Your Questions

Q: Dr. Eppley, I have been treated for facial asymmetry due to hemifacial microsomia with a cheek and eye implant, browlift and a jaw implant and genioplasty for the left side of my face. Despite these efforts, there is still some asymmetry which is not insignificant, particularly around the left brow, forehead, temple and cheek area.

I have spoken to a number of cosmetic and reconstructive surgeons who have said that there is not much that they can do except for soft tissue fillers which I don’t think will address the underlying skeletal asymmetry.

I was hoping to get your opinion and perhaps, given you area of expertise, this would be something you can help with.

A: Thank you for your inquiry and detailing your surgical history. To provide a qualified opinion it would require an assessment of a combination of current facial pictures with a 3D CT scan. No one could say what is possible by merely looking at you on the outside. It requires knowing what your underlying facial skeletal structure looks like, particularly given what has been done previously, and matching that with your external appearance. Then a fully informed recommendation can be given for further facial asymmetry correction.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a 31 year-old mother of 3. I’ve been quite unhappy with my body for awhile now, mainly my butt (or lack-thereof) and have been dreaming of the day that I’d be able to get a procedure done that would make my butt more plump & round… and today’s that day! I’m so excited to make the first step towards happiness! I’m extremely interested in getting a butt augmentation done and would love to meet with you and see what options I have.

Here are some pictures of my buttocks from different angles as well as a picture of my tummy. I’m not sure if I mentioned it but instead of just inquiring about a buttock augmentation, I now would much rather prefer the Mommy Makeover! Although instead of a breast augmentation , I just want to downsize from 36D to 36 full C & would probably need a breast lift as well. But you know best, so I’ll let you make that decision. I have included a front and side picture of those as well. I look forward to getting a consultation date set, as well as hearing your opinion on what procedure you think would work best for my body.

A: Thank you for sending all of your body pictures to which I can make the following body contouring (Mommy Makeover) comments:

1) BREASTS – while you certainly can have a small breast reduction/lift, I would carefully consider whether the scars that would result in doing so. That is your personal decision but I would look carefully at these scars in other patients to be sure the breast shape change is worth that aesthetic tradeoff.

2) BUTTOCKS – you don’t have enough fat to harvest to do a significant or reliable buttock augmentation. Thus you would need to have buttock implants. Whether the size they could achieve would meet your aesthetic expectations remains to be determined and would need further input from you in that regard.

3) ABDOMEN – you would best be served by a mini-abdominoplasty with umbilical float and flank liposuction as your abdominal reshaping procedure.

My assistant Camille will contact you on Monday to schedule an office consultation time.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am planning to have zygomatic and chin silicone implants with you very soon. However I have flat moles on those areas of the face that I am planning to remove at some point.

My question is would laser mole removal in any way “damage” or infect an implant underneath (please note I have very thin tissues with not a lot of fat between skin and bones) as I am not sure which procedure to go with first.

A: While I think it would be prudent to separate the mole removal from facial implant placement, that decision has nothing to do with the risk of infection. Removing a superficial skin mole is not going to infect an implant down at the bone level. Rather it is an issue of potential poor scarring. When done at the same time, and provided the mole removal is done over or close to the site of the implant agmentation, the postoperative swelling will stretch the skin closure from the mole excision affecting its final scar appearance. Thus facial mole removal should be done several months before or after facial implant placement.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about a custom midface implant:

What are the long term outcomes of this procedure? Are patients generally happy? What kinds of issues have cropped up after the healing period that you’re aware of

