Your Questions

Q: Dr. Eppley, I just had a question regarding the masseter muscle and the buccal fat injections to the jaw angles.

1, Will the buccal fat injections look defined or just fat/bloated?

2. How much do you think my masseters would shrink from botox injections, would I be able to chew gum without them revealing themselves? 

I’ve seen some dramatic results from botox injections in the masseters so I’m hoping I would be able to achieve a result where they are virtually non detectable, if you’d make a guess, do you think that’s possible?

3. Let’s say the buccal fat injections does not provide enough augmentation to the angles of the jaw, is it possible at a later time to inject fillers there to augment it even more? 

Thanks again!

A: In answer to your questions:

1) Fat injections will not create a sharp or defined bony look. They create a softer effect as is is a soft material that pushed out on the tissues.

2) How much the masseter muscles will shrink depends on the dose/units of Botox injected. I am not sure that will ever shrink enough to not be visible when maximally working them like in chewing gum….but it may be possible.

3) You can always add synthetic fillers after fat injections, that is not a problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was surfing the web to check about my illness. After spending a lot of time, I somehow got lucky to find this article on your website. I believe I have the same problem. (Zygomatic Bone Arch Tumor). I have the same little bony bump on my left side of the face exactly as shown in the xray on your webpage.

Since, I don’t live in the country where you live, So unfortunately I wont be able to get treatment from you. But I have some questions, which I believe you could answer to in order to help me.

My questions are as follows:

1. Does this surgery leave prominent scars on face? 

2. If yes, Can these scar be made go away? 

3. Does this surgery help in making the face asymmetrical to symmetrical?

I hope to get a good and quick responce from you. Your cooperation will be highly appreciated.

A: In answer to your Zygomatic Arch Tumor questions:

1) Depending upon the location of the bony tumor on the arch would determine the method of surgical access. Since I have done several cases if this type of bony tumor I am not certain where in the arch it is located in your case. But as a general rule surgical access is done intraorally so there is no external facial scar.

2) The best way to make the diagnosis is with a 3D CT scan which I assume you have since you appear to know were the bony tumor is located.

3) If the bony tumor is a source of facial asymmetry then its removal will help to improve facial symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to address three outstanding concerns.

1. I understand the Superolateral OR forms the top and side protrusion of the brow bone. However, I wanted to ensure that this top area would remain untouched, as the concern is not so much brow protrusion, but rather the thickness along the side and at the base of this (near the zygomaticofacial foramen) to provide the angularity desired. In fact, I would rather appreciate having has much “side brow protrusion” as possible, so I wouldn’t want this “top” area reduced. I attach a picture (skull) to illustrate this concern: I would rather leave the protrusion provided by the superolateral rim alone (region A) and rather focus on shaping the angularity of the circled region. Perhaps you could provide some clarity on this.

2. Another issue of great concern is the procedure itself. Is it truly necessary to peel forward the face to achieve the aesthetic result? It seems this is drastic (in terms of exposure of the surface area, infection risks associated, shaving the head, healing time, among many others) and I was hoping there would be an endoscopic alternative or lateral incisions that could be made along the temporal region or at the base of/along the rim itself.

3. Finally, I wanted to make sure that we were in agreement with regards to the aesthetic result. I would like to ensure that the cheekbone area/zygoma remain intact in its width and protrusion. The simple changes I wish to make are essentially a small indentation along the temporal region (see attached photo face example, region A) to result in an indentation between the brow and zygoma (region B). I do not wish to drastically change my face by any means. It is important for me to know if you believe from your professional perspective if this procedure will produce a significantly aesthetically pleasing result in terms of facial balance and angularity, or if you believe this would simply satisfy a request to change a proposed anatomical irregularity. I attach two final photos (a before and after) with an example of the intended aesthetic result. I am interested in what you think. 

Many thanks for all.

A: In answer to your questions:

1) The zone of bone reduction is decided and marked before surgery so there is not confusion as to where to go and not to go.. I think as you have described it is pretty clear that any aspect of the brow bone is not part of the lateral orbital rim.

