Your Questions

Q: Dr. Eppley, I already got my rib removal surgery quote thank you I have to save more money because I only got 10k. I got one question can you tell me how much inches usually reduce this surgery? I just want to know to to see if is good enough to expend all my savings.

A: As a general outcome statement, most patients report to me that their waistline reduces anywhere from 1 to 3 inches.

Since you have chosen to reveal your economic issues with his type of surgery, I can provide the guidance to you that no patient should ever put themselves in an adverse financial position for elective aesthetic surgery ….unless the face or body deformity they are facing is disfiguring and negatively impacts their life in a major way. I would not qualify the desire for waistline reduction in a young lean female as fulfilling that criteria.

In short you should never expend your savings for cosmetic surgery of any kind. That is not a good financial decision.

Dr. Barry Eppley

Indianapoli, Indiana 

Q: Dr. Eppley, I’m contacting you in hopes of getting some information on how I might address an issue I have. I am a transgender woman, and have undergone Facial Feminization Surgery recently. This addressed several of my issues, but I still find that I have a quite flat, hollow, and long face. From my research, these issues (the first two, anyway) appear to be due to “midface hypoplasia.”

I would be interested in hearing what options exist for correcting this which Dr. Eppley is able to offer. From my research, the main approaches appear to be either a LeFort I osteotomy or facial implants (specifically, paranasal and submalar). I have concerns with the LeFort approach. This is partially due to the aggressiveness of the procedure, but also because I feel that the zygomatic bone and the region below it and approaching the maxilla are also underdeveloped. To my knowledge, a LeFort I osteotomy only corrects the maxilla itself. Ultimately, though, I am not a doctor and not really qualified to make the assessment as to what would or would not work myself.

To aid with an assessment, I have included a link below to a set of pictures. These include head shots of me from the profile (both directions), three-quarters angle (both directions), and front. These were taken in bright lighting from roughly 6 feet away. Resolution isn’t amazing, as I unfortunately do not have a high-quality camera. I have also included CT scan images of my skull from roughly the same angles.

A:Thank you for your inquiry and sending all of your pictures and 3D CT scan. Your diagnosis is an overall midface skeletal deficiency. You are correct in that a Lefort I osteotomy would only correct a subtotal portion of the problem….although you would need a LeFort I advancement combined with a mandibular advancement since your lower jaw is also over rotated as a result of the midface deficiency. But given that you have a normal occlusion such orthognathic surgery has additional limitations. From an implant standpoint augmenting the entire midface including the infraorbital and lateral orbital rims with a custom design would be the alternative and superior aesthetic outcome approach that would also be far less invasive with a quicker recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the middle of preparing for a surgery. I will be getting custom PMMA cheek implants modelled off a 3D printed model of my skull. I’m planning on widening my face a little bit and hoping that this will improve my sagging cheeks from my zygoma reduction procedure.

I understand that all implants have a risk of infection and that the highest risk time is in the early post-operative period. However, how common is it for facial implants to get infected without good reason in the long-term?

From my understanding and research, I understand that dental anesthetic or fillers in the implant capsule could potentially inoculate the implant with bacteria and subsequently get an infection. I’ve read about patient experiences where Medpor implants get infected out of the blue years after surgery. Is it possible for an infection to pop out of nowhere without reason?

A: In all due respect these are questions you should be asking the surgeon who is going to perform the procedure. Presumably they have both the skill to not only do the procedure but also the experience to know what the long-term risks are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your profile on RealSelf and it appears you seem to be quite experienced and knowledgeable about facial implants.

I’m of Asian descent and one year ago I had my chin narrowed and moved forward in Korea. I’m near happy with the results of the surgery but I desire more horizontal movement. I regret asking my original surgeon to stay conservative but I guess I would prefer less than too much. 

I’m thinking of going abroad again to get a small chin implant, as I think recutting the bone for such a small additional movement is overkill. Surgery in my home country is also unbelievably expensive and not exactly very well versed when it comes to asian aesthetics.

