Your Questions

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

Q: Dr. Eppley, I wasn’t happy with the results from my jaw reduction surgery and am now looking into jaw implants for restorative purposes. I would like to make it clear that I would like to make improvements on my current physical appearance but not return completely to my facial bone structure pre-surgery.

I am debating between custom silicone jaw implants or using PMMA cement for jaw augmentation. I understand that bone cements are quite hard to shape intraorally, but my case might be the exception as I had my current jaw structure 3D printed in life size on a trip to China I had. 

I read somewhere that PMMA could be pre-formed and I think my 3D printed jaw could be extremely helpful in this case and eliminate the need for custom silicone implants.

I was wondering, is it viable to have my own implants shaped from PMMA cement this way? Using my own 3D printed jaw bone?

Can PMMA bone cement inserted through the mouth have a high chance of presenting infections later in life? (e.g. through trauma and such) I am looking at this surgery as a lifelong restoration and would hate if I had to reopen my incisions over and over due to infections.

Lastly, I am worried about the possibility of masseter muscle disinsertion (through placement of the implants and/or from having to take them out and reinsert them in the case that infection does occur.) Is this a common problem or not-rare occurrence in jaw augmentation surgery? I hear it is a very difficult problem to fix in the case it does happen, but I would still like to length my jaw (not widen) by 7~10mm or so.

A: In answer to your subtotal jaw angle restoration questions:

1) With a 3D CT scan or 3D model, a custom design can be done for either silicone or PMMA.

2) PMMA, otherwise known as plastic bone cement, can not be accurately shaped on an intraoperative basis.

3) There is no value to a PMMA implant either in design or material compoisition. The body is not going to attach or grow tissue into it. It does have a major disadvantage, it has a much higher infectivity risk than solid silicone.

4) Having had a prior jaw angle/line reduction, your risk os massteric muscle is substantially increased for vertical jawline restoration over primary jaw angle implant placement…with a risk probably close to 50%.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Why do I have excess fat on my chin, the chin as in the middle part.It looks like a blob of fat and it’s circular and unpleasant in my opinion. 🙁 Is there anything that can be done to make it smaller?

A: I can not tell you why it is there but I can tell you what it is. What you are describing is the chin soft tissue pad which sits over the end of the chin bone. It is made up of skin, fat and muscle which is stretched out over the bone between the lower lip and the neck. It subcutaneous component varies amongst individuals and some people do have a disproportionate amount of it making it more prominent in some chins.

In large chin soft tissue pad development, reduction in its thickness or prominence may be aesthetically desired. The problem with trying to thin the chin soft tissue pad is that it runs the risk of ending up dimpled and irregular in contour shape, particularly with motion. As a result reduction of the chin soft tissue pad is usually discouraged. This is also true when liposuction is attempted to reduce its thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask a question regarding bony forehead reduction reshaping/reconstruction. My forehead bulges outwardly like that of a beluga whale and I was wondering is there anything that can be done to alter the appearance of it so it’s mess convex and more smoother/flatter. I was reading about scalp advancement and burring of the frontal bone.I’m not sure that will work in my case as my forehead isn’t like a normal one. Please advise.

A: Please send me some pictures of your forehead for my assessment and recommendations. I have seen many cases of frontal bossing and I have not yet seen one where improvement in its shape can not be done.

Reduction of a protruding forehead is done by removing the outer table of the skull bone. Whether that would be enough of a reduction to make a difference in your case remains to be seen. Ultimately a lateral skull film x-ray is needed to see the thickness of the outer table and to see how much shape difference its removal would make.

But in most cases of bony forehead reduction the amount of bone removed that can be done is usually enough to make a very visible and satisfying difference in the amount of forehead protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face is quite wide and I am interested in cheekbone reduction. I’ve done quite a bit of research online about the different techniques that exist and have read some studies online so I know exactly what I am getting myself into.

I’ve read that the L osteotomy cheekbone reduction is quite commonly used and involves taking out a wedge of bone up to 8mm wide. I would like to get my head wrapped around one thing however.

When the cheekbones are reduced, logically there is now excess soft tissue whether it’s from reducing 3mm of bone or 8mm. Where do these excess tissues go as I’ve read some people sag, some people don’t.

Do the soft tissues shrink wrap in size and how long does this process take?

Or does the soft tissue just fall downwards and create a sag that is only noticeable in some people?

