Your Questions

Q: Dr. Eppley, I am interested in a Medpor jaw angle implant revision. Three years ago I had an operation to improve my jawline using Medpor implants. After the surgery i noticed a degree of asymmetry in lateral projection of my right jaw angle. Recently I went through a 3D CT scan to determine the source of this issue and the doctor stated my masseter muscles are not symmetrical and specifically the right jaw muscle is 1-1.5 mm thinner. I would like to know if I can fix this problem by removing the current Medpor implant on my right jaw angle and replacing it with another implant which can increase the lateral projection of my right jaw and consequently remove the asymmetry between my jaws.Thank you in advance and I will look forward to hearing from you.

A: Thank you for your inquiry and detailing your surgical history. While your indwelling Medpor jaw angle implant can be removed and replaced, the initial critical question is whether this is a true muscle asymmetry problem or one related to the implants. I assume you know this answer because you have seen the scan yourself and you have visual assurance that the implants are perfectly positioned and are not the underlying culprit of the asymmetry.

For the sake of discussion there are numerous ways to do a Medpor jaw angle implant revision for a mild jaw angle asymmetry of 1 to 1.5mms, regardless of whether it is of muscle or implant origin, which would not include having to remove and replace the entire implant. An implant overlay can be placed on top of the existing implant which would be far less traumatic to undergo. Of course the complete implant can also be removed and replaced as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Medpor chin implant placed several years ago but have never been that happy with it. I have always felt it was not enough and was too short even though the implant was a large. I am thinking of having it removed and replaced with a sliding genioplasty. Is this a reasonable plan?

A: The critical question in your secondary chin augmentation inquiry is whether you would leave the existing chin implant in place and do the cut above it and carry it forward with the sliding genioplasty or take it out and do the whole chin advancement with the sliding genioplasty alone. It depends on how much more your chin needs to be advanced over what you have now, what the thickness of your bone is and whether the bone alone can make the amount of advancement improvement that is desired. That would require a 3D CT scan to help make that determination as well as measurements of how much further your chin need to brought froward to meet your aesthetic goals. If the Medpor chin implant was a large one it may bee doubtful that a sliding genioplasty alone would be able create your ideal chin augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in a chin augmentation. I am 6 feet tall and somehow my chin does not harmonize with the rest of my face. It’s not that I don’t have a chin, but it just doesn’t seem masculine.

I would be very interested in a chin implant and would also like to have the procedure performed later this year. I would also like my jaw to look more contoured. I had in mind filler + chin implant. Can fillers have the same effect as a jawline implant? In this part I’m not sure yet why a temporary solution would be good but with the chin I’m sure it should be permanent. My eyebrows are pretty asymmetrical, maybe you could fix it parallel. I would be very pleased about a cost calculation and would also like to have the intervention carried out with you.

A; Than you for your inquiry and sending all of your pictures. Doing a chin implant with injectable filler or fat is a good combination when one is uncertain as to the jaw angle effect that they seek or whether it would be what they want. The debate for a jaw angle fillers comes to a synthetic like Radiesse or using one’s own fat. There are arguments to be made on either side.

For the brow asymmetry what can be done is to lift the lower side of the eft inner brow area. It is not possible to lower a higher brow so it would be important to know which type of brow change you seek. I will assume the former for now.

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 can’t thank you enough for the time and effort that you put into answering patient enquiries. Although I may not be a direct patient of yours, your blog has helped me tremendously. Thank you for not beating around the bush, as many surgeons on RealSelf tend to do.

I’m a 24 year old recipient of cheekbone reduction surgery and had some mild midface ptosis, although I was happy from a bony standpoint. This week, I’ve undergone a temporal/intraoral incision cheek lift to hopefully alleviate the sagging. From your blog, it seemed like the most logical thing to do to directly address my cheek sagging post-op zygoma reduction.

How long after my subperiosteal midface lift should I be able to start seeing the final results? My surgeon mentioned that my temple area and cheek area would be hard and swollen. This is the case but my left nostril and lateral nose are also completely numb. I can flare my nostrils fine, but should I expect a full recovery in regards to this nerve disruption? My surgeon said a full recovery is likely but I just wanted a second opinion.

A: It is not rare to have some temporary numbness of the infraorbital nerve distribution after a midface lift which has a major access point intraorally. That should fully recover but will take 3 to 4 months to do so. Because of swelling it may be difficult to see the results of the midface lift initially but you should be able to see some initial results right after surgery. But the true and final assessment of the outcomes will be evident by six weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing with hopes for more information on jaw angle implant removals. It seems jaw angle implants are relatively rare compared to other facial implants so it is difficult to find any information or cases online regarding them let alone their removal. I have seen that you have experience working with this type of procedure. I would be extremely grateful for any information you can provide relating to my case. 

I have always had a weaker mandible and likely should have received orthognathic surgery for this when I underwent orthodontics many years ago, as had been recommended by my orthodontist at the time. As I got older, however, the main concerns were the significant amount of mentalis strain that caused my chin to ball up when I closed my mouth and my moderately recessed chin.

