Your Questions

Q: Dr. Eppley,  I’m a 32 year–old female interested in secondary chin reshaping. A year ago I underwent a sliding genioplasty which I deeply regret as it has affected my work and self-esteem. My chin prior to surgery was very pretty, just horizontally deficient. 

My chin was advanced 5mm and vertically shortened 5mm. However, it appears that it was also widened somewhat, against my wishes (there was no computer imaging done, just tracing). I have a natural V-line jaw and the new segment of chin does not blend into the narrower jawline. To make matters worse, the cut was asymmetrical so that one side veers out more than the other and at a greater distance. 

I have since used HA fillers to improve the chin and these have helped immensely. However, I have a very delicate bone structure and so rather than building up the volume to disguise the problem, I would prefer to have the width of the chin narrowed ever so slightly (at most 4-5mms). I came across this article of yours: http://exploreplasticsurgery.com/case-study-submental-chin-reduction/ and would like to have this procedure done. Would you be able to assist? 

A: From a structural standpoint when you bring the chin forward and up by definition it is going to make the chin wider due to the position of the posterior ends of the osteotomy. This was most likely not a deliberate effort on the part of the surgeon but one that was inevitable by the way the bone was moved. Narrowing of the wider chin can be done from an intraoral or submental approach although it is more effective when done from below for maximal narrowing along the chin/jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My current pre-consultation questions are as follows:

1. Will a combination of custom chin and mandibular angle implant be able to expand the width of my entire jawline from chin to mandible? I am concerned about the possibility of seams and bumps between the separate implants. Would a single-piece wraparound implant be a better choice? How much more expensive would that single-piece implant be?

2. How accurately can we predict the final result? What tools does your office use to predict the result?

3. I am also concerned that my cheekbones are very flat and will look out-of-place with a larger jawline. If cheek implants are out of the budget or not feasible at this point for some reason, would fillers be able to accomplish the same result as cheek implants to complement the finished jawline?

4. What would a ballpark estimate be for this procedure’s cost?

Obviously these questions are all subject to change depending on what is seen and recommended during a consultation. But from my current knowledge, I’d like to hear your opinions and answers at the current moment.

I have an album of pictures from various angles available if you would like to see them for yourself. Please let me know.

A: Thank you for your custom chin and mandibular angle implant inquiry. In answer to your questions:

1) A custom one-piece jawline implant is always the superior jawline augmentation method as it creates the most complete volumetric augmentation, is a single seamless linear implant from front to back, and has the less risk of asymmetry and malposition as opposed to three separate chin and jaw angle implants.

2) No surgeon or design software today can accurately predict the external facial effect of what any implant shape and size will create. Surgical experience helps guide the process but it is not an exact science.

3) Fillers are a frequently used option for cheek augmentation either as a trial or an ongoing treatment. They do not create the same exact aesthetic effect as implants but they can be helpful nonetheless.

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

You may feel free to send me any pictures for my assessment and computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For several years I have been interested in pursuing jumping genioplasty to correct my elongated chin. I have seen a couple of oral surgeons and to my surprise have became aware this is not a common procedure- I finally found one willing but he lacked confidence and told me the end result would be “subtle.” so… I am not interested in spending thousands of dollars and going through pain for only weak results. I want to have an altered appearance.. that is the point. is this not possible. please advise. 

A: While a sliding genioplasty bone surgery for chin advancement is common, its variant of a jumping geniplasty is not. While the jumping geioiplasty provides maximum horizontal chin increase it also has several other aesthetic sequelae….which may or may not be favorable for a patient. First, it will cause a significant vertical shortening of the chin which may be favorable in your case by your description. Second it is prone to making the chin appear wider because the thickness of the sides of the chin has been doubled. Lastly it is prone to bony stepoffs between the jumped bone segment and the natural underlying jawline. 

It may be that a jumping genioplasty is the right procedure for you but I would at the least need to see pictures to make that determination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an old scar on my shoulder that is about 3”x1.5” and I’ve been wanting to get rid of it for some time now. I saw your post about using Acell products after searching for info about Recell. I was interested in Recell after doing some research but if Acell can provide similar results then that would be something I would be very interested in. I guess what I am wondering is, if you do use Acell products are you essentially performing a skin graft and using the Acell product in the place of grafted skin? 

A: Thank you for your inquiry. To provide clarification about scar revision in general:

1) Scar revisions are performed by cutting out the scar and reclosing the wound. Skin grafts are never used for scar revisions.

2) The goal of scar revision is to improve the appearance of the scar….but there will always be a scar but hopefully one that is more normal. But its length will always remain. There is no such outcome as ‘getting rid of the scar’ or complete scar removal.

3) The use of accelerated wound healing agents in scar revision or wound healing in general, while highly marketed by their manufacturers, remains theoretical in its benefits. They are not magic powders that can just make wounds or scars disappear.

