. As you have noted a cartilage graft is needed to do so an the right amount and curve to it comes from a small portion of the subcostal rib #9 or #10.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young male and will be getting angular custom jaw implants, a chin implant and cheek implants next month. When I asked my Dr. about the wrap-around implant you offer, he mentioned he is not a fan of this type of implant because it requires complete degloving of the muscles. I have attached the MRI images showing the custom jaw implant that has been ordered from the implant company. Prior to proceeding with the surgery, I was wondering if I can get the opinion on the type of implants my doctor is proposing. After looking at pictures of the wrap-around implant, I’m concerned that with separate angle and chin implants I’m getting, it will be very difficult to achieve both a smooth jawline and a wider and more projected chin, because the vertical lengthening only exists at the back of the jaw bone, and does not extend to the chin. I would really appreciate if you can provide me your medical opinion on this and whether or not you believe what a better result would be obtained in my case with a wrap-around implant. Many thanks, 

A: Thank you for your inquiry to which I can make the following comments:

1) I do not comment on facial implant designs of other doctor’s patients. That is not appropriate for either the patient or the treating surgeon.

2) I would disagree, however, with the concept that a total jawline implant requires complete muscular degloving as that is not based on an anatomic understanding of jawline soft tissue anatomy. The muscles that do need to be elevated are the mentalis (chin) and the masseter (jaw angles), there are no muscular attachments between the two. Interestingly these are the same muscles that must be elevated for separate chin and jaw angle implants. What is elevated in a total jawline implant is the need for complete subperiosteal elevation.

3) I think your aesthetic concerns are well founded which is why the use of separate chin and jaw angle implants has largely been replaced in my practice with the wrap around implant concept. It simply offers a superior aesthetic result that has fewer postoperative complications such as asymmetry. When the jawline is weak or underdeveloped it makes more sense to augment the whole problem as a single unit that it does to add ‘spot’ augmentations to the three corners of the lower jaw for most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am reaching out to you in regards to my son who is an early teen. He had a nevus sebaceous birthmark removed from the crown of his headless year. The plastic surgeon was able to do a primary closure. At first the scar looked great, but at almost a month , the scar widened dramatically. Now we have him scheduled for a scar revision with a different plastic surgeon who wants to do extensive undermining and galeal scoring with vertical mattress suturing. Can you give me some insight?

A: It is perfectly normal and to be expected that all scalp scars will widen with any form of excision. The size of the excision will determine how much subsequent widening will occur. This is an unavoidable phenomena because the scalp is tight and is really skin stretched over a beach ball so to speak. While the scar may look great for a few weeks, the widening will subsequently occur. The extent of the widening will be fully manifest by three months after surgery and no revision should ever be done before them…as the tissues need time to relax. This is all part of the typical preoperative education. 

I tell all scalp excisional patients, particularly children and teens, that there will be a likely 100% chance of the need for subsequent scar revision. Most likely the wide scar is less than the original excision so the tension will be less and the scar will be better. The techniques that have been described are appropriate and represent the maximum approach for ‘Plan B’.

There is also the phenomenon of lost hair next to scar which can be confused with a ‘wide scar.’ The scar is actually narrow but loss of hair (hair shedding) makes it look wider than it is. In some scars it may be a combination of a true wide scar and loss of hair shafts. This is another reason to wait to see what impact any hair regrowth will create on the scar’s appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for responding so quickly! I would like your opinion on what could make my face look more symmetric and give it more definition, if possible. Basically, I would like to look like I have good bone structure. I’m not trying to look like any particular celebrity, but I’ll use their pictures to show what I like. I have several facial reshaping procedures in mind, but perhaps you will suggest something different.

I’m 27 years old, female, had braces to correct an overbite over 10 years ago, a primary closed rhinoplasty and a subnasal lip lift last ye5ar. I’ve tried lip fillers both before the lip lift and after.

Overall, I think my nose is better, but I’m not completely happy with it. As far as my lips go, I like the view from the side much better now, but the front still bothers me. Fillers never did much for me in my opinion.

I think I look drastically different bare-faced. Makeup helps me create some definition and angularity in my face, larger upper lip and a more symmetric nose. Of course, makeup can only do so much. I’d rather get more significant and lasting changes.