The only thing is that I am deathly afraid of getting an infection. I’ve read on RealSelf that most infections tend to show themselves in the first week up to three weeks post operation. What’s the likelyhood of infection appearing after this period? 

More so, I worry about the implications of cutting through the mentalis muscle twice. As I am Asian, I have been rejected for extraoral incisions due to the scarring implications. Does cutting through the mentalis muscle again have consequential possibilities such as a drooping lip or chin sagging? 

Thank you for your insight.

A: The way to lower the risk of infection to the lowest possible is to use a submental skin approach. That also avoids cutting through the mentalis muscle and quickens recovery. That is a 1 cm incision which I have not seen that to be a ‘scarring’ issue. I have done many Asian male patients through that approach.

But since that approach is off the table, the risks of infection with intraoral placement are higher, how much higher no one can really say. Such infections do not occur in the first week or so but 3 to 6 weeks after surgery. That is typical take period for all facial implant infections.

I don’t consider cutting through the mentalis muscle twice of major concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttocks implants, however, I am worried about a new worldwide discovery of “implant illness”. Do you think this could happen even with solid silicone implants used in buttock augmentation or only breast implants? My second question is can I get buttocks implants and rib removal at the same time so I do not have to be under general anesthesia twice? Do they both have to be done under general?

A: In answer to your question:

1) You are referring to a low grade lymphoma that has only been associated with one type of textured breast implants. This has been associated with the way the textured surface was applied. I do not see a correlation with smooth surfaced silicone buttock implants.

2) I could not think of two body procedures who would need general anesthesia any more than rib removal and buttock implants. These two procedures should not be done, either together or separately, without general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a forehead reduction and forehead implant. Can these procedures be done together or are there limitations? Will this result in a higher chance of shock loss or negative side effects?

A: By your description I believe you are referring to a hairline advancement (forehead reduction) and a simultaneous forehead augmentation. (implant) Whether such a combination of forehead procedures can be done depends on how much forehead augmentation is desired as well as how much forehead reduction is needed. I would need to see some pictures of your forehead as well as your goals to determine whether they can be done together or would need to be staged.

If the desired hairline advancement is not extreme and the size of the forehead implant is not too big, then I suspect both can be safely done together. But a hairline advancement greater than 10mms and a forehead implant thicker than a few millimeters, then there may be some tissue restrictions with combining the two procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a temporal implant procedure done 10 years ago which I’ve not been happy with as the size and thickness of the implants is too large in my opinion. I would want them to be replaced with much smaller and thinner implants.

Some of the notes I have are:

– the original physician does not have records other than it was methylmethcrylate implants, formed from putty at the time of surgery

– I had a consultation with a physician in southern California, he concluded the methylmethacrylate implants are placed along the temporal bone bilaterally after reviewing MRI

– the MRI report is attached but is not too conclusive

– the right side implant is definitely a little thicker, more convex shape than the left side, I particularly dislike the right side result

– I’ve attached 3 pics, the first one I think shows how the result makes my head look bigger which I don’t like, an extremely subtle augmentation is what I’d prefer.  The sideview shows the faint scar line.

A: Thank you for sending all of your prior temporal augmentation information. As I suspected these are PMMA intraoperatively fabricated implants placed under the muscle down on the bone….a common technique done before the availability of standard silicone temporal implants. I could easily identify in your pictures the surgical incision used. Knowing its location and length would be crucial in determining how ‘easy’ it is to revise/replace them. It is one thing to place a moldable putty through a small incision and shape it and allow it to harden than it is to try and get a solid implant out in reverse. It can be how to extract the proverbial ‘ship in a bottle’. However knowing that PMMA is usually inserted through ‘larger’ incisions, which I suspect you have, suggests that it can be similarly removed. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if a custom wraparound jaw implant can address my short chin or it would be better to do a genioplasty and individual jaw implants? I was told by a local Dr that I would need 8mm vertical jaw angle lengthening and 12mm of anterior chin projection but I find your posted results to be superior so I want to know what would you recommend. Thanks.

