Your Questions

Q: Dr. Eppley, I’ve attached pictures for your review. My goals are to eliminate/reduce fat around my stomach, back, arms, flanks,  and inner thighs. I am hoping that I’m a candidate for a BBL (Brazilian Butt Lift), but I don’t know if I have enough fat to transfer.  I would also consider a butt implant. I’d like to get your initial thoughts based on my pictures.  

A: Thank you for your inquiry and sending your pictures. While any fat that is removed by liposuction can be injected into the buttocks, the question is how much fat would that be and how does that compare to the patient’s buttock augmentation goals. In just looking at your body pictures it would be fair to say that the volume of fat extracted (after concentration and % survival) would produce only a very modest buttock augmentation result by itself. If the buttock augmentation goal is more substantial the fat removed by liposuction is better served as a concurrent complement to an intramuscular buttock implant placement. (known as composite buttock augmentation)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have positional plagiocephaly on left side, which is not actually that bad but I can feel it and it affects my face, mostly nose and ears because the skull is like rolled on one side and so the bones on cheek and eye bones are more in front on left side. I would like to get my head more symmetrical but it is possible to get my face more symmetrical?

A: Thank you for your inquiry and sending your pictures. Plagiocephaly, otherwise known as cranioscoliosis, can affect the face (front of the skull) just like it affects the back. The displacement on the face is the reverse of what is seen on the back, meaning that the flat side on the back pushes the ear and face on the same side forward. Improvements can be made to the ear if it sticks more but you can/t change the anteroposterior of the ear on the side of the head as that is fixed by the external auditory canal. The more prominent cheek and lateral orbital rim/brow bone can be reduced and it is a question of whether the reduction of the bony protrusion that is possible is worth the surgical effort. To assess that issue a 3D CT scan of your face is needed to look and measure the differences between the two sides.

Lastly, the nose typically deviates away from the more protrusive side of the face of which traditional rhinoplasty surgery can bring the nose back into better symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a middle age male whom found a post you wrote, which is one of the few bits of information I have found online regarding a problem I have and I would be very grateful for some advice as I’m not sure what to do. This is the post I found: 

https://www.eppleyplasticsurgery.com/how-do-i-correct-my-facial-sagging-after-upper-jaw-surgery/ 

I had double jaw surgery almost twenty years ago. My lower jaw was moved forward to correct a large overjet and my upper jaw was impacted to correct a gummy smile. I was warned that I could develop extra lines under the eyes that I didn’t have before. Unfortunately this happened to a much greater extent than I expected. It is very apparent when i smile or make any facial gestures. Even when I talk I get the lines to a lesser extent. It has effected my confidence and i have avoided photos a lot. I also haven’t seen anyone else with a similar problem which makes it more frustrating. 

I have found it very difficult to find much information on this. I’ve tried Botox but it didn’t do much. I tried injectable fillers last year but it didn’t do much. I had a consultation with a dermatologist who told me that I have lost volume and filler would solve it. I also saw an eye surgeon who didn’t think filler would help. He said he couldn’t remove some of the bunched skin when i smile as the skin is taut at rest. 

It feels to me that there is too much force pushing the skin under the eyes when i smile and it is causing it to bunch and crumple. It feels to me that I have too much tissue under the cheek bone area that is pushing the skin and I have hardly anything under the eye area to resist the push! Not sure I had much under the eyes to begin with as I had a long thin face prior to surgery. But I feel like I’m just guessing. 

Any help would be much appreciated! 

A: Thank you for your inquiry and sending your pictures. Unfortunately more pictures than just a frontal smiling one are needed for a more comprehensive assessment. (non-smiling and smiling front and side views) But based on your surgical history and description of symptoms I would initially speculate that what you have is ‘too much tissue’ for the vertical midface bone height. Thus it bunches up a lot because there is a mismatch between the amount of soft tissue (which hasn’t been changed) and the vertical midface bone height (LeFort I impaction) which has. This would suggest that this isn’t a volume issue (which is why filler will not work) but an excess tissue one. It may be appropriate for a lower blepharoplasty-midface lift…but I would need to see what your undereye-midface looks like when you are not smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about the three operations I will be having. What are the downsides of any of these three procedures (temporal implants, lateral cheek implants, chin reduction)? And percentage frequency of the downsides? Is there any chance the implants would not look natural? Do they look as good as fillers?

I heard once, and it may not make any sense, that injections of saline can give a good idea about how fillers or implants might look, and then a person can make a decision about implants. Is that true? Is there anything else that might work this way to give an idea that might last only several hours or a day?