A: It is important to remember that when any facial bone structure is reduced, there may be soft tissue consequences for the loss of bone support. This is particularly relevant in the chin, jaw angles and cheeks of the face. So your question about whether soft tissue sagging could occur with cbeekbone is relevant. There are numerous factors which can affect whether it occurs or not such as the amount of bone removed, the extent of the subperiosteal tissue dissection, whether soft tissue resuspension is attempted and the patient’s anatomy. It does not always occur and, even if it does, it may or may not be of aesthetic concern to the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor orbital rim implants placed just over a year ago, and my experience with them has not been positive.

The left and right sides of my face were completely numb for 3-4 months, and since then the left side has been very tingly/sensitive to the touch with no improvement. My under eye areas also always feel irritated and “full,” almost as if I always have eyelashes in my eye. Since the operation, when I look straight down I see double, and I have noticed that I now have mild scleral show in my right eye. The muscles in my face/eyes are fully functional and I have feeling everywhere, just not 100% on the left side.

I have read that it is possible that the infraorbital nerves might be being compressed by the implants, and if that is the case, could removing them cause even further damage to the nerves? Also, would removing the implants after more than a year improve the symptoms I am experiencing? 

Thank you so much for your time and consideration.

A: You did not state how your infraorbital rim implants were placed based on the symptoms you are describing. Injury or compression of the infraorbital nerve causes sensory changes such as numbness. Scar tissue and too much volume can cause lower eyelid refraction and other eye symptoms.

Whether removing them will alleviate your symptomatic concerns can not be known beforehand. One piece of information that would be helpful would be a 3D CT scan which can show where the implants sit relative to the infraorbital nerve canal as well as the implant sizee and surface area of bone coverage.

The other factor in whether you should consider implant removal is their aesthetic outcome. If it is good then that should give one pause. But if they have not achieved the desired aesthetic effects and you have these symptoms as well then removal should be more strongly considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will cheek implants cause my eyes to look hollow and sunken in? If they are too big, this might happen. 

I would like to know if I need to wait for the cheek fillers I have in to dissolve. The small shape in my cheeks I do have is because its Voluma.  Do you need my face to look at its original shape or lack thereof?

I cant afford to stay overnight for more than a day or so as well for financial reasons. I have to probably get a hotel for the trip on my there and back as well. 

A: In answer to your cheek implants questions:

1) The placement and size of a combined malar-submalar implant determines how that night affect the eyes. Although hollowing of the eyes is not a typical or expected sequelae from their placement.

2) Whether any fillers in place need to be removed or not prior to Chee implants depends on how much filler is present and how long ago it was placed.

3) There would be no need to stay in town overbite unless you are by yourself and have to drive home.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some brow bone reduction questions. So if I were to undergo brow reduction surgery, would the metal plates in my head prevent me from getting MRI’s?

What are some other things that might result from getting this surgery? I read somewhere that the forehead becomes a bit “loose” because brow reduction decreases surface area. I suppose sort of like the opposite of a brow lift. Is this true?

Will I be able to function normally after I heal (head the soccer ball with my forehead, dive underwater, sneeze, blow my nose, etc)?

Also, may I see some pictures of what the scar may look like post surgery? I know the scar will be somewhere within my hairline, but I’d like to know if it’ll be noticeable.

A: In answer to your brow bone reduction questions:

1) The metal plate used injections brow bone reduction is made of a titanium,  a non-ferromagnetic metal. It will not interfere with getting an MRI or any other x-ray study.

2) There is no truth to the statement that the forehead becomes ‘loose’ after brow one reduction surgery.

3) You should be able to perform all physical activities without restriction after surgery. But I would wait a full 6 months after the surgery before having your head hit by a soccer ball.

4) There are two location for the incision for brow bone reduction surgery, at the hairline (pretrichial) or within the hairline. (coronal) Each incision has its own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I do however still have some questions with regards to the lower blepharoplasty procedure.  My surgery is tomorrow and I’m flying out late tonight.  I hope I get to address these with you.  I really appreciate it.

After searching the limited info online about Alloderm, I read that alloderm is not permanent?  (If true, I don’t see the benefit of going with alloderm and assuming the risk of rejection and higher risk of infection).   Therefore, in the OR can we correct my hollowness by trans-positioning my fat pad and if I don’t have abundant fat pads what are other options (but not fat injections cause I dont want lumping)   Is there any permanent solution for the hollowing that would look natural?  Would that be a tear trough implant?