A: I am not sure where those jaw augmentation estimates are based on as in looking at your face as they seem to be excessive  A horizontal chin augmentation of 8 or 9mms and a vertical jaw angle lengthening of 3 to 5mms is the most you would likely need…although computer imaging would have to be done to determine what you are trying to achieve. A total jawline implant provides the most predictable and connected jawline augmentation method and is always better than three separate unconnected jaw augmentation methods.

Ultimately computer imaging of your face needs to be done to help determine exactly what type and degree of jaw augmentation you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my cheek implants (Terino malar style 6mm size) placed about 10 years ago. As I get older I realize I look tired because of my under eye bags seemingly created by the forward placement of my implants. I have always wanted a more posterior “high cheekbone” extended arch implant that you describe and have pictures on the website. Is it still possible to replace my off the shelf implants with custom extended implants even though I already have implants in place?

A: There is no problem changing out your current cheek implants with new custom designed cheek implants. In fact over 1/3 of all custom cheek implants are done in patients who have had prior standard cheek implants.

In computer designing cheek implants, any existing cheek implants can be digitally removed to make the new ones. it is also helpful once the new implants have been designed to digitally bring back in the existing implants to compare the two designs in shape and bone surface area coverage. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested and serious about the procedure.  Although I am not seeking rib modification for cosmetic reasons only. I am an avid walker and cycler. During exercising and movement, my lower ribs touch my hip bones (or something in there!)   It is extremely bothersome and impedes my workout significantly. I realize there can be some risk and residual rib pain. Staying fit and working out is critical to my health. I realize you may not resolve the issue completely, but any relief would be acceptable. I am financially prepared for this and interested in pursuing rib modification.  Thank you Dr Eppley, I know you are highly experienced in this procedure and I greatly appreciate your assistance.

A: What you are describing technically is known as iliac-costal syndrome. Getting rid of the outer half of ribs #s 11 and 12 on the affected side has proven to be vey helpful in symptom relief in this rib-associated syndrome. I have had some patients who have requested removal of rib #10 also but that rib should have no contribution to impingement on the iliac crest given its more horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cortical jaw reduction done in Asia and unhappy with the results. Do you do custom jaw implants? if so,would PEEK or titanium mandible angle implants be better? Thank you. 

A: I have done hundreds of custom jaw implants out of every available material. Whether the more expensive options of PEEK or titanium are viable options for your jaw restoration would depend on what size of implant is needed and what you are willing to pay for the surgery…as both PEEK and titanium custom jaw angle implants are considerably more expensive than those made out of solid silicone.

Ultimately a 3D CT scan of your jaw is needed to determine what size jaw angle restoration is needed. That may also influence the material choice for the implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 43 yr old female seriously interested in orbital decompression surgery and I believe I may need eyelid retraction surgery as well. I follow Dr.Eppley on Instagram.  He advised me to seek a local oculoplastic surgeon to address my concerns. There are 2 in the city of Memphis, TN.  After consulting one, he admitted he had very limited experience performing the surgery because there isn’t a demand for such a surgery in my city.

I do want to ask some questions, prior to my consultation, if I may? If you can answer any of the following, that will help me to narrow down my questions during my virtual consultation.

I have included pictures to assist you or Dr. Eppley in hopefully answering my questions.

Here are some of my problems with my eyes:

*I have my thyroid tested annually, my last test said all my numbers were in the normal range.

1Bulging – it appears to be getting worse as I age.

2. Excess skin or fat on my lids. Hooded eyes – I do not like it. I do not like it!!

3. Inability to close my eyes fully when I sleep.

4. Asymmetrical eyes – sometimes it is so drastic.

5. Double bags under my eyes when I smile.

6. Eye shape – my down turned eyes ages me, in my opinion. Can an eye shape be changed during surgery?

My goals would be to fix those aforementioned problems.

The questions I have are as follows:

1)Am I candidate for orbital decompression surgery?

2) How long is the recommended stay for out-of-town patients?

3) Does private insurance cover orbital decompression surgery? (I have Cigna, which is out of network).