Are you confident that you can obtain at least 7 mm reduction in chin length (hopefully more)If you are not certain of this then I don’t believe I would go forward unless would be certain that with five or 6 mm  it would make a significant difference ——I am not interested in just a little better or slightly noticeable in its effect on the entire face. I definitely would want 10 millimeters or 1 cm, which is only 2/5 of an inch. In real life, when this is done, is this a lot? Does it usually make a noticeable difference? Will this change the shape of the chin? Do you grind it down with a machine?

Will the scar necessary for the temporal implant be noticeable? If it is behind the hairline, will it change the hairline or be a noticeable scar underneath?Same question for cheek implant.

What are the chances of the implants moving, or shifting, or getting bumpy to where they would have to be replaced?

You may have answered this question, and I apologize if you already have, but is it possible that the temporal implant will erode the muscle or the bone?

How long will the implants last?

Would you have to do any filler around it?

Regarding the possibility of the lateral cheek implant to widen the face, does that look natural or a little strange or different?

Will that significantly widen the face or just a little bit?

When I am very pleased and confident with my face when I change to a wide mirror, obviously, the entire face is widened, including the area from where the jawline begins to the chin. Of course we don’t want to widen this, but I wonder if that will be problematic in terms of the overall look of the wider face I am seeking.

If I go forward with the lateral cheek implant and that fails, and there is some redundant skin, can filler be used as a backup that would look good if needed?

If I hold off on doing the lateral check implant and want to do some injections 1st to see, can the lateral cheek implants be done under local? that really helps with the cost.

Can I go back the next day? Any particular work restrictions as long as I’m okay with the swelling? Any big bandages on the chin?

How many of each of these three procedures have you done over the last year, and since your career? I would suspect because you are board-certified in both maxillofacial and plastic surgery, that you have done many.

Thanks very much and hopefully no more, not too many more questions

A: Like all procedures there are downsides/risks…which is what I think you are asking. Having done a lot of all three procedures I would say that the only real major aesthetic downsides are as follows:

1) Temporal implants –   least risky of them all and completely reversible. The question is how much is enough and what is too much augmentation?

2) Zygomatic Arch Implants – effective but can be tricky to get perfect symmetry…but still reversible.

3) Vertical Chin Reduction – I think the question here is given the amount of bone that can be reduced, is this enough

The only solace I take from #3 is that #1 and #2 help with the overall appearance change. In other words, widening the temples/midface works in concert with the chin reduction to help make the face appear vertically shorter.(diametric movements)

I think with the implants there if very little risk of looking overdone. I worry more about not enough than overdone. As a general rule, implants usually look better than fillers and have a more pronounced effect.

You can try saline injections, and they don’t really create the effect of the implants, but they will at least do something. (a thin liquid can never create the same tissue push as a more firm implant)

Most vertical chin reduction by intraoral wedge osteotomy remove in the 7mm range of vertical bone height. A panorex x-ray is needed to measure how much bone can be safely removed based on the location of the tooth roots and the mental nerve exit.

While the chin shape will change if someone has a more pointy chin (will get more flat or square) yours is already so…so in your case I don’t envision any significant chin shape change.

The temporal implant is put in with an incision behind the ear so it is scarless.

I have never seen temporal or zygomatic arch implants move/migrate. They are very smooth so they will not cause an irregular outer contour. Again symmetry is the issue here.

The temporal implant is a muscular implant which is unique amongst facial implants. It sits on top the muscle underneath the fascia. Muscle erosion is not an issue of concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if head width reduction can only be done by the removal of the temporal muscle, or is it possible after removing the muscle to also apply some bone burring to reduce the width even further?

A: When it comes to head width narrowing by temporal reduction, it is important to appreciate the muscle:bone ratio of the width reduction that is possible. Since all of the muscle can be removed but only a portion of the bone, the bulk of a head narrowing effect comes from the muscle removal. The thin temporal bone underneath can be reduced a bit but it takes a longer incision along the side of the head to do so. Because if this aesthetic tradeoff and the minimal contribution the bone removal creates, most patients opt to go with the muscle removal only with a completely hidden scar. So it is not a question of whether it can be done but whether it is worth it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m thinking about scheduling a consultation with you guys, but before I fly all the way to Indiana I have a few questions. 

With your custom chin implants how many mm will the jaw be extended? I need about a 20 mm extension. I know that’s not common, but I was also thinking doing a sliding genioplasty procedure for more extension. Is it possible to get to get the projection I want with those two procedures? 