My concerns led me to a consultation with a maxillofacial surgeon as I believed I needed to either get orthognathic surgery as had been previously suggested by my orthodontist or a genioplasty to move my chin into better position to address my concerns. The surgeon told me I could undergo a ‘masking’ procedure that would make it appear as if I had the correct orthodontic treatment done, which was a genioplasty in conjunction with a complete jawline build-up with Gore-tex material. I was told that the jaw implants were necessary to do in conjunction with genioplasty to achieve a ‘balanced’ jawline.

I decided to undergo the masking procedure and had a maximal advancement genioplasty with approximately 5mm hand carved Gore-tex jaw angle implants as well as Gore-tex strips in the mid-jaw region to connect the genioplasty with the jaw angle implants. There is also a small Gore-tex strip that was placed across the front of my chin for additional contouring in the labiomental fold.

Due to various concerns, I am adamant to just have the implants removed. The original surgeon refused to do so.

My main questions are:

– What would be the likely consequences/risks of removing 5mm Gore-tex jaw implants, if any? I am a young woman and the implants have been in for about a year. Would there be risk of skin sagging/facial deformity or would my skin likely bounce back similar to how it was pre-op?

– If it is likely that my skin will contract normally, how quickly would it take for my face to return back to normal and what changes could I expect in the shape of my face from the tissue changes caused by the implants?

– Most importantly, what would the impact of removing jaw implants that were placed in conjunction with a genioplasty be? It is difficult to imagine what the outcome would be since the procedure was not isolated. Would it make my chin look very disproportionate to my face?

Thank you so much for taking the time to review my case and questions.

A: Thank you for your inquiry. While the use of ePTFE (the contemporary name for Gore-Tex) for jaw angle augmentation is very rare, it has a long history of use all over the face. In my experience I will occasionally use it to supplement standard or custom facial implants if needed and hand carve ePTFE blocks for some facial augmentation procedures. (I believe your jaw angle implants are probably ePTFE blocks)

While ePTFE does have more tissue adherence than silicone, for example, it can be removed if one is experienced in doing so. (jaw angle implant removals) While I have no idea what you looked like now or before your surgery, 5mm thick jaw angle implants are not very big and, unlike facial implants in other facial areas where soft tissue sagging may be a potential post removal issue, this has a very low likelihood to occur in the jaw angle area. This is because it is the only facial implanted area that is placed under such thick muscle and the attachments to the skin lie above the muscle and not below it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I sent you some pictures not long ago and you kindly recommended a full custom jaw implant because my jawline is vertically deficient.

I wanted to ask your opinion about a genioplasty to obtain an increase in vertical height on my chin. Would this be a viable route to take ? And would it also decrease the mentolabial fold ? I understand you can only tell me so much from these pictures. I appreciate your answer Dr.

A: If you are looking only for a vertical lengthening of the chin, then an opening wedge intraoral genioplasty with an interpositional graft would achieve that nicely. This would probably be in the range of 6 to 8mms of vertical chin lengthening although it can be even greater up to 10 to 12mms. It can achieve an anterior vertical elongation of the chin just as well as a custom implant. It may not decrease the depth of the labiomental fold but at least it will definitely not make it any deeper. Be aware that a vertical lengthening genioplasty affects the chin and the chin only. It will have no effect on the jawline behind particularly that of the jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley: Over the last few years I’ve been intrigued with the idea of customizing implants to fit an individual’s face, and I’m looking into getting a customized implant for my cheekbones. My cheekbones are quite flat but also quite low down my face. Meaning the main part of my cheekbones seem to sit well below my lower eyelid. My first question is whether this can be addressed with a customized implant? Can my cheekbones be brought higher???? 

The other question that I have is whether it’s possible to order a layered-segmented implant from the implant company. I’m scared about getting an implant too big, but also too small. So I had this idea: could we order a single implant that can be ‘layered’, meaning can we order a single segmented implant where the implant is essentially in two similar layers, one over the top of the other. My thoughts were that I could have the lower layer implanted and then reassess whether I want more, and if so I would get the second layer implanted over the top of the first, thus avoiding the need to order two seperate implants from the company. 

Look forward to hearing from you 🙂

A: When it comes to custom cheek implants they can be made just about way we want. One of the most common reasons for custom cheek implants is to get the higher cheek look which standard cheek implants can’t do. Attached are a few examples of the many types of custom cheek implant designs that I have done.

As for making a layered custom cheek implant, that can be done. They concept of secondary placement of the second layer if need, however, is the reverse of what you have mentioned. It is far easier surgically to slide a second implant layer under the first one than it is to secondarily place it on top of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant replacements surgery. I had three spontaneous lung collapses and video assisted lung surgery followed by talc pleurodesis to correct the issues about a year ago. I have breast implants placed yeas before these lung problems and now I want to go bigger. Do any of my lung surgeries prevent me from having another breast implant surgery? 

A: Your description describes a pleurodesis procedure which by your description was done with your current breast implants in place. While on the surface there does not seem to be a contraindication for replacing your breast implants, the following would be the appropriate questions to preoperatively consider. (in essence will breast implant replacements cause recurrent lung collapse)

1) What was the origin of your original lung collapses? 

