Your Questions
Your Questions
Q: Dr. Eppley, I’m looking into getting jaw implants and my bottom wisdom teeth extracted. I’ve contacted several surgeons who either say it can be done in one go or I would need to extract the wisdom teeth first before jaw implants.
What would be your stance on this?
Is a week or a week and a half between wisdom teeth extraction and jaw implants too soon?
A: I will assume you are specifically referring to the lower mandibular third molars or wisdom teeth. As a general rule you should space these two procedures 3 months apart, a week or two is insufficient. Jaw angle implants have the highest infection rate of any facial implant. Why risk doing anything that would increase that risk factor further? It is not a question of whether they can technically done together, as they can. It is a question of the wisdom in doing so. I wouldn’t recommend doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my concerns regarding my chin/ jawline/ lower portion of my face are related to my profile and front views. From the side, I would like my jawline to look more defined, thinner and projected forward horizontally and maybe vertically as well. From the front, I would like my face to look thinner. I feel that my face from the front looks bottom heavy, I have jowls and marionette lines, even though I’m 34 and I am not, nor have I ever been, overweight- I’m 5′ 8” and weigh 128 lbs.
I’ve have had these issues even when I was in my 20s, so I think it is more an underlying lack of bone, chin is possibly too short and/or too recessed, than an actual aging issue. I also think I have fatty deposits in my jaw/chin/neck area. I have looked into chin implants, sliding genioplasty, and neck/chin/ jowl liposuction. I feel that while the research has helped me to better articulate my concerns, it also has me confused as to what treatments would be most appropriate for my specific case.
I have attached some current pictures to this e-mail of my face from different angles. Could computer imaging be done to help me understand the possible outcomes and what procedures would best suit my concerns?
A: Thank you for your inquiry and sending your description of your current facial concerns to which I can make the following facial reshaping comments:
1) While jawline augmentation would provide some improved definition, particularly that of chin projection and vertical jaw angle definition, i would have concerns that this may be a contraindication to the goal of also making your face thinner. By definition jawline augmentation adds volume to achieve its effect. While the jaw angle volume would be vertical and the chin volume horizontal, I have some concerns that this may still make our face ‘heavier’ due to your natural tissue thickness anatomy.
2) The real issue that you have with your fuller face is the thickness of your tissues and the jowl sagging that has developed. This is the main component to your face looking heavier. To achieve a more heart-shaped face, which I think is largely what you mean by a thinner face, your really need a jowl tuck procedure (mini lower facelift) with jowl defatting combined with chin augmentation. (which also includes getting rid of the submental crease indication.
3) I would consider #2 the foundational procedure. I would stay away for now from any jaw angle augmentation as the last thing you need is anything that has a risk of making the lower third of your face heavier.
While on the one hand a lower ‘facelift’ seems incongruous with your relatively young age, it is what the tissues are doing anatomically that matters not their chronological age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently read something you wrote from this website Real Self on recommending an implant for the correction of enophthalmos. I was wondering if you could explain your preference over using an implant instead of fat. I was also wondering if you could clarify whether a risk of filling that area with an excess amount of fat could potentially cause proptosis. Thank you very much in advance.
A: Fat injections are less well uncontrolled in terms of placement and only have a soft push on the structures that need to the lifted. In addition how much volume do you need to correct the problem, over- or undercorrection is as likely as the right amount. A custom orbital floor-rim implant is made from the patient’s 3D CT scan where the exact anatomic differences between the two sides can be determined down to the 0.2mm level. It is the best method of true skeletal correction if that is the goal.
But the treatment plan for each enophthalmos case must be determined on an individual basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I thought it might be possible to have some form of genioplasty, sliding the chin down slightly to lessen the angle of the chin from the side. I thought moving the chin down slightly might reduce the amount of compression of the lower lip. As for the alignment of the lips I thought I might use a fat transfer or filler to align the lips. (at a later date)
A: Your concept of moving the bony chin downward (vertical lengthening bony genioplasty) to try and drop the lower lip down with it is one that on the surface makes anatomic sense. In theory one would think there would be some relationship between the bottom position of the chin and the position of the lower lip. However in dong many vertical lengthening chin osteotomies with interpositional grafts, some up to almost 20mms, I have yet to see the lower lip pull down. (which is actually a theoretical concern about vertical chin lengthening) What that is good news for those patients with normally positioned lips, it may not be good news for someone who has your lip positional issues and is trying to change them. However I am quick to add have I ever done this operation in someone with your specific lower lip issues with that being goal.
Such an operation only makes sense for you if there is an aesthetic reason to vertically lengthen the chin. Then even if the lower lip position is not improved there would still be benefit from the surgery. In your face that is already long and narrow, such an aesthetic change would not seem beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have three questions regarding the combined sliding genioplasty and neck liposuction procedure.
Would my recovery be much more extensive than with a chin implant?
I’ve gained about 20 lbs over the past few months. If I lost that weight, would I still need the neck liposuction?