Here are my specific questions. I’ll start with what had already been operated on and then get to facial implants.

NOSE

I still have a remaining bump that is visible from certain angles. I wanted a more concave bridge and a tip that’s rotated a bit up to create an effect of a slightly shorter nose. I also think it lacks symmetry from the front and even with makeup I have difficulty making it look straight. My original nose had a bump and a bulbous tip, but didn’t seem crooked to me. My breathing was great before surgery, now it’s a bit worse, but not to the point where it bothers me.

Do you think it would be worth it to operate on it again?

LIPS

I just want my top lip to be close in shape and size to the bottom lip. Unfortunately, the lip lift didn’t give me a top lip. And I don’t like what fillers do to me (too puffy, not enough vertical red lip). So I feel stuck. The surgeon who performed my lip lift told me multiple times that both vermilion advancement and V-to-Y would look horrible because there would be no white roll and my lip would look pasted on, but I just don’t see what other options I have. The only thing he suggested was Botox lip flip to prevent the top lip from curling inwards when I smile and more filler. I am not happy at all with the current state of my lips – still very thin top lip when I look straight on, nonexistent on the sides unless I overline significantly, plus now if I close my mouth completely there’s a visible strain in my chin, that’s why I mostly keep the mouth slightly open – if I close it, my chin flattens.I don’t like how (in my opinion) it makes me look sad or angry.

What can I do?

CHEEKS

I’m interested in a custom model implant that extends all the way back. I’d like the effect of very prominent cheekbones, but I know there are limitations.

Do you think that’s achievable for me?

CHIN/JAW

My goals are: shorter, more protruding chin, and a defined jaw. I’ve always felt my chin is a little too long vertically, but in addition to that after a lip lift when I close my mouth my chin looks recessed. I also carry some fat around my jaw even when my weight fluctuates lower. It’s just never been really defined. I’ve had one surgeon recommend a neck lift, but I don’t know if that will be enough – I’m not sure how good my underlying structure is. I think my face always looked soft.

What would be a good solution here? Sliding genioplasty and a custom jaw implant? Something else?

A: Thank you for sending all of your pictures and detailing your concerns. You are correct in that makeup can make a person look completely different. But it is also helpful because it shows what the patient is trying to achieve.

As I understand it your prior surgeries have included a closed rhinoplasty and subnasal lip lift. Your goals now are to basically have a more defined facial structure and fuller lips. In essence this comes down to the following facial reshaping options:

NOSE  While your initial rhinoplasty provided improvement (reduced the hump) it reflects the more modest changes that typically occur from a closed rhinoplasty and largely left the tip relatively unchanged. You are probably seeking a more complete rhinoplasty to lower the bridge further, reduce tip projection and provide some tip rotation This is the way you are going to get a somewhat smaller and more shapely feminine nose.

CHEEKS You need some defatting underneath them from buccal lipectomies and perioral liposuction to create less fullness between the cheekbones and the jawline. This will also create a bit of a cheek augmentation effect. A custom heel-arch style always provide the best definition .

LIPS. When women draw their lips on and they look better they are basically adjusting the position of the vermilion. While a subnasal lip lift creates more central upper lip fullness it does not address the sides of your lip which is why you like it from the side view but not so much from the front view. This can only be addressed by a vermilion advancement.

CHIN-JAW. Your chin needs to come forward and be narrowed (sliding genioplasty) and some small jaw implants that help create a more visible angle to the back would create a more total jawline effect with the chin.

These are my initial thoughts,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if it would be possible to design custom infraorbital rim implants for the under eye out of titanium? I understand that it would be more expensive and that you are usually not a fan of using non-pliable materials for implants. But, since my only concern is under eye hollowing, I would assume for the results I want, the implant would be small. And also what would the price be of the same orbital rim implants made out of silicone? 

Thank You

A: I actually have no strong predilection about implant materials, it just comes down to their cost and whether their construct allows them to be placed through aesthetically acceptable incisions.

You are correct in that because a very rigid implant like titanium for the orbital rim would be small, it could be placed through a lower eyelid incision.

