Your Questions

Q: Dr. Eppley, What type of implant is movable, shave-able, and low risk of infection? I am planning in getting a custom forehead implant, 12mms thick on top of my forehead. And also can a brow bone be shaved once the implant is placed?

A: Custom made silicone forehead and other skull implants have proven to be the most adaptable with the lowest risk of infection in my experience. I have yet to see an infection with silicone skull implants. (unlike PMMA and other bone cements) They are made from the patient’s 3D skull CT scan. Whether a forehead augmentation could be as much as 12mm depends on whether the overlying forehead tissue and scalp can safely stretch to accommodate it.

If the brow bone is reduced at the same time or even later by an osteoblastic bone flap technique, it would be important to seal all the opening along the osteotomy lines with hydroxyapatite cements to ensure there is no risk of an air leak up into the implant space. This is not important in brow bone reduction by shaving as there is no exposure to the underlying frontal sinus. (at least there should not be)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old male interested in jaw augmentation surgery, and from reading your very informative blog posts I believe what would best suit me is a custom jaw implant. In broadly qualitative terms, what I want to achieve is an overall squaring of my jaw, an improved definition of my jawline and a strengthening of my chin, increasing the size and ‘strength’ of my lower third. 

In more specific terms, I think this will include: 

-Chin: Broadening my chin; projecting it forward; and increasing its vertical length. 

-Jaw: Widening my jaw laterally, decreasing the gonial angle, and adding horizontal and vertical length to the jaw. 

I don’t believe I’m able to attach pictures via this online form – obviously they are the best way for you to make an initial assessment on how I might achieve those aims, and I’d be very happy to attach them in further emails for your expert opinion. 

Regarding initial questions about jaw augmentation. surgery more generally, could you advise me on the following: 

1) Does the above sound like it would be feasibly achievable through a custom jaw implant? 

2) Could you sketch out the broad timelines that you would expect going from initial consultations to designing an implant to the surgery itself? 

3) I live outside the U.S. – would this present any problems as an overseas patient, and how long would I need to spend in the US pre- and post- operatively? Would I need to travel to Indianapolis before surgery for a face to face consultation, or can all of these be done virtually? 

4) What is the likelihood of infection in custom jaw implants? Typically how often after surgery would any infection become apparent, and what implications would that have post-surgery (i.e. could it likely just be treated with antibiotics, would the implant have to be removed, could it be replaced, etc) 

5) Beyond infection, what are the other main causes of complication in custom jaw implants? How likely are these? 

6) While all elective surgery obviously carries risk, how risky are custom jaw implants in the grand scheme of elective surgery? (apologies if this is too obtuse or vague a question!) 

7) How long lasting are custom implants? Are they designed to last a lifetime, or is it likely I would need a replacement at some point in the future? 

Thanks you very much for any initial information you can provide, and I look forward to talking further. 

A: Thank you for your inquiry. In answer to your jaw augmentation by custom jawline implant questions:

1) Every dimensional jawline change you have mentioned are very typical for most young males.

2)It takes about 4 to 6 weeks, after receiving a 3D CT scan, to design, manufacture and be available for surgery.

3) Most patients in my practice are from afar so your situation is common. The consult and any subsequent discussions are done in a virtual fashion. There is no reason to come here for a consultation first…unless you want to do so.

4) The risk of infection in jawline implants is about 5%. They are always initially treated with antibiotics and most, but not all, can be successfully treated without further surgery. I have a very specific postoperative care protocol to lessen the likelihood of such occurrences as much as possible.

5) Beyond infection all other custom jawline implant complications are aesthetic in nature. (size and symmetry)

6) A custom jawline implant is not risker than other type of standard facial implant…it is just a bigger implant and to some degree has less aesthetic risks than using standard implants.

7) A custom jawline implant is designed to be lifelong device. The material never degrades or breaks down.

I will have my assistant Camille contact you to schedule a virtual consultation time. In the interim please send me some pictures of your face for my assessment and computer imaging for jawline augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering cheekbone reduction reversal. In your expert opinion, would it be risky for me to try and attempt to flip the cheekbones back out after cheekbone reduction? Would flipping it back in place close the gap as well?

A: Based on your 3D CT scans to move the anterior end of your prior cheekbone osteotomies out you would need an interpositional graft and plate and screw fixation. This can certainly be done as in your case they actually removed a vertical wedge of bone through the whole body of the zygoma. 