A: Every custom midface implant I have ever done has been a favorable aesthetic improvement. In cases where it is larger and extends up over the infraorbital rim and has required an eyelid incision to place it runs the risk of lower eyelid ectropion…but this does not apply to you since it would be an intraoral approach in your case. Some patients, who initially went conservative in size and surface area coverage, have come back for a bigger or modified custom midface implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some septorhinoplasty questions:

a. A desired outcome of this procedure is improved breathing. You’ve mentioned a couple of ways to achieve this through fixing the deviated septum and inferior turbinate reduction. With the CT scan now available, is this still the approach you would take?
b. I’ve been doing research on implant vs cartilage for the dorsum augmentation and based on the long term risks I’d prefer to have a cartilage graft. What is your experience with cartilage graft augmentation rhinoplasty and where is your preferred cartilage source?
c. How long can I expect my nose to be congested for? The reason I ask is that I’ve had issues with severe pressure pain while on previous flights when I have been congested due to allergies. I’m planning on staying in Indianapolis for around 2 weeks after surgery before getting a flight back, will this be sufficient time?

A: In answer to your septorhinoplasty questions:

a. The approach for your breathing improvement remains the same….septoplasty, interior turbinate reductions and possible spreader grafts.
b. The key in nose cartilage grafting is what volume of cartilage is needed to do the job. If modest dorsal augmentation is needed then septal cartilage would be sufficient. Larger amount of dorsal augmentation require a rib graft harvest.

c. Most significant nasal congestion improves by 3 to 4 weeks after internal nasal airway surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some occipital knob reduction questions:

a. With the CT scan available, would you be able to approximate how much bone can be reduced and provide a morph of the image attached so I can get an idea of what the final result might look like?
b. Where will the incision be made, how large is it? I cut my hair short but do not shave my head, I’m guessing as long as this is the case the scar won’t be visible anyway?
c. What are the possible complications and risks of this procedure?

A: The occipital knob can be completely reduced. I have never seen one that can’t. That is because the bone is thicker than normal so maximal reduction is always possible. It is done through a 3.5 cm incision placed just below it. No hair needs to shaved for the procedure. I have never seen any complications with this procedure nor would I expected to given its skull location.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a female interested in custom facial implants and was wondering if you have ever created/installed nasal spine or premaxillary implants. Also, would it be better to get those implants put in before or after a rhinoplasty?

A: When you speak of nasal spine area, you are likely referring to what we call the premaxillary region which is the base of the nose. For that area numerous type of premaxillary implants are available for augmentation. If you are referring to the exact nasal spine to extend it up into the columella to also add to more nasal tip projection, then a cartilage graft is usually done to do so. By your midfacial pictures you could benefit by either premaxillary or direct nasal spine extension grafting.

Regardless of the type of base of nose augmentation used, it would most commonly be done as part of a rhinoplasty as they work in tandem for a better overall aesthetic result.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have several body contouring questions:

How much actual clavicular bone length be obtained in such shoulder widening surgeries.
Can he ribcage similarly be widened by osteotomies?
Can the scalpel be augmented?
Can the wrists be widened
What is the cost of shoulder widening surgery?

A:In answer to your shoulder widening question by clavicular osteotomy questions:

1) The maximum expansion of the clavicles I have done is 2 cms per side or roughly 1 inch for side.

2) There is no method to widen the ribcage by osteotomies.

3) Scapulas can be augmented.

4) There is no procedure to widen the wrists.

5) My assistant Camille will pass along the cost of the shoulder widening procedure to you later today.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m thinking on having a custom jaw implant at your clinic but I’ve been told that jaw implants have a very high rate of infection, specifically of silicone and Porex materials.

What material would you use for my custom jaw implants? I’m very afraid of having a complication and then having to take them off.

Is there a high rate of infection with the material used for the custom jaw implants?

A: Having done hundreds of custom jaw implants I would not say that they have a ‘high’ rate of infection, regardless of their material composition. But implants in the bony jaw angle region, due to the remote intraoral access needed to place them and their location to chewing debris, have an increased risk of infection (4%) compared to every other type of facial implant…standard or custom. (1% to 2%)

When it comes to material composition I am not aware that their are absolutely proven differences between them in terms of infectivity. But as a general implant principle, porous or textured implant surfaces have a higher affinity for bacterial adhesions than smooth implant surfaces do. Thus theoretically smooth implants (e.g., silicone) should have a lower infection risk than textured surface do. (e.g., Medpor)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, last year I had zygomatic reduction in Korea. There was an incision in my sideburn and in my mouth, where they cut the bone and moved it in. I am happy with the reduction, but the part of my cheekbone that is posterior to the sideburn incision (toward the ear) still sticks out, since only the cheekbone anterior to the incision was moved in. Is there a way to reduce the remaining cheekbone that is right in front of the ear, posterior to the sideburn incision?