2) While perhaps a full coronal incision does make it a bit easier to do, I would need think that effort and scar tradeoff would justify that approach. This leaves us with three incisional options, either alone of done in time combination, upper eyelid, lower eyelid and intraoral. The outer half of the upper eyelid incision would be the most practical with possibly an intraoral component as well.

3) You are specifically referring to a lateral orbital rim reduction, which lies between the tail of the brow bone superiorly and the main body of the cheek (zygoma) inferiorly. That would create an indentation between the brow and cheek bones. As for the anesthetic outcome I can only comment on its aesthetic effectiveness based on your own description and imaged illustrations…if that is what looks good to you then can say this procedure is what can do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, People starring all the time at me. I dont know if its cause of my unnatural look or cause of my lips. I had 6 month ago a underlip reduction. Me for myself i see the shape and all of my complete lip as not beautiful. I would like now to know with this last email what you suggest me to do that people stop starring in a bad way to me.  I have taken a pic in the sunlight. It would be nice if you would be honest to me and my situation. I had a lot of surgeries and i dont want to make it more worst so what you suggest me now to do?

Thank you

A: I can not comment on what other people do or why you have the feeling they are staring. Whether they are or not and, if they are, why do so I can not say. 

What I can say as a general statement is that people’s perception of other’s, contrary to what most patient’s think, is usually never one specific facial structure or area. People see more the overall facial picture (gestalt) rather than specific facial features. The analogy would be in art….you may know a work of art by its overall perception of what it creates (e.g., farmer standing in a field) but most don’t see or remember the details. (e.g., was there a cow in the field, what was the color of the farmer’s pants etc)

The face may be made up of numerous individual features, which the person themselves knows very well in detail, but someone else does not see it that way. They just know the overall impression or look that all of these individual features creates. (the composite image)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a complete facial feminization surgery. 

Do you take a more subtle conservative approach, or would you do something more aggressive if I wanted to? I have a very big dysphoria about my face, and I want a radical change.

A: In FFS surgery the first step for me is to determine which of the numerous procedures has the greatest facial effects. From there computer imaging is designed to try and determine what is the extent of change from each procedure that the patient seeks. My goal is to find try and deliver the type of change the patient wants as well as educate the patient beforehand as to what is and is not realistic.

It is important to remember that the amount of facial change that is possible with surgery also depends significantly on the patients natural facial shape…which may or may allow the radical change hat you seek.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, We’ve discussed replacing my standard chin implant and jaw implants with a custom wrap around implant. I’ve also read your post on a juvenile-like Rhinoplasty done on a Hispanic woman and it seems like that is very similar to the structure of my nose. I’m not opposed to using a synthetic implant as well.

What is the timeline for a custom jawline implant? I would imagine creating the implant would take some time. If we did a brow bone implant at the same time, would it add additional lead time?

My goal with the jawline implant is only a smooth connection between the jaw and chin, not so much width.

I’ve also had silicone microdroplets injected into my nasal tip and bridge once by Dr. Kotler probably about 5 years ago. The results were underwhelming so I never continued with additional injections. I believe they may have migrated as I feel a small bump at the level of my nostrils. Would you be able to remove this?

A: In answer to your custom facial implant and rhinoplasty questions:

1) It takes about 4 weeks from the receipt of a patient’s 3D CT scan to go through the design and manufacturing process to arrive for surgery.

2) Multiple custom facial implants are done over the same time course and do not extend the time frame as stated in #1.

3) In the nose that lacks structure, the options are always rib cartilage or an implant which is determined by the patient’s choice.

4) In an open rhinoplasty permanent filler material can be removed. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have facial asymmetry with my right side being smaller than my left. I would like to know what needs to be done to make the right side look closer to the left. Should I have orthognathic surgery and fix my bite and will that correct it? Or should I leave my bite alone and have implants to build up the deficient side? If I fix my bite with orthodontics alone will that help to improve my facial asymmetry a bit? If I was to have orthognathic surgery should my cheek and skull asymmetries be done first or after?

A: In answer to your facial asymmetry correction questions:

1)With a 3D CT scan and computer designing the differences in the right face could be treatment planned based on the dimensions of the left face. What that would include exactly remains to be determined based on what the scan shows. But based on your pictures alone the decision has to be made whether to augment the left jawline or reduce the right jawline for better symmetry between the two sides. That is an aesthetic preference.