While that can be done the more important question is what are your trying to accomplish by doing so? If the goal is to provide a cheek lifting effect that is a possible outcome from expanding the cheek back out but such a result can not be assured. The cause of the cheek sagging is that the tissues have been stripped off the bone to do the surgery. Returning the bone to its original position may not elevate scarred and now shortened cheek tissues back to where they originally were as bone expansion creates a lateral soft tissue push not a vertical one. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am starting to prepare for the custom infraorbital rim-midface implant.This is because even tho the result is okay the off shelf orbital rim implant makes the two sides of my face a bit assymmetric and its not fixed with screws either, which I believe it should.

I would like to ask since I have now been through three surgeries in my under eye and midface area…first custom Medpor midface implants, then removal and now the off shelf orbital rim implants. I wonder, do you think I would have enough tissue left under the skin so the result of a custom infraorbital-midface implant still will be looking good?I believe I have read something you have written before that states every time a surgery is being done, some of the tissue dissolve, due to the swelling or something?

I just want to check in on your thoughts around this.

A: My general thoughts are your situation is that every surgery has risks and no surgery ever turns out perfect no matter how many revisions are done. Thus if you have an ‘okay’ result in the more precarious tissues of the lower eyelid and cheek this would give me pause as to considering further surgery. It is all about how much benefit is their to gain vs the risk in doing so.

That being said, each surgery creates scar but that does not necessary mean the tissues become thinner. So I don’t see this as a limiting factor for considering a custom infraorbital-midface implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am quite stuck and I hope you could provide some surgeon’s insight on my situation. After my cheekbone reduction, I noticed slightly deeper tear troughs lines and minor deepening of the nasolabial sulcus. The sagging was minor, but of course I was hoping for none. I’ve been consulting for cheek resuspension surgery. 

Every surgeon I’ve been to, I’ve explained my surgical history thoroughly as well as my surgical goals – which in my opinion are very reasonable. I know the hollower eyes most likely won’t be helped without an eyelid incision, which is something I am not ready for. I’ve accepted it and it doesn’t bother me too much. 

What does bother me is the nasolabial grooves and cheek puffiness towards the front of my face. I think a temporal and intraoral incision cheeklift procedure would help me solve this aesthetic issue. When I push the front of my cheeks outwards towards where the temporal incision would be, I like what I see.

However, the few surgeons I’ve visited have made me start to lose hope. Even with the surgically induced drooping, they state I am too young for a cheeklift and should stick to fillers. I really don’t want to keep going back to the office every 6 months or so until I age enough to actually get my desired surgery done. Financially and time-wise, it would be hard on me to keep getting fillers, year after year after year, as I am only in my 20s. Even if the resuspension surgery would cause major swelling, I would rather just deal with the whole ordeal once and then move on with my life. 

Is age really the only reason why I am being rejected for cheek resuspension surgery, do you think, or is there something more to it? Is there such a big risk for looking unnatural or ‘wind-swept’ if I were to pursue correcting minor sagging of the cheeks after cheekbone reduction. 

I’m really at a loss. I don’t think the end result that I want is unrealistic and since the sagging was instigated surgically, I don’t see why resuspending tissues that dropped would be ‘too much for my age.’ 

I really can’t understand if it’s me or if it’s the surgeons I’m consulting with.

A: While pushing up the cheek tissues towards the temporal region creates the desired effect, it is surgically not that predictable or simple. Lifting of any facial tissues is based on the concept that the tissues are loose and minimally elastic, as in older patients due to aging. In younger tissues they do not move the same way or stay as well even when repositioned. So to a large degree your young age is the reason surgeons are not very enthusiastic about doing any cheek lift on you. It is not a question of whether your goals are unrealistic it is really whether they are possible or worthy of the effort.

Of course there is one way to answer that question..have the cheeklift procedure done as it will either be successful or it won’t. But then you will know for sure. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am happy with results of my custom jawline implant and am now ready to tackle the masseter muscle detachment issue. It appears to me that there are three options available:

1) Muscle reattachment surgery,

2) AlloDerm or similar regenerative tissue matrix,

3) Permanent/ semi-permanent filler ( Bellafill). Each option obviously comes with its own set of pros and cons. Which approach would you recommend?

A: The one option you have left off the list, which would be under #3, is fat injections. I would not use so called permanent filler.

You are correct, each has their own advantages and disadvantages which are as follows:

1) While trying to relocate the masseter muscle is the most biologic of the treatment options, it has a low rate of success and requires the placement of neck incisions to do so.

2) Placing a layer of Alloderm (cadaveric dermis) over the missing muscle area will increase soft tissue thickeness of the implant and requires only a very small incision right at the angle to do so. Alloderm has proven to be non-resorbable.

