Your Questions
Your Questions
Q: Dr. Eppley, A couple of months ago, I had my masseter muscle trimmed which I totally regretted. Now I have depression on both sides where the muscle was trimmed. I see that the skin is going in a little. How do I fix this problem? Would fat transfer work?
A: In answer to your masseter muscle problem, trimming the masseter muscle is always a bad idea as it leaves soft tissue depressions over the angle. This issue would become magnified of a custom jawline implant is placed to partially restore the jaw angles. Fat injections would be a one reasonable approach to treat it
The restoration of lost volume from a change in the shape of the masseter muscle is not an aesthetic problem that is easily remedied. Whether it is the result of disruption of the pteryomassteric sling (masseter muscle retraction) or masseter muscle reduction restoring its shape can be attempted by various soft tissue strategies. Fat injections is the obvious choice but not the only one. Dermal-fat grafts, allogeneic dermal sheets and even ultrasoft silicone implants can be used. I have done all of these strategies and each had their own advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m contacting your office hoping to set up some sort of consultation for a Chin Augmentation procedure. I’m aware you do quick 10-minute pre-consultations over Skype, so perhaps that would be a starting point? However, I’m more than willing to move forward with a regular consultation if that would be most appropriate. What would you need from me to set up a consultation?
Beyond that, if this initial email might also be used as a launchpad for questions, I’ll include some of the ones I have regarding your office.
1How does your office handle the payments? (Lump/Monthly/ect…)
2What is generally the recovery time for the procedures?
3How bad is the scarring from these procedures?
4Are the implants chosen from a stock set of preexisting implants or are they gathered by some other means?
5Certainly nothing meant against neither you, but I was told to inquire about this–how often do you preform these procedures?
6Are you or can you request to be put under for these procedures? Call me timid, but I’m not exactly experienced going under the knife.
7Kind of a silly question, but from your previous patients, how would you rate the pain before, during, and after?
8I most definitely wish to come in for a consultation fairly soon, how much would that visit cost?
9How far out are appointments made for chin augmentation procedures with your office?
Thank you for your time and I hope to hear back from you soon.
A: Thank you for your inquiry. I will have my assistant Camille contact you today to schedule a virtual or actual consultation time. She can also answer all logistical questions as they relate to your questions #1, 7 and 8. Int answer to the other questions:
2) Recovery is largely about swelling which takes about 3 weeks for most of that to subside. Although it really takes up to 3 months to see all of the details of the final outcome.
3) Submental skin scarring is minimal.
4) The type of chin implant chosen, standard vs custom, depends on the patient’s aesthetic needs and goals.
5) Chin and jawline procedures are performed every week multiple times.
6) Chin implant surgeries are done under general anesthesia.
7) Pain is not a big issue for patients after chin augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you analyze a patients soft tissue during a consult to tell them if they can achieve the angularity they hope for with facial implants?
A genioplasty and chin implant will have the same amount of angularity then, I suppose, right?
Also, does material matter? Do harder materials like PEEK or more brittle ones like medpor have any benefit?
A: In answer to your questions:
1) There is no preoperative test or method of evaluation that can predict how any patient’s soft tissues will respond to what is changed underneath it.
2) A sliding genioplasty and chin implant will have slightly different aesthetic effects because their resultant shapes are different. But both stretch out the soft tissues.
3) It is a myth that that any of the implant materials used will have an influence on the overlying soft tissue effect. There is no biologic basis for that common misconception.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, When it comes to the “short face syndrome” characterized with a shorter lower third compared to middle and upper third, this is often present without any problems in chewing or overbite / upperbite.
In my case, my maxilla is very forward (almost as forward as the likes of Jordan Barrett) but my jaw is small. It is not micrognathic nor retrognathic but just slightly smaller than average. I mean to say that it is short, narrow, and lacks forward projection (lines up with the hollow of the nose but not further than the lips). My bite is okay (class 1 with one or two crooked teeth) as is my breathing etc my only concern is aesthetic
Would your advice to someone who wants peak esthetic modification to be made to their jaw be to have the orthognatic surgery (cosmetic only, and expensive as hell) to fix this JAW OR
Just be to opt for either a simple osteotomy like a genioplasty, or implants like your big ones that fill up around the jaw and chin.
The other reason I am not too certain on the implant route is because they give a “bloated” look in a lot of cases, although I would not be surprised if it turns out that an orthognathic surgery would do the same thing.