A: To determine what is possible, I would need to see a 3D CT scan of your face to determine what the altered anatomy now looks like. But in most cases either an additional osteotomy behind the old one or a burring reduction of the protrusive tail of the zygomatic arch attachment to the temporal bone can be done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, is there a treatment for upper eyelid exposure? I have moderate eyelid expsure and I want my eyes to be completely hooded, this normally occurs in men due a low set orbital bone and brow ridge. But my upper-orbitals are high-set which makes my upper eyelids exposed which are giving my eyes a tired and somewhat feminine look

Fillers usually work quite well for that, but they don’t cover up the upper eyelids to 100%. They also make the eyes look more Asian since Asians generally only have more fat in their upper eyelids, but i want hooded eyes due a low set brow/orbital bone.

Is it possible to place a implant on the upper orbitals/brow ridge?

A: While an implant can be placed in the brow bones, it is never going to have the effect of covering up 100% of the eyelids. You simply can’t drive down the eyebrows and upper eyelids to the major degree to which you seek. A brow bone implant primarily achieves an increased brows bone prominence which may have some slight influence on upper eyelid exposure but not to the degree that you seek.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am just curious about the custom jawline implant option vs a standard chin and jaw angle implants. I feel I have a very weak chin and would like to enhance that and the jawline. Im curious how long this procedure takes? Cost? Cost if performed with a septoplasty? Are there any issues with having a wrap around implant vs the more widely done jaw and chin pieces? Materials?

A: The question you are fundamentally asking is which would be better….standard chin and jaw angle implants or a one-piece custom made jawline implant. The answer to that question is the same for everybody…. a custom jawline implant is always superior because it is made specifically for the patient from their 3D CT scan and it is all connected as one piece. This allows for more controlled aesthetic outcomes and less risks of implant asymmetry. The only reason to ever do three separate standard chin and jaw angle implants is cost. If the patient can not afford the custom implant approach then they have no choice but to use standard implants.

Either jawline augmentation approach can be with a septoplasty.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 years old male and I am interested in undergoing the clavicle lengthening procedure for aesthetic purposes. Do you perform this? In this regard I have a couple of questions. What would be the orthopedic implications of such a surgery? Would I loose shoulder mobility? I am asking this as I am quite into sports and I do practice bodybuilding and rugby. Moreover, I have a condition to my right shoulder. A couple of years ago I broke my AC joint ligament. How would this interfere with the surgery? Would it still be effective? What would be an approximate cost of the operation?

I really look forward to hearing from you. Thank you for your time.

A: Thank you for your inquiry. Clavicular lengthening for increased shoulder width is a procedure that I perform. It is a mid-clavicular osteotomy with interpositional graft so it does not involve the AC joint which is at the lateral end of the clavicular bone. As a result it does not affect shoulder mobility since this primarily relates to the AC joint. It does require a sufficient healing time, much like that of a clavicular fracture, and since it involves both sides it would take three months before one can fully return to strenuous sporting activities.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am now three months after placement of my custom forehead/brow bone implant. I have a weird tingling sensation on the left side of my brow and I’m wondering if ithe implant is getting infected…When I press on it it goes numb.

Thanks.

A: You are undoubtably referring to the supraorbital nerves that exist the brow bone area and supply feeling to the forehead. These sensory nerves lie right up against the implant as you can see in the attached picture of your forehead implant on your brow bones. (arrows) You can see that the implant design was adjusted to account for where the nerve comes out of the bone at the supraorbital notch. On the symptomatic left side the implant and nerve must be directly touching and this is why you can make it go numb if you press on the skin which pushes the nerve down onto the implant. This is not a sign of infection but speaks to the proximity of the implant and nerve which is unavoidable when the brow bones are augmented. Interestingly there is the exact same situation of the right side side and you have no such symptoms.