And at my age, is it better to do neck liposuction or neck lift?
Thanks again!
A: In answer to your questions:
1) A sliding genioplasty has some increased ‘recovery’ time from a chin implant but six weeks later that is an irrelevant issue.
2) Since I don’t know what you looked like 20 lbs ago I can not say. But there is always one way to find out….don’t do the surgery until you lose the weight. That would be the best approach.
3) What you are referring to is the option between neck liposuction alone vs a submentoplasty (neck liposuction + muscle tightening). In fuller necks a submentoplasty always produces a better result than just liposuction alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have bilateral slipping ribs at 10th level. My 10th rib has been slipping under the ninth and causing considerable pain for eighteen months. I am interested in a qualified plastic surgeon performing this procedure vs.a thoracic surgeon. I have yet to find a surgeon who has ever performed this procedure. Thank you for your time.
A: Thank you for your inquiry. When you refer to slipping of the 10th rib, you are likely referring to the cartilaginous end of the 10th rib where its distal end comes around to attach to the subcostal ribcage. That end of the rib is usually not fused to the ribcage and has some mobility in most people but that his usually asymptomatic. If it is excessively loose or mobile that can a rare source of pain in some people. That portion of the rib can be removed to eliminate the movement of that portion of the rib. I have performed that subtotal rib removal before as well as for other rib pain associated cases like the costo-iliac syndrome patient.
To determine of this or any other type of rib procedure would be beneficial, it would be helpful to see an actual drawing on your ribcage of where the exact location of your pain is so I have a clear anatomic understanding of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What are the reservations of my ethnicity in regards to mouth widening surgery? I am Chinese so would there be any issues? Also would there be scarring? I am very interested in this procedure yet I am quite scared of the risks because I do know it involves cutting the orbicularis muscle. I also do not see this as a popular procedure and it seems like a very rare one. My mouth is very imbalanced with the rest of my face as I have a wider face and my smile looks way too small when I smile.
A: Scars at the corner of the mouth are always a concern in any patients with an form of corner of the mouth surgery. But in Caucasian patients that does not usually turn out to be a problem But in patient with intermediate skin pigments (e.g., Asian patients) those scarring risks are increased since such skin tends to be more reactive and the risk of hypertrophic scarring is increased.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in jawline enhancement surgery. In fact I already found a surgeon locally and they arranged my surgery for next Wednesday. The reason why I am contacting you is because I accidentally saw a lady who did jawline/chin surgery from the same surgeon as mine, unfortunately she had a really bad experience. Not just her face looks weird but also she had to get implants removed due to infections. After I read her story and saw her pictures i just feel unsafe and scared. Now I am not sure if I should cancel it…. My problem is the angle of the jaw. Eight years ago I did double jaw surgery in Korea and at same time they did “v line” too , my face looks good in front view but profile not good because it is to straight and no angle at all. So my question is if I fly to Indianapolis how long do I have to stay there from first consultation to surgery. Looking forward to hear from you guys . Thank you!!
A:I can not speak to your concerns in regards to your current planned surgical procedure. What I can speak to is what I normally do in the ‘reconstruction’ of the jaw angle area in patients who have had prior V-line jaw contouring surgery. Since the jaw angles have been amputated and the two sides are never symmetric, my preference is to make custom jaw angle implants due to the altered anatomy in which a portion of the implants has to ‘hang’ off the bone so to speak. This is why I have found to be the most effective with the least risks of problems. It is possible to use standard vertical lengthening jaw angle implants also but there is a higher risk of postoperative asymmetry by doing so.
Dr. Barry Eppley
Indianapols, Indiana
Q: Dr. Eppley, I’m interested in changing the appearance of my nose. However, I understand that the typical nose job is a subtractive procedure and that patient’s potential outcomes are limited to some degree by the nose’s original dimension and position.
I’ve always wanted to correct my long philtrum, which in conjunction with my short nose, leaves a large unappealing blank space above my lip. Similar to Stephen King, although not so extreme.
As far as I’ve researched, the only procedures that exist to reduce the philtrum involve altering the upper lip, which I don’t want to do: I like my lips the way they are.
My question is, is it possible to shorten the philtrum by augmenting the nose, not the lip? Is it feasible to create a longer nose that would extend further down into my philtrum, either through use of an implant or other method?
A: The short answer is ….no. You can only change the vertical distance between the base of the nose and the upper lip (along philtrum) by removing skin. Trying to push down the base of the columella or base of the nose by any method will only exaggerate or magnify the the long upper lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I emailed with you approximately a year ago in regards oto facial masculinization, I went through with the jawline augmentation (three pieces of Goertex 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 month 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 to your facial reshaping questions 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 profusion may be very effective you are talking about costs that will exceed $35,000 to do.
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 noted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Attached are the pictures requested. As previously mentioned, I’m interested in getting a chin implant and perioral mound liposuction. I got buccal fat removal done last year, but didn’t obtain the goal I had in mind. I have a round face, and would like to obtain a more heart shaped face, and more of a hollow cheek look as well. Please let me know what you would recommend.