A: Thank you for your inquiry. To get to 20mms of horizontal chin lengthening the backbone of that procedure would be a horizontal sliding genioplasty done first of 12 to 14mms, followed by either a second sliding genioplasty or a custom chin implant. The stretch of the soft tissues will not permit an immediate 20mm of horizontal chin lengthening. The custom chin implant would be the preferred secondary chin procedure as it could address the narrowing effect of the large sliding genioplasty movement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After having my cheek implants removed, I feel like my mid-face is looser and less smooth. I think as thinking about getting co2 ablative laser to tighten it and hopefully help the tissues settle to how they were before. I think there is some sagging and my lower cheeks appear fuller, but I’m only two weeks after removal, so I assume I have to wait a few months to make a final judgement. I also want to get cheek and under eye fillers. 

1) how long do I have to wait to get ablative co2 and do you think it can help with tightening/settling the soft tissue? 

2) how long do I have to wait to get filler in the area? 

3) if I get filler and co2, should the co2 come first? 

Thank you

A: In removing cheek implants it is important to recognze that the tissues are very unlikely to ever return to exactly what they were before. If you recognize that cheek sagging is evident now aye this early point after their removal, now further healing time is not going to make sagging tissues snap back into place…those ligamentous attachments have been lost. While treating the outer skin by any form of laser will not hurt, that can not address the deeper cause of the sagging nor will a minor skin tightening effect make any change. Volumetric addition by injectable fillers  may provide some temporary lifting effect. Fillers should always be diet after laser treatments so the heat from the laser does not prematurely cause breakdown of the filler that lies underneath.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think I have cutis vertices gyrata (CVG) of the scalp. I have not consulted with a dermatologist so I’m not sure what CVG type it is. Ideally, I would like to have a scan CT/MRI to identify the disorder and plan treatment moving forward. If your facility provides all these services then I would like to schedule a consult.

A: CVG is a scalp disorder not a bone one. Thus MRIs or CT scans are not helpful in making the diagnosis or for treatment planning purposes. There is no method to diagnosis it over than by its appearance and clinical examination. The cause of CVG is unknown. It can only be treated by either  excision (cutting it out) or by fat grafting. (release and fill with injectable fat grafting) Each treatment method has its advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long chin and I know you said that the correct treatment for it was a vertical chin reduction done from inside the mouth.The computer imaging you sent looked like a good improvement. But I wanted to know one more thing. If you could make the chin this it would be perfect. My other question is can I also get a rhinoplasty to go with it. On the side it just all sort of needs to come down a little and be straightened. I have a lot of cartilage around the sides. When I smile there’s a pretty good bump. Thats all for now thanks alot. 

A: In answer to your vertical chin reduction and rhinoplasty questions. 1) If I understand the purpose of the two pictures properly, I believe you would like to achieve that degree of vertical chin shortening in the frontal view. While that is an admirable goal, the limitation in vertical chin reduction is how much bone can be removed given where the tooth roots and the mental nerve exist are located. As a general rule 8 to 10mms of bone be removed which I suspect will not exactly achieve your ideal vertical chin shortening goal.

2) It is common to perform rhinoplasty with any other facial procedures particularly that of chin surgery. What you are fundamentally describing is the straightening of the dorsal lines of the nose as the fundamental goal of your nose reshaping objectives. This is a common and achievable goal for many rhinoplasty patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a wide and asymmetric forehead. I have asked people if the right side of my forehead was larger than the left side but they said they didn’t really notice. But my forehead is definitely bigger than the rest of my face. What would be the options for making the forehead more in proportion with the rest of my face?

A: Thank you for sending your pictures and inquiring about forehead reduction surgery. From the frontal view I see two issues that make your forehead appear wide. 1) The posterior temporal area at the side of the forehead (marked in black) and wide bony temporal lines of the more anterior forehead. (marked in yellow) The temporal widening is treated by a temporal reduction procedure done from an incision behind the ear. (scarless)  While the bony temporal lines can be reduced to make the forehead more narrow, this requires a scalp incision which is more aesthetically challenging in a male. Forehead reduction in a male requires a thoughtful approach to the decision for incision placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Since I live out of town I assume that the creation of a custom chin implant is a process which would probably (?) necessitate my traveling to Indiana more than once. It would take a lot of effort for me to travel for the actual surgery. Therefore, I was hoping that the Implantech off-the shelf VLC chin implant would work for me. Your last email seems to indicate that this type of standard chin implant might not work for me.

A: In answer to your chin implant questions>

1) A custom implant approach is all done remotely, meaning you never have to come here to get the scan or design the implant. You only come here for the surgery.