Another question is that my lower eye skin is crepey like ,very thin and  not tight.  Can I expect the lower blepharoplasty to address this? or Can CO2 laser be an alternative to the lower blepharoplasty?  I read online that worse crepy appearance can occur after the swelling of the lower blepharo procedure goes down. (is that true?) Is it important for you to assess the quality of my under eye skin to determine which is best for me?

Also with regards to the cheek lift  I found this picture on your website with the following description of a 47 year old female that had a cheeklift done through lower eyelid incision.  The cheek tissues were lifted up and sutured high up onto the cheekbones to a reabsorbable screw.  Would this be the technique you would use for me for my cheek lift?

A: Let me address/answer your lower blepharoplasty quesrions:

1) I have never seen Allodem resorb in the lower eyelids.

2) You probably do not have enough lower eyelid fat for transposition without running the potential risk of increasing lower eyelid hollowness. But that determination can not be made except during the procedure.

3) A tear trough implant is not appropriate for a thin-skinned hollowed lower eyelid as it will not look natural. The role of Alloderm is to serve as a method to address the lower eyelid hollowness that will not have the same risk of that of an implant.

3) While the lower blepharoplasty will improve some of the lower eyelid loose skin/wrinkles, it is not going to get rid of of all of them. My concern for you is that I don’t think you may have a realistic expectation for your lower eyelids. You can’t improve all of the aging concerns without the risk of other complications. (lower eyelid retraction, irregularities) While one can be aggressive on the upper eyelid, you must be more conservative on the lower eyelid to avoid problems. And being more conservative means you have ti settle for subtotal improvement.

4) The type of midface lift you have highlighted is as direct midface lift with fixation to the orbital rim. I just don’t use a resorbable srcrew anymore because it is very palpable for months.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in paranasal implant revision. I had Medpor paranasal implants placed one year ago. My surgeon told me that it is an implat on each side of the nose.I also had an open rhinoplasty at the same time.

Here are comparison pictures I took around 2 weeks after my surgery last year in June (I was extremely happy with the results) and around a month ago. The lighting is different and I put on around 5 pounds but I feel like since the swelling went down, I actually find the results less optimal (especially the fact that my nose still looks a bit droopy like before surgery and the nasolabial folds came back more than I would have liked)

A: Thank you for sending your pictures and detailing your surgical history. It is not rare that the facial fullness caused by midface implants early after surgery is very appealing due to its wider overall effect. But when the swelling goes down the effect is much less. I don’t know the premise for why you had paranasal implants but the treatment for nasolabial folds would not be one of them. Their primary purpose is to bring out the base of the nose which can have some slight improvement of the triangular fossa at the top of the fold next to the nose. But that effect will usually be very modest. Whether a more profound midface effect could be obtained by paranasal implant revision with a different implant design or size depends on knowing the exact paranasal implants you have in now. If they are Medpor paranasal implants they only come in one size although they may have been modified in surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wasn’t aware that cheekbone reduction surgery was offered in the US as it is rarely heard of and is over shadowed by cheekbone augmentation. 

I hope you can help me as I am worried for my face. I’m one week away from being 3 months post op from cheekbone reduction. My zygomatic body was reduced by 5mm on both sides, pushed in and fixed with screws after a temporal cut to the end of the zygomatic arch (also fixed).

Two or three weeks after the large swelling went down after surgery, I noticed that my nasolabial area looked like there was wrinkling. I asked my surgeon about this and he said it was due to all the swelling in my cheeks. This being such a major surgery, I simply nodded and brushed it off and returned to my home country. 

Now that I’m so close to the three month mark, I am starting to get nervous. The nasolabial puffiness/wrinkling improved only slightly since that time I consulted with the doctor about it, but they are still deeper than it was before surgery. Specifically, the malar bag area seems slightly puffier than before and I’m not sure if it’s residual swelling or slight sagging as I’m only in my early 20s.

I consulted with two plastic surgeons in my own country, though they do not have experience with zygoma reduction. 

One surgeon said that three/four months would generally be the result I’ll have. He explained that the tightness of the zygomaticus minor and major loosened after moving my cheekbones inwards, so the puffiness was not a surprise as they wouldn’t “tighten”. Moreover, a cheeklift was not suggested but adding cheek implants (though it seems counter intuitive to add cheek implants after I went through surgery to make them less prominent.)