I am curious what makes this procedure look so angular and sharp:
When these ones were still effective but you can see they look a bit “bulkier” and less angular:
http://www.customfacialimplants.com/photos/custom-implants/customimplants36.jpg
One user on a board I frequent (and if you know the website Lookism, you know it’s filled with nonsense) theorized this is because of the material of the implant and that silicone gets “squished” by the tautness of the soft tissue. Others theorized it’s because of the masseter muscle.
What made the implants that I linked in that picture so effective when the others looked “bulky”?
Thanks so much for your time.
A:There are many variables that go into what happens with the external facial appearance after any underlying implant or bone moving procedure. But the most important one is the patient’s natural soft tissue thickness. In short, angular faces end up with greater defined results. Fuller faces do not usually get angular just bigger and fuller. The best analogy I know is lip augmentation. Full lips get nicely fuller with any form of augmentation. Thin lips never get nicely fuller no matter what is stuck in them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty where they lowered my columella and used a premaxillary implant at the base of my nose where the incision was in my upper gum line similar to the way you insert them.
I didn’t care for the premaxillary implant and had it removed. I now notice my upper lip is longer and the red part of my upper lip hangs down lower.
Is this because the premaxillary implant stretched the muscle and skin in my upper lip area?
What can be done to bring my upper lip position back to where it used to be?
Would a lip lift work and if so, doesn’t this only address the skin and not the muscle that was also stretched?
A: Like the method that stretched out the upper lip, you have to do the same to restore it….an intraoral lip tuck to shorten the vermilion and a subnasal lip lift to shorten the vertical distance between the nose and the upper lip. This dual approach would be the most effective approach in lifting the lower lip back up after premaxillary implant removal..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 21year-old male. I had my brow bone shaved because it looked like a Neanderthal. Although my surgeon shaved it too much and now it looks too feminine.My question is can fat grafting make my brow ridge more masculine and how masculine can I achieve? Since I don’t want to have an invasive procedure again.
A: Given your own restrictions (no surgery) you are left only with the options of injectable fat for fillers. How aesthetically successful they can be can not be predicted beforehand. But suffice it to say that ‘soft’ materials like fillers and fat do not create the same effect as stronger augmentation materials like bone cements or implants. While I see little harm in doing injectable fillers, which are reversible, I would try that first before doing fat injections. Perhaps for just a little bit of indistinct brow bone augmentation these softer materials may be effective for your brow bone aesthetic needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing you with my concerns as I have seen you respond to Real Self posts concerning similar issues.
About two years ago I have v-line jaw reduction done (I am transgender and currently 30 years old). I had a fairly broad jaw before surgery. The surgery was fairly good and I’m mostly satisfied with the bone work, but I find I have too much soft tissue now which makes my face appear bottom heavy. I have very very subtle signs of jowls and do have pre-jowl indents. My skin is in excellent shape. I would like to improve my jawline and I’m not sure if some sort of mini lower lift or lipo would be the way to go here. I’d like to hear your opinion.
A: Just by your general description and having seen a lot of patients with your exact soft tissue issue after V-line jaw reduction surgery, only a limited form of a lower facelift can address the now lax tissues which have resulted due to the removal of bone support. This so called ‘tuckup’ lower facelift produces skin tightening right over the jaw angle area which is most affected by the prior jaw reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The crown area of my head is quite flat and I have been doing the hair camouflage technique since I was in my mid teens. This has impacted my life significantly. I am working interested in the bone cement technique to reshape this flat portion. I live in Nevada and cannot find a surgeon who performs this procedure. I would like to do this procedure within the next 12 months and am curious what the cost is so I can prepare.
A: Thank you for your inquiry. Bone cement skull augmentations have largely been replaced with the use of custom skull implants which offer better results with the need for a far less scalp scar. I will assume for now that you would receive an immediate custom skull implant (does not require a first stage scalp expansion) for which I will have my assistant Camille pass along the cost of such surgery to you on Monday.
In he interim please send me some side view pictures of your head for my assessment for this procedure from which I can do imaging to determine whether you need a one stage or two stage skull augmentation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve already had a 6mm sliding genioplasty in the past so this would be my 2nd genioplasty, effectively making it a 12mm chin advancement. I saw a statement online and I’d like to know if there’s any truth to it.