2) But for the sake of further discussion on the less than ideal approach of trying to make a standard chin implant work, the VLC provides an equal amount of horizontal projection as well as vertical so the implant would have to be significantly modified in surgery to try and create the pure vertical lengthening effect. You simply can not use the VLC implant as it was designed in your case of vertical chin elongation.

3) And for the sake of thoroughness on the topic of vertical chin lengthening, the intraoral vertical lengthening bony genioplasty is the traditional approach to accomplishing that and it works well when the lengthening needed is 7mms or more….which an implant does not do well beyond that length requirement due to the need for the soft tissue chin pad to stretch over the implant.

4) As an overview you have three options for your vertical chin elongation which would be in the ideal order of:  vertical lengthening bony genioplasty, custom chin implant and modified VLC standard implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, About six months ago I had jaw implants. Three days ago I had unbearable pain from a toothache. The next day I went to a dentist and was prescribed Clindamacyn 300mg 3 times daily to treat a tooth infection. A day later I had the tooth drained, and next week it’ll be treated with a root canal. I’m concerned that the infection may have/will spread to the implant. The infection was around my upper molar. It led to severe left cheek/jaw swelling that I still have two days after beginning antibiotics. I wouldn’t say I have sharp pain at the implant site, but definitely some tenderness. 

I guess my questions are: 

1) is it likely that the infection could have spread to the implant? 

2) is there any way I can verify definitively whether the infection spread? Would x-rays be able to determine that? 

3) is 300mg 3x daily clindamycin the only thing I can do about it for now regardless? 

Thank you

A: In answer to your questions about potential jaw angle implant infection:

1) Generally an upper tooth infection does not spread to the jaw angle area as that is in a different tissue plane. There may be overall swelling in that side of the face but that does not necessarily mean the jaw angle implant is infected.

2) Infection can not be ruled in or by out by a CT scan unless there is a large fluid collection present.

3) Clindamycin is one of the first line drugs of use for oral-based infections. But like any infection the primary and most effective treatment is to eradicate the source.

4) These questions are more appropriately directed to the surgeon who placed your jaw angle implants. He/she would want to know about these concerns and followup up accordingly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long chin and I know you said that the correct treatment for it was a vertical chin reduction done from inside the mouth.The computer imaging you sent looked like a good improvement. But I wanted to know one more thing. If you could make the chin this it would be perfect. My other question is can I also get a rhinoplasty to go with it. On the side it just all sort of needs to come down a little and be straightened. I have a lot of cartilage around the sides. When I smile there’s a pretty good bump. Thats all for now thanks alot.

A: In answer to your vertical chin reduction and rhinoplasty questions. 1) If I understand the purpose of the two pictures properly, I believe you would like to achieve that degree of vertical chin shortening in the frontal view. While that is an admirable goal, the limitation in vertical chin reduction is how much bone can be removed given where the tooth roots and the mental nerve exist are located. As a general rule 8 to 10mms of bone be removed which I suspect will not exactly achieve your ideal vertical chin shortening goal.

2) It is common to perform rhinoplasty with any other facial procedures particularly that of chin surgery. What you are fundamentally describing is the straightening of the dorsal lines of the nose as the fundamental goal of your nose reshaping objectives. This is a common and achievable goal for many rhinoplasty patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think it might be best just to ask a few questions along with a few photos for you to view. I understand a chin implant or a sliding genioplasty would highly benefit myself, although being 26 years of age, I am leaning toward a sliding genioplasty.

If I’m deemed a suitable candidate, my main concerns are: 

1) The “step off” created from moving my chin forward creating a narrow profile (sliding genioplasty), being a male with an already narrower jaw/chin a smooth tapered jaw/chin is ideal. Some surgeons use materials like Goretex to place along the chin/jaw for a nice look. What would likely be recommended in my case?

2) A unnatural labiomental fold is, this is a big concern and reason I’m looking to avoid an implant. Based on a quick assessment of my photos provided, would grafting to my labiomental fold be necessary to avoid an unnatural look? If so, what type of grafts are used?

My goal is a well balanced natural looking face with a stronger chin and jaw. 

Here are two patients of a sliding genioplasty along with my facial profiles to get a quick assessment of myself

A: Thank you for your inquiry about sliding genioplasty and sending all of your pictures to which I can say the following:

1) The deepening of the labiomental fold occurs in both implants and the sliding genioplasty. There is no difference between the two in terms of having that effect as the labiomental fold is a fixed anatomic point due to the origin of the mentalis muscle. That is not a good reason by itself to choose a sliding genioplasty.

2) The sliding genioplasty does offer the ability to manage the depth of the labiomental fold better by placing something into the anterior step-off which is either a graft or an implant. The anterior step-off is better managed by some form of a bone graft.