3) Fat injections requires no incision to place and provide unlimited volume for coverage if one has enough fat to harvest somewhere. Its issues is its unpredictability of survival. This is often the first option to pursue because there is no risk of any aesthetic tradeoff.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in vertical lengthening jaw angle implants. I am curious if you have more before and after photos of men who have had the vertical mandibular implants. I have browsed your website and google image results. My doctor used the old school “lateral mandibular jaw angle†implants. The result was a rounded appearance from the front and side. I feel the vertical mandibular implant gives a sharper “L†shape. I also feel my jaw angle needs to be lowered slightly.

I like the sharp L shape of their jaw angle and then the jaw angle softly slopes into the chin angle. I see in your before and after photos that you lower the jaw angle completely for a continuous angle from the chin to jaw. I like how the chin slopes off fr the jaw angle.

I had the jaw implants removed because the incisions would not heal and I didn’t like the end results of how rounded it looked. You can see in the picture the jaw angle is lacking that L shape. I think my jaw angle would be a perfect candidate for the vertical mandibular implant. I love my chin implant. I was curious what size you would recommend. I know they come in three sizes. I would like a sharper jaw angle but not a continuous angle from the jaw to chin. I prefer the jaw angle that slopes into the chin.

A: Due to patient confidentiality the only before and after pictures that can be viewed as those patients that give consent to do so…and amongst male patients that is a very small percentage. Whomever has done so has already been posted.

When it comes to the vertical lengthening jaw angle implant most men use the large size. It is a standard implant so there is not an option to choose how it slopes into the chin, it will have an effect in that regard based on the patient’s anatomy. Only custom jaw angle implants afford the option to have potentially more control on such shape issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering custom forehead implant but I have a huge concern. Is it possible for someone who underwent a forehead reduction in the past ((via coronal approach, anterior wall of the frontal sinus set back and brow bone shaved) to have their forehead restored as it used to be using a custom implant?

During surgery the surgeon also lifted the eyebrows by taking out a strip of skin from the coronal cut.  Will an implant be able to lower a bit the eyebrows (2 or 3 millimeters) as they were before?

Thanks a lot for reading this and I look forward to your answer.

A: The restoration of a forehead/brow bone shape that has been previously reduced/modified is not an impediment to secondary augmentation surgery with a custom forehead implant.  But replacing soft tissue that has been removed, however, is a different matter particularly in the face of underlying bony augmentation. Lowering the eyebrows in this situation would be viewed as impossible to do. An implant or any other surgical procedure is not going to drive the eyebrows to a lower position. To do so requires more soft tissue of the forehead not bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttock implant replacements. I currently have 550cc buttock  implants and wish to get larger ones as I have a large body frame. (buttock implant replacements)  What is the largest size available and is it possible to make custom sized implants if I would like them larger than the maximum standard size? How is the determination made as to the biggest buttock implant size I can get?

A: There is no exact method to determine what is the maximum buttock implant size that will safely fit, that is a judgment that can only really be determined during surgery. The reality is that the size that will safely fit is probably not going to make you happy. As a general rule no more than a 50% increase in volume should be attempted. That would mean for you around 700cc which visibly would NOT make them dramatically bigger on a large body frame.

It is important to remember that just because you had a first successful surgery without complications that is no guarantee that the next one will have the same outcome. As you push up the load of implant per volume of the surrounding tissues, the risk of complications also increases as well. Trying to take a good result and make it ‘great’ with larger buttock implant sizes runs the risk of significant complications and even loss of the implants. Buttock implants are the one augmented body area where being too ‘greedy’ in size can backfire and have disastrous complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m at 45 year-old male who had Medpor cheek implants for 18 years and had no problems until about 2 years ago. One became infected and wasn’t attached to bone or by screw so it was removed about 3 months later. I’m now at 15 months after having the implant removed and dealing with odd sensations just in my upper lip. Basically everything moves and looks fine but the area on my lip is super sensitive. I feel fine in the morning but as the day goes on and I speak it almost feels like a stretching feeling and I become aware of my upper lip. It’s bothersome but not painful. I’m thinking this is sensory nerve damage but not sure. Will it get better or what are my options for relief?

A: What you are experiencing is infraorbital nerve dysesthesia as an effect from cheek implant removal. Whether it will resolve adequately on its own depends on the linear progression of symptoms over the past year. In other words are the symptoms you are experiencing lessening over time or have they plateaued now for many months. If it is the former you give it another 6 months and see if further improvement is seen. If not then you consider infraorbital nerve decompression (removal of scar tissue around it) with fat graft coverage (a small buccal fat graft) to prevent recurrent adhesions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had surgery for scoliosis in the decades ago. My ribs literally touch my hip bones when I sit or bend. I have a hard time finding pants that sit low enough on my hips in order to keep them from trying to dig in to the very small space that is there. (maybe a finger width). I am looking to help correct this issue which I hope would leave me less boxy looking as well.