2) Where is the incision site for the previous lung surgery?

3) What does your pulmonologist say about having a general anesthetic and the breast implant surgery?

With an established breast implant capsule, replacing breast implants is far less traumatic than making the initial implant pockets. If necessary it may be possible to do your breast implant replacements under a local anesthetic if your pulmonologist is apprehensive about a general anesthetic.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want a chin reduction and already had one 5 years ago through under the chin. I feel its still too long and broad and pointy. It needs 6mm vertical reduction and 6mm horizontally reduced and tapered to narrow it. Is it best to perform a osteotomy reduction or burring it instead? Also I have muscle that pulls down the soft tissues when I smile still even though its less than previously. Also is sliding genioplasty the same as osteotomy reduction?

A: When it comes to a combined 6mm vertical reduction and a 6mm horizontal reduction, the submental approach is essential because it can manage the resultant excessive soft tissue that will result from such soft tissue deflation from the substantial bone removal. While sliding genioplasty can effectively reduce the vertical height, sliding the chin backward will create a submental fullness as the excess soft tissue must go somewhere. A submental approach is always the most effective for a 3D chin reduction. When you slide the chin bone back, two negative aesthetic consequences occur…the back ends of the genioplasty stick out below the inferior border (creating a bump) and the attached muscles bunch up. (which is why liposuction won’t solve it)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in weird head shape surgery. I’m 24 years old. I have thinning and receding hair which I have come to terms with. However I can’t come to terms with my weird head shape. I will include pictures below as well.

Picture 1:

Left and right arrows show dips in the sides of my head which gives the skull such an uneven look and very coney. This goes back quite far as well but not far enough to get to the back of the head.

The middle arrow shows a coned look, however it may be because it goes so thin due to the dips in the head which makes it seem worse. 

It’s a slightly better picture of the dip on the side of the temple specially on the left side. You can see it looks like it’s on another platform. 

I have looked at a lot of the surgery posts on your site and feel encouraged that you can assist me I just hope I’m correct in assuming this to be honest. I would love to have a normal smooth rounded head shape rather than dippy lumpy and coney.

A: In consideration of weird head shape surgery, we first have to define the exact skull shape abnormality. The side dips to which you refer is known as the temporal lines where the top of the temporalis muscle meets the outer edge of the skull. While in many people this is a smooth transition as the muscle gets very thin in this area, there are men like you where the muscle actually remains or appears thick (or the skull bone is more narrow than normal which better describes your situation) creating muscle pseudofullness and making the normally flat temporal line look indented. The other indicator to your scaphocephalic skull shape is the high peak or sagittal ridge with narrow parasagittal sides creating what is known as the ‘roof’ skull deformity.

The effective treatment approach is usually a combination of sagittal ridge reduction combined with parasagittal augmentation that crosses the temporal line. Together this is the only effective way to reshape the current appearance of your head shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim implant removal. Is it possible to remove OMNIPORE Inferior Orbital Rims Implants? Will be an emptiness there after removing which has to be concealed? How to conceal? What is the earliest/best time to remove them after placing?

A: Omnipore facial implants is just a branded name for porous polyethylene. (Medpor) As such they can be removed just like any other Medpor facial implant. The time to remove them is when you have given the result long enough to really see the final result and have adjusted to it. (2 to 3 months after their placement)

You are correct in assuming that the lower eyelid/midfacial tissues may not return exactly to normal given that a subperiosteal elevation and tissue expansion has been done. Thus thinking about tissue management from the deflation caused by the implant removal is appropriate. What one would do depends on what you looked like before and what your original goals were for having the implants in the first place. Tissue resuspension and some volume coverage with allogeneic dermis is one approach.

I will have my assistant Camille contact you on Monday to schedule a virtual consultation time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eye asymmetry correction. I have also always been conscious that my right eye is slightly lower than my left. Looking at the CT scan, I can see that this could be caused by the bottom of my eye socket on the right side being lower than the left.Another thing I noticed on the CT scan is asymmetry of my cheek bones. The right one appears lower than the left, or at least extends lower. 

I did some research and mostly your articles came up. I found examples where you were able to correct all 3 of the above issues using custom implants. Therefore, I was wondering if you could recommend a solution to this? If it’s possible/feasible, I would likely look at getting it done after I recover from my jaw implants.

A: What you are describing for your eye asymmetry is a modest form of vertical orbital dystopia. (VOD) By definition, since the orbito-zygomatic bone complex is a combined unit, if the eye is lower so will be the cheekbone…the two go together since they are connected. Custom orbital floor-orbital rim-malar implants do offer the most effective method of VOD correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Sculptra injection reversal. I had Sculptra injections about 6 months ago and it has given me a square chin and is making me very depressed. The doctor is using an enzyme to dissolve the other fillers I had put into my face but, of course, the Sculptra won’t dissolve. Do you recommend trying to get rid of the dissolvable fillers anyway as there’s quite a large amount too? Would appreciate any help. 