“Bony changes and skin surface changes are not the same with sliding genioplasty. It is possible to advance the the bone over 10 mms but the skin surface changes are typically 1:1 up to 8mms then about 1:0.6 beyond 8mms advancement.”
Also, some surgeons say beyond 8mm, the step-off becomes apparent.
Thank you very much, Doctor Eppley. Your insight is always very helpful.
A: I would not read too much into those soft tissue change opinions about a secondary sliding genioplasty. While it is probably true that the greater the chin bone is brought forward the soft tissue thins a bit so the changes are not 1:1 at larger augmentations. But at the clinical level this is not really very relevant and would not factor into how the genioplasty procedure was done.
The bigger the horizontal chin advancement the bigger the step off can be. But in a ‘staged’ sliding genioplasty I am to sure now relevant the step off concern is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been having trouble finding an affordable solution to my neck wrinkles on the East Coast. I’m beginning to think it might be more cost effective to have the procedure done in Indiana even with the extra travel expenses.
One plastic surgeon I consulted recommended a rotational neck lift with incisions around the ear lobes and In the IPI crease behind the ears. The scars are hidden behind the cartilage of the ear and beneath the earlobes. It sounds as though the scars may be less noticeable with the rotational neck lift than a short-scar facelift. Is the rotational neck lift a procedure that you perform?
A: A rotational neck lift is just another name for a variation of a shortscar lower facelift. Either way I can see that a possible effective short or long term solution for neck wrinkles. It would depend on the location and depth of the neck wrinkles as well as your interpretation of how much improvement is needed. One also has to be careful about the scars around the ears to perform the procedure and ‘trading off one aesthetic problem to treat another’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i wanted to ask you if you think i could have a chin implant done if i have overbite (upper teeths are 4mm more projected that the lower teeths) , i plan to get braces to fix it soon but i would like to have a chin implant because if i pull my jaw forward untill the overbite is gone i am still lacking chin projection! I would also like to know in your opinion if my problem with overbite can be fixed with just braces or would i need also jaw surgery BSSO?
Pd: the las pic is with my jaw pushed forward, i would need 1,1cm more projection to reach the line traced
Thanks and greetings!!!
A: You would be best served in the long-term by having orthognathic surgery to have your entire lower jaw moved forward if you want to fix your overbite. You can, however, undergo a chin implant or a sliding genioplasty if your do not want to go through the combined orthodontic-jaw surgery process. Such an implant placement does not preclude having total lower jaw advancement later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw that you had performed the surgeries on Pixee Foxx and seemed very confident in his ability. I tore the cartilage on my last true rib on my left side and it has begun to protrude. I have been misdiagnosed several times and have decide I just want it removed. I hope to hear from you soon.
A: When you speak of the last ‘true’ rib I assume you mean rib #10 as the floating or so called false ribs are #11s and 12. I also assume that by tearing the cartilage you mean a separation off the costochondral junction between the bony and the cartilaginous portion of the rib as it goes around the ribcage before int connects to the subcostal region. This is where the protrusion would occur as a result of the separation. Do you have a CT scan that makes the correlation between the protrusion and the underlying costochondral junction? Certainly the protruding rib portions can be removed through a small incision over it. Excising the bony portion next to the costochondral would presumably alleviate the discomfort from the non-union and motion of the rib segments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to narrow my chin without implants? Also I had double jaw surgery before so I don’t know if that will complicate things. I can send pictures of myself. How long do I need to take time off from work for this procedure? Also, please let me know the estimated cost of this surgery. Thanks!
A: Thank you for your inquiry. First, implants can only widen a chin and can never make it more narrow since it is an additive procedure. There are two methods for chin narrowing. The first method is an intraoral approach where a sliding genioplasty bone cut is made and then central edge of bone is removed. When put back together this creates a T-shaped pattern, hence the name T-shaped chin reduction. The other approach is done from a skin incisions below where the chin is narrowed by shaving off the sides of the bone known as submental chin reshaping. Each method has its advantages and disadvantages.
I would need to know which method your prefer to adequately answer the cost question. Please send me some pictures of your chin for my assessment and recommendations.
While the swelling takes 4 to 6 weeks to largely resolve, I would not think you would take more than 5 to 7 days off work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Inquiring about en bloc explant of 700cc mentor moderate plus silicone breast implants, implanted April 2014, and fat grafting to reshape breast (either immediately after explant or at a later date). 32 year old female. Experiencing pain/tingling/itchy sensation in left breast.