A:  What you are describing is known as Costo-Iliac syndrome, a well known ribcage problem in which the lower ribs extend down and impinge on the hip when bending over. Whether this is due to the free floating ribs being too long (rib #12) or being angulated too much downward can be debated. Please send me some pictures of your body/waist for my assessment. By your  very own description the bottom floating ribs could be removed to increase the costal-iliac distance. This may also give you more of a waistline narrowing effect to make you look less boxy. This is most effectively down by removing ribs #10 and #11 as well. Technically this rib removal is subtotal removing the outer half of the rib length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve come across the case study “Derma-Fat Grafting Of Buttock Indentations” from December 4, 2017. I have a very similar case, I have about 3 indentations on my buttocks, it looks like I’m missing part of my butt. My right buttock one is very deep and appears to have a scar/dimple and about 3 inches away from that I have another indentation that’s small. My left buttock side isn’t nearly as bad. I agree with your study on how the indentation happen, I was adopted from Russia when I was a baby, I broke out in chickenpox when I was in the process of getting adopted. I’m sure I was given lots of injections of steroids to cure my chicken pox along with immunizations and etc. I’ve been looking for answers for quite sometime as to why I have these indentations. I want to be able to feel good and confident about my self in a swimsuit along with wearing yoga pants. I’m 21 and will be turning 22 in October. I would like to know if you are able to help me and what an estimate cost would be. Thank you for your time.

A: Thank you for your buttock indentations inquiry. I would need to see pictures of your buttock indentations to provide a qualified answer. But in general fat grafting of some type (fat injections vs dermal-fat grafts) are what is needed to treat the indentations. Dermal-fat grafts do require a harvest site and scar which is fat injection grafting may be more appealing in some cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation and hairline lowering. The problem is that my skull is very small for a man size, around 52 centimeters roughly measured, And I have a very big forehead. I was approaching you to see if I could enlarge my skull, specially the back part and widen the right and left sides. And if it was possible to lower the hairline or decrease the size of the forehead along this procedure. 

A: Thank you for the skull reshaping clarifications to which I can provide the following general statements:

1) Skull augmentation and hairline lowering can not be done together or even separately. One procedure works against the other one. Once one of them is done the other can never be done.

2) Skull augmentation can be done for any part of the head, including the back and both sides using custom made skull implants from the patient’s 3D CT scan. The critical question is what amount of augmentation and whether the natural elasticity of the scalp will permit the placement of an immediate skull implant or whether a first stage scalp expansion procedure is needed to accommodate the implant’s size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been consulting surgeons in my home country to fix cheek sagging that happened after a cheekbone reduction. I hope you can give me advice because I am really stuck and very confused about what exactly I need.I am in my mid 20s and I have received varying responses from different surgeons about what they think I need. I’m not even sure what it is I need anymore.

My major problem areas are deeper nasolabial folds and puffiness around the sides of my mouth. It wasn’t a problem I had before and I would like the most ‘permanent’ solution that I can get.I’ve been suggested temporary fillers, thread lifts, fat grafting, cheeklifts, and more. I’m tossing up between the thread lift and cheeklift.  I was offered a TESS lift which is kind of like a threadlift but using permanent sutures. But I’m worried it will not have as good of an effect as it only tackles the uppermost tissues when I think the deeper tissues need to be moved.

I read on your blog that cheek sagging could be helped with an endoscopic scalp/intraoral technique or using a bone suture intraorally. Are these two techniques applicable in my case and do they tackle the deeper tissues as I need? Thank you.

A: Midfacial tissue sagging is a not uncommon aesthetic problem after cheekbone reduction surgery which is a difficult problem to improve. That is why there are so many different treatment options for it, a sure sign that there is no one universally effective treatment technique. 

The fundamental differences in the treatment approaches for postoperative cheek sagging is whether it provides more of a superficial or deeper aesthetic effect. Synthetic and autologous fillers material exert more of a superficial outward pushing effect which adds volume and fills out the tissues but with only a very limited cheek lifting effect. Implants at the bone level add volume and a more effective checklist but seem counterintuitive give the reason you had the surgery in the first place. Cheeklifts, of which there are a variety of techniques, provide a more effective soft tissue lift as the deeper tissues need to be mobilized. I would avoid placing any type of permanent sutures or threads as at your young age the placement of such materials in the facial soft tissues dos not seem like a good long-term strategy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to partially reverse my v-line surgery.My chin was perfectly fine pre-surgery. My chin was narrowed from the front view which was what I wanted, but my chin was also pushed forward 2mm without discussion.