Whether this will completely resolve I can not say. But for now I would just give it time and see what it does.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m 25 years old and my natural facial bone structure is lacking. I’m interested in getting chin and jaw implants, or possibly a wraparound implant if it is called for. I would appreciate if you could answer some general questions about the procedure, as you seem most experienced when it comes to facial augmentation with implants.

(1) When lowering the mandible angle, how many millimeters would you say is needed to be able to appreciate any sort of difference? If I were to get non-widening jaw implants that drop my angle down by say 5mm, would I be able to see a noticeable difference? While 5mm seems like quite a lot when it comes to chin implant projections or nasal implants, I’m not sure how 5mm would work for the angle.

(2) What % of patients or what % chance exists of getting a post-op infection? If the implant was to be inoculated with bacteria from the surgery itself, what time period post-op would it be most common to get an infection? I’m not very fond of the idea of having to pluck the implant back out if it were to happen.

(3) After surfing through RealSelf, I’ve learned that no branches of the facial nerve are affected by chin or jaw implants. The main nerve at risk of permanent or temporary damage seems to be the one that provides sensation to the lips and chin. Would you be able to expand on why some chin implant patients experience lip paralysis or their bottom lip moves strangely post surgery? If motor nerves are not affected, why does this happen?

(4) Have you ever had a patient experience permanent nerve damage from chin and jaw augmentations?

Thank you for your time. I hope you continue to help people surgically and with this blog as it has been a great educational tool for me and undoubtedly others as well.

A: In answer to your jawline augmentation questions:

1. Whether a 5mm drop in your jaw angles would be aesthetically significant I can not say since I do not know what you look like or what your aesthetic jawline augmentation goals are.
2. The chance of infection in any type of jawline augmentation procedure is in the 2% to 3% range. They typically do not appear until 3 weeks after the surgery. The initial treatment of such facial implant infections is an extended course of oral antibiotics of which about 50% resolve without the need for further surgery.
3. It is not true that the only nerves at risk in any chin or jawline implant are the sensory mental nerves. There is also the marginal mandibular branch of the facial nerve that crosses over the inferior border of the lateral chin which supplies movement to the lower lip.(depressor anguli oris muscle) It is possible in some cases that this tiny nerve branch gets stretched and the affected lip side may take some time to recovert. I have never seen any cases permanent paralysis of the lower lip from traction injury to his nerve in jawline implants. That issues aside you are more likely referring to the initial changes of lower lip and chin movement from the swelling and initial expansion of the tissues…which filly resolves in most cases as full healing takes place weeks to months after the surgery.
4. As noted above I have not yet seen any patient with permanent damage to either the aforementioned sensory and motor nerves branches around the chin from any form of bone or implant surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, As for my chin, I’m not so worried about the profile aspect of my face, so bring my chin forward isn’t so important to me. It’s more of the front view of my face. I’m not really interested in getting a sliding genioplasty. I’ve done a lot of research on it, and it just seems too invasive and adds many more complications than what chin implants do. I’ve spoken to other surgeons, and some recommended a older type of implant called a “button” implant. Since it tends to produce a more pointy chin. Or a custom cheek implant to produce more definition in my face, would have narrow my face a bit more. 

A: In answer to your chin augmentation questions:

1) Implant options are either a custom chin implant or a hand carved v-shaped anatomic implant.

2) A button or central style of chin implant can used but it would have to be hand carved into almost a v-shape as it is otherwise a round implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I read your answer about the helix being out of view in an otoplasty that is overdone or pulled back too far.. I would like to know if I come to you for a reverse otoplasty, how long would it take for the surgery and do I need someone with me? I would rather keep the procedure to myself. Right now a simple rolled up double sided piece of tape stuck in the crease between the head and ear makes me very satisfied and no one has noticed it that I know of for over a year doing so. It makes me self conscious that someone might see it though and I would rather have something permanent that will make it more comfortable as after several hours it pinches the skin.