Thank you
A: Thank you for sending your pictures. To make your chin com both further forward and the more narrow you need a narrowing sliding genioplasty not a chin implant. A chin implant would help in that regard if it was custom made as most standard chin implants wil make you chin wider.
With your buccal lipectomy you should have had perioral liposuction also. A buccal lipectomy alone is an incomplete facial defatting/thinning procedure.
I trust that you do realize that your ideal facial reshaping goals, as you have indicated in the model pictures, is not a realistic goal coming from your natural facial shape. You can get definite improvement but not to level of that degree of a heart shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Before my LeFort and sliding genioplasty operation I had a very bad malocclusion but they only worked on the top jaw. It just seems my mandible is still retruded. If I go through cosmetic chin augmentation I wouldn’t want my face long like it once was. I have been told that my sliding genioplasty was 3 mm and I think it should have been 10 mms.
A: Thank you for sending your pictures and detailing your surgical history. The short version of your current situation is:
1) Your chin is still horizontally short.
2) Only a postoperative cephalometric x-rays can answer how much chin augmentation was actually and how much more can be done.
3) Further chin augmentation should be done by a repeat sliding genioplasty not an implant
4) A sliding genioplasty is far preferred in your case because it is the only chin augmentation procedure that can vertically shorten her chin as well as bring it toward AND it will pull the submental musculature forward helping to thin out the submental area of the neck a bit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would be so thankful if you could help me with a question.
I lost eyebrows and I decided to take Lumigan. I didn’t have Latisse… but as I know it is the same. I found Lumigan 0.3 which is expired since 2016. But I used it anyway for around 1 week. It was closed and seemed like new.
Unfortunately, i used to many drops… I think it were 10 drops in a small cap in water (bottle top)… I used just a bit of it for each brow.
Later I used Revita Brow for two weeks …
Now I am just really desperate because I’ve read that bimatoprost (Latisse) could make fat cell loss.
My question to you:
Can it destroy fat cells around my eyebrows/eyes in just 3 weeks of usage ( + too high dosage of Lumigan and even expired … will the expired Version be stronger or less strong ?? )
I would be so thankful for a short answer
I really hope that in this short duration its not destroying fat cells —
Thank you so much !
&
Warm regards
A: This is not an issue of which I would have any concern with short term usage. This is a potential issue with chronic use which is how it is most commonly used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was looking through your site and I think I’ve figured out that I would benefit from paranasal implants. I’m confused as to what type of paranasal implant I might need, and how far it should go up the piriform aperture, and what shape it would be. I will send you a picture of me compared to a pic of what I think would be a properly filled out paranasal area. Also, I wanted to ask you about paranasal filler. Before I commit to a full implant, I would like to test filler to see if I like the result. I would like your input on how much filler I would need to approximate the result of the implant. I don’t mind using lots and lots of filler, as it would just be a one-off before I get the implant.
Thanks!
A: There are volumetric comparisons that can be made between injectable fillers and facial implants. To make such correlations the exact shape and size of the paranasal implant is needed. Since we do not know your exact implant needs yet I would have to use standard paranasal implants as the basis. (which may or may not apply to you) In that case it would be approximately 1.8cc to 2.2cc filler per side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am searching for a surgery of skull reduction and i know that you are able to do surgeries such as reduction as well as implants. My question is will there be side effects like headaches or any other un expected side effects that might come by time in future like 5 to 10 years as well as the back part of head (occipital) has to do with nerves that can cause serious problems and will a neurosurgeon doctor in surgery … I want to do the surgery but I am really scared because alot of doctors told me that a small mistake can cause death or it can make you never walk again and also doctors keep saying that its a really dangerous procedure and as well that one doctor told me by time like 5 to 10 years you might be mentally disabled and have Alzheimer’s disease … what is really important to me is whether it will affect my nerves or press on my brain in the future. What I really care about is that i want to be normal as I am now with just a better head shape so i can continue following my dreams in sport.
A: Thank you for your inquiry. It is important to realize that aesthetic skull reshaping surgery is an extra cranial procedure, not an intracranial one. Thus none of the adverse side effects to which you or other doctors have mentioned will occur. The biggest challenge with aesthetic skull reshaping surgery is to try and achieve the aesthetic outcomes that the patients seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for consulting with me about chin soft tissue reduction. I have attached the Pan X-ray and photos that you requested in order to get a better idea of the type of procedure that I require.
My main issues with my chin are the long, sagging look from the front and side profile view and the non-smooth, jagged transition from my jaw to the chin.
Ideally I would like for my chin to look “shorter”, tighter, and less square (more pointed) at the tip with a smooth transition line from jaw to chin.
Thank you in advance for taking time to review my case.