3) Every sliding genioplasty, by definition, creates lateral or posterior stepoffs which will narrow the chin or create indentations. That can be managed by implants of which ePTFE (what is historically known as Goretex) is one option.

4) A sliding genioplasty provides aesthetic enhancement to the chin not the jawline that is behind it. It is not a jaw enhancing procedure by the anatomic definition of the jawline.

5) Attached imaging is one flavor or degree of chin augmentation, you may prefer more for less….yet to be determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, when it comes to my eye area i suffer from extremely ” big “/ puffy and swollen upper eyelids which have gotten even ” bulkier” since my usage of oral minoxidil ( a medication which cause water retention that i can’t unfortunately stop) So I would like to know if there is a way to actually reduce the size of my upper eyelid in itself especially if i’m still using medication that cause water retention or with people suffering from congenitally ” bulkier” upper eyelid than average 

That’s a question I’ve had in mind for quite some time now and I would to have an answer from a skilled surgeon like you. Most surgeons in my country when it comes to an enlarged upper eyelid due to water retention / allergy or congenitally bigger than the norm seem to work by skirting the issue using upper eyelid fillers or fat graft but won’t touch to the upper eyelid in itself. 

Here is a picture (which is not of my eyes but with a problem similar to mine when it comes to upper eyelid minus the droopy upper eyelid skin ) to illustrate my case. 

A: Thank you for your inquiry and sending your picture. The use of fillers or fat grafting to the upper eyelid would be counterproductive in terms of decreasing the upper eyelid above the level of the crease. Your assumption is correct in that a surgical procedure is needed which may consist of fat, muscle and skin removal based on what the preoperative exam shows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am an older female who had a small chin implant placed many years which I have never been happy with. It provided a small amount of increased chin projection but it still looks short. I think it needs a vertical increase which I think would be best done by a vertical lengthening chin implant. Does this sound right to you? 

A: Thank you for your inquiry and sending your pictures. While I think the attached imaging is clear that vertical chin lengthening is of aesthetic benefit, there are other dimensional issues to consider that go behind just that of the vertical dimension. In particular in the front view your perception of the width of your chin (do you want it wider as that is what a standard vertical lengthening can implant will do) and also in your case the prominent prejowl indentations which will not be eliminated by the use of a standard implant. (see attached image) It becomes important to know before surgery what the limitations of any implant style and size will do and not do so you don’t end up where you are now…improved but still with some missing improvements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a small anatomical chin implant five years ago and am seeking a revision. I want additional height and projection to the chin without looking too boxy along the jaw. Can you tell me which would work better? The flowers mandibular glove chin implant or the vertical chin lengthening chin implant?

A: Thank you for your inquiry and sending your pictures. If your description of a small anatomic chin implant is accurate this means you have a central chin style (no wings) implant of 6mms horizontal projection. Your pictures show no compelling need for any significant vertical chin lengthening. While it is not clear how much more horizontal projection you desire, the large or x-large mandibular glove chin implant should suffice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a recovery question after my perioral liposuction surgery. My healing process is going great and I feel great too! I was just wondering if I need to be massaging the liposuctioned area at all as it feels a bit hard? Perhaps that is normal but I wanted to ask, in case I just need to leave it alone…

Thanks for your help! Talk to you soon! 🙂 

A: Any area of the face or body that undergo liposuction area will feel very hard up to 6 to 8 weeks after surgery, perioral mound liposuction is no exception.tThis is normal and will resolve naturally on its own over time. But the process can certainly be expedited by massage which helps break up the scar tissue and get the lymphatic drainage in the area returning to normal sooner. Within reason you can’t overdo the massage manipulation of the perioral area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, With my surgery approaching, I wanted to reach out with a couple of very specific questions. On the phone we discussed that I would still be about to practice martial arts (specifically Brazilian jiu jitsu) following rib removal surgery. You explained that the ribs removed really aren’t shielding anything and so it’s totally safe to resume all activities after healing. Now that I’ve decided to have the operation, I just wanted to confirm this and explain a little more about the sport. It’s basically wrestling with submissions, and it can get pretty rough. Along with striking, its the main martial art used in the UFC and training often involves people far heavier than me putting maximum pressure on my abdomen, crashing into me, taking me down hard, etc. While there is no striking, human beings lifting each other and hurling their bodies through the air can create a lot of impact and the sport can get a little extreme. At my gym, we try to be as safe as possible in training but not everyone has a high level of body awareness and this can lead to injuries. I also wanted to share that prior to scheduling my surgery. I talked to another surgeon about rib removal and he seemed nervous/hesitant when I asked if I’d be able to train Brazilian Jiu Jitsu afterwards. He explained that he trains the sport himself and said he was nervous I’d get hit in the kidneys. I forgot to share this with you at the time of our consult so I am trying to understand why he might have that hesitation–whether it’s overly cautious or warranted due to his knowledge of the sport. Martial arts is my passion, and I wouldn’t want to lose the thing I love to do most. At the same time, if it’s safe, then I absolutely want to do it—but since the operation is not reversible, I am feeling the need to clarify and explain in depth. 