I will have my assistant Camille pass along the cost of both materials for custom infraorbital implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is the one to which every patient needs an answer and most doctors hesitate to give: cost. I need to know as funds are limited. Its nasal labial and marionette lines, plus overall tightening of sag and increasing luminosity of skin. Thanks. I’ve been reading about Bellafill and other flllers, but they are costly and may have unpredictable and very short lasting outcomes considering cost. Thanks. P.S. At some point, maybe they’ll make some implantable bone to restore lost bone volume in faces. That and a fat transfer may do nicely then. Anyway, can you give me and idea of your facelift cost – spec. marionette and NL folds.

A:I have no hesitation about giving costs as long as I know exactly what one is being quoted for. In facelift surgery there are three different types which vary in extent and cost and that choice is based on the patient’s anatomic needs. Not knowing your exact needs makes it a guess but I have no problem doing so, I will have my assistant Camille pass along what I would guess is the type of facelift you need. Beyond that I can make the following two comments:

1) While a lower facelift can improve marionette lines, its effects on the nasiolabial folds is limited to the lower end of that fold.

2) A facelift should be be confused with other forms of facial voluminization procedures such as injectable fillers, fat or even injectable bone substitutes. Their resultant aesthetic effects are not comparable and are used for different indications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My goal is simply to become more handsome and aesthetic. Ideally, I would like to like to acquire typical male model aesthetics, i.e. strong chin and jawline with high cheekbones and low facial fat. Although, I know there are limits to what surgery can do, so I’m trying to keep my expectations in check.

I was assuming that the ideal chin width would be relative to the rest of my face. That’s why I was considering jaw and cheeks implants at the same. I suppose I’m a little concerned about changing my chin to match the current dimensions of my face, then changing other parts of my face at a later stage.

I have considered starting by fixing the chin, then using fillers to enhance the cheeks and jawline to get an idea of what my face will look like with additional implants.

Based on your experience working on male faces, what would you recommend to approach the typical features of a handsome male face?

Thanks,

A: I would agree that if you just change the chin it doesn’t really match the rest of your jawline. The typical approach most patients take is to the whole jawline (chin and jaw angles) with a custom jawline implant and then see how they feel about the cheeks later. Although I have just as many patients, if not more, that just jump in and do it all at once. It is really a question of comfort as to a staged vs a total facial reshaping effort. There is no right or wrong way, it is based on the patient’s comfort level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in doing a combined large skull reduction and removal of temporalis muscle. 

I was wondering though, as I have read that there is some swelling after, and that it would take time before the result is apparent. Could you give a “timeline” of how much of the result is achieved percentwise, say 2,4,6,8 and 12 weeks after surgery? I suppose the swelling from the temporalis reduction is milder than that of the skull reduction?

A: As you have mentioned there will be swelling afterward of which the worst will be in the first 10 days at which point one is more publicly presentable. Finer details of the result take 8 to 12 weeks after surgery to fully appreciate.

You are correct in that the swelling from temporal reduction would be somewhat less than that if it was combined with skull reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to ask you this question since I read your answer on Real Self regarding a revisional genioplasty immediately post op. 

I had my genioplasty 3 days ago – even at the peak of my swelling I feel I was not advanced enough. My surgeon agreed to advance me more horizontally and vertically in 2 days if I wanted it.

He told me the procedure would be straightforward since the suture has not healed fully, scar tissue has not formed, and the bone does not have to be recut.

My main concern is additional nerve damage – I already have numbness in my bottom teeth post op which I heard is normal. Would a second procedure so soon increase the chances of the nerves not recovering? Also, when he stitches the sutures back up a second time, could this cause issues perhaps?

I think he did a great job otherwise, I just didn’t fully communicate my goals.

Thanks for your expertise.

A: What your surgeon is telling you is accurate in that an immediate secondary genioplasty is a lot easier to perform now than when you are fully healed. This will not increase the risk of the nerve recovery not proceeding like it would have after the first surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had several scalp contouring surgeries done with you (6 or 7 coronal scar “openings” in total if I remember correctly). I wonder if it’s safe for me to have a hairline lowering surgery done, if it’s over 1 year post op since the last head surgery, or is there a risk of skin necrosis between the coronal scar and new scar from the hairline lowering then? I’ve heard it should be safe 1 year post op, since the head grows new arteries and blood vessels, but I wonder if this is the same case with me since I’ve had so many scalp surgeries done…? 