A: Thank you for sending your pictures and x-ray. What you have is chin soft tissue pad ptosis with jawline defects from your prior sliding genioplasty. Trying to make a chin that is vertically shorter, tighter and less square is a challenge as some of these dimensional changes contradict others. Such your excess soft tissue chin pad when you reduce the bone to make the chin vertically shorter and then shave the jawline to get rid of the only indents, there is going to be too much soft tissue chin pad. While some chin pad can be excised from underneath the limits of an acceptable submental incision/scar make reducing enough soft tissue chin pad laterally impossible….leading to either keeping the chin width you have now or even making it appear wider.
While I can see the chin becoming vertical shorter and with a smoother jawline I do not see how the chin can become structurally smaller and then end up being more narrow from the front view with the volume of soft tissue chin pad that you have. This combination of desired chin changes is not surgically possible to create.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A year ago 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 bone behind the incision that is closer toward the ear?
A: That is not an infrequent ‘problem’ that is seen after cheekbone reduction osteotomies. It has to do with the projection of the remaining posterior zygomatic arch which sits behind the osteotomy. This can be reduced by an additional osteotomy further back along the arch or direct burring down of the projection right down to its temporal bone attachment.
Provided that the posterior zygomatic osteotomy was not plated, a useful technique I have found to be help for this aesthetic problem is a percutaneous osteotomy technique. By walking a small 2mm osteotome along the posterior zygomatic arch a series of bone cuts can be made to push the bone further in…without having to reopen the surgical incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, so basically I got jaw and chin implants about three weeks ago and most of the swelling went away and so my doctor told me my jaw implants are in the right place. But I really don’t think so. The bumps on my face are firm and i really think those are the implants but my doctor doesn’t want to admit it. What do you think? I’m really concerned doctor, I don’t like the outcome at all. I was expecting results like this (photoshopped picture) , but I didn’t end up like that. I asked my doctor if he can use the Implantech widening mandibular implants (WMA), so those were the ones we used. Please help, thanks so much!
A: If you really want to know where your implants are positioned, you get a 3D CT scan. That will end all debate about where they are.
At three weeks after surgery, not all the swelling is gone. Only about 2/3s of it at best has resolved. It takes up to 2 months to appreciate the fine details of any facial implant result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just wanted to thank you in advance for reading my e-mail. I have seen some of your work with regards to custom facial implants on your website as well as Real Self and I think your work is absolutely incredible. I have read nothing but good things about you on various cosmetic surgery forums as well.
There is much that I do not like about my appearance that I wish to correct in the future as soon as I am financially able to. I have written down a list of what I think I would benefit from. I am seeing my doctor tomorrow to get a referral for a 3D CT scan. I would like to find out first if I have any growth abnormalities or deficiencies with regards to my upper/lower jaw, chin and maxilla,ect.
I would like to put a detailed e-mail together with some pictures with regards to what I look like, and what I would like to achieve.
If you don’t mind I would like to ask you kind of a quick question in the meantime as my midface area is really bothering me. I have a midface that I feel is too long. The distance between my eyes (pupil to pupil) is a good amount shorter then the distance from my pupil to the middle of my mouth creating a long mid face. Ideally the length or ratio should be 1:1 roughly.
I was wondering is there is any surgical procedure that can be done that can move my mouth further up on my face without messing up other area’s of my face? There was some procedure I was reading about called a CCW Rotation or something along those line that might achieve something like this? When I smile my front 4 teeth do not show any gums but the teeth on both sides beyond that do but not by a huge amount.
I have attached a picture of myself next to a male model who’s features I really like and you can see his midface is a good distance shorter than mine. I would like to do a lip lift in the future to shorten my long philtrum as well as a rhinoplasty as this would help shorten the appearance of my long face but my mouth would still be in the same spot so the liplift would kind of only give the illusion that my midface is shorter.
As far as the whole picture of my appearance my lack of eyebrows stand out the most in my photo’s and I underwent eyebrow restoration surgery 2 months ago which should help improve my appearance a bit.
I would love to put together a more detailed e-mail with some photo’s for reference and a list of potential procedures/implants that I think may help move me more in the direction I wish to go and would love to get your opinions and maybe do a computer graphic morph is possible.
Thank you VERY much for taking the time to read and reply to my e-mail Dr.Eppley I really appreciate it.
A: Thank you for your inquiry and sending your pictures. In short, and it is a very common concern and question, there is no non-surgical or surgical procedure that can substantially shorten the midface. (i.e.,decrease the distance between the eyebrows the base of the nose) The only procedure that is a bit helpful in that regard is a a subnasal lip lift or a vermilion advancement…procedures that shorten the distance between the lip and the base of the nose. A procedure that your picture shows would be beneficial in your case as you have a long upper distance between the base of the your nose and your upper lip. Like your eyebrow hair transplants, that is a procedure that can be performed under local anesthesia with minimal recovery and an immediate impact.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a transgender woman and am looking into possible feminisation surgery. I have heard you come highly recommend among the transgender community, I’m curious to know if my insurance with my employer would cover it? Could you give me some info on that? I appreciate any thing you can do.