My commitment to explant waivers greatly with the uncertainty/fear of outcome and the inevitable mental ramifications. I understand that I have very large implants and it’s virtually impossible for my skin to retract. The desire for fat grafting would be to restore some volume and “correct” shape, in lieu of a lift (if that would even be possible). I do want to try to avoid more scars. The plastic surgeon who performed my initial breast augmentation said that I could easily drop 200ccs without the need for a lift. I had contemplated staged breast implant revisions with smaller implants until eventual explant, but that seems like unnecessary trauma and certainly expense. I do have a good amount of native breast tissue. My implants are subglandular and were implanted via inframammary incisions.
A: While I don’t know what your breasts looked like before the implants or now, I can say as a general statement is that it would be unlikely that fat grafting would the a substitute for a breast lift should that really be needed. Fat grafting is a volume addition procedure but doesn’t have the push that an implant provides, it is too soft to do so.
I would caution you to be very careful about trading off one problem for another. Total explantation of 700cc implants is a drastic decision and should be done for a problem that is equally significant in magnitude to justify the aesthetic sequelae that will occur. Recovery of breast volume is not going to be done by fat grafting as that is not realistic.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m very interested in getting the custom midface implant as advertised on your page. I have a recessed mid face and as a result weak under eye support and a gaunt looking face. I would like to fix that. I’ve already had a nose job and I feel like this is the final step I need. I have a couple of questions in regards to the implant. I’ve done a lot of research but can’t find anything on it since it seems like not many doctors are offering it.
1. What is the price?
2. Is the custom mid face implant a better option than getting cheek implants in combination with paranasal and infraorbital implants? Is there even a difference in results? Also infection and complication wise – which of these two options is more safe?
3. Will the mid face implant have the same effect on the eyes as an infraorbital rim implant would? I have weak under eye support so I’m wondering which would give me the best result.
Thanks so much for taking your time to read this and answering. Have a blessed day.
A:Thank you for your inquiry. While I have no idea what you face looks like our what your exact aesthetic needs are, I can provide the following general comments:
1) I will have my assistant Camille pass along the cost of the surgery to you later today.
2) All midface implants carry the same safety profile and risk of complications, regardless of their design. Obviously the more midface surface that an implant covers the aesthetic outcome will be different.
3) The infraorbital component of a total midface implant can have the same undereye effect if it is so designed to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I currently have been using filler injections (mostly Voluma) to approximate the amount of augmentation I would want if I was to do a full custom jawline implant and infraorbital-malar implant.
Is it possible for you to get a very rough idea for the amount (millimeters) of jawline and midface enhancement I would like if I was to give you the volume and location of my filler injections?
For instance, the surgeon I went to for filler injected:
About 0.75 syringes of voluma along each cheekbone (had to get a small amount removed as I thought it was a little too much when he used 1 syringe for each cheekbone). The location he injected was high and over zygomatic arch moving forward all the way to infraorbital area, or there about)
About 4 syringes of voluma to the jawline (included the mandibular angles, body, and chin).
Knowing the above, does this help approximate the amount of volume for implants that I would be looking for?
A: Knowing the volume of filler injected does not provide a useful approximation of how to design custom infraorbital-malar and jawline implants. While the volume injected is not useful, what does count is the facial appearance that has been created. Knowing by pictures what facial look has been achieved, provided it is satisfactory, does help provide a guideline for such implant designs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it looks like I’ll be moving forward with the custom infraorbital-malar and jawline implants next year.
I am seeking temporary improvement before I see you. I find that when I pull my skin in an upwards/diagonal vector, I see large improvements in the nasolabial area and my overall appearance. Would a PDO threadlift (I know its effectiveness is debated, but the nurse I’d be seeing uses a newer thread and had compelling before and afters) be contraindicated given implants with you in May? My understanding is that most of the effects of the threadlift would likely dissipate by May, but there is a chance some of the sutures won’t have completely dissolved.
A: Pulling your skin upward by fingers is not representative of what a thread lift can really do. It will have a much less significant effect than that simulation and will never make the nasolabial folds appear less deep. Such digital manipulations way over estimate what is possible with any thread lifting procedure.