A: As you may know Sculptra is not like the more commonly used hyaluronic-based fillers. It is composed of PLA particles (small bits of resorbable polymers) which create their effect by inducing collagen formation around them. Such PLA particles are not responsive to enzymatic digestion as they are a chain-liked polymer strand. Their resorption will eventually occur through a hydrolytic process (water absorption) but this is a slow process that could take 12 to18 months with the presumption that the reactive scar tissue will fade away as well as the stimulus is removed.

There is no known method to remove the Sculptra filler from soft tissues that would not potentially cause other long-term issues, particularly in the chin area. Steroid injections or liposuction should be avoided due to potential soft tissue deformities from them. 5FU injections are the only injectable strategy that would not cause a potential soft tissue problem but whether they would be effective in this situation is unknown. 

One other potential treatment option, if the Scupltra was injected down at the bone level (your injector would know this), is to remove the material from the bone surface through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in side profile enhancement. I am really insecure about my side profile, I know I want to do something about it, but I’m not sure what the best course of action is! I would like to have a less receding chin and defined jaw line (I’m not overweight). At the moment I’m leaning towards fillers in my jaw/chin and kybella but would it end up being more cost effective as opposed to jaw reconstruction or chin implant? Any advice or personal experience is greatly appreciated! 🙂

A: When it comes to side profile enhancement, you must define your profile goals as either chin or jawline augmentation because they are different. Fillers or a chin implant are the options for chin augmentation. Fat reducing by injection (Kybella) or liposuction can remove submental fat which will be a favorable adjunct to the chin augmentation. Thus the non-surgical approach of fillers and Kybella has a role in subtle to modest chin augmentation efforts. However neither a surgical or non-surgical chin augmentation approach will improve your jawline. That requires different procedures for which fillers, Kybella and even a chin implant will not achieve. To augment the whole jawline more defined (chin and jaw angles) it all must be augmented with implants. Whether this is using standard chin and jaw angle implants, a sliding genioplasty with jaw angle implants or a custom jawline implant requires a more in-depth discussion.

Dr. Barry Eppley

Indianapolis, IndianaSide P

Q: Dr. Eppley, Last year, I went to South Korea for a simple chin narrowing genioplasty. I consulted for a mini-vline surgery, which is what they call chin-narrowing surgery without the jaw bone shaving. 

I don’t know if things got lost in translation or if my surgeon just didn’t understand what I wanted. But my jaw angles did end up getting cut off. I strictly did point out I wanted my jaw angles left alone but when I saw the before/after CT scans, I was absolutely mortified. Only later did I find out, the Korean word for jaw and chin are literally the same.

In fact, a lot of my jaw bone was amputated off. I wanted a slimmer look but I didn’t want that egg-shaped face that Koreans strive for. I think around 2cm or slightly less of vertical bone was amputated. 

Now I find that my face is severely disproportional at the side view and the 45 angle view. And I can pinch a lot of excess skin and fat around the bottom/back area of my jaw. 

I am looking for solutions to remedy my botched surgery of which it appears only custom implants can successfully achieve V-line reversal. 

(1) Would it be ‘dangerous’ to try to restore my original jawline contour with a 2cm vertical implant. Or would I have to compromise and go for a smaller increase such as around 1cm? Ideally I would like to get my original contour but if the risks of complete masseter sling disruption are higher with a larger increase, I would rather opt to compromise. Are the risks of complete disruption high when my masseter muscle is scarred and contracted? My understanding is that the muscle can contract and be shortened, but it cannot be lengthened. 

(2) What would be the risks of using a harder material such as PMMA or PEEK to rebuild my jawline contour? Even if it requires larger incisions, if a person’s jawbone can be taken out, hypothetically, it can also be put back in? 

(3) How long would I have to stay in the US for this procedure to safely rule out the possibility of an infection?  Is it possible to get a delayed infection aside from needle penetration from fillers or dental anaesthetic?

(4) Would it be possible to have the implant extend into the pre-jowl area to give that area width?

I apologize for the long list of questions. I am quite distressed about the situation and really do look forward to your take on my situation

.A: I have heard your jawline surgical story many times. It is not really a language barrier, it is more of a cultural issue. They are simply going to do what they want to do. There is no such thing as customizing or doing an individual treatment approach. Regardless of language issues, it is seemingly hard to confuse a chin procedure with one where the jaw angles are completely removed.

In answer to your V-line reversal surgery questions:

1) Making custom jaw implants to restore your jawline is the only effective treatment approach for it. How much you should attempt to restore it is a matter of personal preference. It is very likely that the massteric muscle sling may already been disrupted as there is no emphasis in its preservation in a bone shortening operation where the muscle needs to contract anyway. That being said it is true that the greater the vertical jaw angle lengthening is after jaw angle reduction that risk is increased. But there is no known actual number of lengthening where the risk substantially changes. I would say that 2 cms is probably too much.

2) When it comes to the material used for custom jaw angle implant restoration, the body doesn’t care what the material is. That will all work the same. And the stiffness of silicone (durometer) can be made to almost match that of Medpor or PEEK. What matters most is whether any of the material can be designed appropriately, placed without trauma and incisional length and can be manufactured at reasonable cost.