It may seem silly to undergo another major operation just to reverse this small additional projection. But, because my chin was already aligned with my lips and nose tip pre-surgery and my chin was narrowed so much, I feel my chin just draws more attention. It now sticks out that extra length, PLUS all the soft tissue from the chin-narrowing has bunched up at the front and makes my chin all more prominent. 

My surgeon will not perform another sliding genioplasty as he says it’s not worth the very minor reversal, so I’m looking to go somewhere else. But I’m not sure what surgery path would be best. I am of asian descent and don’t scar well so I would like to know what other options I have to reduce my chin prominence. 

Would intraorally burring or cutting off the 2mm tip that it was brought forward create a hanging chin effect? I know that this may not make that huge of a difference but it would bring me peace of mind. I’m not sure what horizontal chin reduction options exist for people of asian descent.

A: Thank you for detailing your surgical history and current goals. I would agree that you are not going to redo your sliding genioplasty for a 2mm reduction of chin projection…..but you also don’t have to. There is nothing wrong with an intraoral burring chin reduction which is such a small amount of horizontal reduction. As long as the tissues are resuspended back up that should not be a problem. The even simpler approach would be a submental approach to the horizontal reduction where there is no risk of tissue sag but in an Asian female i would not put that submental scar no matter how well it usually heals.

Be aware that the soft tissue bunching effect is not going to improve as this is a normal sequelae of the bony narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have scheduled double jaw and midfacial advancement surgery with a surgeon to correct an overbite and to enhance midface projection. My surgeon has proposed two methods of approaching the midface either though a coronal or a subcoronal incision. I wanted to know what approach would you advise for me to take in regards to having a forehead implant done afterwards by you. I’d like to send in pictures for better evaluation, based on the size and shape of what id eventually want my upper 3rd to look like.

Thank you very much for your time.

A: I assume when you mean ‘subcoronal’ you are referring to a hairline or pretrichial incision as opposed to a coronal incision which is further back in the hairline. Without knowing the location of your frontal hairline and the amount of forehead augmentation you would eventually need I can not provide a fully informed answer. But as a general statement I would say the coronal incision would be better for a male who is planning on getting a custom forehead implant after their orthognathic surgery. Being placed back in the hairline it has better camouflage should the frontal hairline location change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have some midface/maxillary hypolasia and I am mostly interested in augmenting my infraorbital rims (having some more forward projection in my lower and lateral rims, maybe some elevation of the rim and some malar projection as well). Right now I only have this pic available, if you need better ones, please let me know. I live overseas and hope that in the near future I can manage to pay a visit to address this problem. Thank you very much for your attention!

A: Thank you for your inquiry. There are a variety of ways to design custom infraorbital rim implants including raising the height and projection of the bone as well as how far out onto the anterior cheek one wants the implant to reach. What is unique about a custom approach to them is that they can be designed like a ‘saddle’ to sit on the infraorbital rim producing a true 3D effect. While there are no true standard infraorbital rim implants, tear trough implants only provide a horizontal augmentation effect to the infraorbital rim.

I will have my assistant Camille contact you on Monday to schedule a virtual consultation time as well as pass along the cost of such surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It was a pleasure meeting you. You made me feel very comfortable and confident in proceeding with the surgery by exhibiting your extensive knowledge of this uncommon procedure.The pictures reflect exactly what I am looking for; a subtle more feminine change. I will be contacting your office this week to schedule an appointment. I must admit, I am very nervous about the intraoral approach after our discussion. Of course I have been researching this procedure for years at this point, and I am continuously running into horror stories about losing feeling in the lower face, and things of that nature with intraoral surgery. I know you mentioned the scar if we were to go with a submental approach, but the scar almost seems more appealing since once you said the submental approach is a direct visual of what you’re able to work with, also that you’re able to tuck in any excess soft issue/skin.

I have just a few questions that I failed to ask at the consultation (possibly due to nervousness): 

– Are there any difference as far as possible risks/complications between intraoral and submental? 

– Any differences with the healing process between the two options?

– Is there a higher chance of nerve damage with the intraoral approach?

– Does the procedure cause premature sagging or complications in the future? Of course I will be happy with a change for now, but being 26, I feel that the future is also very important.

Thank you so much! I truly look forward to working with you, I’ve heard that you are simply the best! 