Otherwise any threadlift done now will not impact any custom facial implants planned for next year.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In a previous email you said you wouldn’t drop the jaw angles any further down than 7mms for fear any muscle coverage problems which I understand– purely out of curiosity, is 7mm the maximum you can lower the jaw angles or does it depend on each individual patient?
A: The risk of masseteric muscle dehiscence exists any time you use an implant to extend the existing shape of the jaw angles vertically downward. There is no absolute number which has been determined to be ‘safe or not safe’ to do so. In my experience I have dropped it down 25mms and not seen any muscle problems and have dropped it down 7mms and have seen it. It is not a completely predictable effect. What I can say for sure is that the more it is vertically elongated the more the risk increases What I have also learned over the years is that the amount of vertical jaw angle lengthening that is really needed is often over predicted preoperatively. In essence a little bit goes a long way particularly when there is some width added also. Lastly, like all aesthetic surgery it is a balance between benefit vs risk. One must always be careful in the goal of the ideal result to not incur other aesthetic complications that are hard to fix. (and masseter muscle dehiscence is very hard to fix) It is always better to have 80% of the ideal result with no complications that it is to have 100% of the ideal result with complications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am strongly considering a temporal reduction in the near future due to my wide head, but i have a few questions.
1. Is this procedure dangerous in any way?
2. Will the temporalis muscle grow back once it is reduced?
3. With my age being only 19, am i too young for this operation?
4. How often do you perform these procedures?
5. Roughly, what is the cost for this procedure?
I hope I am not asking for too much, but a response would be greatly appreciated. Thank you.
A: In answer to your temporal reduction questions:
1) This is a very safe procedure.
2) The muscle will not grow back.
3) Age 19 is not too young for the surgery.
4) I perform Temporal Reduction surgery on a regular basis.
5) My assistant will pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a cartilage chin implant for 13 years and it was ok. A Dr. convinced me to replace it for a silicone implant which I had for 15 years and caused bone loss and chin ptosis. I didn’t want a replacement but no Plastic Surgeon would remove it without a replacement. I had a plastic surgeon replace it with a Medpor which was AWFUL so 3 months later it was replaced with another Medpor chin implant with 4 screws. I have had 2 chin pad resuspensions as well. Now 7 years later I am seeing my chin get pointy and believe it is due to bone loss. My body is not liking this implant. Would you be able to remove this Medpor chin implant without another synthetic chin implant. Do you do cartilage chin implants or is there something else I can do as my chin might look deformed? Thank you.
A: While I don’t know what you look like or the size of your existing chin implant, a synthetic chin implant can be replaced with either autologous (your own tissue) or allogeneic (cadaveric) cartilage or bone grafts if avoiding another synthetic chin implant is the goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have asked you questions before and I read your boards here and you seem very knowledgable in implants. I had a right cheek implant replaced from silicone to medpor 2 weeks ago. Have medpor in the left side as well. My Dr is well known and well versed in implants but not a good communicator and I really don’t want surgery with him again. My question is about pain. I have some swelling but not significant and some redness but not much, no fever and no heat at the site. However, I have a significant amount of pain. I will do an MRI to look for possible low grade infection. I think this is unlikely but possible. My question is, could things down the road be okay possibly? I mean, could things settle down and this pain be from swelling and tissue/nerve disruption of the infraorbital nerve? It is placed mid cheek (slightly higher) It is very bothersome (obviously). I don’t want to remove it, but also could not live like this the rest of my life either…Thank you for your input.
A: I think the fundamental question you are asking is whether the cheek implant is impinging on the infraorbital nerve…as this would be the only reason to have more than the typical pain associated with cheek augmentation which usually is not very significant. The best way to check cheek implant positioning, or any facial implant positioning, is to get a 3D CT scan. That will answer that question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, a friend of mine has had large prosthetics and augmentation in his entire forehead region and even supraorbital a while back. He doesn’t care for them now however, and in fact, finds that his forehead is too prominent now and wants them removed. He is wondering what will happen to his upper eye area when this happens. Will his eyes become more hooded and his eyebrows descend? He actually prefers this because he feels his upper eyes at the moment are too hollow and eyebrows are too high at the moment
He is also considering a hairline lowering procedure but was told by a doctor that his scalp was too tough. Would the removal of these implants also make it possible for him to achieve a hairline lowering without the usage if a tissue expansion?
A:I think it is fair today that removing a large forehead augmentation will result in some potential brow ptosis and even upper eyelid hooding….which sounds like what he prefers anyway.