3) Infection does not occur until 3 to 6 weeks after implant placement. So no one is going to stay here until that time has passed. The goal is to get home as soon as you can, often between 2 to 4 days after surgery. One does have to be vigilant ab outany injections therapies around the implants. (didn’t inject down into the bone) Such needle tract-induced infections are very rare but they have been known to occur.

4) The implant design can be made to what surface and dimensions one wants including a forward extension out to the prejowl area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, several years ago I had double jaw surgery plus a sliding genioplasty. The jaw surgery itself created what I believe to be alignment issues with my bite, and possibly TMJ and  tinnitus.

My major concern right now is that my lower lip and chin tightness, especially when talking or smiling. With my lips it’s like they were turned inward, and are stretched against my teeth. My chin was moved forward and up, and it feels as if the skin is being pulled taught against the new position of the bone and plate.

My question is, will getting the 7mm bent plate on the chin removed be enough to resolve this or should I get a revision of the chin surgery done? I don’t really care about aesthetics at this point. I just don’t want this tight feeling all the time.

My surgeon is concerned about going in and risking nerve damage. He’s not sure this isn’t nerve damage, but from what I understand nerve damage is typically numbness, not a thinner lip and tightness of the chin. It’s like wearing a chin strap when you talk.

Thanks!

A:  As best as I can tell from your description you had a combined lower jaw osteotomy with a sliding genioplasty advancement. (the maxillary osteotomy is irrelevant for this discussion) While you did not provide the specific numbers of movement for the mandible and the chin was brought  ‘up and forward’ (millimeters of movement?) I will assume that between the two there has been some substantial anterior bony movement and the chin was so done because of the severe retrusion you had where it was sitting down and back so to speak.  Given the tissue tightness symptoms you are describing it is reasonable to assume that the soft tissue chin pad is very tight which will also affect the lower lip position.

Without seeing pictures and the x-rays I can only make a general comment that it is not unreasonable to think that undoing some of the bony movement of the chin may be helpful (down and back a bit) for their relief. But without knowing anything else I am certain that just removing the metal fixation plate is not going to relieve your symptoms. This is not due to the metal plate, it is a soft tissue stretch issue from how the bone underneath has been changed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is that I am a 60 year old male and have had this problem for many years and have now decided that I would like to do something about it. It is not due to weight. I would like to make an appointment but thought I would first ask you what the success percentage is. I realize that must be a vague question and you may not be able to answer it without seeing me in person. I just dont know enough about this. Not sure if the surgery is done if they would grow back or not and do not want to waste money and time if that would be the case. I look forward to hearing back from you. Thank you for your time!

A: Thank you for your ‘older’ gynecomastia reduction inquiry. With gynecomastia reductions in general breast tissue does not grow back, particularly in someone of your age. The more relevant question is what type of gynecomastia reduction do you need as older men often have an excess skin issue/sag and this requires a different gynecomastia technique. I would need to see pictures of your chest to provide a more qualified answer in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in jaw reduction reversal surgery. I’m looking to fix the aesthetics of my face after an over-done jaw reduction surgery. My jaw bone was sliced off up to 1cm below my ear, which gives me a long-chin, long-face and aged appearance that I find difficult to get accustomed to.

My surgeon wants to do custom jaw implants made of PEEK to reconstruct my jaw to the original state or to my liking. In your experience, is surgically going into this site again highly prone to complications?

My surgeon has experience with PEEK implants for craniofacial and maxillofacial use, but not in the context of reversing a badly done v-line surgery (it is a very uncommon surgery here.) I’m worried that having done this surgery will make me more prone to complications.

My biggest worry is the disruption of the sling muscle or tearing of the masseter muscle. Would this complication risk be extremely high? I feel like this nightmare is neverending and I’m extremely weary of having to go through surgery a 3rd time to fix such a problem if it were to occur. 

Also, what is your opinion on the longevity of PEEK implants? I am having difficulty finding any case studies on the material’s longevity or delayed infection risk, which worries me as well.

A: In answer to your jaw reduction reversal surgery questions:

1) A custom implant approach is the only method to reconstruct the previously removed jaw angle/jawline bone. One can have a debate about the implant material and I would submit the body doesn’t care what is used as it will treat it all the same with the same risks. (infection, wound dehisce, asymmetry, over/underdone….all of the standard risks from this type of surgery)

2) The material properties you need to think about is not their biology (which is what most patients and surgeons focus on…which is actually not that important for the reason I have just mentioned) but the mechanics of the implant’s placement and the potential capability of secondary revision should that be needed. (and that risk is much higher in a scarred and anatomically altered area) In other words, how easy is the implant to get in initially and OUT if a revision is needed. A PEEK implant is very rigid which makes it harder to place (bigger incision), requires greater tissue dissection (larger pocket) and is less adaptable. If a surgeon has never used this material in a tight and confined space like the jaw angles and their PEEK experience comes from doing skull implant surgery (a big wide open space) they will likely be in for a surprise during surgery. 