A: Like all plastic surgery procedures that potentially may be covered by insurance, an insurance predetermination process needs to be done. This is where a letter is written from the surgeon with pictures and coding for the carrier to make that determination. Only by going through this process can the patient ever really know before surgery. It is not something the patient can find out by reading their policies or calling the insurance company themselves.
Even if coverage is approved for some or all of the facial feminization procedures, all expenses of surgery may not be covered. Because I do not perform these procedures in a hospital but in a surgery center, any implant items that may the used during surgery (e.g., plates and screws etc) will not be covered by insurance. This is more relevant for the brow bone reduction part of facial feminization surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have two questions for you:
1. I will be getting jaw surgery in order to advance both my maxilla and mandible. Would it be a good idea to let my surgeon know that I plan to see you afterwards for both custom jaw as well as midface (orbital and zygos) implants? Or would it not matter? I planned on telling him to give me the best aesthetic result he can from jaw surgery before I came to you with implants.
2. How much forward growth can be obtained from custom midface implants (orbitals and zygomas)?
A: It is irrelevant what you are going to do with your face after orthognathic surgery, custom facial implants not withstanding. That has no influence on how the orthognathic surgery is planned or done,
The amount of forward midface augmentation (not growth) that can be done with custom facial implants is in excess of whatever anyone’s aesthetic needs are.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask in general if it is okay to do a chin implant and cheek implant prior to jaw implant if I am considering a jaw implant as well. Or rather would it be better if all 3 implants are done at once (cheek + chin + jaw implant). Last question if a drill hole canthoplasty is done say 10 to 20 years later I wanted to do a revision are drill hole canthoplasties can it be done again does the orbital bone that’s drilled initially heal over time where another drill hole can be done again or would the previous drill hole still be used for future canthoplasty revisions. Thank you
A: Presuming we are talking about three separate implants (chin, jaw angle and cheeks), I don’t think the order matters. It is all a personal preference as well as which procedures have the highest aesthetic priority. When they are separate implants they can be placed at any time.
Most drill home lateral canthoplasties are done as high up on the lateral orbital rim as possible. So once it is done it can never be moved higher as there is nowhere else to go.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering having a large skull augmentation. And am considering no where or no one else in the world to do it other than you and your brilliant team!
I have uploaded the photos of the shape of my head to WeTransfer.I have taken a shot from each angle, to give a thorough idea of what my head shape is like, to give the best possible idea of what I may need. I have a long birthmark running along the top of it, and asymmetric ears which might make it hard to tell the true shape. I also have quite a few asymmetries over my whole head in different areas which I would like to be corrected with whatever method I choose for a perfectly smooth outcome from all angles.
I have also attached a few photos where I have outlined the areas I want volume to be added to. I have also attached photos of the look I am going for which is one similar to the shape of Amber Rose’s and ideally Jorja Smith’s head.
I have quite prominent facial features, and adding more volume to my head area, wether its through hair or the use of a hat, always takes the focus away from that, and balances it all out.
I have a few questions to ask before, so that I know I am clear on as much as possible before I move forward with important decision making. And also so that I can reference back to the answers whenever I need to.
1) Ideally, I would prefer to use a material such as PMMA instead of a custom fit implant, due to my assumption that it will require smaller incisions.
However if an implant is more suitable, will it be necessary to fly out to design the implant, and then back again for the date of the surgery? Or is it possible to design the implant without me being present, by sending over some sort of scan of my skull?
And if not would it be possible to make the implant within days or the same week as the date of surgery?
2) From the pictures, the shape of my skull and my desire for it to be, as an estimate how much can I expect this to cost?
3) How long after the surgery date would I be able to fly back home? And then resume casual non strenuous work?
4) What solutions for reducing the visibility of scars are there? Are there any good creams or treatments?
5) How long after (and if at all), before I can return to dancing how I usually do, which is very fast, energetic and involves a lot of head banging and sudden head and neck movement?
Thank you Dr. Eppley for taking the time to read this email, and answer my questions, I really do appreciate it.
You are the best! And I look forward to moving through with all of this!
A: Thank you for your skull augmentation inquiry and sending all of your pictures. To answer your questions:
1) Only a custom skull implant can provide such a large area of skull augmentation in a smooth manner with a smaller scalp incision. PMMA bone cements require a full coronal scalp incision for placement and such material can not be placed over any muscular skull areas…which much of your desired skull augmentation does. PMMA bone cement is not a skull augmentation options for you.
2) Based in the total amount of skull augmentation it most likely would require a first stage scalp expansion procedure.
3) Such custom skull implants are designed are from a 3D CT scan of he patient which can be done in a remote or virtual manner.
4) It takes an average of 30 days from the receipt of the 3D CT scan to got though the design and manufacturing process to have to ready for surgery.
5) My assistant Camille will pass along the cost of the surgery to you in a day or two.
6) Most patients fly home in one to two days after other surgery.