Secondly, I wanted to ask about child birth. Is it possible to have a child after this operation? I don’t even know if I plan to have kids, but I read that the model Sophia Vegas suffered complications after having the child and having the rib surgery. From what I read, it sounds like her organs shifted and she required an operation. I was wondering if you heard about this story and if you think it is a risk factor as long as the operation is done correctly. 

Sorry for the long winded email. Because there isn’t a lot of information online about this surgery, it’s hard to look things up and do the level of research I normally would. The martial arts question is my main one, and I basically just want to make sure I’m emphasizing how rough it is, so you can advise whether that activity would still be absolutely safe post op–of course once I am healed. 

Thank you so much for your time.

A: In rib removal surgery the portions of the ribs that are removed do not affect the medial portion of #12 which is what is covering/protecting the kidney. So in theory this should not be an issue from an anatomic perspective. That being said I have never performed this surgery in someone who is exposed to this degree of physical activity or trauma. And since this physical activity is your passion, and rib removal surgery is purely elective, the absolute safest choice is to not do the surgery. If, however, one wants to take a ‘riskier’ or unknown outcome choice, do the surgery and leave #12 rib alone which has the least impact on the outcome due to being the shortest of all ribs.

As for child delivery after rib removal, I have never heard the story to which you refer nor do I believe it. Subtotal rib removal of the lower ribcage would have no bearing on pregnancy or delivering a child either vaginally or by C-section.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgery for a full custom wrap around jaw/chin implant. The desired outcome is to augment the chin both horizontally (widen) and vertically (elongate) whilst creating a more ‘square’ shape. The desired outcome is also to widen and create definition in the 

lower mandible border and vertical elongation of the mandibular angles – again to create a more ‘square’ shape. I also have some asymmetry in the chin/jaw which I would be looking to improve with the implant. 

I am based in the UK and willing to travel internationally for surgery. Is this something which can be accommodated? Are my desired outcomes something that could be achieved via a custom wrap around jaw/chin implant? 

A: Thank you for your inquiry and detailing your facial reshaping objectives. It is fair to say that only a custom wrap around jawline implant can accomplish the complex 3D changes in the shape of the lower jaw. I will have need to get some pictures of your face to do some computer imaging to determine the exact magnitude of these jawline changes. I have many international patients so your request is a common one in my practice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question regarding cheek sagging/puffiness after cheek implant removal. I had my cheek implants removed after 2.5 months because I wasn’t happy with the look. I felt my soft tissue didn’t look chisled, and the implants didn’t look natural. Even when they were in, I noticed that my lower cheeks seemed fuller, despite there being no implant there. After getting them taken out I still feel that my lower cheeks, particularly near my nose, look fuller and bloated. It’s not so much that they’re sagging; it’s more that it’s just not tight and thin like it was before. 

I feel the reason for this is after the soft tissue was detached from the bone, it’s simply not reattaching the way it was before. So even though it may not be sagging, the area is still bloated. When I push down on it I feel like I can push down half an inch. Is there anything I can do about this? I’m basically just looking to tighten the skin to the way it was before. The whole thing is just extremely depressing for me, as I lost thousands of dollars and feel like I was permanently disfigured. Had I have known that it wasn’t a reversible procedure I don’t think would have ever done it. 

Are my concerns valid? Essentially, does it make sense for the soft tissues to be bloated as a result of them not reattaching to the bone? And will they ever reattach? And is there anything I can do to tighten it up again so my face is not so bottom heavy/bloated. Would soemthing like laser work? 

Furthermore, if there is a solution is it risky? I’ve gone though enough emotional and financial trauma that I don’t want to do it unless it’s a relatively straightforward fix.

A: Thank you for your inquiry and detailing your surgical history and postop cheek implant removal concerns to which I can say the following:

1) By definition placing cheek implants requires the disinsertion of the osteocutaneous ligaments to the cheeks. The implant then acts as a spacer lifting up the released tissues. (soft tissue float) If the implant is removed these ligaments do not reattach. In a facial structure like the cheeks, which is like being on the side of a cliff, the released and floated soft issues fall down. Thus your supposition of what you are feeling is anatomically correct.