3) When you have a jaw angle/jawline reduction surgery by definition you already have a massteric muscle tear….you just can’t see it because the vertical height of the jaw angle is so reduced and the muscle has shortened around it. There is a very good chance that may become apparent when the vertical height of the ramus is restored. I am not saying that it will absolutely occur but the prior surgery may have already created it. That is unknown that can not be predicted before surgery but the patient needs two be aware of that issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I first heard your name from your TV interview concerning Pixee Fox. I came across you again while googling for information concerning shoulder width reduction by clavicle shortening, and was excited to read your post. I’m very interested in eventually getting this procedure, if it is possible. You mention that it would take an extremely motivated patient to have this surgery – I would like to be that patient, eventually. 

I’ve read a few studies concerning the effects of clavicle shortening on shoulder movement, and my impression (as an layman reader) is that there are very few or no significant changes to shoulder function. Additionally, there are a few pictures online that seem to show some perfectly normal-looking shoulders with shortened clavicles. 

Have you since performed the procedure? Have you learned any further information about it? Is my impression regarding the functional outcome and the effects accurate? Any information is welcome.

Thank you!

A: My limited experience with shoulder width reduction by mid-clavicular ostectomies conforms the following:

1) A motivated patient is one that can accept the incisions over the clavicles to do the procedure and the recovery of having operated on both clavicles at the same time.

2) You are correct in that there are no changes to shoulder function since it is done well medial to the AC joint.

3) With a 2 cm resection of the mid-clavicular bone the shoulder will have a reduction of about 1 inch per side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, A comparatively recent (4 weeks ago) facelift revealed a prominent Adam’s apple and even more prominent larynx. I am a fairly slim woman, and those two bumps stick out visibly and are quite unsightly. Could you please advise on whether anything could be improved?

A: Thank you for sending your after facelift pictures. While tightening the neck and redefining its angles is usually a positive aesthetic outcome, the more rigid structures in the center of the neck can be more evident.  I think what has been revealed from your neck tightening is the hyoid bone (upper) and the Adam’s apple. (lower) An Adam’s apple reduction (tracheal shave)( can be done in the usual fashion with a successful improvement. The hyoid bone is slightly different in that it is a suspensory bone with numerous ligaments and muscles attached rather than a fixed structure like the Adam’s apple. But its prominence can still be reduced somewhat by resecting its central portion.

Anatomically the Adam’s apple is the larynx so they are not separate structures. I would advise waiting at least 3 to 4 months after the facelift to give the tissues time to relax and see of these two central neck prominences remain the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a combination problem consisting of a venous malformation over my right ribcage and a prominent frontal bulk, which I assume is rib cartilage, in the front. My questions are; 

1) Where would the scar be for the venous malformation and rib removal? Would it be in the same place (around 10th rib) as the normal method, only slightly longer? And then another incision on the front chest to reduce that bulk? Or would the incision continue in one long line from back to front? I do have partial rib removal already from a failed otoplasty when I was younger and rib graft from my front rib so already have a scar there and a dent. I hope to cut out the remaining area of this out so it isn’t a sharp dent anymore and also on the other side. I can’t wear corsets right now to try and waist train for any longer than a few hours due to the pain of this sharp dent from where the previous rib reconstruction was taken. I included a pic of the rib graft incision. Would it be ok the same place on the front? 

So basically removing the back ribs as much as possible with the venous malformation and muscle and also reducing frontal ones. Would this give me a dramatic change to my waist size? You can see on the pics below how large and disproportional my ribcage looks compared to the rest of my body. I’ve always had this broadness. 

A: To answer your more specific rib removal questions and to clear up some misconceptions:

1) What you refer to as ‘frontal muscle bulk’ is actually the subcostal margin of the union of the cartilaginous ribs # 6,7,8 and 9. This is all cartilage and not muscle.

2) You have had a prior left rib graft harvest in which portion of cartilaginous rib #6 was removed….which was for your otoplasty procedure. This has left you with a blunt cartilage end of #7 and the union of the ends of #8 and #9 exposed lower.

 3) With your very thin body frame with little soft tissue cover over the ribs I would be concerned that any rib removal would show the remaining ends from their removals.

4) Removing the anterior subcostal rib margins creates what is known as ‘vertical waistline  elongation’ as it creates more distance between the bottom of the ribs and the waistline in the front view.

5) #4 should not be confused with horizontal waistline reduction which refers to ribs #10, 11 and 12 and is done  from the back with the goal of bringing in the sides of the waistline at the level of the belly button.

6) The incision for the anterior rib removals would have to be different for each side, using the existing one on the left side but a longer and more posterior one on the right side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had fat injection at lower eyelid three months ago. Now there is lump under one of my eyes. When I touch it I feel something under my skin which is almost lying on my lower eye orbit but I can almost move it a bit up and down with my finger under my skin and it is also almost firm  (not feeling soft like an ordinary fat texture)  I am wondering what is that.