4) Scar revisions across moveable joints, like the shoulders, are challenging to improve no matter what is done because of the motion across the scar revision site.

Dr. Barry Eppley

Indiaapoliss, Indiana

Q: Dr. Eppley, I have a question about elbow lifts and what can be done after the surgery in terms of physical activity. I was wondering how long before a patient would be able to bend her arm fully after having had elbow lifts? Thank you

A: What you are referring is when can the patient after an elbow lift bend their arm beyond 90 to 110 degrees without risk of creating a wound separation of the incision line which is placed perpendicular to the extension-flexion movement of the arm. That answer is around 3 weeks after the surgery. Fortunately most activities of normal daily living do not require such full arm flexion movements.

Being well aware of the need to protect the incisions after surgery, elbow lifts are performed with the arm bent at 90 degrees. This ensures that over resection of skin is not done preventing undesirable scarring and the risk of wound separation if one should accidentally bend their arm over 90 degrees in the first few weeks after surgery.

Careful preoperative marking with the arm both straight and bent at 90 degrees is paramount in deciding on how big the crescent of tissue excision should be.  But following the principle of ‘less is more’ is a good approach with elbow lifts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can the subnasal lip lift be done as an upper lip lift with a no scar suspension as an in-office procedure? The upper lip is shortened via an intranasal incision and suspension suture that elevates the upper lip and anchors it to the anterior nasal spine. I would like this technique if possible. 

A: That technique you have described for a subnasal lip lift is not a good one for two reasons. First, putting the incisions inside the nose eliminates the natural nasal sill, making it look abnormal. Once the nasal sill is lost it can not be reconstructed. Secondly anchoring it to the nasal spine or any deeper tissues will affect your smile, making it stiff and abnormal. Such suturing interferes with the normal sphincteric movement of the orbicularis muscle as well as may interfere with the excursion of the upper lip in smiling.

A subnasal lip lift is a delicate technique that requires prevision in its execution to avoid asymmetry, poor scarring and smile alterations. It is important to not over resect skin as it can not be put back. My general rule is to not remove skin in the range of 25% to 33% of the natural philtral length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently researching for a possible revision rhinoplasty. To provide some background, I had a prior rhinoplasty procedure that included an alar base reduction to narrow the nostrils. Unfortunately there is asymmetry, and I believe it is a bit too narrow. I am aware that these types of procedures are difficult to revise, but I wanted to know if there are any possible solutions. 

For one, I have have researched PDO threads used in temporary nonsurgical face-lifting. Is it possible to use PDO threads to slightly widen the alars by pulling the skin outwards? Similarly, is it possible to do a surgical procedure using permanent sutures to widen the nostril base? If it is feasible, I would definitely be interested in consulting on possible solutions.

Thank you 

A: Nostril narrowing achieves its effect by removing tissue to do so. As a result to reverse their effects is not going to happen by any form of tissue suspension to suturing. Such excisions-based procedures can only be changes by adding tissue back in. And while this can be done, the placement of such a graft will create a mismatch in skin color which is why it is rarely ever done.

That being said an intraoral vestibular subperiosteal release (like is used in the surgical access for a LeFort osteotomy) is well known to widen the nostrils and is one of that procedures acknowledged adverse aesthetic effects. Numerous closer techniques have been advocated in that type of midfacial surgery to prevent nostril widening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m seriously considering reversing my sliding genioplasty. 

Here are two questions:

1) I read your post about genioplasty reversal on Real-Self. You said: “resuspend/tighten the mentalis muscles at the same time so you do not get a soft tissue ptosis (witch’s chin) as a result of the loss of bony projection/support”

In my case, do you think we would need to resuspend the mentalis muscles? (I’m almost one year from the original genioplasty and the movement was 4mm forward and 2 downward) Is it a technique used in every genioplasty case or only in reversal ones?

2) Is that possible for the muscle and tissue to go back to where they were before the surgery?(not 100%, but mostly) I’m worried about skin sagging and facial deformity. (I’m 32 and my skin is good).

Thank you so much!

A: In answer to you sliding genioplasty reversal questions:

1) By definition every closure of a sliding genioplasty, regardless of the direction of movement, entails resuspending the mentalis muscle since you have to release it during incisional access to do the procedure. How tightly you may reattach the muscle is what varies on an individual patient basis.

2) It is safe to assume in the reversal of any enlargement procedure of the body, albeit a sliding genioplasty, breast implant removal or pregnancy, that the tissues will never return to what they were before the enlargement procedure. All surgery causes some irreversible changes. So the question is not whether one will return 100% to normal, as you won’t, but how close to normal would it be. Given that your original sliding genioplasty was relatively modest, your chances are better than a sliding genioplasty in which much bigger movements were done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking through your patient pictures and found a 43-year old male who had surgery to correct his vertical dystopia. He opted for cheek augmentation with an implant, but even in the after-picture I can see his vertical dystopia is still there, although very much improved. The inner corner of the affected eye (medial canthus) is slightly lower than the opposite side. This is also the case with me. I have slight vertical dystopia (left eye higher than right with the medial canthus being lower on right eye as well) but is there any disadvantages/advantages by going for orbital box osteotomy rather than cheek augmentation? I know it’s a highly delicate surgery with certain risks but I imagine the result being better. Do you have any experience in this type of surgery? 