A: Thank you for your inquiry. The success of a reverse otoplasty depends on the placement of an interpositional cartilage graft…which may come close to replicating the effect of a roll of tape that you put behind your ear. This is a procedure done under local anesthesia so there is no problem with you coming by yourself.

I will have my assistant Camille pass along the cost of the surgery to you on Monday. In the interim please send me some pictures of your ears for my assessment for this procedure.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, In regards to a vertical lengthening chin implant. I’ve read a lot of conflicting things in regards to the labiomental fold., I have a deep one. I don’t mind that it deep and I am not looking to correct it. I just want to know if I could still have this type of implant while maintaining a natural look and not making the fold worse. I am reaching out to you guys because I’ve done a lot of research and know that you designed this implant. I need vertical length and am not interested in a more invasive surgery.

A: The best way to avoid making the labiomental fold deeper and look natural is to do a vertical lengthening bony genioplasty. Otherwise a custom chin implant would need to be designed to achieve a similar effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I emailed with you approximately a year ago in regards to facial masculinization, I went through with the jawline augmentation (three pieces of Goretex around my jawline), cheek augmentation and paranasal implants and am now post-op 1 month. Although It looks better than before I still am not happy with the lower/middle part of my face. I am aware that I’m still a few months away from the final result, however I realized now after some more research (which I should have done before) that the problem is my maxilla. Because the maxilla is underdeveloped I don’t get the protrusion that I need which makes my face look flat and mouth/lips sunken in. I feel like the surgeon was a bit to conservative as I wanted it a bit bigger and this might explain why.

I guess I would need both the mandible and maxilla to move forward to get the desired result. From my research there are two ways of doing it, one is bimaxillary augmentation through surgery which is very expensive + higher risks not to mention having to wear braces which adds to the cost and maybe even removing the jawline augmentation which would be a waste.

The second is from the use of braces like “Fixed Anterior Growth Guidance Appliance” (FAGGA) or DNA Appliance and such. Although They might not make as big of a difference as i would like. Which do you think would be the best choice?

Here are pictures of what I think i would look like (i tried my best with Photoshop) postop is how I look now, example 2 and 3 is what I’m guessing i would look like after using FAGGA/DNA or imaxillary augmentation. I’m not sure if the nose gets pushed forward but i implemented that in example 3 anyways (even though I’m not a fan of the nose in 3, i still look a better there than what I do now).
Because I plan to get browbone/forehead augmentation in the future it could make my face look even more “flat” as i want more brow/forehead protrusion.

Are these augmentations unrealistic?

Do you perform Bimaxillary augmentation and if so what is the price range?

Thank you

A: My comments are as follows:

1) More healing time will only make your results look less significant as all swelling goes away and tissue contraction pulls the elevated tissues inward. In other words your results are only going to become more ‘conservative’.

2) What you lack is overall implant volume in the midface and jawline…which is to be expected when a patchwork approach is using just laying in thin sheets of Goretex. This approach is always bound to create a minimal type result. In essence there has been a mismatch between your aesthetic facial goals and the treatment approach used to try and achieve it. This is why custom implants made from a 3D CT scan is a far more effective treatment approach for increased facial projection.

3) Comparing orthognathic surgery and any type of orthodontic bone protraction is like comparing a bullet to the hydrogen bomb. One is very minimalistic and is never going to create your desired look and the other is far more effective but tremendously invasive.

4) While maxillary advancement surgery may be very effective you are talking about costs that will exceed $35,000 to do so.