A: Good to hear from you again. If I understand what you wanting to do, you want to move the entire scalp (which is what a hairline advancement is) which would necessitate undermining well past the coronal scar. And the pertinent question would be whether the intervening scalp between these two incisions (new frontal hairline one and the old coronal one) would survive? That is obviously a very good question and I have not seen a similar case of hairline advancement. It is possible the scalp will survive without any problem, but if it does not….

All I can say about that question is when in doubt….do a delayed approach. You make the hairline incision needed down to bone and then simply suture it closed. Then 4 weeks later perform the actual hair advancement. This is what is called a true ‘delayed flap’ approach and has been used for skin flap surgery for one hundred years. In this way you ensure that new blood vessels find they way into the narrow island of skin between the two incisions from each side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw a response that you wrote on Is There Surgery For Cutis Verticis Gyrata? at http://eppleyplasticsurgery.com//is-there-surgery-for-cutis-verticis-gyrata/

I was wondering .. how does the fat injections you spoke of work and or is surgery a better option now? 

And do you do both?

A: I don’t think trying to cut out the areas, as has been historically done, is a very effective approach and has a risk of just making them worse. Fat injections tend to make them less deep, and while not a ‘miracle cure’ for them. is a less risky treatment option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my pectoral implants replaced last year. If the photo looks familiar, Implantech has posted it on its website. I am very happy with how they turned out. I am now planning on ab etching of the waist, lower back, and flanks. I have read on your site that you have experience with fat transfer to the shoulders. My ideal would be to harvest as much fat as possible and transfer to areas where it would most successful. I am thin 5’10 and 155lbs and 56 years old. From first glance, do you think I would be a candidate for fat transfer to the shoulders? 

A: In answer to your question, you are a good candidate for far transfer to the shoulder IF your primary motivation for the surgery is the liposuction/etching etc. The reason I make that statement is because in that scenario you have nothing to lose by taking the harvested fat and transferring it to the shoulders. The worst that can happen is that the fat doesn’t survive. But even if that occurs it prepares the shoulder tissues for the placement of deltoid implants if you are so motivated. (the definitive shoulder augmentation procedure)

You have to recognize that at your age and low body weight, fat transfer to any face or body area is far from assured in terms of volume retention. The reality is that fat is more likely to survive at a very low percentage than a higher one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I do apologize if this is not the correct way to contact you but i recently saw your Youtube video about custom jaw implants.

I was just wondering a few things. 

I am from the UK and was wondering if you are able to complete surgeries on someone out of the with US? 

I also am going to start saving soon for the cosmetic work I wish to have done and was wondering if there was any chance you had a rough cost so iIknew what i was looking to save ?

I do not want to waste you time by asking for a full consultation as I may not have the money for a few months and I fully understand costs may vary greatly depending on the patient, but just a ballpark figure would be fantastic.

Im 18 also and wonder also if it would be advised to wait until I was a little order or if i can get the procedure soon ?

Thank you so much and sorry for any inconvenience this may cause you.

A: Thank you for your inquiry. In answer to your custom jaw implant questions:

1) The vast majority of patients for custom jaw implant comes from may different places all over the world. So it is common that patients travel in for the surgery.

2) My assistant Camille will pass along the cost of the surgery to you on Monday.

3) At age 18 your lower jaw is adequately developed to have the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I reached out to you a year ago. I had a sliding genioplasty two years ago (6mm horizontal movement) that left me with some scarring/webbing that has my lip pinned down.  I am also dealing with numbness (I have the slightest sensation) on lip/chin area and tightness.

Also, I had an endoscopic brow lift done at the same time, that I feel was overdone, especially my right eyebrow, which i can hardly move at all.  

I feel after two years I can not expect any improvement and my original surgeon is no help.  

I would like to schedule a surgery date with you if you feel this something you can improve.

A: I do reminder your inquiry from a year ago. I am not sure if this is the first time I have seen your postoperative pictures of your browlift result or not. I have seen and treated numerous high browlift results and, while it is straightforward to lift the eyebrows, it is not so easy to bring them back down. It is not a matter of just releasing them and they will move down…as they will not. An endoscopic browlift is an epicranial scalp shift. As a result the forehead and scalp tissues are stretched and pulled back and now scarred into place. 