A: The key in treating a vertical orbital dystopia (VOD), in which there is no perfect result obtainable, is to get appearance improvement WITHOUT causing any other aesthetic issues. This is why in smaller or more aesthetic VOD patients (6mms or less of horizontal pupillary discrepancy, building up the bone deficiencies and adjusting the soft tissues around it is the aesheticaily safer approach. 

Orbital box osteotomies are reserved for more severe cases of VOD where the aesthetic tradeoffs to do so (risks of adverse scalp scar, bony irregularities, palpable hardware, lower eyelid retraction, numbness and even frontal nerve weakness) may be worth it for the degree of bony change.

But the most assured way to trade off into numerous new aesthetic problems is to apply a big operation( orbital box osteotomy) for a much smaller problem. (vertical orbital dystopia < 6mms)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle augmentation done with hydroxyapatite granules at the end of last year. While the outcome produced some improvement, I have a very short lower jaw and I am looking for anbetter solution to vertically lengthening my jaw angles.

The question is in the case if I would like to have an operation with you shall I remove the hydroxyapatite granules which might be difficult or you can put implants on top of the hydroxyapatitite? I should mention that the maximum projection on the jaw angle is just 2.0mm.

A: You would need to augment your jaw angles with implants on top of the hydroxyapatite granules as they are very difficult to remove and have bone growth throughout them at this point. Given what is probably some asymmetry induced by the granules this raises the question of whether standard vs custom jaw angle implants would be needed. One approach is t burr down any irregular jaw angle surfaces and place standard vertically lengthening jaw angle implants, The other option is to have custom jaw angle implants made to account for any asymmetry and irregular bine surfaces caused by the hydroxyapatite granules. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What are the risks of the temporal implant surgery? What would be the worst outcome? What is the recovery period?  Can any natural techniques like bone grafting be used instead of artificial implant….because these artificial implants may have risk of infection and  may visually appear unnatural.

A: There are a variety of types of temporal implant surgery but I will assume you are referring to standard temporal implants for Zone 1 and 2 anterior augmentation for classic temporal hollowing. Temporal augmentation is about augmenting the muscle not bone as that is what makes up all of the anterior temporal region. Such implants are placed under the fascia on top of the muscle which is closer to the skin. Their subfascial location ensures no visible implant outlines and a more effective and natural augmentation result. Because this is a muscle implant the risk of infection is very low…so low that I have yet to see one.

Bone grafting is not an effective technique for temporal augmentation. If one was to consider a natural technique for temporal augmentation the option would be fat injections not bone grafting. Fat grafting has as a role in temporal augmentation but has potential issues with retention and smoothness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to have a chin implant, and possibly jaw angle implants within the next few months. I’ve ruled out a custom jawline implant. I think it would be a bit too invasive and costly. I’m fairly happy with my overall base, so i think off-the-shelf implants would work well.     

In particular, I’m seeking to have more defined, angular chin and jawline. I think your work here looks very good.   I would prefer something similar.

A:To provide clarification as to your jawline augmentation goals:

1) A custom jawline implant is no more invasive than three separate chin and jaw angle implants, it is the same operation just with a connected implant shape whose dimensions have been made based on the bony anatomy. One may not choose a custom jawline implant due to cost but not because it is more invasive.

2) Whether standard chin and jaw angle implants will achieve your jawline goals can not be precisely predicted before surgery. Whether you would achieve a look similar to the picture you have shown is not assured. That is a connected jawline or linear jawline look and standard implants are not connected.

3) I would not disagree that standard chin and jaw angle implants are a reasonable approach for you but let’s not confuse that potential result with that of what a custom jawline implant can do which always produces a superior aesthetic jawline look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have been to a couple of consultations but most plastic surgeons told me that I do not have enough fat to transfer into my hip area. I would like to know if you do hip implants. I am not happy with my shoulder to hip ratio.  I have broad shoulders and its making my lower body look even smaller. I am pretty fit and even with a fat transfer as much cardio as I do that will be disappear within a couple years. Please let know after talking to the doctor if he can possibly do something ? I have photoshopped the pictures below so you can get an idea of how I want my hips to look like.Thank you in advance for your time. 

A: You are correct in that you do not have enough fat to do hip augmentation with it and any fat transferred would not stay in a vey active person which your pictures demonstrate that you are. Based on this reality, here are your considerations for permanent hip augmentation:

1) Hip implants are your only option and they are good option if you can accept the 4 cm incision on each side to place them.