2) If a male gets standard cheek implants, they are more likely than not to created that bloated facial look and not achieve a more chiseled look. That is because such standard cheek implant create anterior submalar fullness and are not design to create the high cheek bone look that many men desire. This requites custom implant designs to do so. The standard cheek implant styles are largely made for women not men.

3) While there are techniques to try and reattach the cheek soft tissues up higher and back into place, they are neither straightforward or have an assured outcome of doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, if I’m going to vertical chin reduction done as part of my facial widening I want it to be substantial and not an improvement by just a little bit, it seems as though you’re suggesting that the shaving approach is much more involved and actually I thought that’s what we were going to be doing. You would mention 5 mm to a maximum of seven for the vertical chin reduction. If we were to do the 7 mm, plus temporal implants, do you think that would significantly widen my face and do the trick?

A:In reference to the vertical chin reduction there are two approaches to it, an intraoral wedge reduction bony genioplasty and a submental shave technique. (technically using a saw) In both approaches the maximum of 7m ms of vertical bone reduction can be achieved. Since you have an existing submental incision that would seem to be the logical approach. To really know if 7mms vertical chin reduction would reach your desired aesthetic change, I would take a 3 x 5 card or piece of paper and place it at the horizontal level of the chin up from the bottom that looks like the amount you see as being effective and then mark it. Take the vertical measurement then from the bottom of the chin. That number will tell us where 7mms is in the ballpark of being aesthetically effective for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really need help and advice. About two weeks ago I had chin implant surgery for the third time. The first time was five years with a .  Medpor 5mm implant. The time was in January of this year to make more volume. My surgeon desided to use a Medpor 9mm implant on top of the first one. Together it is 14mm. It was too big for my face and did not look good. I also got marks on each side of the implant. My surgery decided to operate again. I was hoping he would take both Medpor implants out and give me a new start with an implant 8 or 9mm. But he didn’t. He was afraid to inquire my nerves. So he carved to make the top implant smaller and melt them together. Now I have 10mms of implant projecion. Last operation was this past February. It feels better because of my mouth movement and is easier to speak and smile. But I still have marks on each side and my chin does not look smooth. And it doesn’t blend well together with my jaw/cheeks.  I know it is still early and I have to wait. But I’m scared that the implant are the wrong ones. I may need another shape. My face looks longer and don’t like that. I really don’t know what to do now. My surgeon is one of the most qualificated in the city. And he seem nice but I have a feeling that taking both out and give me one with other shape could be the correct to do. But maybe I’m wrong… I’m so confused and sad 😔. Is there anything to do? 

A: Thank you for your inquiry and detailing your surgical history. I believe you have largely answered your own question. Stacking chin implants (or any facial implant for that matter) often creates new aesthetic issues (such as the ones you have) as it is virtually impossible to not have visible transitions unless what lies above or below is very small compared to the other stacked implant. This is particularly true with Medpor implants as they do not have feathered implant edges. Your options at this point are:

1) Remove both implants and replace with the largest size available as a single implant.

2) Have the chin implant custom made. (which, of course, is always the best choice)

3) Remove both implants do a sliding genioplasty.

There is no advantage to delaying another surgery when you know another one needs to be done. Further healing time does does not help you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I see you do forehead implants. My question is do you prefer silicone or Medpor? I would not want to do bone cement. If the Medpor supra orbital implants are done, do you only get fullness just above the brow, or do you think you can also get a bit of central fullness with those? Which do you prefer?

A: For forehead implants, whether it is just the forehead or includes the brow bones as well, I prefer silicone for several reasons: 1) the need for a much smaller incision for placement, 2) a substantially lower implant design and fabrication cost and 3) the greater precision of the final manufactured implant compared to the design.

The implant design can dimensionally be done for whatever the patient’s aesthetic needs are…that is why it is a custom implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am planning on going on a high altitude hike four days after my skull reshaping surgery. I’m wanting to know would this be alright, and would the surgery affect my ability to do this hike? 

A: I am not aware of any adverse effects of high altitudes on the healing and recovery any form of autologous skull reshaping surgery. However this is the first time that any patient has asked this specific question so I have no actual experience with such activities just 4 days after the surgery. All I can confidently say is that I am certain you will still have some surgical swellling at that time which may or may nor be mildly aggravated by strenuous activities at high altitudes so soon after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw implant surgery using Goretex implants in my jaw, and ended up putting them all around my chin in areas I didn’t want. 