7) Scalp incisions can heal remarkably well and the most important component in how well they heal is in how they are surgically made and closed. The use of scar creams after surgery never hurt but they are not magical.
8) They are no physical restrictions after surgery, patients return to any physical activity as they feel fit to do. I suspect it will be a few weeks, however, before any ‘head banging’ sounds or feels appropriate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in shoulder widening surgery by lengthening the clavicle bone. How does the scapula move after the procedure and how much change can there be in shoulder width.
About the widening, does the scapula widen in conjunction with the clavicle ? Does the bi-deltoid width increase and by how much? Also why is there such little research on this topic across the internet.
A: The scapula moves normally since the AC joint is not involved in the clavicular bony lengthening.
A 2 cm mid-clavicular osteotomy and interpositoinal bone graft is done roughy increasing shoulder width almost 1 inch per side.
The scapula bone does not widen per se, its angulation changes slightly to accommodate the change in the lateral clavicular and AC joint positions.
There is an an approximate 80% correlation between the linear lengthening of the clavicle and the increase in the outer contour of the deltoid soft tissues. Thus about 2 cms per side.
Clavicular lengthening surgery is a rare aesthetic treatment for shoulder widening given that there are already two other treatments methods which are less invasive. (fat injections and deltoid implants) Thus it is rarely requested and is done by very few surgeons around the world leading to a paucity of any information about it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope you’re well. I am loving my rib removal results. I would like to know if complete buttock hip augmentation can be done if my current buttock implants are intramuscular? Can the size of my buttock implants be increased at the same time? How common is hip implant shifting and malposition? How much hip Augmentation can be achieved with custom implants? And my last question is have you done thigh augmentation with quadricep muscle implants?
A: Good to hear from you and I am glad to hear that the rib removal surgery has been successful. In answer to your questions:
1) I am not completely sure what you mean by complete buttock-hip augmentation but I assume you mean a confluent augmentation as the buttocks cross into the hip area. Having hip and buttock implants in the same tissue plane is really only most relevant to very thin individuals with little subcutaneous tissue for implant camouflage. Thus I think you are alright in that regard and a hip implant that extends back over the lateral buttock area, even with intramuscular buttock implants, will work just fine.
2) Secondary buttock implant enlargement can always be done as the first implant acts like a tissue expander. As a general rule up to 50% volume increase can secondarily be done.
3) For hip augmentation a maximal thickness over the defined central projection point can be 2.5 to 3 cms per side. But don’t let that number fool you as the surface area hip implants cover is much greater than buttock implants and thus their effects are more impactful than that linear number alone would suggest.
4) I have done thigh augmentation numerous times and have a specific thigh implant design to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if I would be prescribed any pain medication for the post surgery aftercare for lip advancements while the stiches dissolve and while the incision closes up ? As my skin is very sensitive I’m worried I will be very irritated around the area and really don’t want to feel the need to itch the incision, feel too uncomfortable or harm the work you have done.
How long will it take for the incision to properly close up and for the chance of infection to pass?
Will it be possible to wear a pollution mask while I am out in public as I would prefer to cover up the incision while the stitches are in if possible
And how long will it be till I am able to wear lip stick /cover up around the area ?
And how long will it be till I can do exercise again?
Thank you
Sorry for the overload of questions
And if you have any recommendations for aftercare please let me know!
See you very soon!
A: In answer to your lip advancement questions:
1) Pain medication will be provided for yourafter surgery needs, although lip advancements are not particularly painful afterwards
2) Lip incisions heal well in about three weeks after surgery.
3) Lipstick can be worn in one week after the procedure.
4) You can exercise immediately after surgery.
5) You can wear a pollution mark any time after the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Overall, my aim is to have a more chiseled face but also want it to look very natural – currently have c. 2-2.5ml of fillers- done last year and I am happy with results. Might get 2ml more fillers for minor improvements in upper cheeks and jaw. Can the fillers be dissolved pre surgery?
Only started noticing a more droopy/chubby face after I turned 30
Looking for a more sort of a makeover (but natural) from Dr Eppley, happy to consider multiple minor improvements
Unhappy with my resting face (seems tired/angry at times) and smile (which is quite unattractive – as per all my friends)
Have had multiple filler since past 4 years for tear trough. Would tear trough implants be a good long term solution? Is the insertion via lower eye lid?
What sort of cheek implant would you recommend? I have attached a pdf of a result from Real Self which i really like. Can this sort of an implant be combined with a tear trough implant?
I am also intrigued by a the full jaw + chin implant i saw on your website. What is the typical downtime post such a surgery? Is the implant placed above the masseter muscle?
Assuming I go for cheek and jaw implants, would the temples then look hollow? In my opinion, they already look hollow but i can somewhat hide this when I have longer hair. They are really exposed when I have short hair.
Do I need ptosis surgery? Had an email exchange with an oculoplastic surgeon who said it will help for upper eyes after looking at few of my pictures. I am just scared of overcorrection in this sort of a surgery.