The only chance at dropping down the eyebrows is to create the extra tissue to do so. This would require a tissue expansion approach of the scalp which would release it and create the necessary stretch of the scalp/forehead tissues to allow them to stay lower.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could fillers achieve similar results as an implant for paranasal augmentation, or are the soft fillers not as good at creating the look of a more forward set maxilla?

A: It would depend on how much of a midface effect you seek. If it was an isolated paranasal augmentation their effects may not be that different. But if it is a total midface augmentation effect then it would matter. It is all about the amount of miudface surface area coverage. Since you used the term ‘more forward set maxilla’ that implies the latter, only an implant can create that type of bony augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you forward me some photos of a custom wraparound jaw implant before/afters?

How soon after you receive a 3D CT scan is the implant produced?

By now I suppose you have become extremely proficient with these implants, so I hope your aesthetic eye would catch if the implant would look way too big/too small for my face. I want to minimize the risk for revision..

Thank you in advance!

A: In answer to your custom jawline implant questions:

1) We do not pass out patient photos due to confidentiality reasons. Any patient who has agreed to any part of their pictures being used will have them posted on one of my websites, www.exploreplasticsurgery.com, searching under Custom Jawline Implants of which there will be many blog postings on that topic.

2) The typical design and manufacturing time from obtaining the 3D CT scan and the implant delivered for surgery is 4 to 5 weeks in most cases.

3) The aesthetic interpretation of what is ‘too big to too small’ is open to wide variability amongst patients and is extremely individually based. What is too big for one patient may be too small for another and vice versa. But through the use of computer imaging I can determine for the implant design process what your aesthetic goals are from which I can best direct the dimensions of the implant design….so what you are saying is true about my expertise in implant designing when put into proper context.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are fat injections in the treatment of Cutis Verticis Gyrata (CVG) permanent? Are there any side effects? Do you have any before and after pictures of this that you can send me? How much does this cost?   In the google photos link below, it is some pics of my head. Mine are not extremely bad if I keep my hair a certain length. But I want to have it where it looks even better. 

A: In answer to your questions regarding fat injections for CVG:

1) Fat injections anywhere on the face or body are unpredictable interns of survival and volume retention. But usually there is always some volume retention but the percent can not be accurately predicted beforehand.

2) There are no side effects with fat grafting surgery to the scalp.

3) My assistant Camille will pass along the costs of the surgery to you on Monday.

4) Your pictures shows a moderate case of CVG which is better to treat than the advanced cases where the grooves are completely stuck down to the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some facial reshaping questions and I’ve done some crude arrows with correlating numbers to try and illustrate what I mean in the attached pictures.

1) Would it be possible to achieve a lower vertical mandibular angle or would it not be appropriate for me?  

2) Will there be any paranasal adjustment to give more projection of the nose and reduce this fold? Or is this a weight loss/buccal fat removal thing?

3) Would I also benefit from a forehead/brow ridge implant in order to lift up the edges of my eyebrows and make them straight and the forehead more prominent?  

4) As mentioned in the email from from your assistant you said that “Mouth widening surgery should not be done at the same time as any form of intraoral surgery.” After I get the jaw and midface implant, is it possible to come back in a year or two and get the mouth widening surgery/ fix my lips?

5) Is there any solution to fix my droopy upper eyelids?

6) Is there any solution to reduce my upper eyelid exposure? Is a fat transfer or something possible?

7) Would I benefit from buccal fat reduction to get more defined cheeks or should this also be done at a separate time to any intraoral surgery?

A: In answer to your facial reshaping questions:

1) Some vertical jaw angle lengthening would be appropriate for you.

2) The paranasal area requires direct augmentation and is not affected by buccal fat removal.

3) Whether brow bone augmentation would be beneficial would require some eventual computer imaging to assess its effect. But in general brow bone augmentation does not make the tail of the brow bone become straight, it merely pushes out what you have.

4) Mouth widening surgery should be delayed at least 3 months after the other surgeries.

5) I believe when you use the term ‘droopy upper eyelids, you may be referring to ptosis correction which raises up the level of the eyelid to expose more iris of the eye.