2) The timing of orthodontic therapy is irrelevant IF one is not going to purse subsequent orthognathic surgery. But you should have a full orthodontic evaluation to determine if orthognathic surgery may be a good option since you are already aware that is one treatment option. If done that would serve as the foundation for anything under the eye area first.

3) The ipsilateral right skull and cheek asymmetries would be treated by custom designed implants. Those issues can be pursed independently of the jawline asymmetry which awaits a full orthodontic-orthognathic surgery evaluation.

Dr. Barry Eppley

Indianapolis, Indiana  

 Q: Dr. Eppley, I have attached two images, one of me now and another of an ideal outcome of a genioplasty. I have a couple questions:

1) How much advancement has been made both vertically and horizontally in the ideal outcome?

2) Is this a realistic outcome? 

I’d ideally like my chin to pass my lips in the frankfurt horizontal plane head position and for my lower third to be the tallest third of my face.

Thank you

A: In answer to your sliding genioplasty questions:

1) Those chin advancement movements in profile look approximately like 10mms horizontal and 2mms vertical.

2) I don’t see anything about that imaged result that would suggest the actual clinical result would not be close to it. Your own imaging is helpful as it makes it clear what kind of chin augmentation result you are seeking…one which would not be obvious to your surgeon since it is an extended or more extreme type of chin augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve always had a big butt naturally but I ended up having two BBL fat transfers from my stomach to my hips and butt to try to achieve the hourglass shape because I’ve never liked my hip indents.. straight after each of the BBLs the fat made my hips look curvy and hourglass but the fat didn’t last in my hips and I have gone back to having hip dips. I’ve always contemplated getting hip implants but was just worried about it looking unnatural and also not sure about where the scars would be for that. I’m actually really considering it but just wanted your honest advice whether it would look natural at all? Or will you be able to tell its implants.

A: I have yet to see a successful significant hip augmentation result by fat transfer of any magnitude so your experience is not uncommon…but it is always worth trying first. Getting a natural look from hip implants means that they do not stick out like a bump. Thus one always needs a custom design approach that has an implant design that blends into the convexity of the hips, both in front and back. This looks very different from any other form of body implant where creating roundness is the goal. (breast and buttock implants) Taking that approach looks natural as the hips do not have a naturally round shape but a convex and extended contour to them. It does require a 5 cm incision placed above the hip areas to place them. For the motivated hip augmentation patient this scar has not been an issue.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I was wondering what your opinion was regarding a buccal fat removal to enhance my cheekbones and remove some of the fullness from the middle of my cheeks. Is that something you’d recommend for me or do you think the ROI/ROE is not worth it?

A: Buccal lipectomies for you I would not do. You already have a thin face and extracting  buccal fat today may likely create a very gaunt face down the road which is hard to correct. I don’t say this to many buccal lipectomy inquiries but yours is the one young face to which this applies. Thus to make your cheeks bigger you should take a direct approach and turn to cheek implants

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have 2 questions. 1). I have cheek implants in my face and am interested in having my eyebrows microbladed. Is it safe to have my eyebrows cut at the dermis level or do I risk infection? Should I take antibiotics before and after microblading procedure? 

2). I am interested in chin implant. What type of chin implant do you use, Silicone or Goretex? I am a male 30’s . Thank you

A: In answer to your cheek and chin implant questions:

1) There is no risk of infecting cheek implants by microblading of the eyebrows. Before and after procedure antibiotics are not necessary.

2) I use whatever material the patient prefers…if the dimensions needed for the chin augmentation exist or can be designed in the implant.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom infraorbital rim-malar implants and canthopexy to correct negative canthal tilt to a slightly positive one whilst reducing my slight amount of sclera show)

I just was wondering if I could see this simulated and how it would realistically. If it looks good to me then i’ll be ready to book the surgery within the next couple of months. 

My only concern is in regard to the eye region. I know you’re a well regarded surgeon but I just simply don’t know if i’d be making a bold decision by going the direction of a non oculoplastic surgeon to work on my eye region in regard to canthoplexy. 

Essentially I just want infraorbital rim implants to get rid of my tear troughs in sync with the mid face implant to enhance the zygomatic region for aesthetic purposes. I don’t mind it being fairly conservative and nothing too crazy. 