The other surgeon said swelling would last up to one year to 18 months, then showed me out with no other suggestions. 

I hope you can advise me on what to do, with your experience of performing this surgery. Is it possible that I still have residual swelling at this point and should wait a couple of extra months or would the swelling have dissipated by now? 

Or at 3 months is this pretty much the result I’ll have. Would an extra 3 months waiting show any noticeable improvements in your opinion?

A:The short answer to your question is, while it takes 6 to 12 months to appreciate every final detail from any kind of facial bone surgery, what you have is largely the result it will likely be. While cheekbone reduction surgery is effective at narrowing their prominences, the cheekbones are midfacial skeletal structures that provide soft tissue support. As a result in some patients the tradeoffs for such maneuvers are associated soft tissue changes which always is in the downward direction most commonly sagging in the lower cheek areas often seen as a more prominent nasolabial fold.

Dr. Barry Eppley
Indianapolis, Indiana 

Q: Dr. Eppley, I am interested in thigh implants. I wish to increase the volume of the thighs, the front and the back, I am aware that there are limitations and that everything is not possible at once. The front of the thighs, so that they grow wider would be desirable. I understand that it is probably not possible to do both the front and the back of the thighs at the same time. 

A:Thank you for sending your pictures and detailing your thigh implants augmentation objectives. You have now have thigh-calf disproportion after your calf implants. Augmenting the calfs is a very successful procedure because there is one defined muscle belly and the implant-muscle ratio is fairly high. (a lot of implant for the size of the muscle) Thigh augmentation, while it can be successfully done, is not as easy to get such a good result as calf augmentation because there is not one muscle that makes up the thigh and any implant-muscle ratio is going to be much much lower than that of the calfs. 

That being said, there are two fundamental approaches to thigh augmentation. The most biologic approach, although not one that produces the most augmentation, is to place the implant under muscle fascia. (which is always preferred in implants if possible) This largely leaves the rectus femoris muscle on the anterolateral thigh which is the largest muscle belly. The other approach is to ignore subfascial placement and place it on top of the muscle fascia. In this way a larger augmentation can be done as it does not have to stay within the defined underlying muscle fascial borders. It has a slightly higher risk of infection and implant show although the latter can be overcome by implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would such 3D custom facial implants still have a risk of asymmetry after they are inserted? I have been told that as the implant is printed to perfectly mold to every crevice and shape of your own bone, there would be no need for fixation.

A:It does not matter how any 3D custom facial implants are made or their material, they all have risks of asymmetry as they still have to be surgically placed through limited access incisions. Such surgery is not like Lego Blocks or mounting the implants on a skeletal model, they don’t just snap into place. It is far harder to do than it looks due to the presence and importance of the overlying soft tissues and the limited visualization to the bone sites that the surgeon has. A 3D design process makes it look ‘easy’ because you are just looking at the bone model but that has little to do with actually doing the surgery to place them.

And, quite frankly, whomever made the statement that they don’t need fixation because they are perfectly made to the shape of the underlying bone has either never done such surgery or has very limited experience as that is simply not true.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about liposuction irregularities.  i had liposuction 1one year ago to abdomen, then liposuction to flanks and low back. he second liposuction was done three months ago and has left me with irregularities and lumpiness, I suspect due to over aggressive treatment…can you help me? I am in great shape, muscular, thin and healthy, no meds.

A: Some modest irregularities after liposuction are common based on the quality of one’s skin before the procedure and how agres. But if they are significant they often occur in thinner patients where more aggressive liposuction has been done in an effort to maximize the contouring effect on an already thin subcutaneous fat layer. Once this has occurred it is a very difficult problem to improve as further cannula releases and smoothing efforts often will fail or at best produce a very modest improvement. Ideally the best improvement for liposuction rregularities comes from subcutaneous releases and fat grafting but this is both counterproductive to the original procedure and such patients often have no fat to harvest to do so. I would need to see pictures of the liposuction areas to provide a more qualified answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My mother wanted to know if you would recommend anything for her aging eyes, Specifically the hollowness around the upper and lower eyelids. 