Whether he could get any significant hairline lowering without tissue expansion I can not say given that I have no idea what he looks like or have felt his scalp. Suffice it to say that hairline lowering is most effective when a first stage scalp expansion is done.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, Does a custom midface implant or any other implant (significantly) reduce naso-labial lines? If not, what is the best procedure? Am I stuck with continuing to use fillers?
A: Thank you for your inquiry. If you are having success with injectable fillers, it is possible that you MAY benefit from some type of midface implant. It would all depend on your facial anatomy and the depth of your nasolabial folds. I would need to see pictures of your face/folds to determine if underlying soft tissue release and midface skeletal augmentation would be of benefit.
But the concept of building up the bone beneath the nasolabial fold makes sense in terms of pushing the overlying soft tissue outward. The best test to determine if this would work is to have the injectable filler placed down at the bone level….which would verify the effect of a ‘bone push’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a temporal brow lift which I got reversed 3 weeks after the initial surgery as it was VERY aggressive. However though it has been reversed I feel that the surgeon totally messed up the upper third of my face, my forehead/temple and eyebrow shape is no longer feminine and softer. there are dents and bulges in random parts around my temples. gives me an almost masculine look. Can you please suggest what could be done to help regain my old structure back. Thank you.
A: Thank you for sending your pictures. That was an aggressive temporal browlift procedure. Fortunately most of the pleating and tissue irregularities has resolved. Short of further skin release and allogeneic dermal interpositional grafting, I am not sure you can obtain much further improvement other than what more time and healing has to offer. Time and aging will eventually be the most important factor that will reverse most of the effects of an undesired lateral temporal browlift.
Dr. Barry Eppley
Indianapolis, Indiana
A: You have wisely thought through the always delicate balance between the amount of facial bone removal vs the risk of postoperative soft tissue sagging. It is always better to be more conservative with cheek and jawline facial bone removal as I have done many more secondary surgeries for rebuilding back removed bone than I ever done for more bone removal later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year old male, and I am interested in getting custom zygomatic implants to augment my cheekbones. Reading through your site, I’ve come to learn that the key to the chiseled, high cheekbone look is to augment the zygomatic arch. So this is what I want to do. I also have a lack of projection in all directions of my zygomatic body and my infraorbital rim, so I want to cover those areas too.
However there are a few things which I’m not clear about when it comes to cheek implants, and I thought you might be able to help clear them up for me. I’ll number the questions. I hope they aren’t too long.
1) Angularity. I wanted to ask you how much the shape of the implant contributes to achieving the ‘angular’ look that a lot of models have. The angularity I’m referring to is where the zygomatic body progresses posteriorly into the zygomatic arch. A lot of models have an angular transition here. Would making the implant more sharper (slightly more square shaped) as it wraps around the zygoma help achieve this, or will this look unnatural?
2) Anterior projection. I wanted to ask for your opinion on giving more anterior projection to the zygomatic body. In your opinion does this an anteriorly protruding zygoma look feminine? Basically I don’t want to divert attention away from the zygomatic arches by making the zygoma too big anteriorly, but at the same time I don’t want to miss out on the benefits of making my face look more anteriorly developed.
3) Lateral projection of the zygomatic body? I’m confused as to whether it is desirable to laterally project the zygomatic body, or just the zygomatic arch. Would you be able to explain to me the aesthetic effects of projecting the zygomatic body along with the zygomatic arch, compared to just the zygomatic arch alone?
4) Will it be possible to modify the implant at a later date by burring/shaving if there are some minor imbalances?
5) The cheekbone ‘pop’ underneath the outside corner of the eye. A lot of models have this definable pop/prominence in this area. I’m trying to figure out how to achieve this. Am I right in saying that we would need to take into account the balance between the infraorbital rim and the zygoma, ensuring that the zygomatic prominence sticks out relative to the infraorbitals? I’m concerned that this will leave me with infraorbital hollowness.
6) Frontal process of the zygomatic bone (inferior portion of the lateral orbital rim). Is it possible to include this area? I’m concerned that building up this area might make the zygomatic prominence look less developed (protrude less). Is this concern justified?
A: In answer to your questions about custom infraorbital-malar implants:
1) The shape and dimensions of any custom facial implant are a major reason for the external facial shape seen. I would not make any such implant with a square shape as that would appear unnatural.