Also in regard to the eye region I have negative canthil tilt and droopy eyes but i’m not sure if they’re as a result of the lateral canthus. In an ideal world I slightly reduce the amount of sclera show I have to make them slightly deeper set whilst making the tilt go from negative to slightly positive. 

Do you think this sounds feasible and is very possible? Do you think the result will look similar to the morph and do my goals sound realistic?

A:Thank you for your inquiry. In answer to your questions:

1) I have done one front view imaged picture for modest custom infraorbital-zygomatic implants. Whether the lower eyelid would become that smooth is open to speculation but your natural lower eye appearance looks the way it does now because it is volume deficient. The only way to get close to that prediction is to add volume. The custom implant approach is the best method as it increases both vertical height and some horizontal projection of the infraorbital rim as well as blends the augmentation out onto the cheeks.

2) The solution to raising your lower eyelid margin for less scleral show (droopy eyes) is not a canthopexy or a canthoplasty. In my experience a canthopexy is a protective corner of the eye procedure to prevent postoperative sag. A canthoplasty is a procedure to actually raise the level of the corner of the eye. But neither procedure can effectively raise the level of the lower lid margin across the entire lid and, most importantly, at the pupillary level of mid lower eyelid. In short you can’t just pull up the outer corner of the eye and raise the lid margin…that never works in any sustained fashion. It may look like it does on the operative table but not in a healed vertical position later.

3) To raise the level of the lower eyelid margin you have to add support. (build up the lower eyelid and not just try and stretching it)  This can be either a soft approach with an interpositional graft at the middle lamella or a hard tissue approach by raising the level of the entire infraorbital rim. (custom implant) Either method helps drive up the lower eyelid margin and can keep it there in a sustained fashion. 

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I already got my rib removal surgery quote thank you I have to save more money because I only got 10k. I got one question can you tell me how much inches usually reduce this surgery? I just want to know to to see if is good enough to expend all my savings.

A: As a general outcome statement, most patients report to me that their waistline reduces anywhere from 1 to 3 inches.

Since you have chosen to reveal your economic issues with his type of surgery, I can provide the guidance to you that no patient should ever put themselves in an adverse financial position for elective aesthetic surgery ….unless the face or body deformity they are facing is disfiguring and negatively impacts their life in a major way. I would not qualify the desire for waistline reduction in a young lean female as fulfilling that criteria.

In short you should never expend your savings for cosmetic surgery of any kind. That is not a good financial decision.

Dr. Barry Eppley

Indianapoli, Indiana 

Q: Dr. Eppley, I’m contacting you in hopes of getting some information on how I might address an issue I have. I am a transgender woman, and have undergone Facial Feminization Surgery recently. This addressed several of my issues, but I still find that I have a quite flat, hollow, and long face. From my research, these issues (the first two, anyway) appear to be due to “midface hypoplasia.”

I would be interested in hearing what options exist for correcting this which Dr. Eppley is able to offer. From my research, the main approaches appear to be either a LeFort I osteotomy or facial implants (specifically, paranasal and submalar). I have concerns with the LeFort approach. This is partially due to the aggressiveness of the procedure, but also because I feel that the zygomatic bone and the region below it and approaching the maxilla are also underdeveloped. To my knowledge, a LeFort I osteotomy only corrects the maxilla itself. Ultimately, though, I am not a doctor and not really qualified to make the assessment as to what would or would not work myself.

To aid with an assessment, I have included a link below to a set of pictures. These include head shots of me from the profile (both directions), three-quarters angle (both directions), and front. These were taken in bright lighting from roughly 6 feet away. Resolution isn’t amazing, as I unfortunately do not have a high-quality camera. I have also included CT scan images of my skull from roughly the same angles.