2) All hip implants are custom made based on measurements of the patient’s hip areas. So not only would their size be correct but that they will have feather edges which is critical to not have visible implant outlines showing through the skin.

3) Given your desired area of hip augmentation (trochanteric depression) they would have to be placed on top of the TFL fascia, a location where feather edging of the implant is critical.

4) Given that the #1 ‘complication of suprafascial hip implants is a fluid collection (seroma), it is of critical importance that one does not return to working out for 3 weeks after surgery to lower this potential postoperative problem risk.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in injectable lipoma removal. I have a small forehead lipoma about the size of a quarter near my hairline that I want to inject with Lipodissolve to get rid of it. Will this work and will int injection do it?

A: For a forehead lipoma that lies near the hairline the far better and more efficient solution would be to remove it through a hairline incision. Lipodissolve (now reinvented and marketed as Kybella) solutions are not FDA approved for the face and it would take 3 to 4 injections sessions spaced  6 to 8 weeks apart to get it as flat as possible….provided it will respond to the injection. In a thirty minute surgery done under local anesthesia an excision will remove the lipoma intact on an assured permanent basis. 

With such a small lipoma that lies right up against the hairline the small incision needed to remove it would leave an imperceptible scar in its wake. While an injectable approach sounds like it would be quicker and easier to do, the reality is that it is currently inferior to surgical excision for the reasons so discussed. It would also cause much more swelling each time it is injected that its surgical removal would create.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in short face surgery. I have a very short lower face. I had been on braces for the past 2 years and now on retainers. While the alignment of my teeth has improved and it’s almost a normal occlusion, I’m still not happy about my aesthetic facial results. Here are my main concerns:

My lips are actually over lapping each other and as you can see the upper lip actually rolls inside the upper teeth giving it a weird shape. I feel this is due to the deep seated maxilla and teeth which supports my upper lips inadequately.  I do not show any teeth when I smile. I have a non-existent jawline and a slight double chin despite being relatively lean.  My chin appears receding and gives me a chubby look. 

Here are a list of my expectations : A proper support to my upper lips by my upper teeth and proper visibility of my upper teeth when I smile naturally and even when I talk . A balanced chin for my face and a visible jawline and to remove the bloated look on my face and give it some structure 

Here are my questions: 

1. Can you please explain the cause of such aesthetic issues for me. 

2. What would be the best course of treatment in your opinion?

3. If you are gonna suggest double jaw surgery with vertical and horizontal advancement and genioplasty, can the pre braces phase be done away with , now that there is proper alignment between my teeth. 

4. I get pain in the jaws when I chew on something hard. Would it also benefit from the surgery ?

5. Would my already prominent nose get wider  if I opt for a maxillary advancement ?

6. Are there chances of relapse of the maxilla after surgery ?

A: In answer to your short face surgery questions:

1) What you need is vertical facial lengthening. The key to deciding which approach to do comes down to tooth show.

2) If tooth show is a very important aesthetic element then only a bimaxillary orthognathic procedure will accomplish that by dropping down the maxilla 4 to 5mms as well as bringing it forward a bit. The mandible comes with it of course which pulls down the lower face as well. Other soft issue procedures around it would be beneficial (buccal lipectomes, neck liposuction) but the vertical maxillo-mandibular lengthening is the key. (probably a lengthening bony genioplasty would also be done with it of another 5mms) 

This approach increases tooth show and pulls the face longer which will also help make it thinner.

Dropping the maxilla down requires an interpositional bone graft with plate and screw fixation. This is the best way to prevent relapse.

Whether such an orthognathic procedure will improve your jaw pain can not be predicted.

To avoid increased nasal widening from a maxillary osteotomy procedure, alar base cinching is needed during the closure.

If one has a good and stable occlusion, then further orthodontic work is not needed for this surgery as the same bite is maintained. Like bimaxillary osteotomies for sleep apnea (large horizontal movements) this is not a bite-changing surgery.

3) If tooth show is not a primary aesthetic goal, then a 12 mm intraoral vertical lengthening genioplasty or a custom vertical lengthening total jawline implant can be done which will vertically lengthen the face effectively. This will need to be combined with maximal facial defatting procedures as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did breast implant replacement and capsular contracture surgery over one year ago. I am feeling lumps and some hardness in the same breast. Is it possible the capsulation is returning? Is there a treatment or something I can do to stop it from continuing?

A: Capsular contracture is a difficult problem which is not well understood nor are there are procedures that can alway produce a 100% cure of it. Usually once a capsular contracture is released any return of it typically takes place 3 to 6 months after surgery. But it is possible that it could return any time even decades later…although this is not typical.