2) A high anterior zygomatic projection never looks feminine, you are referring to a low submalar anterior projection which does so.
3) You can not separate the lateral projection of the zygomatic body from the zygomatic arch. They are closely linked.
4) Revisions of custom facial implants are not rare since there is not accurate method to correlate the actual implant design to the desired outcome.
5) The implant design would extend up onto the lateral orbital rim.
6) answered in #5.
Dr. Eppley
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found you on RealSelf and noticed you have a lot of experience in this area. (cheekbone reduction reversals) I had my cheekbones reduced in Korea over a year ago. I’m very disappointed with the results and incredibly depressed with this surgery. My question is:
1) Is it possible reverse this surgery by pushing the zygomatic arch and malar bone back out?
2)if bone graft is needed is there a computer program tthat can make a mold of my cheekbones ad estimated how much bone graft is needed?
3)Have you done this or met anyone who reversed this surgery with pleasing results? Thank You.
A: In answer to your cheekbone reduction reversal questions:
1) Cheekbone reduction osteotomies can be successfully reversed. The anterior osteotomy is almost always more important than he posterior osteotomy site.
2) The most precise way to do is with virtual planning. A 3D CT scan can be done and the cheekbones moved out digitally from which the bone grafts can be digitally created in design to be used for the surgery.
3) Most cheek bone osteotomies reversal that I have done (by osteotomy and one grafting or custom cheek implant augmentation are usually happy to be back ‘home’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, a friend of mine has had large prosthetics and augmentation in his entire forehead region and even supraorbital a while back. He doesn’t care for them now, however, and in fact, finds that his forehead is too prominent now and wants them removed. He is wondering what will happen to his upper eye area when this happens. Will his eyes become more hooded and his eyebrows descend? He actually prefers this because he feels his upper eyes at the moment are too hollow and eyebrows are too high at the moment
He is also considering a hairline lowering procedure but was told by a doctor that his scalp was too tough. Would the removal of these implants also make it possible for him to achieve a hairline lowering without the usage of a tissue expansion?
A:I think it is fair to say that removing a large forehead augmentation will result in some potential brow ptosis and even upper eyelid hooding….which sounds like what he prefers anyway.
Whether he could get any significant hairline lowering without tissue expansion I can not say given that I have no idea what he looks like or have felt his scalp. Suffice it to say that hairline lowering is most effective when a first stage scalp expansion is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have asked you questions before and I read your boards here and you seem very knowledgable in implants. I had a right cheek implant replaced from silicone to Medpor two weeks ago. Have Medpor in the left side as well. My Dr is well known and well versed in implants but not a good communicator and I really don’t want surgery with him again. My question is about pain. I have some swelling but not significant and some redness but not much, no fever and no heat at the site. However, I have a significant amount of pain. I will do an MRI to look for possible low grade infection. I think this is unlikely but possible. My question is, could things down the road be okay possibly? I mean, could things settle down and this pain be from swelling and tissue/nerve disruption of the infraorbital nerve? It is placed mid cheek (slightly higher) It is very bothersome (obviously). I don’t want to remove it, but also could not live like this the rest of my life either…Thank you for your input.
A: I think the fundamental question you are asking is whether the cheek implant is impinging on the infraorbital nerve…as this would be the only reason to have more than the typical pain associated with cheek augmentation which usually is not very significant. The best way to check cheek implant positioning, or any facial implant positioning, is to get a 3D CT scan. That will answer that question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a cartilage chin implant for 13 years and it was ok. A doctor convinced me to replace it for a silicone implant which I had for 15 years and caused bone loss and chin ptosis. I didn’t want a replacement but no plastic surgeon would remove it without a replacement. I had a plastic surgeon replace it with a Medpor chin implant which was AWFUL so three months later it was replaced with another Medpor chin implant with four screws. I have had two chin pad resuspensions as well. Now seven years later I am seeing my chin get pointy and believe it is due to bone loss. My body is not liking this implant. Would you be able to remove this Medpor chin implant without another synthetic chin implant. Do you do cartilage chin implants or is there something else I can do as my chin might look deformed?
Thank you.
A: While I don’t know what you look like or the size of your existing chin implant, a synthetic chin implant can be replaced by either an autologous (your own tissue) or allogeneic (cadaveric) cartilage or bone grafts.
Dr. Barry Eppley
Indianapolis, Indiana