A: Thank you for sending your mother’s pictures which shows hollowness (loss of volume) on both the upper and lower eyelids. The question is what type of material/graft can be used to add volume to these area. On the upper eyelids it would unequivocally be fat grafts as the upper eyelids have a lot motion so anything applied there needs to be soft. The only debate there is whether it should be done by fat injections or the open placement of a dermal-fat graft. On the lower eyelids options include fat, tissue bank dermis (Alloderm) or implants. Unlike the upper eyelids the lower eyelids don’t move much so they can tolerate grafts or implants. The one requirement they do have is the skin is thin so whatever is placed there must be smooth. For this reason I would favor cut sheets of Alloderm or autologous dermis to lay under the entire lower eyelid and down into the infraorbital-cheek junctions. Many surgeons inject fat into this area but my experience is that often ends up lumpy and puffy looking.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant put in twelve years ago and I have had intermittent pain and numbness from what I believe was a severed nerve. I read a post that you wrote for another patient’s question that sounded like he or she was in exactly the same situation. You referred to it as neuroma. Can you fix this? If a virtual consultation is better in this situation then I am open to that. Thank you.

A: Being this late out from a mental nerve injury and possible neuroma formation can only be treated one of two ways; 1) neuroma resection and direct nerve repair or 2) neuroma resection and a cross-mental nerve graft. The latter would likely more effective at this late date after the event. Whether either one of these nerve treatment approaches would be reasonable depends on the severity of your nerve symptoms. With symptoms that are intermittent in nature, at the least you should get a 3D CT scan and confirm the position of the wing of the chin amount in that side. I would suspect it is right up against the nerve. With mild symptoms simple nerve decompression can be tried by getting the implant off the nerve for your chin implant nerve pain.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get a sliding genioplasty or maybe shaving plus fillers (on the front, not on the angle of the chin). I want vertical shortening and minimal increased projection (~3 mm) and a bit more definition/chiseling on the front view. I got a rhinoplasty last August, which gives the illusion that my chin is larger. I like my side view way better but the front is worse. I’ve done a lot of research and without a doubt I am going to do something. 

A:Thank for sending all of your pictures. As you may or may not recall this is not the first time that I have seen them. Based on your own imaging and desired goals (vertical shortening and increased horizontal projection) the only treatment option would be an intraoral sliding genioplasty if one wants to use their own bone to accomplish both types of dimensional changes. The other alternative would be a submental approach from below with an inferior border reduction with the addition of a small 3mm central chin implant.

But I think a sliding genioplasty would be the bette choice as it addresses both concerns in a single procedure without an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are you familiar with or have you ever had experience with Parry Romberg syndrome? I’m a 38-year-old male patient (victim) with this disease. I had a muscle flap surgery in my 20s which failed and have had no other procedures since. There is a significant asymmetry as my right cheek has major atrophy in the soft tissue. I was wondering if a custom implant could be made to improve my looks. I’ve never wanted to go through surgery again but I was hoping new technologies may hold some hope for me.

A:  I am very familiar with Parry Romberg syndrome and have seen and treated many cases of it. Thank you for sending your pictures, you did very good with them. It appears most of the atrophic defect is in the soft tissue and not involving the underlying bone.  

You have a couple of options that would be far simpler that the initial free muscle transfer that was tried years ago. They include the following:

1) Dermal-Fat Graft placed through a nasolabial fold incision. I can’t tell if there is a scar along the nasolabal fold more not.

2) Dermal-Fat graft placed intraorally.

3) Injection fat grafting to the whole right cheek area

4) Custom midface implant (although the defect does actually involve bone. The concept is to try and push out the overlying soft tissue.

The easiest and probably first option to try is #3, injectable fat grafting. While unknown back in the time when you had your muscle transfer surgery, this is common today and is a standard approach for facial soft tissue defects of almost any kind and location. Its success in Romberg’s disease is variable because of the thing atrophic tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have inquired previously about custom implants however I have my concerns about custom jaw implants such as bone erosion and the fact they negatively impact with age so I am looking toward the chin wing osteotomy surgery option. I would like to know if you can perform a side wing (not increase the vertical size of the frontal part of the chin) but simply increase lateral jaw width and length.

I am interested in having this procedure and then repeating it for further adding width and length to my aesthetic goals. Can you do this procedure and how much does chin wing cost? 