4) If insurance does not cover any of the costs, how much roughly would it costs for the procedures I have listed and/or any procedures Dr. Eppley deems necessary?

I greatly appreciate your time and consideration.

A: In answer to her questions:

1) I think you ideally need the following combination of procedures:

     a) orbital decompression

     b) upper blepharoplasty

     c) lateral canthoplasties

     d) orbital rim augmentation

    While you may have orbital proptosis, there is also a signficant contribution of infraorbital rim/midface deficiency.

2) Patients usually come home in a few days after the procedure. Recovery is largely about swelling and its resolution.

3) I do not take insurance

4) My assistant Camille will pass along he cost of such surgery.

You would need a 3D CT scan to determine the bone anatomy as well as a preoperative ophthalmology evaluation that determines you do not have a metabolic basis for your orbital proptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reviewing some information with a custom jaw and chin implant that was one piece and appeared to have some soft portions to it.  I don’t believe that I need a chin implant.  I was just checking in regard to the custom jaw implants.  

How long would it take to examine me, design and fabricate the implants?  Approximately how long for surgery?  Would it be better for me to be there in person for you to examine me initially? 

A: I am not sure what information exists that suggests that any custom one piece total jawline implant has some ‘soft portions’ to it. But that is certainly not true. 

To be implant type specific the term ‘jaw implant’ refers to any implant that may be used along the jawline at any location, it is a general term. What you are seeking are ‘jaw angle’ implants, one type of implant that is used for the back end of the jaw.

On average it takes 30 days to design, manufacture and ship for surgery any custom implant…after a 3D CT has been obtained from which the implant is so designed. That would be the shortest possible time.

The surgical time required for removal of your existing jaw angle implants and their replacement with new custom jaw angle implants would be 90 minutes.

Seeing you in person doesn’t really add much to deterring what a new implant design would be. Having existing implants in place is the single most important aid in a custom implant design. Such implants can clearly be seen on the bone in the 3D CT scan. When you know what you have in you doesn’t work well, you have a good guide as to how to improve their design and dimensional requirements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just sent a request for the “Predict my face” on your website. I am scheduled for a submental chin reduction on January 15th. It’s obvious when I’m smiling that my chin needs reducing. This is what motivated me to pursue this procedure. However, when playing around with photo morphs, I came to realize that when I’m not smiling, the chin seems to be in the right place (very slightly protruded). I have a unique profile view because my lower jaw may be slightly receded (although my bite is good, there is a slight overbite). When I reduce my chin in the non-smiling photos, it doesn’t take long before I look like I have a receding chin.

I have attached a video of me progressing from not-smiling to smiling. About how much are you thinking needs to be reduced? I believe that the procedure will still benefit my profile, do you agree?

On another note, I have attempted to get the cone beam x-ray, but places around here will only let me use their machine if I am patient of theirs. I’m not planning on getting it done unless you think it will be helpful in determining the amount to be removed.

A: In answer to your questions:

1) In hyperdynamic chin ptosis , the chin position at rest is often normal. That always poses a dilemma because surgery is done in a static position (at rest) for the treatment of largely a dynamic problem. (in motion) The key is to not overdo the procedure and treat it like it is a large protruding chin at rest.

2) While at rest I would not consider your chin overly protrusive it is still a strong chin in profile that a few millimeters of projection loss would not cause it to become recessive. 

3) The removal of 2mms of bone is merely to allow the soft issue resection to be tucked in to reduce the dynamic protrusion of the soft tissue chin pad. 

4) A preoperative x-ray is not needed since the procedure is not largely based on bone resection as so indicated in #3 above.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a bimaxillary advancement in due to sleep apnea and a receded chin/ midface. 

After this i was hoping to get a custom jaw implant from your surgery. Would the sliding genioplasty as part of a maxillary-mandibular advancement effect the ability to design a custom implant? 