Rhinoplasty to reduce bulbous tip – not looking for anything significant, just a minor reduction, should look natural. If it goes well, may think of a more significant revision in a year.
Buccal fat removal? Will it help for a more chiseled look? Can you remove Buccal fat if I have a low fat body? I am aiming to reduce body fat to 15% in the next 3 to 4 months.
Double chin – This has been really bothering me since 2 years now. I visited two aestheticians regarding this, one suggested ultherapy because it was saggy skin and other suggested fat dissolving injections. I underwent ultherapy. I can see the jaw looks better now, still far away from the chiseled look I desire
Less curved/more straight eyebrows – hair transplant or any other options? An aesthetician told me Botox to lower central forehead may help, but I am not sure if that is correct, I haven’t seen/read anything about it online
Can something be done about lip asymmetry?
A:In answer to your facial reshaping questions:
1) All hyaluron-based injectable fillers can be dissolved before surgery.
2) Tear trough or infraorbital rim implants are usually inserted through a lower eyelid incision.
3) Combining a tear trough implant with a cheek implant is commonly done in my practice and is known as a custom infraorbital-malar implant.
4) All custom jawline implants, like standard jaw angle implants, are placed on top of the bone in a subperiosteal pocket underneath the masseter muscle.
5) Ptosis surgery will open up your eyes a bit. The technique used will determine how much upper load shortening is obtained. You probably just need a mullerectomy for a 1 to 2mm change.
6) Rhinoplasty surgery can help narrow a bulbous tip. Your thick skin would prevent any type of change from being too narrow or looking overdone.
7) For facial derounding/slimming you need buccal lipectomies and perioral and submental/neck liposuction.
8) Any change in the shape of your eyebrows os one of hair management strategies, not a surgical or Botox treatment.
9) Your left upper lip asymmetry is of less vermilion show on the left upper lip. To correct it that requires a vermilion advancement on that side by a few millimeters to match the right sided vermilion show.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am hoping to replace the standard mandibular implants and chin implant with a custom wrap around vertical lengthening implant. I am a little over 3 months post op and still have a lot of swelling. The doctor that did my procedures told me that he thinks that the right mandibular implant has shifted forward. After the procedure, he told me that he didn’t use screws. He offered to do a revision and said that he would put the mandibular implant back in place and shave it (if necessary) as well as bring it as far back to my ramus as possible. Being the result I wanted was a strong (drop down) vertical lengthening to my jawline. He also “repositioned” a previous botched chin implant that had migrated and shifted upward on my chin and had caused bone resorption. He was actually supposed to replace the old chin implant with a new one (that was more squared) But, unfortunately I was told after I awoke from anesthesia, that he had decided to just use the old one I had and just repositioned it more downward. Needless to say, I’m very unhappy with this result. I’m hoping and praying that you can help me!! I have attached some pictures of the RESULT/GOALS I’m aiming for. Do you think that a custom wrap around vertical lengthening implant will get me close to my desired result? Also, would you recommend a larger more square implant, and or a sliding genioplasty?? Any recommendations by you is greatly appreciated!!
Thanks again so very much.
A: Thank you for detailing your surgical history and your current situation. First and foremost, whether it was your original surgery or any revision thereof, your desired goals based on your model pictures were never realistic. That is not going to happen with any standard or even custom jawline implant. You don’t have the facial anatomy for it. That requires a very thin face that is already skeletonized to achieve that degree of facial definition. Your original surgeon or any subsequent surgeon should have provided realistic computer facial imaging that could show what is possible with YOUR face. You can’t get someone’s else facial shape…which is basically what showing those type of ideal facial shapes is trying to achieve.
Secondly most facial implants revisions or replacements require a 3D CT scan in my experience so the exact placement of the implant can be known. From that better implant positioning can be obtained ad/or new implants made that will have an improved facial result. You don’t guess or eyeball facial implant revisions/replacements…that is a recipe for just creating ongoing aesthetic problems.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got hip augmentation with implants but i’m not happy with them. The doctor has his hip implants, and although i got the largest, it’s pretty clear they were made for someone smaller (i’m 6’1″ and about 180lbs.) I was doing a bit more research and came across some pics that you posted:
These are much closer to what i am looking for and if they could be scaled for my tall stature…(!!!)
i’ve also got some ideas that i was curious what you’d think….
first the easy stuff: for reference here is one of the pix i sent you post op:
Would my current hip augmentation be similar to breast augmentation, where the first pair stretches the skin a bit so that a larger implant could replace it? in other words, could the fact that I have already had hip implants and that area has already been stretched a bit, mean there is a possibility that I might be able to get implants with a ‘higher superior profile?” I’ve always admired pear shaped women, or women with thick thighs. I am black and there is a lot of emphasis on thicker lower body shapes, so i’m hoping this is the case. I’d love it if i could have a shape similar to Ely Ivy (or as close as we could get to it):
I’d prefer something longer rather than shorter because of my height, if possible. I know you can’t go as high up as the following illustration, but wherever the start, ideally I’d love it if they’d taper at mid thigh like drag queen pads. I’d absolutely love it if they could have the upper thigh curve of the second pic below (and maybe some of the booty shaping on the left side of both pads?)