My surgeon went way off base and I asked to have them removed. What he didn’t tell me, was that he shaved down the back gonial area of my jaw to put these implants in. If I knew he was going to do that, I wouldn’t have consented. Honestly, it doesn’t make sense to me how he does that since goretex has such a high rate of infection. 

Anyway. He took away the one thing I loved about my old jaw, the angles. And I really want them back. 

I was wondering if it was possible to do very small gonial implants in hope to mimic the old shape that I had? What’s left now are these very weird significantly sanded down parts. 

I will have to wait a few years to be able to afford the surgery again. But knowing that there’s hope to look like my old self is something I really need. 

Hopefully it’s possible, I like how you do the imaging for the implants. So what are the limits in size? 

Have a good day,

A: Thank you for your inquiry and detailing your surgical history and objectives. Jaw angle implants can be done in any size that suits the patient. There are no size limitations when it comes to ‘smallness’. All that matters is what the patient needs. The only question is whether such ‘reconstructive’ jaw angle implants need to be custom made or whether modified standard implants will suffice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I am 25 years old and have been extremely self conscious of my head shape for half my life. It causes me low self esteem every day, and am at a point where I don’t want to live with this problem anymore I want to know if there is a procedure that can help. Specifically the back of my head is flat.. This makes my head shape look odd and I cannot leave the house without using techniques that will cover the issue. I never let anyone see me with wet hair because of this. Do you offer a procedure such as implants or something that would help with my problem? Or any recommendations?

A: Building out the back of the head is one of the most common uses of custom skull implants which is a frequent procedure in my practice. The key about occipital augmentation in particular is how much desired change is needed and whether the stretch of the scalp can accommodate the size of the implant or whether a first stage scalp expansion needs to be done first. The best way to make that determination is computer imaging. If you can send a side view picture of your head I can do some imaging to determine how much back of the head augmentation would be desired by you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can I ask a few questions please about brow bone reduction. 1. What does this procedure entail ?. How long is recovery? I used to be a boxer, obviously I don’t compete anymore but I still train regularly in judo. After the operation am I still able to do sports that I’m passionate about. Can I go without being struck in head as I don’t spar or compete anymore but I still like competitive physical sports. Will my forehead be weakened at all ?? Thank you.

A: In answer to your brow bone reduction questions:

1) To fully understand the surgical aspects of the procedure I would go to www.exploreplasticsurgery.com and search under Brow Bone Reduction where detailed descriptions of the procedure are fully available.

2) Recovery is largely about facial swelling which will take about two weeks to largely look normal.

3) Once the bones are fully healed (three months) you can return to any contact physical activity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering getting a skin treatment (likely either broadband light therapy, fraxel laser, or something else of the sort) to mitigate some facial wrinkles/sun damage, etc. I am wondering if you think that there is a substantial risk that the heat from the lasers would penetrate beyond the skin and cause any problems with my facial implants (you may recall that I have jaw, chin, and malar implants). I can’t remember what you said my implants are made of (? silicone ?) or if they would warp or become distorted if I had laser treatment. 

Thank you for your consideration of the question and for any help that you might provide!

A: Good to hear from you. Your question is a common and understandable one. To clarify the science behind your question, solid silicone can only change physical form at 375 degree F. While any of the skin tightening/wrinkle reduction lasers does generate heat below the underside of the skin, the maximum temperature achieved is usually less than 140 degrees. Thus there is a great margin of safety and no risk of any harm or malformation of your facial implants

Hope all is well with you,

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I am very pleased with the morph you created for the augmentation of the chin only. (no jawline augmentation).

I’m leaning towards sliding genioplasty combined with submentoplasty, but I have a few questions:

1)  In our consultation, you mentioned that this procedure would narrow the chin. Would the amount of narrowing have an obvious negative impact on facial harmony and is there anything that can be done to lessen the perception of this narrowing?

2) I have heard that significant horizontal advancement can lead to a step in the mandible. Would this be noticeable in my case?

3) How long would it take for the swelling to be reduced to a degree where I no longer appear “post-surgical” to people I know?

Thanks,

A: In answer to your sliding genioplasty questions:

1) The narrowing effect would be slight but it is relevant to be aware of that potential change.

2) The step to which you refer is at the back end of the osteotomy, whose magnitude depends on the angle of the bone cut and whether there is any significant vertical lengthening as well. One of the reasons corticocancellous bone chips are used in my sliding genioplasties is to fill in unnatural contours that the sliding genioplasty can create in some cases.

3) Most ‘social’ recoveries from sliding genioplasties take about 3 weeks until one feels more comfortable with their early surgical appearance.

Dr. Barry Eppley

Indianapolis, Indiana