Thanks 

A: The simple answer is no. It does not matter what the underlying bone shape is when it comes to computer designing a custom facial implant to lay over it. It is quite common in my experience to do custom jawline implants in patents who have had a prior sliding genioplasty. In fact it is also not rare to do a simultaneous sliding genioplasty with a custom jawline implant overlay.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if there was any type of surgical procedure that would directly involve changing the shape of the pelvis, not through fat transfers or implants, but with a modification of the bone itself. Specifically of the iliac crest, to give a male pelvis less height and more width if that makes sense?

Is there a way to make the male iliac crest more like the female iliac crest, giving a female hip flare to a male pelvis? I’d be very interested to know if this surgery is possible and if so the costs/recovery of such a procedure. If not, I’d very much like to hear alternatives to the procedure to produce wider, feminine hips. 

A: There is no surgical method to change the shape of the bony iliac crest that dimensionally reduces it height and gives it more width without undue scarring, plate fixation, risk of bony non-union and considerable postoperative pain The only treatment option is to augment the sides of the iliac crest with an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about rib removal surgery. I’m a MtF transgender and have a very hard time narrowing my waist. This gives (in my opinion) a very masculine appearance to my body. I was wondering how much a rib removal is, how dramatic you think it can be in a transgender patient, and if it would be enough to give a feminine appearance to the ribcage, or if corsetting would still be required for a “tapered” look. I’m looking for something drastic in my body, but something that still seems natural for a woman if that makes any sense. 

I’d also be interested in any before and after that may be available for transgender patients that have had this procedure, if there are any available! 

A: About 1/3 of the patients in which I perform rib removal for horizontal waistline reduction are MtF transgender patients. They seek the procedure out for the exact same reasons to which you have described. Because of their genetic male ribcage and torso shape there is no other effective alternative. Removal of the lower half of ribs #10, 11 and 12 (as well as a wedge of latissimus dorsi muscle) removes an anatomic barrier for whatever maximal waistline reduction is possible. The degree of such waistline change is open to personal interpretation as to what constitutes ‘drastic’. Noticeable is what I could call it but I would never use the term ’drastic’ as that implies an unrealistic surgical expectation. I have never had a transgender patient, or any rib removal patient for that matter, complain afterwards that the result was inadequate…but I know why. This is all that can be done for waistline narrowing, there no other alternatives so whatever the result is is the best that can be achieved.

A period of postoperative corseting is always helpful as the compression helps with swelling and the shaping of the waistline. But I do not see it as a necessary permanent waistline shaping method to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in information on a chin implant. I have currently have a chin implant However I’m not quite satisfied with the results.  I’m not sure of what kind of implant I have however I can get that information. I feel that my chin appears very “chubby” and I was expecting more of a narrow silhouette. I will attach before and after pics. The first two are before and the second two are now. 

A: Standard chin implants by definition can not make a more narrow chin as the most common type of chin implant used has extended wings…which always makes the chin wider in the front view. I suspect you have an extended anatomic chin implant with long side wings. It would be crucial to know exactly what type of chin implant you have.

Fo your chin implant revision you need a central chin implant with no wings that creates more of a V-shape to the front of the chin. This is what most female chin augmentations need in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you also do Scapula widening surgery? Or even ribcage widening surgery?

A: Scapular widening surgery is not a procedure I have ever heard of nor could I envision from a bone perspective how any such procedure would be done in an aesthetic manner. While I have never done it or heard of it I could envision scapular widening by the placement of an implant.

I have been asked many times about ribcage widening, which similarly would take implants to accomplish not bony osteotomies. But because it would requiters numerous levels of rib implants it has never been surgical yet done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My short midface questions are:

1. I feel that that my horizontal proportions of my face is a weak point. Hence I feel that my mid face between the subnasal area and the glabella region is too short. Hence I was wondering if there was any way of lengthening the mid face region. I am wondering if there is any type of brow lift that will be able to lift the eyebrows as well as the glabella region to increase the length of the middle third of the face. 

2. I was also wondering about how much vertical height chin reduction can be obtained through the chin reduction procedure.

3. I also had the query of procedures that lengthens the forehead and also the maximum possible increase in length of the forehead. To give the appearance of an increased forehead length couldn’t one just wax the present hairline and part of the frontal hairs to vertically lift the hairline up?