There are no known medications or other non-surgical treatments that have proven to provide a definitive solution for capsular contracture….surgery is the only proven method to treat and release it. Massage and other external manipulations (e.g., deep ultrasound) can be helpful but have to be done regularly and have only moderate improvements in breast softening.

Once a breast had had capsular contracture it rarely will ever feel quite as soft as the breast that has never had it. As long as it is not painful, has not distorted the breast and does not appear to be progressing then doing nothing for now would be the best course of action.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry surgery. Here is the list I came up with of the asymmetric facial features that bother me the most.. It is in order of which corrections I believe will minimize the asymmetry:

• Cheek

• Jawline/chin

• Lip

• Nostril

• Eyelid

I would like to know your opinion.

A: From a surgical perspective I look at facial asymmetry issues as what structures can be either changed the most successfully (which ones would have the biggest impact on improving facial symmetry) and/or the most straightforward. (which has the least risk to do and is most time and cost efficient but their impact by themselves is limited) Successful and straightforward surgeries are usually not the same.

As that relates to your list:

biggest impact = cheek and chin/jawline

straightforward = eyelid, nostril, lip

The point being is that one usually wouldn’t just do the most straightforward procedures by themselves, that would be reserved for the most impactful. But the overall best effect is going to come from a combination of them in a more comprehensive approach.

The priority list is important as cost considerations may only one to do the top two or three and I want them to be the most effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, As a surgeon with experience in Asian cheekbone reduction/narrowing surgery, I hope you can advise me on the best path.

It’s been around 6 months since my surgery. I have thick, acne-prone skin and I believe this combined with the surgical dissection has resulted in some slight cheek sagging. From a bony point of view, I am pleased with the results but I am now consulting to fix the soft tissue aesthetics – by that, the mild sagging. 

I consulted with a highly experienced craniofacial plastic surgeon in my city. He advised me that this type of sagging is nothing he hasn’t seen before with his experience in cheekbone repair and cheek implant removals. His take on my situation was that fillers would be extremely temporary at best and that fat grafting or cheekbone implants would be unideal in my situation with my reason for having the surgery in the first place and my thick, chubby tissues.

The surgeon told me that since gravity was the problem, pulling the tissues back upwards was the solution – He pointed me in the direction of a midface lift (not endoscopic, using sutures) via incisions in the temple and reusing my cheekbone intraoral incisions. 

The procedure does sound like it will address the real issues, but I am very worried as I am only 25 years old. I am very much aware that facelifting in a young individual can lead to disastrous results and I am worried this may lead to a look that is “done” or “windswept.”

I am especially worried about the risks of nerve damage with a subperiosteal midface lift from the temple and mouth. I have read online about another individual’s experience of synkinesis after a midface lift. 

I want to put my faith in my surgeon but of course, I understand that there is no 100% of no complications. As a highly regarded and experience craniofacial plastic surgeon, what do you think of this surgical plan? Is it prone to a lot of nerve and aesthetic complications in a 25 year old?

A: Thank you for detailing your cheekbone reduction surgery history and the not uncommon postoperative sequelae of some soft tissue sagging. In short I think the surgeon you have seen as summed it up nicely and the logic of coming to some form of midface lift is both logical and practical in your situation. While the potential complications to which you have described can occur, they are not ones I have seen, albeit one time on one side, and would not be the issue that would be of primary importance in making the determination for further surgery. I would be thinking about what are the chances of success in lifting the cheek tissues in a young person who does not have a tissue sag due to aging with naturally tighter tissues and the risk of undergoing an operation that may not work as well as you would like. It is important to remember that all facial lifting operations have their origins in aging patients with loose tissues that have lost elasticity. Trying to accomplish a real cheeklift in a limited exposure procedure in a young person does not work the same as in the older patient.

in short, I consider it a low risk procedure for medical complications but a higher risk one for truly correcting your cheek sagging problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read a couple of your answers to questions about the mentalis muscle, and I was hoping you could help me. I had a chin implant place intra-orally a few years back. 

A doctor on ReaSelf said that in all intra oral chin implants, the mentalis muscle attachment must be cut in order to place the chin implant which causes the muscle to sag later in life. 

Is this the case? Will my chin start to sag because the attachment was cut? Could you help re suspend the muscle if it is a problem? Thank you for any info you can give, I’m very concerned about this. 

A: While it is true that all intraoral chin procedures (implants, sliding genioplasty, bony reshaping) requires cutting through the bony attachment (origin) of the mentalis muscle, it is put back together during the wound closure at the completion of surgery. I can only assume that was done in your case because you do not have a chin sag now… as if it was not you would have a chin sag now. I have no idea why a surgeon would say it would sag later….as that is not true nor is there a biologic explanation for that statement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently doing braces for a year. I am sure you can’t do a genioplasty or customized jaw implant just yet. However is it possible to make a customized jaw implant that is designed to make a thicker and protruding mandible angle completely outward to create a sharp jaw line and a square chin implant? Also I am interested in a revision otoplasty. 