Is that living fat or a  fat necrosis. It is not stuck to my skin, its feeling apart from the skin and my skin is normal. If I use corticosteroid ointment or nitroglycerin ointment on my lower eyelid is it helpful? If i wait more will it dissapear? Can i ask someone to aspirate this for me with needle or its dangerous?

Is mesotherapy or radiofrequency helpful?Is there any way to get rid of it at this early stage?(three months postop)

Please answer me if you are able to help, its really  urgent for me.

I really hope for your help because my own doctor didn’t help me. He said its not important.and didn’t care. But for me it really matters  🙁

A: It is fair to say if you had undereye fat injections three months ago the lump you are feeling is an injected fat lump…which is not uncommon around the lower eye. No topical cream will cause it to go away. Such fat lumps are very unresponsive to injection therapy.  The only assured method of removal is surgical excision through a transpalpebral lower eyelid incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of secondary jaw angle implant surgery. I have had medlar jaw angle implants done twice and both times they had to be removed due to infection. In addition on one side I developed masseter muscle dehiscence. If I go for third jaw angle implants try what can I do to reduce the risk of infection? Can I get the masseter muscle dehiscence fixed at the same time as placement of new jaw angle implants?

A:  My overall assessment of your situation, by just reading it, remains me of the old motto…’past history predicts future behavior’. Jaw angle implants have the highest incidence of infection of any facial implant (about 4% to 5%  in my experience compared to other facial sites of about 1% to 2%) and the Medpor material due to its surface roughness has a higher risk of infection than silicone. I do not know why your implants got infected (placement inoculation vs postop wound dehiscence and implant seeding) but if you have to give a third try silicone jaw angle implants would clearly be the better material choice to lower the infection risk.

In regards to master muscle dehiscence, once that has occurred it is a very difficult problem to try and improve. Muscle repositioning is incredibly difficult and unpredicatable and most certainly would not be performed concomitantly with new implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking eye asymmetry surgery. I added pictures and you can clearly see on it my eyes are not right. Also I know my jaw is not right but will have consultation in August about that. I am not worry about my jaw beacuse I know is possible to fix it but I am worry about my eyes. It is hard to accept. I am always trying avoid any pictures or selfie with my friends, wife etc. Is any help for mm ? Is any chance to fix it ? If yes how much will it cost? Thank you for reply and your help. 

Kind regards

A: Thank you for your inquiry and sending your pictures. As you know you have vertical orbital dystopia as part of your overall left facial asymmetry. In appears to be in the range of less than 5mms by your own horizontal line measurement in your pictures. That puts it in the range of being very improvable whose management is based on how it looks in a 3D CT scan. When it comes to eye asymmetry surgery, usually a custom infraorbital floor-rim implant is made to provide optimal skeletal symmetry to the other side. Whether the lower upper eyelid and brow should also be managed is a considerations as you don’t want to lift the eyeball only to have the iris and pupil further buried up under the upper eyelid margin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in zygomatic arch reduction. I am asking this because I have a wide face due to my zygomatic arch flaring out heavily toward the back, giving a somewhat rounded appearance.

Specifically I would like to know a few things:

1) Is a moderate width reduction possible without cutting the anterior portion (which seems too invasive for me)? How much is possible with just a posterior osteotomy? 

2) Is the recovery difficult? I.e. heavy bruising, difficulty chewing, swelling? Would an out of town patient be able to travel home shortly after surgery? How long after the surgery can a person return to work?

3) Are the results subtle or is it possible to tell that the bone was cut, like depressions, protrustions of bone, etc? 

4) Can the skin be affected afterward, as in drooping? 

5) What is average cost for such a procedure? Ballpark range?

Thank your for your time Dr Eppley. I have been considering this for a while.

A: In answer to your posterior zygomatic arch osteotomy questions:

1) It is fair to say that a moderate width reduction is possible just by cutting and moving in the posterior arch. Although the definition of ‘moderate’ is open to interpretation. In some cases optimal reduction is aided by a mid-arch osteotomy as well.

2) Recovery is not difficult at all. You would be able to go home the following day and return to work within a week out less.

3) The results would be subtle and smooth. There are no obvious depressions or irregularities because the overlying soft tissues are very thick.

4) No skin drop will occur for the same reason as in #3.

5) 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 am interested in mouth widening surgery. My questions are:

•Once the procedure is done, how long after it do the stitches come off? I can manage a 2 week trip at most to the US.

•Should any infection or complications arise when i head back home what could be my options?

•What would the expected cost of the procedure be?

•I know there will be scarring. Could the scarring be reduced or removed with laser treatment?

•Will this impact the ability to use my lips normally? Such as drooling or leaking of any liquid items such as water from the sides where the lip is widened? 

•Will you also be making incisions to bring my lips forward as well to make them look fuller or is this a separate procedure? 

A: In answer to your mouth widening surgery questions:

1) For all of my international patients dissolvable sutures are used so they may return home shortly after the procedure. When permanent sututes are used that have to be removed that is done on day 7 after the surgery.

2) This is not a procedure where infection is likely to occur so that is not a complication of concern. The only issue with this procedure is how well do the scars do and that is a an issue not be judged for months later.