A: Besides the fact that your concerns about jawline implants are unfounded, a chin wing osteotomy can add no width anywhere along the jawline and does not make any change back at the jaw angles. It can only provide vertical lengthening to the chin and the middle part of the lower jaw as well as increased horizontal projection of the chin. It is not a jaw widening procedure no matter how the diagrams make it look like it can. A chin wing is really an extended sliding genioplasty with long back wings to the chin segment.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, i am interested in custom infraorbital-malar implant and a custom wraparound jawline implant. I guess the best way is to do them together? 

I would be interested in predictions of custom infraorbital-malar implants and custom wraparound jawline implant, does separately and then together. 

I am also interested in before and after pictures of patient who had either such custom implants.

I guess it’s irrelevant if I do Veneers before or after?   

A: Thank you for your inquiry and sending your pictures. I will have my assistant Camille contact you to schedule a virtual consultation time. In answer to your general questions:

1) Whether one does more than one custom facial implant at one time is a personal decision not a medical one. But it is certainly common to do so.

2) Due to patient confidentiality patient pictures are not distributed without their permission…which is done by very few patients. Any such permitted pictures would be posted on the website, www.exploreplasticsurgery.com.

3) You are correct in regards to veneers, it is irrelevant whether they are done before or after. But because of the intraoral approach for much of a custom jawline implant, I would vote for veneers after that procedue is completed. to avoid any trauma to them.

4) Computer imaging of your pictures will be done after the virtual consultation is completed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am iunhappy with the appearance and shape of my chin. My bite was corrected with braces, and my chin isn’t receding or over-projected, but it is admittedly quite narrow and pointy from the front view. 

I have a tapered heart-shaped jawline/face which only serves to exacerbate my self-consciousness about my narrow and pointy chin.

I have consulted with a local surgeon, but I found out you are the go-to expert on facial bone surgeries and chin surgeries through RealSelf. I really hope you could provide some insight onto the options I was provided so that we can have some foundation to go off of during the video consultation. 

My surgeon, who is a plastic surgeon with a craniofacial background, assessed my chin at a consult and gave me three options. I would really appreciate your opinion on the suggestions as a medical expert so that I can have the best surgical plan to achieve what I desire.

(1) A laterally widening genioplasty. I was advised this would be an option as only a minor widening effect was needed. 

Would this bone widening make my lower facial shape more rounded and less angular, or would it just make my chin flat and square? Would I still have a natural curve to the chin? I’m a little worried it will make my chin more masculine looking.

(2) Hydroxyapatite on the sides of the chin. As a craniofacial surgeon, he mentioned he had quite a bit of experience with this material and that it could be placed on the sides of the chin and shaped.

However, from looking through your blog, this material seems to be quite unforgiving for augmentation purposes. I’m worried about potential asymmetry and not being able to remove the material if the shape is bumpy or doesn’t achieve what I want.

With your experience of the material, should we even entertain this option? It does seem less invasive than a bone-cutting surgery but there seems to be so much more that could go wrong (eg. asymmetry, not the right shape.) Can this material get infected?

(3) Lastly, the surgeon mentioned an implant but he did mention that off-the-shelf implants wouldn’t be suitable for my case, considering that no other dimensions of her chin need any augmentation. 

A custom implant was possible but it added on thousands financially, and for such a minor augmentation it just didn’t seem worth it. 

I am not sure what is the best option out of what I was advised. I would really appreciate your insight and I thank you for your time.

A: Thank you for your inquiry. Since I have no idea what the chin/face in question looks like nor have any knowledge as to what the aesthetic chin change goal is (I assume computer imaging has been done to determine the exact amount and extent of the chin/jawline widening effect), I can only make the following general comments:

1) Widening of the chin is accomplished by creating more width from the center of the chin back a certain distance along the jawline. That posterior widening extension will need to be longer than one would think and its shape as to be fairly precise to end up with the desired effect that is both a adequate and symmetric.

2) There is little question as to what is the best treatment option to create the desired chin widening effect…computer designed implants based on the bone on which it is intended to augment. Having precise control of their design simply can not be beaten, that is not the actual question you are asking. Because of cost considerations the actual question is what else can she done that costs less that may come close. to their effects. From that perspective I will address your current options.

3) The use of hydroxyapatite granules is very prone to irregularities and asymmetries, it is just not a precisely controllable contouring material in the unforgiving projection of the chin.