4. Are there any loans etc that are available to cover the costs of certain procedures?

A: In answer to your short midface questions:

1) There is no procedure that actually lengthens the midface. Procedures such as a subnasal lip lift and certain rhinoplasties may create the illusion of some midface increased shortness but not increased length..

2) Depending upon the tooth roots locations a 6 to 8mms vertical chin length reduction is possible by an intraoral wedge osteotomy.

3) The only way to lengthen a forehead is to wax the frontal hairline as you have mentioned.

4) Care Credit is the most source of cosmetic surgery financing in the U.S.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year old male and realized in early high school something was wrong with my face when I first took a picture of myself. I always thought I was good looking when I looked in the mirror but when I saw what I truly looked like to everyone else I was very concerned.

From early trauma / sleeping on one side / torticollis, I realize I have plagiocephaly, with my head leaning to the left. This means my right side is elongated in comparison to my left, with my jaw hanging lower and being skewed off center, my right eye is higher, and I also have a flatter right side of the head as well as a forehead protrusion on the right forehead also. Basically my right side is my bad side, and in comparison my left side looks fully developed and frankly very good looking. 

My head naturally tilts into this position I believe to support this deformity, when I force tilt my head to the right I am able to line up my eyes and ears but obviously my jaw stays very asymmetrical (can’t move that so easily.) So I had some questions, I believe I have torticollis, which in my case means the left muscle in my neck is shortened, hence the head tilt.

1. Is the sternocleidomastoid release something you can operate and perform?

2.If you cannot, should I get that operation first before moving on to fixing my face cosmestically?

3. I know skull implants are possible, but is shaving down the protruding bone in the right forehead possible as well, to match the left sides sloped back appearance, which I think looks very good.

4.If I were to get jaw surgery, going off the things I have seen online, what side of the face would you try to match up, my right jaw is very elongated and skewed off center, so I would like to match the left sides more up tight and angular position, not trying to make the left side like the right side, if that makes sense?

You seem to be the only surgeon that specializes in these niche catogories, so I hope to hear back from you, I have heard great things about you!

A: In answer to your questions:

1) Sternocleidomastoid (SCM) release is a procedure typically done in young growing children to avoid many of the symptoms to which you have described. I have done many of them in young children. However the procedure is not known to be effective in adults meaning that the releasing the muscle will not make the head become straight nor improve any of the craniofacial asymmetry appearance issues.

2) Thus, correcting its symptoms of craniofacial asymmetry is all you can do.

3) Reducing one side of the forehead, within the limits of the thickness of the bone, with augmentation of the opposite side would be the appropriate aesthetic approach to frontal forehead asymmetry.

4) A 3D CT scan and pictures is ultimately needed to first make a diagnostic assessment and establish the proper treatment and its sequencing. While what you are describing for your jaw asymmetry may be the correct aesthetic approach, I can not comment on your exact situation with such information.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was hoping to get more information about the rib removal/modification surgery.  My waist is currently at 27” and I would absolutely love to get it down to 23”. Is that a possibility? How many of these surgeries did Dr. Eppley perform? Were there any cases that had complications arise? If yes, how many? What is the cost of this procedure?

A: Thank you for your inquiry.  In answer to your rib removal questions:

1) Whether you can get from 27″ to 23″ with rib removal surgery can to be predicted. Most patents report a 1″ to 3″ reduction in their waistline after the procedure and whether they corset for a short time after surgery. 

I have done dozens of these cases an no postoperative complications have yet been seen…nor would I expect given the nature of the surgery. (it is the removal of tissue rather than the rearrangement of it or he placement of implants)

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

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently underwent double jaw advancement surgery. However my surgery is somewhat overdone and now im left with an extremely full lower third and some irregularities and deficiencies in my middle third.

I read on your blog that its possible to get rid of this fullness through maxillary reshaping of the back end of the maxillary bone. pushing that part back to where it was and thus, restoring the definition that the face had before.