A: In answer to your chin reduction questions:

1) The fundamental differences between the intraoral and the extraoral submental approach to chin reduction are a modestly higher risk of mental nerve injury (feeling to the lower lip) with the intraoral approach, the skin scar with the submental approach and a more profound bone reduction with the subcentral approach.

2) Neither of these procedures have any long-term skin sagging issues as that is addressed by the excision of extra soft tissue with the subcentral approach and the maintenance of soft tissue attachments with the intraoral osteotomy approach.

Dr. Barry Eppley

Indianapolis, Indianapolis

Q: Dr. Eppley, I have had problems for over ten years with chronically peeling, inflamed lips after taking the acne drug Accutane. I have been extensively assessed by doctors and no ongoing physical cause can be found. My upper lip causes me the most discomfort and when I exhaust all other options, I will be looking into the possibility of surgical treatment.

How feasible is this? I understand that a conservative approach can be taken by taking away a strip of vermilion, but if this failed, is drastically reducing the size of the lip (from relatively full sized to very thin) a realistic option?

A: Thank you for your inquiry. Because your lip symptoms are caused by a medication, this indicates to me that the entire dry vermilion is involved. (unless you can identify focal areas of dryness/peeling) Thus removing a strip of vermilion would seem to provide little improvement. (although it would be a conservative approach) But if that failed then you would to consider removal of all of the dry vermilion (lip resection) with a mucosal advancement flap like is done in cases of lip dysplasia/cancer involvement. The elasticity of wet mucosa allows it to stretch forward towards the vermilion-cutaneous junction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding a prominent ribcage and breast implants. I’m only 4’9 and 90 lbs,my rib cage measures 29 inches which for my frame is quite large and my breasts are about a 34a..My question is would breast implants help balance out my upper body and maybe help to make my rib cage less wide? Thank you.

A: While I have no knowledge as to what your exact body looks like, it would be logical to assume that larger breasts would help to camouflage a more prominent ribcage that lies below them. While the location of the flare of the ribcage lies well below that of the breasts, if the ribcage sticks out more than the projection of the breasts one could easily assume that increasing the size of the breasts would be of benefit.

This is a body contouring question I have heard numerous times before and, having done breast implants in such patients, my and the patient’s observation has been that it has been effective in that regard. It does not completely eliminate the ribcage protrusion, as it obviously does not affect It directly, but does provide a camouflaging effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having my chin reshaped (reduced) in order to correct asymmetry of my chin. I had x rays taken and my chin is 12mm off center. I had a consultation with a doctor and was thinking of having a sliding genioplasty procedure but I read a lot about it online and it seems like so many people have a terrible experience with the genioplasty, long term swelling and numbness, change in shape of their lips and need for revision. Alternatively I could use filler to even out the asymmetry but I think that will make my chin too large (less feminine) and I won’t be happy with it. I was reading instead about the possibility of having the bone reduced instead and I’m wondering if this is a less invasive procedure than the genioplasty with less side effects? To me it seems like it would be a lot less invasive than moving the bone but maybe it is not… Thanks!

A: The short answer to your question is that it is more important to select the chin reshaping procedure that fixes the problem the best, not the one that is least invasive. if the two options produced equal results (which I am sure they won’t) then of course you choose the least invasive. The aesthetic outcome of moving the bony chin back to the midline or shaving down the more asymmetric side may not have equivalent results. I would need to see pictures of your chin and x-rays to provide a more qualified answer for your chin reshaping needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know all the options of webbed neck correction. I have a webbed neck, but I don’t have Turner’s Syndrome. I’m 32 years old. I also want to know how people are born with webbed necks without the syndrome. No one in my family, including my children, have this deformity, except me. I am interested in the cost of these procedures, too.

A: Thank you for your inquiry. I have seen webbed necks before in patients that don’t have classic Turner’s syndrome. This is known as mosaic Turner’s syndrome. While Turner’s syndrome involves a completely missing X chromosome, mosaic Turner’s syndrome is where the abnormalities in the X chromosome only occur in some of the body’s cells. In this situation it is possible to have a webbed neck without any or very few of the other signs of Turner’s syndrome. Whether this applies to you I can not say.

I would be interested in seeing pictures of your neck to determine if webbed neck surgery correction would be successful for you.

I will also have my assistant Camille pass along the costs of webbed neck surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the list waiting to my scalp advancement and brow bone reduction and other procedures. My questions are about this 2 i mentionx today only want to reafirm with the first goals: 

– Scalp advancement with the maximun advance as i ask before using the technique one dr name frost (a minimum advance of 3cm at least).