6) You are correct that a fat graft is needed to fill in the more deficient fullness of the upper  eyelids.

7) Buccal lipectomies and perioral liposuction are common strategies to try and reduce tissue fullness between the bony cheeks and the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One more question that relates to midface augmentation. I’d like to get the your read on fat grafting for infraorbital augmentation vs. implants. Would also be great to know how much fat grafting costs if that’s an option.

A: Fat grating is always an option for midface augmentation but the take and persistence of injected fat in the face of young patients is both predictably unpredictable and often poor volume persists. But there is never any harm in doing so as it is an autologous operation with few downsides…other than it may not work. For the patient who is unsure or skiddish about infraorbital implants that is usually the best patient for midface fat grafting as the initial procedure of choice.  

Fat grafting is popular because any plastic surgeon can do it…but that should not be confused with whether its is always a good procedure for the problem being treated or whether it makes is a superior procedure to do. Knowing the advantages and disadvantages of each procedural option is the best way to make an educated choice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, you recently responded to a question I posted on Realself.com and, if you wouldn’t mind, I would like your advice on a matter.

I have recently had a CT scan done as I’m planning on having custom implants made. The only problem at this stage is that they are being made in overseas, were I’m not residing, and also most of the surgeons where I am currently residing, don’t have any software with which to show their patients rough results or possibilities.

I’m aware that I’m not a client, but if you could perhaps just glance over my CT scan and profile shots, I would greatly appreciate it. I would just like to know what implant you would create if you were the surgeon. It would give me something to compare their ideas to so as to get the best possible result. These things are somewhat difficult to coordinate overseas.

Thank you for your time.

A: I would be very suspect of any custom facial implant design process where the planned results and the design used to create it are not made available for you to see. For best results a collaborative relationship about the implant design needs to be preoperatively established between the patient and the surgeon. Given that the revision rate for any custom facial implant averages 33% mainly due to a mismatch between the design and the patients expected aesthetic result from what I observe, this is not how I would have this process done.

Given that you are not my patient, and no such relationship has been established as indicated above, it would not not only be impossible but ill-advised to provide any commentary on your custom facial implant designs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding infraorbital rim implants. I recently asked an oculoplastic plastic surgeon whether custom implants can be used to augment under eye hollows. He said he used them for reconstructive cases, but the results never looked “normal,” and he would “never recommend it for cosmetic reasons.” I’m aware that you disagree, but I’m curious to know why this procedure is so controversial in the medical community compared to other procedures such as a rhinoplasty. Is it simply ignorance on the part of many doctors who have not performed this procedure or who rely on outdated techniques? This procedure is something I’m interested in, but the lack of information, as well as before-and-after photos online (especially of young patients like myself), makes it difficult to be assured of its effectiveness as well as what sort of an outcome can be reasonably expected. 

A: I can not speak to other doctor’s experiences or the basis for their comments. A good general rule that I have learned when listening to any surgeon’s opinions on a topic is….have you actually done the specific procedure in question and, if so, how many times? In other words what is the basis for this supposed learned opinion. 

I believe on the topic of custom infraorbital rim implant techniques you have likely hit on exactly the reasons for any strong onions against them….lack of any experience in doing them and relying on non-contemporary techniques. Using 3D design technology and custom making any infraorbital or infraorbital-malar implant, it would be very hard to replicate the fit and the result that it creates any other way.

There is a very specific reason you will find few before and after pictures of young makes who have had the procedure….these are exactly the patients who almost never want their pictures shown. And I would this would likely apply to you as well. Not many young male patients agree to have pictures posted across the internet that show their eyes…which is impossible to do with infraorbital implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing to inquire about Sagittal Skull Reduction Skull surgery. It states on your website that this can be done with bone burring of the sagittal ridge or/and with an implant. I was hoping you could take a look at the photos I attached and if you would be able to determine whether a significant change could be made through bone burring alone.

Also what would the cost of such a bone burring surgery be?

Many thanks.

A: Thank you for your inquiry. Given the height of your sagittal ridge, reduction of it would be the only approach for it. The areas beside the ridge (parasagittal) seem to be of adequate height so sagittal reduction would be the only treatment option. How much it could be reduced would need to be preoperatively determined by a CT scan to check the thickness of the ridge but usually a 5 to 7mm reduction is possible.