A: Good to hear from you again. Being in active orthodontic care with braces in place is not a contraindication to any type of aesthetic jawline surgery albeit a sliding genioplasty or a custom jawline implant since the teeth are not being manipulated in the surgery. Many of my patients for such surgeries are in orthodontic appliances which do not pose intraoperative surgical restrictions nor influence the aesthetic outcome. They are merely metal or plastic applicants on the teeth. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Congratulation for your surgeries. I saw on your website the earlobe rotation by the fish tail technique. I did an otoplasty 15 years ago.

I sent you an e-mail Months ago and you suggest me to do an earlobe reduction with an otoplasty revision. But I’m still afraid to do another complicated surgery revision because i think there are many risks of a deformation of cartilage through the scar release.

So two months ago I did an earlobe reduction through a scar excision. The earlobes are a bit better as the surgeon reduced their width and height. (they were big) But didn’t rotate the earlobe, so they still protruding.

Finally, is the “rotation” possible just to setback a little bit my earlobe to the head? What are the risks? I think I need less than 0.5 cm of earlobe setback. 

A: Since the earlobe doesn’t contain cartilage, it requites skin excision to change its position against the side of the head. The fishtail excision is an effective method to bring the earlobe back closer to the side of the head. It is unfortunate it was not done as part of your initial otoplasty but it can still be done secondarily.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old and have always had long philtrum or at least just very minimal teeth show. I have no recession, my teeth are fine and my palate is wide. If I were to get the needed upper lip lift, it would kinda make the outer corners of my mouth sag downwards. Would it be possible to then also get my corners lifted to look normal, after an upper lip lift?

Also, I think all the sagging of my philtrum and upper lip makes my midface look longer than it actually is supposed to be without the excess skin.

So in theory, those two procedures would make the “lip line” or the line created where the lips “seal together”, be moved up, right? Making my midface appear shorter?

I hope this makes sense, if not let me know, so I can try to rephrase it a bit. Also let me know if you need some pictures, to get a better idea of my case.

Thank you very much!

A:It would not be uncommon to do a simultaneous subnasal lip lift and corner of the mouth lift at the same time for the very aesthetic reason you have described. If the corner of the mouthy are already low or downturned they will become more so when the central part of the upper lip is shortened.

Whether it will make your midface appear shorter is less certain. But a subnasal lip lift is one of the few procedures that may potentially have that effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a abnormal chin … it’s long and wide I would love to completely shave it cause I hate my chin…. if I could have no chin it would have been better… that’s how much I hate it… I been bullied because of my chin and now I’m ready to do something about it.

A: Thank you for sending your pictures. You have a vertically long and wide bony chin. There are different methods for reducing large chins but one method is an intraoral osteotomy method to remove a wedge of bone to vertically shorten the chin as well as narrow it. The bone would also have to be removed behind it to maintain a more normal mandibular plane angle. Your submental fullness would also need to be treated by liposuction as that will look fuller as the chin becomes smaller. The other treatment approach is to do the entire bony chin reduction from an incision below the chin. Each of these two chin reduction methods as their advantages and disadvantages. 

In addition, chin reduction is very challenging to perform due to the bony and soft tissues excesses that exist. Most patient will need a secondary touchup or revision to get the best result possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have thought long and hard about a skull implant revision and I’d like to go through with a revision on the left side. I tried my best to take pics that would show you exactly what I’m trying to describe… hopefully these will work. 

You can see a gradual rise from the center of my head on over to the left side of my head. I believe shaving or essentially reducing the thickness of the implant will do the trick. The other trick is how much should the implant be reduced? and how will it be reduced? Is there a way to determine how much should be reduced to achieve my desired shape? MRI/CT?

Also, we discussed several options and using the same incision… but I’d like clarification on the risk of infection. I know it is always a consideration, but I’d like to know if simply having a revision will increase the chance of getting an infection? 

The other topic we discussed was the approach. Has this type of revision been done before? And if so what approach was used then? I read on your site that patients at times ask for revisions… is there a percentage on how many achieve their desired state after a revision?

 I am very satisfied with the right side of my head. There is a small area that I can feel and wonder if it can be shaved down or reduced? There was a concern of thickness and I would not risk it if that was a concern. Just wondering. 

Thoughts? 

A: To answer your questions about a skull implant revision:

1) The original incision would have to be completely re-opened. It may or may not heal as well as the first time.

2) The entire implant will need to be removed to be hand carved for the revision.

3) There is no scientific method to determine how much it should be reduced. That is an artistic judgment.

4) Every time you place or revise any implant in the body the risk of infection exists. Just because it did not happen the first time does not mean it can not happen the next time. Each surgery involves a new set of risks that are independent of what happened before.

5) Whether patients are satisfied with any revision depends on the aesthetic concern being treated and what is being done.