My question is, How effective would this method be? as in, What percentage of the definition that the face had before the surgery could possibly get restored after a large MMA advancement?

Thank you for your time.

A: The determination of effectiveness of maxillary reshaping would depend on seeing the actual shape of the bone as it exists after the maxillary advancement. This would require a 3D CT scan to assess.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The untreated torticollis has left me with a head tilt as I mentioned before, but when I force my head to the right I can line up my eyes and my ears. I would like to model the surgery around my head in this position, not the tilted one, if that makes sense? I was wondering if that was possible, and if there are any treatments to fix the shortened muscle in adults? If there isn’t however I still ultimately rather fix my asymmetric features based on the position in which I tilt my head lining up my eyes and ears. Let me know if you need any clarity on that.

Lastly, would it be possible to do a CT scan, figure out surgeries I need and the cost of the surgeries then come back at a later date to have them performed? I would like to know what the total cost would be and then I could start saving with a direct goal in mind, instead of just guessing.

A: As I mentioned earlier you can not change the head tilt regardless of what is done to the muscle. Besides the fact that the muscle can not be lengthened, even if it were possible the head tilt would remain the same. There are many more anatomic derangements than just the shortened sternocleidomastoid muscle that accounts for the head tilt.

I would agree that any craniofacial changes should be based on a more neutral head position even if that is not your ‘natural’ head position.

It would be essential that a 3D craniofacial CT scan is done for treatment planning purposes. You can not do any facial asymmetry surgery without it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My midface (pupil to lip corner) is a bit too long for my liking.  (aka long midface) I know that shortening the nose could help, but I am wondering if a lip and mouth corner lift could have a significant affect in shortening the midface? Could the mouth corners perhaps be lifted as much as 10mm and the upper lip 5mm if ones philtrum is around 15mm in length ? Could a cheek lift maybe also help with lifting the mouth corners? 

Thank you for your time!

A: In answer to your long midface questions:

1) A subnasal lip lift can have some influence in making the midface looks bit shorter.

2) A corner of the mouth lift can not be done at the 10mm elevation level and would not make the midface look shorter.

3) A cheek lift can never raise the corner of the mouth n any sustained manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just recovering from my rhinoplasty and am very happy with the results so I am starting to plan and save for my wraparound jaw implants and cheek implants with you.

I apologize if I have asked this before, but which material will you be using for the implant and what is the probability of these implants having to be removed down the line? Is it something that happens often?

I remember you mentioned that some photos without my beard would be good to send you. I took some when I shaved my beard for my rhinoplasty. Man oh man, my chin is severely recessed – I realized after shaving my beard.

I really hope that the wraparound jaw implant can give me a result similar to the guy I forwarded you images of in my last email. I have attached to this email a morph of what I hope my jaw will look like as well as several photos of different angles of my face without a beard.

Do you still think, given how recessed my whole mandible is, that a significant deviation and improvement is possible?

Thank you very much for your time.

A: The material for custom facial implants that is easiest to place AND secondarily remove or modify is by far solid silicone. It is also the most economical.

I don’t see anything unrealistic about the imaging you have done with the exception of that of the depth of the labiomental fold which will not forward with the chin as you have imaged. But overall, by my experience, that is not an extreme or large jawline augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cortical jaw reduction done in Asia and unhappy with the results. Do you do custom jaw implants? if so,would Peek or titanium mandible angle implants be better? Thank you. 

A: I have done hundreds of custom jaw implants out of every available material. Whether the more expensive options of PEEK or titanium are viable options for your jaw restoration would depend on what size of implant is needed. Ultimately a 3D CT scan of your jaw is needed to make that determination of implant size and dimensions from which the material  choice for its fabrication could be decided. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask if my head asymmetry where one side of my head is bigger than the other or it looks like it is leaning to one side, would be fixable by any of your surgeries? I am guessing one side should be reduced and the other augmented? If you need pictures from different angles please let me know.

Looking forward to your reply. 