3) My assistant Camille will pass along the cost of the procedure to you later this week.

4) If scars turn out to be an adverse issue that is best treated by scar revision not laser treatments.

5) Mouth widening does not cause any functional effects as you have described.

6) Mouth widening moves the corners of the lips outward but does not make the lips fuller….unless something is done separately to do so. (e,g., fat grafting)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  How much would a custom jawline implant cost?

How quickly can it be arranged?

What will my face look like after the surgery?

What complications may arise?

What happens if the result is unlike that which I desire?

A: In answer to your custom jawline implant questions:

1) My assistant Camille will pass along the cost of the surgery to you by tomorrow.

2) It takes four weeks once a 3D CT scan is obtained to do the design and implant manufacture process.

3) Preoperative computer imaging is used to try and determine your facial reshaping goals which helps guide the design of the implant.

4) The most serious complication is an infection, the most common complications are aesthetic in nature. (asymmetry and how close to achieve the patient’s goal did the surgical result achieve)

5) Every surgeon has a revisional surgery policy and forms of which it is mandatory that they have read it and agree to them. No surgery can give guaranteed results eve with custom facial implants

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface augmentation efforts. First of all, thank you for your fast reply. So my first problem is the malar and midface area after my double jaw surgery, which I underwent about a year ago. The skin and soft tissues in this area used to be “tight”, in other words: They sticked to my skull. But after the surgery the skin around my nose became loose, droopy and puffy and it has not improved to this day.

I’ve already asked some doctors on Real Self if there is any proper procedure to tighten the skin. Some of them mentioned fillers and some others talked about facelifts and laser lypolisis. To be honest I’m really desperate because I’m looking for the male model look. I heard about your custom made implants and that’s the main reason I’ve decided to get in contact with you.

My cheekbones are not pronounced they are flat, but I want them to be wider, more prominent, chiseled and high set. Espacially the zygomatic arch is very importnant to me.

Nevertheless as I’ve already mentioned I think the first problem we need to solve to get the best results, is to treat my midface area first. I guess when the skin is too droopy and heavy we won’t get the desired results.

I’ll send you some pictures before and after my double jaw surgery and also some pictures of a few examples so that you can get an idea of what I want.

Please feel free to judge and give me your honest opinion about my situation and also tell me if it is achievable in my case or not.

Thank you very much Dr. Eppley for any type of help

A: Thank you for sending your picture and detailing your surgical history. When the entire midfacial tissues are degloved to perform a maxillary osteotomy there will be some permanent soft tissue changes induced by the surgical swelling and the disruption of the ostecutaneous attachments. There is no form of soft tissue tightening or surgical lift that is going to solve that aesthetic concern. 

You are correct that midface augmentation is the only effective method to fill out the loose midface tissues. You are also correct in that custom designed implants are the only implant design to try and accomplish the type of facial reshaping change you seek. However you may not be correct in that the final facial result will look like the male model picture you have shown as that is not a realistic outcome with any form of facial augmentation. You have to have a ultrathin face with little facial fat to achieve that type of result…which is not your natural facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have sone questions about zygomatic arch implants. 1.I am wondering if this patients results are a normal outcome of this procedure? 2. Where is this type of implant usually inserted? 3. Did he augment his malar area as well 4. Is buccal fat removal a good procedure to combine with the zygomatic arch implant with to get better results Thank you

https://www.realself.com/review/indianapolis-custom-infraorbital-rim-malar-zygomatic-arch-implant-dr-eppley

A: In answer to your zygomatic arch implants questions:

1) Since I can not see the case to which you refer I can not answer your questions specifically about whether such outcomes are normal or not. But if your question is whether one can achieve a more well defined and sculpted midfacoal appearance as a result depends on the natural shape of one’s face. Thinner faces always get more defined results than fuller ones.

2) The case study has the title of ‘custom infraorbital-malar-zygomatic arch implant’ indicating that it did cover the malar area as well. Such custom implants are usually placed through lower eyelid incisions. Isolated zygomatic arch implants are placed through an incision inside the mouth.

3) Buccal lipectomies are commonly done along with many types of midface implants to create a bit of more defined facial result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal artery ligations. I’ve found you while searching for a problem I have which is swollen superficial temporal arteries. I believe weight lifting caused this.

So it is possible to remove these arteries or at least the offending parts? If so, can weight lifting be resumed?

If I don’t have a procedure done, will further weight lifting make the already swollen arteries even worse or branch out?

A: While prominent temporal arteries typically develops almost exclusively in males, weight lifting or any type of physical activity would not be the cause of it. Such activity certainly aggravates it but is not the cause of it.

The treatment of prominent temporal arteries is done by an approach known as multi-level temporal artery ligations from the bottom of the superficial temporal artery by the ear up to the top of the forehead. With this approach I have not seen recurrences. It s possible that some ‘new vessels may appear afterwards if undetected feeder vessels are not seen and treated during the initial procedure. Weight lifting can be resumed after the procedure.

No one can say whether the prominence of your temporal arteries will become worse if they are not treated.

Dr. Barry Eppley

Indianapolis, Indiana