That being said I will pass along to you two basic concepts about revisional implant surgery that I have learned in treating many patients:

1) If you are largely satisfied with an aesthetic outcome, the risks of manipulating implants for making small adjustments could turn out to be a poor benefit t risk decision.

2) There are no perfect implant results. Just like the natural human body there are going to be imperfections. Living with them offers the safest medical course of action.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting surgery to correct my facial asymmetry and I am curious as to how much it would cost for me. My main concern is the lower part of my face. My jawline and chin is uneven. The right side on my face (left side for you) is noticeably bigger than the left side (right side for you) of my face. Another top concern that I have is my nose. I would like to even it out some more, create a higher bridge and a more rounded tip. I am also thinking about maybe getting cheek implants or filler but that is not a top concern for me right now. I just want my face to be more balanced. I have seen some of your work online and on Instagram so that is why I am reaching out to you today. 

Thank you.

A: As to your facial asymmetry concerns the following are pertinent questions/decisions to be made that affect the type of surgery and its associated cost:

1) Which side of your face do you like better? If it is the bigger right side then the smaller left side needs to be built up. Conversely if it is the smaller left side then the larger right side needs to be reduced. These are radically different types of surgery.

2) Building up the nose can be done by an implant or a rib graft, which do you prefer? These are again radically different approaches to the same problems.

Knowing your answers from these questions determines the cost of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom facial implants of the jawline, infraorbital, and temporal Implants. My questions are:

•Will the chin part of my custom wrap around implant be inserted beneath the chin using the same incision site that was used for my current chin implant? I have read that inserting chin implants through the mouth carries the risk of losing lip feeling.

•Can you confirm that the jaw parts of the wrap around implant will be placed through the mouth?

•Can you confirm that the infraorbital-malar implants will be placed through the lower eyelid?

•Is there any risk of silicone implants becoming displaced by liquids within the soft tissues surrounding the implants in the future?

•Is silicone the best material to use for my goals?  What about PEEK?

•What is masseteric-pterygoid sling disruption and should I be worried about it?

•Will there be any loss of movement, muscle swelling, nerve damage, numbness or loss of sensation post-surgery with any of the implants?

•My biggest fear is scarring, I know Dr Eppley said the incision scar for the forehead widening/temporal implants in the hairline would be small and it would not cause missing hair but I need assurances as I have seen two reviews below which talk about bad scarring.  How wide and how long will the scars be in mm?

•Will I need to shave the side of my head for the placement of forehead widening/temporal implants?

•What other risks should I be aware of?

•What happens if the outcome does not turn out right or I am not happy with the result?  Can implants be removed 3 to 5 days post-op? 

A: In answer to your custom facial implant questions:

1) If you have a submental scar from a prior chin implant, that scar will be used as one of the three incisions needed for the placement of a custom jawline implant.

2) There is no other way to place the jaw angle portions of a custom jawline implant but through intraoral posterior vestibular incisions.

3) The lower eyelid incisional approach is the only way custom infraorbital-malar implants can be adequately placed.

4) There is no risk of facial implants being displaced by the normal interstitial fluid contents of the surrounding soft tissues.

5) Silicone is the best material because it can be precisely designed and made and is flexible which is critical for insertion through small incisions in the least traumatic fashion. Stiff materials are problematic for a wide variety of reasons including the much larger incisions and greater tissue trauma to place them.

6) Massteric sling disruption is always a possibility when any jaw angle implants are placed. Such risk is magnified if there is significant vertical lengthening of the jaw angle portion of the implant.

7) All placement of facial implants causes temporal swelling, muscle stiffness, facial distortion, and numbness around the surgical areas. Such expected soft tissue responses usually fully recovery within two months from the surgery.

8) The vertical hairline temporal implant scars are 3 cms in length and usually about 1mm wide.

9) No hair shaving is needed.

10) The biggest risks are aesthetic in nature and include implant asymmetry and lack of desired aesthetic outcomes. (too big, too small etc)

11) You should read the Revisional Surgery form and understand it in detail. No aesthetic outcome can be guaranteed despite the best effort of any implant design and surgical placement. Facial reshaping surgery with implants is the most psychologically challenging form of elective aesthetic facial surgery and can be very stressful for the patient. No revision of any implants are done for three months as the full healing process is not complete by then. You would not be able to tell anything about the final result at just 3 to 5 days after surgery when you are still very swollen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had recently posted a question on Real Self regarding diced cartilage grafts and that there is growing evidence that source of the cartilage has an influence on the longevity of the graft. You had kindly answered my question stating that it makes a difference where it comes from (below link). 

Could you be so kind as to advise which one would hold better in the long run if I am faced between using either ear or rib for DCF? I understand that ear curls, deforms or may shrink on the bridge but I also fear that rib graft will ossify over time. Which graft would give me a better chance of it being permanent.