A: For your head asymmetry I would certainly agree that the flatter right wide, from the forehead back to he posterior temporal region, needs to be augmented. I am less certain about the need to reduce the left side which appears more normal in shape. I do see some benefits to left-sided facial surgery reduce the tail of the brow bone protrusion, correct the upper eyelid ptosis and correction of the chin asymmetry.

What you have is an overall craniofacial scoliosis which affects both sides of the skull and face. For further and more definitive treatment planning, a 3D craniofacial CT scan would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you based on a post I saw on realself where Dr. Eppley discussed options for paranasal augmentation with a patient.

I am a 32 year old female with some sinking in the midface area and prominent nasolabial folds for my age. I saw a maxillofacial surgeon to discuss correction and he told me that the sinking is due to bone deficiency in this area and suggested a goretex implant. I believe he is correct in his analysis as I was born premature and have had quite a lot of dental work in my life. I have also been told my orthodontist(s) that my upper jaw is quite small, making much of this dental work a bit complicated. 

I came very close to having the procedure done with goretex but ended up deciding that I was not comfortable with having a plastic implant as infection is possible even many many years after placement and removal is very difficult. I would prefer another material… And after doing alot of research and it seems that coral hydroxylapatite is a good option as it is fairly permanent and typically does not get infected because of vascularization. 

I would like more information regarding the technique used, how permanent it is, how much experience the Dr. has with this procedure, cost and potentially to book a consultation. Would the doctor be using radiesse or is this an actual implant which he would use? Thank you so much 🙂

A: When it comes to paranasal augmentation, any variety of alloplastic materials can be used. While one can have a debate about which material is the best, one thing that is clear is that hydroxyapatite granules are no longer commercially available. This leaves the only option for an hydroxyapatite material as hydroxyapatite cement…which is probably better anyway since it can be formed and allowed to set into place. (granules tend to spread out and become uneven) As a participant in the original development of one of he existing hydroxyapatite cements that is currently commercially available (Mimix from Biomet-Stryker), I have tremendous experience in its handling properties and surgical placement. Such a material is a permanent bone cement into which bone directly attaches. While infection is always possible with any surgical procedure, I have never seen it with hydroxyapatite cement into which antibiotic powders are added in its intraoperative preparation.

I would not confuse the Radiesse injectable material with hydroxyapatite cement. That may seem similar but they are not in many ways. Besides being injectable, Radiesse contains the type of hydroxyapatite particles that end up being absorbed and the injectate only contains 30% hydroxyapatite particles and 70% carrier material…which is why it is injectable. While Radiesse does last longer than most other injectable fillers, and it is a perfectly fine injectable option for paranasal augmentation, it is not a permanent augmentation material.

Besides taking a lot of experience to know how to work with it, particularly in the limited confines of an intraoral application, its cost is another reason it is not commonly used for facial augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 5 months post operation from a temporal midface lift. I had some questions about my recovery as my own surgeon is not being very helpful in answering my enquiries.

On one half of my face, I seem to be having some issues with nerve recovery. My motor function is all intact but my sensory nerves seem to be having some trouble? 

When I blink, I can feel a tiny tickling sensation near the side of my nose. It’s been this way since one or two month post op and I haven’t been aware of any dramatic improvement. It’s not painful and it doesn’t burn, but it’s a very tiny tickling feeling every time I blink. It’s quite bothersome and annoying as I’m always feeling and aware of it, and I always have to aggressively massage it away. (After a few minutes the tickle every time i blink still comes back) Moreso, when I very lightly brush my finger down the bridge of my nose, I can feel the same tiny tickling feeling next to my nose. 

My surgeon says to wait it out for another 7 months. But it’s been bothering me for so long and my mind is always thinking about it. 

I’m not sure if I should be worried at 5 months post-op but there just hasn’t been any big improvements in the last two months. I’m worried it’s permanent. What could I possibly be experiencing and what are my options to resolve if?

A: The reality is that all you can do is wait and see how much the sensory nerves recover as there is no operation or treatment for them if they don’t. In addition it can take up to 12 to 18 months for such sensory nerves to exhibit a maximal recovery.

Dr. Barry Eppley

Indianapolis, Indiana