4) A widening genioplasty will make the sides of the chin wider…to a point. But there may be step offs along the back ends of the wings of the bony genioplasty when the bone flares out at its back ends when the center of the chin is widened, creating  a contour deformity along the jawline without a smooth transition. You are also correct in that it may have more a chin squaring effect than a rounding one and it does seem to a ‘solution that is bigger than the actual problem’.

5) There are standard prejowl implants that add some width to the side of the chin without increasing its horizontal projection. Whether this should be adequate I cannot say since I don’t know the exact aesthetic chin widening goal based on computer imaging. These can also be made by a special design process for whatever the desired width increases are needed.

6) There are also ePTFE (Gortex) blocks and sheets that can be handmade and carved to create one’s own intraoperatively fashioned ‘custom chin widening implants’. 

In conclusion, trying to cut and move the bone to create the exact chin widening effect one wants is harder than it seems. The chin bone can be cut and centrally widened but precise control of the resultant shape is not assured. Placing granules into a. subperiosteal tunnel and them molding them from the outside is not an assured method of bone contouring with both symmetrym, smoothness and an exact shape is desired. The best method for such minor chin widening, in my opinion, is to get a preformed implant shape to do it. As discussed there are various implant options in that regard.

Dr. Barry Eppley

Q:Dr. Eppley, I am very interested in the Lip Lift procedure and was wondering if you have experience with patients who have a slightly gummy smile? I have found that some doctors say it can make a gummy smile worse and some say it won’t affect it at all.

A: A subnasal lip lift, in the face of a gummy smile, certainly has the potential to make it slightly worse. (more gum exposure) Whether it would have no impact at all on it or whether it would slightly exacerbate it depends on how the lip lifing is being done. (% of vertical skin distance being reduced) Obviously the less lip lifting being done or a vey modest change will minimize its impact on your gummy smile but its aesthetic lip lifting effect would also be very modest. More aggressive lip lifting most certainly will as there will more likely be an elevation of the upper lip smile line. The bottom line is that any effort at lip litfing incurs the risk of making the gummy smile worse, there is no assured way to every say it can not happen. The only way to eliminate that potential risk is to either not do the procedure or do a some gummy smile correction at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I´m a patient who would like to have a rhinoplasty with you in your clinic. I have a big hump and also a big tip. I will make photos this week to send you, In the meantime I would like to know, Is that procedure very hard to perform? Should I worry that my nose won´t look natural after the first procedure?Is it usual to have more than one procedure?

A: Thank you for your inquiry. How difficult your rhinoplasty is and what that potential outcome may be will await the receipt of your pictures and my analysis of them. Seeing the magnitude of the nasal shape changes that are needed and what the thickness of your skin is goes a long way in determining how successful rhinoplasty surgery can be.

While the technical aspect of many rhinoplasty surgeries are not ‘difficult’, the outcomes of such efforts are not always completely predictable due to how the overlying skin contracts over the reshaped osteocartilaginous framework.

Rhinoplasty has well known risks of potential aesthetic issues that may require a subsequent revisional procedure. The usual stated risks is around 15%. Whether your surgery has a higher for lower risk of revisal surgery would depend on what type of shape changes you are seeking.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in an arm skin graft. I have multiple self-inflicted scars on my arm from when I was younger. I am in a much better place now and want to rid myself of their appearance from an earlier time. I have some questions about the procedure:

Where is the skin graft from? I’ve read thigh region. 

Recovery time?

Will the stitches be visible after? And for how long? I had a scar revision done and the interior stitches are still noticeable, dark. It’s been about 1.5 years. 

What is a procedure like this cost?

How soon can this be set up?

I was thinking of tattooing the area once healed, would this be a concern? How long would I need to wait?

Would it be possible/advisable to tan the area to be used as the graft to match the affected area prior?

That is all I can think of for now. It would be great to speak with you. 

A: In answer to your arm skin graft questions:

1) The skin graft is harvested from the lateral thigh.

2) Ir depends on ow you define recovery…to work in a few days depending on what kind of work you do.

3) My assistant Camille will pass along the cost of the surgery to you on Wednesday.

4) You would have to ask my assistant Camille and let her know when is a good time for you.

5) You would have to wait a minimum of three to four months after the surgery.