I will have my assistant Camille pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant by another surgeon several months ago. My dissatisfaction with it is with the lack of forward and downward projection. I also believe the implant is either crooked or has magnified any natural asymmetry. I am concerned that the shape of the implant is too round. My original chin was more squarish (a slight “butt chin”) and as you can see in the included picture the implant has shifted the soft tissue, making my facial hair off center. I’m not totally opposed to keeping it if this asymmetry can be fixed by the sliding genioplasty procedure, or if the implant itself can be altered.

I am also interested in what my options are for the incision scar on my neck. It is large and raised although I don’t know if the picture shows it well.

I initially raised my concerns with the size of the implant with my surgeon who said that anything more than 5mm would look “cartoonish”, because of this confident dismissal I figured he knew what he was talking about.

I am interested in using 3D imaging/scans to see exactly what my options are.

Please advise next steps.

Again, thank you for your time.

A: By definition most chin implants are round, particularly all Medpor chin implants. So anyone with a naturally more square chin is going to end up with a rounder one. That is an important preoperative discussion about chin implant selection.

All standard chin implants can only produce horizontal augmentation, not any vertical elongation. Only a sliding genioplasty or custom chin implant can increase both horizontal and vertical projection. 

How your chin implant is positioned can not be known completely from viewing the outside. Only a 3D CT scan of the mandible can provide unequivocal clarity in that regard.

The hypertrophic submental scar can be revised to be a finer line.

I will have my assistant Camille contact you to set up a virtual consultation time.

In the interim what you need to get is a CBCT or cone beam scan of your lower jaw which can be done where you live. Search that term in your local area to find a provider of it. It is a common scan used in many dental offices particularly that of oral surgeons, orthodontists and dental implantologists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have a question about jaw enhancement surgery and chin enhancement surgery. If a patient was approved for orthognathic surgery to correct overbite/overjet, could they also while enhancing their jaw later and or at the same time of surgery have jaw implants as well combined with orthognatic surgery as well as genioplasty and chin implants. Thank you.

A: You can not have jaw angle implants or a total jawline implant placed at the same time as orthognathic surgery that involves a mandibular sagittal split ramus osteotomy. This will have to await a healed mandibular osteotomy result. However a sliding genioplasty or chin implants can be done at the same time as any form of orthognathic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a trans male and I’m looking to get some facial implants to really masculinize my face. I am most interested in your custom cheek implants that I saw on your Instagram.

I noticed that you tend to design them differently. You make them much longer such that they extend all the way back close to the ear along the zygomatic arch. 

Do you have to make an incision over by the ear and an incision inside the mouth to insert these?… I see in the pic attached that the man has an incision along his ear 

 Also, I’ve read about some people on Real Self who can’t smile the same after getting cheek implants… Have you seen this ever in your practice? What are the odds of this happening?

A:Thank you for your inquiry. Many patient’s today wants a more contemporary model-like cheek implant result which comes from extended arch style designs. Provided they do not include a significant infraorbital extension they are placed through an intraoral approach. There is NEVER a need for an external ear incision with their placement. What you are seeing in that picture is a patient who also had a facelift procedure which has nothing to do with the insertion of the extended cheek-arch implant.

Like any intraoral approach to the maxilla or cheek there can be some temporary stiffness to the smile from the swelling but this is a self-resolving issue in the recovery process. I have never had a patient who has had any long-term issues in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a couple of questions about wrap around jawline implants: 

1) I’ve read that silicone may not resemble bone very well. This seems to make some sense given how soft and bendable it is. After being inserted, does it look and feel like actual bone? 

2) how predictable is the sizing of the implant relative to the outcome? Can scar tissue severely alter the width of the jawline relative to what is assumed from the implant size? 

Thank you

A :In answer to your custom wrap around jawline implant questions:

1) Implants make of silicone may be bendable but they are not soft., When placed on bone they will feel just like bone. Anyone that says otherwise simply lacks adequate knowledge of bionmaterial properties.