5) Any forehead/brow bone reduction without further facial change below it, is going to make your lower face look even more retrusive as you have correctly noted.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I will be visiting you soon for a custom jaw implant. I wanted to ask if it is OK to do a one stitch facelift /mini facelift to pull the skin around the nasolabial folds and cheeks to the ears to eliminate nasolabial creases. Would an Endotine device provide a long term permanent solution by anchoring around the ears to give a permanent results. Of course natural aging will occur but would essentially the surgery and fixation make it impossible for the skin to retract to allow cheeks and nasolabial folds to crease again once a mini face lift is preformed. Also can jaw / chin implant be done post face lift. 

A: There is no operation that effectively resolves nasolabial folds including a facelift. Short of direct excision no form of a facelift can solve them beyond the initially swelling period, certainly not any form of a mini facelift. The concept of a more permanent result, particularly at reducing the nasolabial folds is not achievable as you have described it.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Upon further consideration, I think the implant I know I will absolutely need is a chin implant. I think that alone will make a significant improvement for. However, I feel that mandibular jaw angle implants may help too, but may not be absolutely necessary.

I think I would like to do a 2 step process where I first get a chin implant and then see how it looks, then maybe in a year after if I feel like I need it (and could afford it) maybe consider getting jaw angle implants.

I guess my question is: If I really wanted to do this in 2 steps (instead of the all in one chin/jawline implant), could I get nice results still? If so, would off-the-shelf implants suffice or do you think custom chin and mandibular implants would be the way to go.

I am very interested in working with you with regards to my chin and jaw improvement. Thank you for your time! Your responses have been appreciated immensely. 

A: A chin implant alone is just fine…as long as you realize what it can and can not do. it affects the chin and the chin only. If your definition of a ‘nice result’ is an isolated chin augmentation effect that you will achieve your goals.

Given your potential staged approach to the process, I would go with a standard chin implant first. I would only consider a custom implant approach if you decide to complete the jawline effect later….as many patients ‘learn’ a lot from their initial chin implant and often want to change that later as well. It is then that the whole custom jawline implant approach is taken.

It is very common in my experience that the chin implant, which could well be the end of the process also, serves a ‘toe in the water’ approach where some patients may graduate to the whole jawline augmentation approach later. When you are changing the structure of ones face and its subsequent appearance it is hard to know exactly what one wants until you ‘wear it for awhile’.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m an Asian female looking to enhance my midface region, namely frontal cheekbone and paranasal area. I also plan on getting a rhinoplasty either before or after facial implants. I was wondering if getting a midface/paranasal implant would affect rhinoplasty – would lateral osteotomy and alarplasty be affected if I got the implants beforehand? If I got implants after rhinoplasty, would the paranasal implants alter rhinoplasty results? Would you recommend getting facial implants or rhinoplasty first?
Thanks!

A: It would make the most sense to have the rhinoplasty first since paranasal/midface implants may be either in the way of the osteotomies or become secondarily infected by the location of the osteotomy line.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m fully aware that I won’t be able to achieve exactly what I have in mind, but either way, I’d be content with any sort of improvement overall. With buccal lipectomy, it definitely did decrease the “chubby” look to my face. But as you said, the results would have been even better had it been accompanied with perioral mound liposuction. So would it be too late to get it still? Is it usually only done with other procedures as the same time? Also, is it a safe procedure? I noticed that not many doctors tend to conduct this procedure? Or what other procedures can be done to reduce the fat in my cheek area? 

A: In answer to your perioral mound liposuction questions:

1) Perioral mound liposuction can be done secondarily and, is often do so, in patients who have had a prior buccal lipectomy.

2) Perioral mound is a perfectly safe and effective procedure that complements the buccal lipectomy.

3) There are np other facial defatting procedures other than buccal lipectomy and perioral mound lipectomy.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have Lipedema and have had some surgeries with a lipedema doctor and they were very conservative. My biggest concern are the knees and the tops of my thighs, my public area and inter thighs. I have calf concerns but that can be later on down the road. 