A: When you dice a cartilage graft tin rhinoplasty the issue of shape maintenance is irrelevant regardless of the donor source…as that is the primary reason it is diced. It is done to both achieve the desired shape and prevent any long-term shape deformation. Whether the donor source has a major difference in longevity can be debated but what is most important is the volume of graft needed. For small nasal augmentation diced ear grafts may be fine but most nasal augmentations in Asian patients require more volume than  even two ears can provide.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached a picture of my nose. This is how it looks every time I smile today – I get a distinct white spot at the tip of my nose. It’s extremely embarrassing in any social situation, because it looks so unnatural and weird. I’ve had three rhinoplasties already. The two first ones were to lengthen my nose, with rib graft. After the first rhinoplasty I didn’t have this problem, but after the second when the nose was lengthen further – that’s when the problem arose. The third surgery was made as an attempt to correct this issue, but with no real success. My surgeon told me he just shortened it 1-2 mm and put some skin grafts on the sides of my tip in order for the tip to not look so pointy and white when I smile. But as I said, it didn’t help. Maybe the tip got a bit rounder, but that’s all, the whiteness every time I smile is still there as you can see on the photo. My last rhinoplasty was a little over a year ago. Now to my questions:

1) Do you think this issue can be fixed by shortening the nose back to the length it was after my first surgery (about 3-4 mm shorter than it is now)? Or do you think it can worsen the problem, since I’ve already had three rhinoplasties done to my nose?

2) Do you think a skin flap/graft will be needed to the tip of my nose in order to make the skin thicker there – or how would you approach this problem, technically? 

30 Have you come across this problem before – is it hard to fix? Do you think my condition is permanent or fixable? 

4 My original rhinoplasty surgeon told me to “pull” the skin of my nose tip 10 times x 10 times a day in order to stretch the skin. He thinks this will fix my problem, but I have been doing this for two months now and I can’t see any improvement at all. Do you think this approach is realistic/promising, or just a waste of my time? 

A:The blanching of the tip skin after rhinoplasty when smiling is very uncommon but I have seen it before. Since the tip of the nose is the most stretched out portion of the nose, when it is lengthened (I assume cartilage tip grafting was done) excess pressure is created on the tip skin when one smiles causing a temporary loss of circulation. Deprojectioning the tip would be the appropriate solution if one can feel a firm cartilage graft under it which would the source of the aesthetic problem. Since it has been attempted once to deproject it and it has not been successful I would assume that any protruding cartilage graft putting excess pressure in the tip has been removed. Further deprojection may be successful but if it didn’t work the first time I would no have confidence that it will the second time. (although not impossible) I would think that placing a small fat graft under the tip skin many be helpful since such a graft is soft and will help improve the circulation to the skin in the long run.

While the stretching the nose tip skin sounds reasonable and it is harmless, I would not think its continued use ameliorating your nasal tip concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you very much for the effort that you have put in to illustrate the estimated outcome of the temporal reduction procedure in my son. I have had a conversation with a surgeon, and he said that narrowing the skull is not possible because it compresses the brain, and I really do hope that this is not the case and that a potential surgery like this does not risk the health of my adult boy in the future.

A: The imaging results I have shown you are based primarily on temporalis muscle reduction with some external bone removal. This is an extracranial operation not an intracranial one. So whatever surgeon suggested to you that it can not one done due to brain compression is misinformed. Most people, including doctors, do not understand that the temporalis muscle makes up a significant amount of head width above the ears with a lesser contribution from the thickness of the bone. It is both a safe and effective procedure that poses no long-term issues for brain or skull growth if done in younger patients like a teenage boy. It also poses no functional issues such as difficult with lower jaw function.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping surgery. Please see the attached picture. I hope this provides an adequate image of my skull shape despite my current hair length (note my hair is very wet and patted down in these images). Please let me know if more shots from different angles would be beneficial. As you can see, my sagittal crest is very pronounced and is noticeable even with a full head of hair. I am looking for a smoother ‘outline’ of the skull, visible from both the front and side perspectives. I am hoping that the bone is dense enough in this area to allow for maximum reduction.

A: Thank you for sending your pictures. What you have is a combined sagittal ridge with a parasagittal deficiency. (actually the parasagittal deficiency is they bigger problem, it only looks like a ridge because of it) This is why sagittal ridge reduction (see attached imaging) of maximal amount (7mms) is woefully inadequate to treat the problem. What you really need is a combined sagittal ridge reduction with parasagittal augmentation. (see attached imaging) The parasagittal augmentation also needs to extend around the back as you have an upper parietal skull deficiency as well. (see attached imaging) Before I saw your pictures I knew this was going to be the overall skull shape problem because, when it showed through one’s hair, it is always more than just an isolated sagittal ridge.

Dr. Barry Eppley

Indianapolis, Indiana