– You tell my the burring technique can get the amoung of reduction of brow bone protusions (i measure the reduction like 4mm)

Thank you soo much!

A: In answer to your hairline advancement and brow bone reduction questions:

1) The goal of almost every frontal hairline advancement is the maximum of whatever the scalp elasticity will allow. It is very hard, and I have never seen it, where the frontal hairline is advanced too much or makes the forehead too short. The technique that is used in every case that I have ever done over the past two decades is what is decribed in the ‘frost’ technique. There is nothing new or novel about that method as that has always been the way it had been done. That being said how much hairline advancement you can get can not be precisely predicted before or guaranteed. In the end the inherent elasticity of your scalp plays as much a role as any technique used to move it.

2) With the burring technique the maximum amount of brow bone reduction is determined by the thickness of the anterior table of bone over the frontal sinus. Whether the thickness of the bone over the frontal sinus will permit a 4mm reduction can only be determined before surgery by an x-ray. This is a pertinent issue over the inner half and central brow bone areas where the frontal sinus exists. It is not an issue over the outer half of the brow bones which are solid bone and without an underlying sinus cavity. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in jaw implant augmentation and am hoping you can point me in the right path. I’m not from the US and love your work but I would feel more comfortable with a surgeon a bit more closer to home.

There’s only 2 surgeons in my country that provide custom implants. One surgeon is on the other side of the country and is trained in oralmaxillofacial surgery as well as plastic surgery. The other surgeon is within 90 minutes of where I live and background is mainly in oral maxillofacial surgery. Their use is for aesthetic purposes after corrective jaw surgeries but can also be used for primary augmentation purposes.

I understand that the experience of the doctor and work examples and having that good connection is key. But would it be safe for someone not trained in plastic surgery and plastic surgery aesthetics to perform augmentations for areas such as the jaw?

A: The direct answer to your question is the surgeon’s specific training (plastic surgery vs. oral maxillofacial surgery) is not as important as their experience in performing this very specialized type of facial surgery. If they do not have extensive experience in the designing and placement of custom facial implants the complication rates are high regardless of their surgical speciality.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am exactly 3 months post-op from a cheekbone reduction. My cheekbones were reduced with an L shaped bone cut which removed 4mm of bone from each body of the zygoma.

I’m not very happy with my current results but I’m not sure whether I am in the right position to be judging yet. A lot of doctors I’ve consulted say that my results now are pretty much the final results with unnoticeable changes to occur in the next 3 to 6 more months. Others say that I will see noticeable difference between now and 6 months post-op. I’m not sure what to believe.

I’m only 22 and I had no wrinkles next to my nose prior to surgery. At 3 months, my cheeks look puffy and slight nasolabial wrinkles have appeared. I think that the excess soft tissue that was suspended outwards fell downwards as the 4mm of bone projection was removed. Nevertheless, it is not an acceptable tradeoff for me. 

Is it too optimistic to hope that this completely resolves in the next 2 or 3 months? Could it possibly be due to residual swelling and may go away with further time and tissue contraction? My soft tissues I think are quite thick and I’m not sure if that made me more prone to soft tissue sagging.

Fillers for the rest of my adulthood is not an option for me and a cheeklift seems quite extreme. I have no jowling around the bottom area of my face, it’s just the nose wrinkles that are of concern to me. ‘m scared that my cheeks will look unnaturally pulled upwards and wide if they are pulled towards the temple. 

If I were to get my pre-surgery CT scan and got custom implants to restore my original bone structure, would this lift the tissues back out and resolve my current issue of the nose wrinkles? I am still quite young and I don’t think my tissues are stretchy and loose. Is it possible to resolve this wrinkling issue with just implants?

A: In answer to your soft tissue changes after cheekbone reduction surgery, which I have heard many times, I can provide you with the following two specific guidances:

1) The only way to know whether the soft tissue effects you see now, at 3 months after surgery, are the final result or will improve is…time. Give it a full 9 to 12 months and you will have your definite answer. Any opinion about that issue short of this time period is just that,,,an opinion not a confirmed fact.

2) Whether custom designed cheek implants will completely correct these soft tissue changes caused by cheekbone reduction can not be accurately predicted beforehand. But partially or fully reversing the cause (loss of bone upper) wold be the most anatomically based approach to the problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower facial reshaping surgery. My concerns regarding my chin/ jawline/ lower portion of my face are related to my profile and front views. From the side, I would like my jawline to look more defined, thinner. From the front, I would like my face to look thinner as well. I feel that my face from the front looks bottom heavy, I have jowls and marionette lines, even though I’m 36 and I am not, nor have I ever been, overweight-  I’m 5’6” and weigh 125 lbs.