A: Thank you for sending your pictures. The critical question becomes in the face of lipedema what happens with liposuction? Will it be effective or overwhelmed by chronic swelling? Will it aggravate the existing lipedema or make it worse? The prior lipedema surgeries may have been ‘conservative’ but may have been done for a good reason…to avoid aggravating the lipedema.

Forgetting the underlying lipedema for a minute, the treatment of your type of lower extremity lipodystrophy requires a very aggressive liposuction approach. With that comes one known and and one unknown risk. The known risk is that the cellulite appearance on the thighs will undoubtable get worse, not better. That is unavoidable. The unknown risk is will it aggravate the lipedema? Just because the conservative treatments did not, that is no guarantee that a more aggressive approach will not.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Thank you so much for your reply. The custom implant  approach sounds good . My doctor says He will use Goretex implant and craft the  implants right there during my surgery.  I also want to know is it possible to use Goretex or Medpor  because he mentioned  these material are more natural than Silicone and it will grow into my bone? Silicone will look more unnatural later on when body starts to  form capsule? Now i would like to know how soon can i get surgery done after first consultation?and how long does it take to make a custom jawline implant, I hope  one trip can do it all. Thank you.

A: The concept that Goretex or Medpor is more natural than silicone to the body is a completely bogus statement with no basis in scientific fact. Nor are they more natural or create a better facial look. In the end what matters is the shape and dimensions of the implant, that is the key.

The limitations of trying to patch a bunch of different implants together during surgery by hand to create a good result and have the right dimensions of the implant that is needed and symmetric for both sides, speaks for itself.

Biologically all implants produce a capsule (layer of encapsulating scar) around them, Medpor and Goretex are not different. Capsule formation is a normal reaction to any synthetic material placed in the body, and short of actual bone, all compositions of implants form an equal amount of capsular formation. To say that one implant material forms more or less scar than the other one fails to have adequate knowledge about the implantation healing process.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m 2 weeks post my surgery so I wanted to quickly touch base with you.  First things first, I’m so happy with my results! The projection is perfect, surprisingly my lip position has changed too it doesn’t look receded anymore. I also have no loss of sensation- yay! I’m so grateful to you, THANK YOU! Attaching a few pictures for your review.

My only concerns are:

1) I have some muscular/soft tissue asymmetry. My right side drops lower than my left when I smile or open my mouth. Not sure if that’s due to residual swelling or muscular tightness. Although I don’t think there is any swelling left. Is there anything I can do about it?

2) I started working out 10 days after the surgery and have noticed there is generally more swelling and slight pain the next day. Should I continue going to the gym or take a break?

Thanks again,

A: Thank you for the follow up. I would say that your sliding genioplasty went absolutely perfectly. It could not have gone any better. I actually used an 8mm plate and bent it to make for a 4mm vertical lengthening. I thought it replicated your jaw thrusting maneuver fairly closely. Not having any loss of sensation, temporary as it might have been, is always a bonus.

In answer to your questions:

1) It is common and expected that the mentalis muscle function will temporarily work a bit abnormally as its entire attachment to its bony origin was separated and was reconstructed back together. (that has to be done on all sliding genioplasties) The muscle recovery will take the longest time to normal function and that could be up to 3 months after the procedure.

2) I would not hesitate to get back to working out. That may cause some mild increase in swelling, which is expected, but is not of any concern.

Despite how well the first few weeks of surgery have gone, it is important to realize that a complete recovery, and the many nuances of it, takes a full three to four months. So you have a long way to go yet!

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’ve had jaw realignment surgery, along with a genioplasty (burring) followed by a revision genioplasty 2.5 years ago. The initial surgery was done because my jaw grew longer on one side. The initial jaw surgery/genioplasty did a great deal to correct the asymmetry, but I still had some nagging asymmetry especially when viewed from below, and I was also interested in a slight narrowing. Following the revision genioplasty (also burring) I have quite a bit of dimpling in the chin and it did nothing to narrow the chin. First, I’m curious for a professional opinion if my desired look was ever actually achievable or realistic (I’ve attached photos). Second, I’m wondering if there’s anything that can be done to improve the dimpling/ scar tissue to gain a better contour. I would like to avoid filler or anything that would make the chin longer/ wider.