6) Whether you tan the donor site or not before it is harvested does not affect graft take.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction surgery for my prominent brows.
I have read your posts online and I see there are 2 different options for the scalp incision. What would you recommend for having it the least bit noticeable and the best chance of healing the best?

A: In a male, the scalp incision is usually going to be back further in the hair, rather than right at the hairline because you don’t know how stable the male frontal hairline is. The exceptions to this would be in a male if one wanted to do a hairline advancement at the same time as the brow bone reduction, one had a good familial history of hairline stabiity our one wanted to eliminate any risk at all of any hair damage along the incision line. Having used the hairline incisions in men numerous times for different indications I have not have any postoperative concerns about the scar or the recession of the front edge of the hairline behind it.

But both hairline and more posterior scalp incision can be successfully used and the scars heal well in both locations. But it is important to carefully these incision location choices in the male brow bone reduction patient.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am going through with custom infraorbital-malar implants from a CT scan. However, I am afraid that the prominence of the custom implant would be too much at 5mm. 

1.Is there a general reference for when implants would be extreme when looking at the skull, similar to where mandible angle implant width is considered extreme if it extends pass the zygomatic bone/arch?

2. Is it a bad idea for a surgeon to custom shave down a cheek implant further if it looks too prominent during surgery, even thought the implant was custom designed/fitted already? (I.e good chance of creating an abnormal shaped cheekbone?

3. I heard that custom designed implants at 5mm are more similar to the projection of off shelf implants of 3-4mm, since they have no space between the bone and implant. In general, have you noticed a 5mm custom designed malar implant to be less noticeable/prominent than a 5mm off shelf implant?

4. How much do you charge for a custom infraorbital-malar implant with both the payment to moldhouse and the expense for you to place it?

A: In answer to your custom infraorbital-malar implant questions:

1) For the midface there are no specific skeletal landmarks to keep an implant’s projection inside the ‘aesthetic window’.

2) If the surgeon feels the implant looks too big or unnatural in the cheek area after it is placed, it would be prudent for an adjustment by shaving reduction to be done at that time. I have done that many times as it is far better to have an implant that may end up slightly too small thank one that is too big. The latter has a 100% chance of revision.

3) I have never seen nor have any biologic rationale to the cheek implant comparison you have referenced. In fact it is quite the converse, custom cheek implants can much more easily be oversized compared to standard cheek implants because they cover a much greater surface area and thus their volumetric effects are more profound.

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

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am researching for my 20 year old son. He had a large craniectomy done two years ago and the replacement was a plastic implant. They were not able to reattach his temporal muscles and it has left a bump at his temporal area above his ear and a drooping eyelid. Can this be fixed? Can the muscle be reattached? What are the future complications? Thank you for your help.

A: Thank you for your inquiry and sending his pictures. What your son has is a temporal muscle retraction which has no functional implications. It can not now be unraveled and lifted back up and repositioned due to muscle atrophy and scarring. To treat the contour defect my approach is to build up the temporal area with hydroxyapatite cement (temporal augmnentation) to replace the bulk that was once there from the muscle. This can be done through his existing scalp incision.

The drooping eyelid is a facial nerve issue for which there is restoration of the motor nerve function that was lost. That is treated like ptosis repair to lift up the eyelid to a better level to the upper rim of the iris of the eye.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip asymmetry surgery. I have upper and lower lip asymmetry. I have had it as long as I can remember. It is present when I am not smiling and becomes more so when I do smile. What can be done for it?

A: Thank you for sending your lip asymmetry pictures and lip asymmetry surgery objectives. In the rest position I can see a left upper lip asymmetry with less very vermilion exposure and the lower lip looks just fine. In animation the left upper lip asymmetry becomes more noticeable and the lower develops an asymmetry the left side of the lower lip staying in the same position while the right lower lip gets pulled down. (which is normal) The lower lip acts like a marginal mandibular nerve paresis where the depressor muscle is not working.

The two things you can do are a left upper lip vermilion advancement to correct the upper lip asymmetry. This will provide improvements at both rest and in animation. Since you can’t bring depressor muscle movement back into the left lower lip side, the initial treatment should be Botox injections into the right lower lip depressor muscle to se how much correction of the lower lip occurs in animation. If successful and the Botox proves that weakening the normal depressor action of the lower lip is effective, one can move on to having a subtotal depressor muscle resections done for a permanent effect.

Dr. Barry Eppley
Indianapolis, Indiana