I’ve have had these issues even when I was young so I think it is more an underlying lack of bone. The chin is possibly too short and/or too recessed than an actual aging issue. I also think I have fatty deposits in my jaw/chin/neck area.  I have looked into chin implants, sliding genioplasty, neck/chin/ jowl  liposuction and buccal fat pad removal. I feel that while the research has helped me to better articulate my concerns, it also has me confused as to what treatments would be most appropriate for my specific case.

A: Thank you for sending all of your pictures for lower facial reshaping. The key determinant in deciding what procedures to do for any facial reshaping is what are the dimensional changes needed from a 3D standpoint. If you want your jawline to have more horizontal projection (side view), be thinner from the front view as well as adds some slight vertical length , you have narrowed it down to the only two procedures that are capable of making that type of dimensional chin change…a sliding genioplasty or a custom made chin implant. Neither chin augmentation method will address the perioral fullness or jowls so microliposuction of these areas would have to be added to it as well. The role of buccal lipectomy is for reducing fullness below the cheekbone as the fat pad does not extend down to the mouth or jawline level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin reduction with bone removal a long time ago. I had a large amount of tissue that ended up causing chin ptosis and I had another surgery to try to lift and remove some of the tissue. Now my chin is not drooping but it is vertically long and uneven with dimpling.With aging and early signs of jowls my lower face looks square and masculine. I’d like my chin to be shorter and more narrow. My face lifted and more oval appearing. My chin is mostly scar tissue so I’m not sure any correcting can be done. I would like to know what could be possible. Thanks!

A: Thank you for your inquiry. I would need to see pictures of your chin and face to determine what can be done. But ti sounds like all of your prior chin eduction efforts were done from an intraoral approach, resulting in chin sagging and the need for soft tissue resuspension procedures. The best approach now, and even then, is an external submental approach where the redundant soft tissue can be more effectively managed. While additional soft tissue can be removed, the chin pad dimpling is probably not improveable.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a mild/moderate case of cutis verticis gyrata on the top of my head consisting of four ridges going from my temples to the rear of my head. Through research i found that you do fat grafting to minimize the grooves. I am begining to lose my hair and would like to have a relatively normal shaped head so that I can shave it without feeling self conscious. Do you have any before and after pictures of this procedure and approximate cost? I live out of state so it would be difficult to be there for a consultation, any info would be greatly appreciated. Thank you.

A: There are no known effective methods that are proven to reverse or partially reverse the effects of cutis verticis gyrata. I am treating such cases with linear groove release and fat injections but the success of that treatment approach, as logical and biologically based as it is, remains to be further evaluated long-term. Short-term results show good improvement, although not complete smoothing of the scalp, but its long-term effects remains to be seen. In particular will secondary fat grafting be needed for further improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had three attempts at chin augmentation with silicone injections; none have worked. Unless silicone oil has been improved and attachment techniques have improved, I need a bone implant. I need consultation to determine the next steps for chin augmentation.

A: Thank you for sending your facial pictures. You have a significant case of lower jaw/chin deficiency for which an injectable filler approach to itsaugmentation was never an option that was going to be effective. It is hard to imagine who would have tried an injection approach on you when your horizontal chin deficiency is at least 15mms if not greater.

Given the magnitude of the deficiency you are much better off with a sliding genioplasty than a chin implant for your chin augmentation. If you combined that with a lower neck-jowl lift the degree of improvement would be substantial. Bringing the chin bone out with its muscle attachment would help your neck significantly as well as that of your profile.

If a chin implant was being considered it wold have to have a design that provided substantial horizontal projection but with no lateral wings to avoid making the chin too wide.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implamts. Here are some photos to give you a general idea of how I look.  All things considered my jawline doesn’t look all to bad in these photos. My main concern is definition, I’d like there to be a more defined separation between my neck and head while at the same time improving the angularity of the jaw, helping to balance the look of my large nose while improving my overall appearance, namely in the area where the ear appears to connect to the jaw.  I’d like this to be a subtle change, one that is additive while not altogether making me look entirely different, rather an improved version of myself. I’m actually very excited to hear what you think of all this and any recommendations are very welcome.

A: Thank you for sending your pictures. By your description and the pictures, it appears that you are referring to jaw angle augmentation….and that appears to be largely about width. Your jaw angles appears to have adequate vertical length. Standard widening jaw angle implants would appear to be sufficient for your aesthetic needs. Although I would point that your result is not going to look like Tom Cruise’s jawline afterwards.

Dr. Barry Eppley

Indianapolis, Indiana