A: Thank you for your inquiry.  If I understand your history correctly you have had two bony genioplasty surgeries both of which used a burring technique. It was the second chin surgery that has created the chin indentations/dimpling you have now. I am assuming that both burring efforts were done from an intraoral approach since I don’t see a submental scar.

In answer to your secondary chin reshaping questions:

1) Your initial desired chin shape results may have been possible but never with a primary burring technique done from an intraoral approach. That technique completely degloves the soft tissue of the chin, reduces bony support and then often creates chin irregularities due to the mismatch between the same volume soft tissue and the reduced bone size which it envelopes.

2) The better initial approach would have been either intraoral t-shaped osteotomies or a submental shaving technique with some soft tissue reduction. But that is irrelevant now.

3) The more relevant question is what can be done for any further improvement. This is a primary soft tissue problem which can only be done from a submental soft tissue excision/tuck up procedure. How much improvement could be obtained can not be predicted beforehand. When such irregularities occur in the soft tissue chin pad they can be very difficult if not impossible to eradicate.

4) I would agree with you that adding fillers into the indentations will make your chin bigger which is the antithesis of what you are trying to achieve.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I have two healthy testicles. I’m interested in your envelope implant procedure. (testicular enlargement implants) What are the available sizes (max) and how much volume in milliliters? Are implants oval or ball shapes? How hard or soft is the material? My assumption is as it envelops the testicle that it is a very soft material would feel natural? Do you have pictures of envelope implants a couple of months after surgery? I’m looking forward to your answer. Kind regards

A: In answer to your testicular enlargement implants questions:

1) The maximum external size to date has been 6.5 cms as measured longitudinally along its oval axis.

2) They are made of the softest durometer of which silicone can be made and still be a solid. They are ultrasoft. That softness is enhanced since there is no inner core of material.

3) Since all of my patients are from afar I never see them back again…unless they have a problem which as not occurred to date.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can I please also ask for your honest opinion about using Botox for temporal reduction? I read on your website that it’s another remedy, but I was wondering if you think I could expect similar results, and if I could get it at your office?

A: Like the use and effectiveness for reduction of the large masseter muscle, Botox injections will similarly create a  reduction in size of the temporal muscles as well. Like all Botox injections its effects will be temporary and how effective it will be is based on dose. (number of units injected) Generally it takes a 100 unit treatment session (50 units per side) to see any appreciable size reduction. Such an effect will last 3 to 4 months.

While Botox can reduce the size of the posterior temporal muscles, it is to not as effective surgery which removes 100% of the muscle and thus has a more profound effect.

The value of Botox injections in the temporal muscles is really a test to determine if one may like the effect. Given that its effects are temporary this not a long-term solution to the problem. But for the unsure patient as to the value of surgery, this is a harmless and completely reversible treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a growing interest in temporal reduction surgery, as I have had life-long issues with my head shape/size during my life. 

My number one hesitation, however, is a failure to comprehend how “the posterior portion of the temporalis muscle is removed and the anterior portion shortened” without an effect on function. Did God/evolution put these muscles here for no reason? 

I am amazed at the work you have done on others and am in disbelief that this type of procedure even exists, which is something I’ve wished for many times in the past. 

If there is anything you can provide in redone to my concern, I would appreciate it.

A: I can not speak for what God intended. But it has been my extensive observation on doing a lot of these surgeries that removal of the entire posterior portion of the temporalis muscle causes not functional changes in jaw opening and closing. This undoubtably occurs because when looking at muscle volume, that section only makes up about 30% of the muscle’s total volume.

While the posterior portion of the temporalis muscle is removed I don’t ever remember writing about ‘shortening the anterior portion of the muscle….as that is not technically possible from an incision behind the ear.

Dr. Barry Eppley

Indianapolis, Indiana