Speaking of the height of the implant, is there any way to make a small pocket above the implant to make it go up a bit higher? i know usually surgeons make one pocket, then slide the implant in, but i was wondering if something more like a envelope pillowcase would work.
Instead of there just being one pocket there would be two, a smaller one above the incision, and the main one below. This way the implant could be just a little above the incision line. would that work or is it still impractical?
You had some questions about my prior hip implant surgery so i’ll include those with the answers below (to the best of my knowledge):
1) Where are the incisions for the hip implants?
Below the top of the hip. if you look at the pix, you can see the white of the bandages.
2) What type of material for the hip implants?
The same used for butt and calf implants; soft, semi solid silicone.
3) What type of implants were used since there are no standard hip implants?
It was a specific rounded corner triangle shaped implant made specifically for hip augmentation. It is placed downward pointing underneath the fascia, below the top of the hip.
4) What is the tissue pocket for the implants?
It is placed downward pointing (the shortest side of the triangle at the top) underneath the fascia, below the top of the hip. i do know he keeps it at a certain weight to prevent any migration. because i am looking for something longer, that adds to the total thigh thickness as well as hips, i am hoping that a pocket can be made beneath muscle or another implant could be placed beneath his implant and muscle.
So my questions:
- What is the approx. cost of your hip implants (including room, anesthesiologist, etc) I know i’ll need a consult, but to plan, i need a ballpark estimate. 🙂
- Like breast augmentation, would my first implants allow me to replace them and get bigger hip implants with you, since the skin has been stretched by them?
- Do you think we could get anything close to Ely Ivy’s pear shape?
- Is implants that go down to mid-thigh be possible, with my question #2 in mind?
- Would the double pocket envelope pillowcase idea work?
A: In answer to your secondary hip implant questions:
1) Having existing hip implants is both beneficial and a disadvantage. Stretching the tissues out is the helpful part as that would allow for a greater implant size increase. The negative is that the existing implants have created a scarred capsule which makes extending the tissue pockets, a necessity for larger surface area implants, more difficult, Not impossible but the bottom part of the pocket, which is the furthest away from the incision, is a hard place to reach. But given that you would need a new tissue pocket above the fascia makes your existing implant pocket irrelevant.
2) For your goal standpoint, given where you are now and what your pictorial goals are, I do not think that is surgically achievable in a single operation. Realistically it would likely be about closer to halfway between the two.
3) Going higher with new hip implants is not an issue, it is how far down the thigh one can go that is always the greater challenge. But clearly you have to and can go longer down the hip/thigh that where you are now. Hip implants are unique in that they need to cover a lot of surface area to create their effect. They are not rounder mounds like buttock or breast implants.
4) The incision would be at the same location that you are already have. They may be longer, however, although I don’t know/can’t see how long yours are now.
5) Hip implants in my practice are all made custom out of ultrasoft solid silicone.
6) To cover the larger surface areas of most hip augmentation patients the implants need to be on top of the TFL fascia, not underneath it or in the muscle. Those pockets are much tighter and more restrictive.
7) While you have the general shape of the implant design, the illustration is too big and thick.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Attached is a morph (current is on the left) of what I am hoping to achieve with facial reshaping surgery.
Jawline:
A few years after I had the sliding genioplasty with you, I had a chin implant & fat transfer to the chin done by a surgeon close to me. However, the shape is not smooth or natural. I suspect the fat injection is causing an unnatural contour – specifically, a ridge higher up on my chin. Would it be possible to remove the injected fat possibly by small cannula liposuction? I’ve attached a photo of me smiling where the ridge is more obvious.
Nose:
I would like some more projection and structure overall. As I understand it, the dorsum can be augmented with an implant but the tip must be cartilage. Is this correct? Would it be simpler to just use rib for the entire nose?
Brow bone:
I am okay with a subtle increase in projection. You’ve mentioned that pre-formed brow bone implants are also an option. Is there any advantage to going custom since the jawline will be customized as well?
A: In answer to your facial reshaping surgery questions:
1) The approach to removing some of that fat from the chin would be using a microcannula technique, a 1.5mm cannula. That would have the least risk of causing irregularities.
2) You are correct about using implants in the nose. They should be restricted to the dorsum and cartilage should be used for the tip. Thus usually means that the septum or ear cartilage harvest will suffice for the tip. It would not be ‘simpler’ to use a rib graft since it requires a donor site. The logic of using a rib graft wold be if one wants to avoid the use of an implant in larger nasal augmentations.
3) If you are going to have a custom jawline implant then it would be best to just have the brow bone made custom as well. That is because the design and manufacturing cost is less for the second concurrent custom implant and there would be no economic advantage to using a performed special designed brow bone implant.
Dr. Barry Eppley
Indianapolis, Indiana