A:Thank you for your inquiry and sending all of your pictures and 3D CT scan. Your diagnosis is an overall midface skeletal deficiency. You are correct in that a Lefort I osteotomy would only correct a subtotal portion of the problem….although you would need a LeFort I advancement combined with a mandibular advancement since your lower jaw is also over rotated as a result of the midface deficiency. But given that you have a normal occlusion such orthognathic surgery has additional limitations. From an implant standpoint augmenting the entire midface including the infraorbital and lateral orbital rims with a custom design would be the alternative and superior aesthetic outcome approach that would also be far less invasive with a quicker recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the middle of preparing for a surgery. I will be getting custom PMMA cheek implants modelled off a 3D printed model of my skull. I’m planning on widening my face a little bit and hoping that this will improve my sagging cheeks from my zygoma reduction procedure.

I understand that all implants have a risk of infection and that the highest risk time is in the early post-operative period. However, how common is it for facial implants to get infected without good reason in the long-term?

From my understanding and research, I understand that dental anesthetic or fillers in the implant capsule could potentially inoculate the implant with bacteria and subsequently get an infection. I’ve read about patient experiences where Medpor implants get infected out of the blue years after surgery. Is it possible for an infection to pop out of nowhere without reason?

A: In all due respect these are questions you should be asking the surgeon who is going to perform the procedure. Presumably they have both the skill to not only do the procedure but also the experience to know what the long-term risks are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your profile on RealSelf and it appears you seem to be quite experienced and knowledgeable about facial implants.

I’m of Asian descent and one year ago I had my chin narrowed and moved forward in Korea. I’m near happy with the results of the surgery but I desire more horizontal movement. I regret asking my original surgeon to stay conservative but I guess I would prefer less than too much. 

I’m thinking of going abroad again to get a small chin implant, as I think recutting the bone for such a small additional movement is overkill. Surgery in my home country is also unbelievably expensive and not exactly very well versed when it comes to asian aesthetics.

The only thing is that I am deathly afraid of getting an infection. I’ve read on RealSelf that most infections tend to show themselves in the first week up to three weeks post operation. What’s the likelyhood of infection appearing after this period? 

More so, I worry about the implications of cutting through the mentalis muscle twice. As I am Asian, I have been rejected for extraoral incisions due to the scarring implications. Does cutting through the mentalis muscle again have consequential possibilities such as a drooping lip or chin sagging? 

Thank you for your insight.

A: The way to lower the risk of infection to the lowest possible is to use a submental skin approach. That also avoids cutting through the mentalis muscle and quickens recovery. That is a 1 cm incision which I have not seen that to be a ‘scarring’ issue. I have done many Asian male patients through that approach.

But since that approach is off the table, the risks of infection with intraoral placement are higher, how much higher no one can really say. Such infections do not occur in the first week or so but 3 to 6 weeks after surgery. That is typical take period for all facial implant infections.

I don’t consider cutting through the mentalis muscle twice of major concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttocks implants, however, I am worried about a new worldwide discovery of “implant illness”. Do you think this could happen even with solid silicone implants used in buttock augmentation or only breast implants? My second question is can I get buttocks implants and rib removal at the same time so I do not have to be under general anesthesia twice? Do they both have to be done under general?

A: In answer to your question:

1) You are referring to a low grade lymphoma that has only been associated with one type of textured breast implants. This has been associated with the way the textured surface was applied. I do not see a correlation with smooth surfaced silicone buttock implants.

2) I could not think of two body procedures who would need general anesthesia any more than rib removal and buttock implants. These two procedures should not be done, either together or separately, without general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a forehead reduction and forehead implant. Can these procedures be done together or are there limitations? Will this result in a higher chance of shock loss or negative side effects?

A: By your description I believe you are referring to a hairline advancement (forehead reduction) and a simultaneous forehead augmentation. (implant) Whether such a combination of forehead procedures can be done depends on how much forehead augmentation is desired as well as how much forehead reduction is needed. I would need to see some pictures of your forehead as well as your goals to determine whether they can be done together or would need to be staged.

If the desired hairline advancement is not extreme and the size of the forehead implant is not too big, then I suspect both can be safely done together. But a hairline advancement greater than 10mms and a forehead implant thicker than a few millimeters, then there may be some tissue restrictions with combining the two procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a temporal implant procedure done 10 years ago which I’ve not been happy with as the size and thickness of the implants is too large in my opinion. I would want them to be replaced with much smaller and thinner implants.

Some of the notes I have are:

– the original physician does not have records other than it was methylmethcrylate implants, formed from putty at the time of surgery

– I had a consultation with a physician in southern California, he concluded the methylmethacrylate implants are placed along the temporal bone bilaterally after reviewing MRI

– the MRI report is attached but is not too conclusive

– the right side implant is definitely a little thicker, more convex shape than the left side, I particularly dislike the right side result

– I’ve attached 3 pics, the first one I think shows how the result makes my head look bigger which I don’t like, an extremely subtle augmentation is what I’d prefer.  The sideview shows the faint scar line.

A: Thank you for sending all of your prior temporal augmentation information. As I suspected these are PMMA intraoperatively fabricated implants placed under the muscle down on the bone….a common technique done before the availability of standard silicone temporal implants. I could easily identify in your pictures the surgical incision used. Knowing its location and length would be crucial in determining how ‘easy’ it is to revise/replace them. It is one thing to place a moldable putty through a small incision and shape it and allow it to harden than it is to try and get a solid implant out in reverse. It can be how to extract the proverbial ‘ship in a bottle’. However knowing that PMMA is usually inserted through ‘larger’ incisions, which I suspect you have, suggests that it can be similarly removed. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if a custom wraparound jaw implant can address my short chin or it would be better to do a genioplasty and individual jaw implants? I was told by a local Dr that I would need 8mm vertical jaw angle lengthening and 12mm of anterior chin projection but I find your posted results to be superior so I want to know what would you recommend. Thanks.

A: I am not sure where those jaw augmentation estimates are based on as in looking at your face as they seem to be excessive  A horizontal chin augmentation of 8 or 9mms and a vertical jaw angle lengthening of 3 to 5mms is the most you would likely need…although computer imaging would have to be done to determine what you are trying to achieve. A total jawline implant provides the most predictable and connected jawline augmentation method and is always better than three separate unconnected jaw augmentation methods.

Ultimately computer imaging of your face needs to be done to help determine exactly what type and degree of jaw augmentation you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my cheek implants (Terino malar style 6mm size) placed about 10 years ago. As I get older I realize I look tired because of my under eye bags seemingly created by the forward placement of my implants. I have always wanted a more posterior “high cheekbone” extended arch implant that you describe and have pictures on the website. Is it still possible to replace my off the shelf implants with custom extended implants even though I already have implants in place?

A: There is no problem changing out your current cheek implants with new custom designed cheek implants. In fact over 1/3 of all custom cheek implants are done in patients who have had prior standard cheek implants.

In computer designing cheek implants, any existing cheek implants can be digitally removed to make the new ones. it is also helpful once the new implants have been designed to digitally bring back in the existing implants to compare the two designs in shape and bone surface area coverage. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested and serious about the procedure.  Although I am not seeking rib modification for cosmetic reasons only. I am an avid walker and cycler. During exercising and movement, my lower ribs touch my hip bones (or something in there!)   It is extremely bothersome and impedes my workout significantly. I realize there can be some risk and residual rib pain. Staying fit and working out is critical to my health. I realize you may not resolve the issue completely, but any relief would be acceptable. I am financially prepared for this and interested in pursuing rib modification.  Thank you Dr Eppley, I know you are highly experienced in this procedure and I greatly appreciate your assistance.

A: What you are describing technically is known as iliac-costal syndrome. Getting rid of the outer half of ribs #s 11 and 12 on the affected side has proven to be vey helpful in symptom relief in this rib-associated syndrome. I have had some patients who have requested removal of rib #10 also but that rib should have no contribution to impingement on the iliac crest given its more horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cortical jaw reduction done in Asia and unhappy with the results. Do you do custom jaw implants? if so,would PEEK or titanium mandible angle implants be better? Thank you. 

A: I have done hundreds of custom jaw implants out of every available material. Whether the more expensive options of PEEK or titanium are viable options for your jaw restoration would depend on what size of implant is needed and what you are willing to pay for the surgery…as both PEEK and titanium custom jaw angle implants are considerably more expensive than those made out of solid silicone.

Ultimately a 3D CT scan of your jaw is needed to determine what size jaw angle restoration is needed. That may also influence the material choice for the implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 43 yr old female seriously interested in orbital decompression surgery and I believe I may need eyelid retraction surgery as well. I follow Dr.Eppley on Instagram.  He advised me to seek a local oculoplastic surgeon to address my concerns. There are 2 in the city of Memphis, TN.  After consulting one, he admitted he had very limited experience performing the surgery because there isn’t a demand for such a surgery in my city.

I do want to ask some questions, prior to my consultation, if I may? If you can answer any of the following, that will help me to narrow down my questions during my virtual consultation.

I have included pictures to assist you or Dr. Eppley in hopefully answering my questions.

Here are some of my problems with my eyes:

*I have my thyroid tested annually, my last test said all my numbers were in the normal range.

1Bulging – it appears to be getting worse as I age.

2. Excess skin or fat on my lids. Hooded eyes – I do not like it. I do not like it!!

3. Inability to close my eyes fully when I sleep.

4. Asymmetrical eyes – sometimes it is so drastic.

5. Double bags under my eyes when I smile.

6. Eye shape – my down turned eyes ages me, in my opinion. Can an eye shape be changed during surgery?

My goals would be to fix those aforementioned problems.

The questions I have are as follows:

1)Am I candidate for orbital decompression surgery?

2) How long is the recommended stay for out-of-town patients?

3) Does private insurance cover orbital decompression surgery? (I have Cigna, which is out of network).

4) If insurance does not cover any of the costs, how much roughly would it costs for the procedures I have listed and/or any procedures Dr. Eppley deems necessary?

I greatly appreciate your time and consideration.

A: In answer to her questions:

1) I think you ideally need the following combination of procedures:

     a) orbital decompression

     b) upper blepharoplasty

     c) lateral canthoplasties

     d) orbital rim augmentation

    While you may have orbital proptosis, there is also a signficant contribution of infraorbital rim/midface deficiency.

2) Patients usually come home in a few days after the procedure. Recovery is largely about swelling and its resolution.

3) I do not take insurance

4) My assistant Camille will pass along he cost of such surgery.

You would need a 3D CT scan to determine the bone anatomy as well as a preoperative ophthalmology evaluation that determines you do not have a metabolic basis for your orbital proptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reviewing some information with a custom jaw and chin implant that was one piece and appeared to have some soft portions to it.  I don’t believe that I need a chin implant.  I was just checking in regard to the custom jaw implants.  

How long would it take to examine me, design and fabricate the implants?  Approximately how long for surgery?  Would it be better for me to be there in person for you to examine me initially? 

A: I am not sure what information exists that suggests that any custom one piece total jawline implant has some ‘soft portions’ to it. But that is certainly not true. 

To be implant type specific the term ‘jaw implant’ refers to any implant that may be used along the jawline at any location, it is a general term. What you are seeking are ‘jaw angle’ implants, one type of implant that is used for the back end of the jaw.

On average it takes 30 days to design, manufacture and ship for surgery any custom implant…after a 3D CT has been obtained from which the implant is so designed. That would be the shortest possible time.

The surgical time required for removal of your existing jaw angle implants and their replacement with new custom jaw angle implants would be 90 minutes.

Seeing you in person doesn’t really add much to deterring what a new implant design would be. Having existing implants in place is the single most important aid in a custom implant design. Such implants can clearly be seen on the bone in the 3D CT scan. When you know what you have in you doesn’t work well, you have a good guide as to how to improve their design and dimensional requirements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just sent a request for the “Predict my face” on your website. I am scheduled for a submental chin reduction on January 15th. It’s obvious when I’m smiling that my chin needs reducing. This is what motivated me to pursue this procedure. However, when playing around with photo morphs, I came to realize that when I’m not smiling, the chin seems to be in the right place (very slightly protruded). I have a unique profile view because my lower jaw may be slightly receded (although my bite is good, there is a slight overbite). When I reduce my chin in the non-smiling photos, it doesn’t take long before I look like I have a receding chin.

I have attached a video of me progressing from not-smiling to smiling. About how much are you thinking needs to be reduced? I believe that the procedure will still benefit my profile, do you agree?

On another note, I have attempted to get the cone beam x-ray, but places around here will only let me use their machine if I am patient of theirs. I’m not planning on getting it done unless you think it will be helpful in determining the amount to be removed.

A: In answer to your questions:

1) In hyperdynamic chin ptosis , the chin position at rest is often normal. That always poses a dilemma because surgery is done in a static position (at rest) for the treatment of largely a dynamic problem. (in motion) The key is to not overdo the procedure and treat it like it is a large protruding chin at rest.

2) While at rest I would not consider your chin overly protrusive it is still a strong chin in profile that a few millimeters of projection loss would not cause it to become recessive. 

3) The removal of 2mms of bone is merely to allow the soft issue resection to be tucked in to reduce the dynamic protrusion of the soft tissue chin pad. 

4) A preoperative x-ray is not needed since the procedure is not largely based on bone resection as so indicated in #3 above.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a bimaxillary advancement in due to sleep apnea and a receded chin/ midface. 

After this i was hoping to get a custom jaw implant from your surgery. Would the sliding genioplasty as part of a maxillary-mandibular advancement effect the ability to design a custom implant? 

Thanks 

A: The simple answer is no. It does not matter what the underlying bone shape is when it comes to computer designing a custom facial implant to lay over it. It is quite common in my experience to do custom jawline implants in patents who have had a prior sliding genioplasty. In fact it is also not rare to do a simultaneous sliding genioplasty with a custom jawline implant overlay.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if there was any type of surgical procedure that would directly involve changing the shape of the pelvis, not through fat transfers or implants, but with a modification of the bone itself. Specifically of the iliac crest, to give a male pelvis less height and more width if that makes sense?

Is there a way to make the male iliac crest more like the female iliac crest, giving a female hip flare to a male pelvis? I’d be very interested to know if this surgery is possible and if so the costs/recovery of such a procedure. If not, I’d very much like to hear alternatives to the procedure to produce wider, feminine hips. 

A: There is no surgical method to change the shape of the bony iliac crest that dimensionally reduces it height and gives it more width without undue scarring, plate fixation, risk of bony non-union and considerable postoperative pain The only treatment option is to augment the sides of the iliac crest with an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about rib removal surgery. I’m a MtF transgender and have a very hard time narrowing my waist. This gives (in my opinion) a very masculine appearance to my body. I was wondering how much a rib removal is, how dramatic you think it can be in a transgender patient, and if it would be enough to give a feminine appearance to the ribcage, or if corsetting would still be required for a “tapered” look. I’m looking for something drastic in my body, but something that still seems natural for a woman if that makes any sense. 

I’d also be interested in any before and after that may be available for transgender patients that have had this procedure, if there are any available! 

A: About 1/3 of the patients in which I perform rib removal for horizontal waistline reduction are MtF transgender patients. They seek the procedure out for the exact same reasons to which you have described. Because of their genetic male ribcage and torso shape there is no other effective alternative. Removal of the lower half of ribs #10, 11 and 12 (as well as a wedge of latissimus dorsi muscle) removes an anatomic barrier for whatever maximal waistline reduction is possible. The degree of such waistline change is open to personal interpretation as to what constitutes ‘drastic’. Noticeable is what I could call it but I would never use the term ’drastic’ as that implies an unrealistic surgical expectation. I have never had a transgender patient, or any rib removal patient for that matter, complain afterwards that the result was inadequate…but I know why. This is all that can be done for waistline narrowing, there no other alternatives so whatever the result is is the best that can be achieved.

A period of postoperative corseting is always helpful as the compression helps with swelling and the shaping of the waistline. But I do not see it as a necessary permanent waistline shaping method to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in information on a chin implant. I have currently have a chin implant However I’m not quite satisfied with the results.  I’m not sure of what kind of implant I have however I can get that information. I feel that my chin appears very “chubby” and I was expecting more of a narrow silhouette. I will attach before and after pics. The first two are before and the second two are now. 

A: Standard chin implants by definition can not make a more narrow chin as the most common type of chin implant used has extended wings…which always makes the chin wider in the front view. I suspect you have an extended anatomic chin implant with long side wings. It would be crucial to know exactly what type of chin implant you have.

Fo your chin implant revision you need a central chin implant with no wings that creates more of a V-shape to the front of the chin. This is what most female chin augmentations need in my experience.

Dr. Barry Eppley

Indianapolis, Indiana