2) While this is a good question, it is actually the wrong question. All implanted materials in the body form a layer of scar tissue around it which has no influence on its external appearance. The real question is what are the dimensional requirements of an implant in any patient that can come closest to achieving their aesthetic goals given their anatomy and thickness of overlying tissue? Since there is no mathematical or computerized method to make that exact determination how are the implant’s dimensions determined? These are estimated decisions made between the patient and the surgeon with the understanding that all one can do is make the best guess possible for all the implant dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would there be a chin implant which would be wider at the sides while still keeping a more V shape? As you can see from the photos attached I have quite a V shaped face but lack definition around my chin and into my jawline. Would an anatomical implant help with that? I did see the pre jowl chin implant but i’m not sure if that would make my face too boxy or would actually help with the definition. I don’t want to change my chin shape too much only want the same shape slightly bigger. I’m probably only wanting 3mm of projection forwards while increasing the width of my face chin slightly to improve my side profile. If a chin implant would not help with this could you recommend what you think would improve it.

A:If the required dimensional chin changes are to maintain a v-shaped chin shape that is wider at the sides, no standard chin implant really accomplishes that type of change. An anatomical chin implant only add projection at the front of the chin and that is a round implant…clearly not the type of change you are seeking.  A prejowl implant adds a little width to the sides but has no projection. The only one that remotely comes close would be a chin-prejowl implant but its basic shape would need to  be modified because it is a round implant not a V-shaped one. Ideally the best approach to addressing those type of chin changes is a custom chin implant which can be made to fulfill those exact dimensional changes and also havhe a design that flows into the jawline naturally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a huge fan of your work and website, and I think I should have come to you in the first place. 

I’ve had a chin implant from outside the mouth done 7 days ago by a doctor in Beverly Hills, and I have problems with my smile. 

I can’t pull down the lip on either side. I can feel everything on both lips and chin, but I simply cannot lower the lip for normal function. (i’ve attached photos of me trying to smile, and of me moving the lip otherwise which is not impaired) 

I’ve seen you have an article on mentalis function. Can I come in and see you for a consult? I’ll gladly pay for the consult. Restoring my normal lip function is my top priority and i’m considering removal of the implant. Whatever is most likely to return normal muscle function!

A: Being only 7 days out from chin implant surgery what you are experiencing does not look uncommon. You have to remember that you put a space-occupying mass right under all of the chin tissues for which the soft tissue cover of the chin was not initially designed to accommodate. Thus it takes time between the swelling and the relaxation of the tissues for the function of the lower lip to work properly. This will be an issue for which time, and the full recovery from chin implant augmentation surgery is a 6 to 8 week one, to fully recover. Short of taking the implant you are not going to expedite the time course of this recovery process. While I can no guarantee your lower lip will fully recover I see no treason it would not and have not seen one that doesn’t.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I spoke with a surgeon who told me this:

“Bone cement cannot be inserted on the sides of the head because there are important muscles named Temporalis which cannot be separated from the bone. 

So, the asymmetry of the occiput can be improved to some degree, but you should consider that there is the limit of correction or asymmetry, especially on the sides of the head and the perfect symmetry cannot be achieved by any kind of surgery. 

The lowest margin for bone cement insertion is situated on the occiput as a parallel line as eyeball level. The neck muscles are attached on the below this line so bone cement cannot be inserted on this portion.”

This made me concerned, since part of my affected area is located on the left side just above the ear. I understand that this is where the temporalis muscle is located? 

What is your opinion on this, and does it also apply to custom made implants?

Also, do you have any before and after pictures of similar cases that you could show me?

A: What you have been told is not completely accurate in terms of the temporal muscle and its release to place bone cement. I have done that many times. What is accurate is that the low end of the occipital bone sits at the same horizontal level of the upper ear…higher than most people realize.

But when it comes to custom implants the muscle on the side of the head is irrelevant as it is placed over the muscle. Another reason for why a custom implant is far superior to the use of bone cements.

To learn more about custom skull implants and their use in plagiocephaly and all forms of occipital asymmetry I refer you to one of my websites, www.exploreplasticsurgery.com  and search under such terms as Custom Skull Implants,, Occipital Asymmetry, and Plagiocephaly. You will find dozens of case examples which so illustrate that good head shape symmetry can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana