Your Questions

Q: Dr. Eppley, I would like to ask if my head asymmetry where one side of my head is bigger than the other or it looks like it is leaning to one side, would be fixable by any of your surgeries? I am guessing one side should be reduced and the other augmented? If you need pictures from different angles please let me know.

Looking forward to your reply. 

A: For your head asymmetry I would certainly agree that the flatter right wide, from the forehead back to he posterior temporal region, needs to be augmented. I am less certain about the need to reduce the left side which appears more normal in shape. I do see some benefits to left-sided facial surgery reduce the tail of the brow bone protrusion, correct the upper eyelid ptosis and correction of the chin asymmetry.

What you have is an overall craniofacial scoliosis which affects both sides of the skull and face. For further and more definitive treatment planning, a 3D craniofacial CT scan would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you based on a post I saw on realself where Dr. Eppley discussed options for paranasal augmentation with a patient.

I am a 32 year old female with some sinking in the midface area and prominent nasolabial folds for my age. I saw a maxillofacial surgeon to discuss correction and he told me that the sinking is due to bone deficiency in this area and suggested a goretex implant. I believe he is correct in his analysis as I was born premature and have had quite a lot of dental work in my life. I have also been told my orthodontist(s) that my upper jaw is quite small, making much of this dental work a bit complicated. 

I came very close to having the procedure done with goretex but ended up deciding that I was not comfortable with having a plastic implant as infection is possible even many many years after placement and removal is very difficult. I would prefer another material… And after doing alot of research and it seems that coral hydroxylapatite is a good option as it is fairly permanent and typically does not get infected because of vascularization. 

I would like more information regarding the technique used, how permanent it is, how much experience the Dr. has with this procedure, cost and potentially to book a consultation. Would the doctor be using radiesse or is this an actual implant which he would use? Thank you so much 🙂

A: When it comes to paranasal augmentation, any variety of alloplastic materials can be used. While one can have a debate about which material is the best, one thing that is clear is that hydroxyapatite granules are no longer commercially available. This leaves the only option for an hydroxyapatite material as hydroxyapatite cement…which is probably better anyway since it can be formed and allowed to set into place. (granules tend to spread out and become uneven) As a participant in the original development of one of he existing hydroxyapatite cements that is currently commercially available (Mimix from Biomet-Stryker), I have tremendous experience in its handling properties and surgical placement. Such a material is a permanent bone cement into which bone directly attaches. While infection is always possible with any surgical procedure, I have never seen it with hydroxyapatite cement into which antibiotic powders are added in its intraoperative preparation.

I would not confuse the Radiesse injectable material with hydroxyapatite cement. That may seem similar but they are not in many ways. Besides being injectable, Radiesse contains the type of hydroxyapatite particles that end up being absorbed and the injectate only contains 30% hydroxyapatite particles and 70% carrier material…which is why it is injectable. While Radiesse does last longer than most other injectable fillers, and it is a perfectly fine injectable option for paranasal augmentation, it is not a permanent augmentation material.

Besides taking a lot of experience to know how to work with it, particularly in the limited confines of an intraoral application, its cost is another reason it is not commonly used for facial augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 5 months post operation from a temporal midface lift. I had some questions about my recovery as my own surgeon is not being very helpful in answering my enquiries.

On one half of my face, I seem to be having some issues with nerve recovery. My motor function is all intact but my sensory nerves seem to be having some trouble? 

When I blink, I can feel a tiny tickling sensation near the side of my nose. It’s been this way since one or two month post op and I haven’t been aware of any dramatic improvement. It’s not painful and it doesn’t burn, but it’s a very tiny tickling feeling every time I blink. It’s quite bothersome and annoying as I’m always feeling and aware of it, and I always have to aggressively massage it away. (After a few minutes the tickle every time i blink still comes back) Moreso, when I very lightly brush my finger down the bridge of my nose, I can feel the same tiny tickling feeling next to my nose. 

My surgeon says to wait it out for another 7 months. But it’s been bothering me for so long and my mind is always thinking about it. 

I’m not sure if I should be worried at 5 months post-op but there just hasn’t been any big improvements in the last two months. I’m worried it’s permanent. What could I possibly be experiencing and what are my options to resolve if?

A: The reality is that all you can do is wait and see how much the sensory nerves recover as there is no operation or treatment for them if they don’t. In addition it can take up to 12 to 18 months for such sensory nerves to exhibit a maximal recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope this email finds you well. Its been a while since I was last in touch as I was busy at work and trying to save for the procedure. I have a few questions if you would be so kind to answer when you have a few minutes to spare from your schedule. Firstly, after the physical structure that is the muscle is removed how does the scalp react in regards to its laxity. Does it sag or how do you achieve for the scalp above the ears to become ‘tent’ and tight to show the straighter profile where the temporal muscle was removed?. Also, does this have to be done under general anesthesia and how long would I have to abstain from work for? I appreciate any feedback you may give me.

A: In answer to your questions:

1) No loose scalp has ever occurred after posterior temporal muscle reduction.

2) Most patients can easily return to work in one week after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Recently I have been researching German maxillofacial surgeon Hermann Sailer’s theories about forward growth being a prime indicator of attraction. My questions along that line are:

1. You have written an article in which you discussed the “male model” face being one comprised of angularity and defined features, which can be achieved by some patients with thinner facial tissue and little bloat through surgery. In your opinion, does forward growth contribute to angularity and is it a part of the “male model” face?

2. Many people seek midface and mandibular osteotemies to improve their forward growth. Do you think that you could create an ante face with just implants? Achieve a result similar to that one?

Thanks for taking the time to help out.

A: You have shown a surgical result That is a well within what custom facial implants can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Last year I had a chin augmentation. It has come to my attention the implant sits crooked/asymmetric. My chin was asymmetric to begin with but I was assured it would not be an issue. Judging by the photo, do you think it’s reasonable to ask for a revision? What surgical methods are available to correct this?

A: I can not tell you whether it is reasonable to ask for a revision, that its between you and your surgeon.

For chin implant asymmetry it would be critically important to know the exact location of the implant on the chin bone as well as the shape of the bone. This is why a 3D CT scan of the mandible is needed. That visual information will provide the corrective approach needed. There is no merit to guessing from its outside appearance how a correction should be done. Obviously the approach of ‘eyeballing’ is not adequate since that didn’t work the first time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw angle implants placed six months ago. Over past few years, I’ve had intermittent sensitivity in bottom left rear molar. About 3 months ago, finally went to see a more experienced dentist who was able to identify a ‘hairline’ crack in the tooth. As luck would have it, the problem is getting worse…suddenly –over past two days.  Before, it would only ‘flare up’ when I brushed w/hard toothbrush vs. Sonicare.

Am traveling out of town Wednesday, but don’t want to do anything stupid in terms of infection. Can I have the root work done? If yes, I have Keflex and Clindamycin. Should I take anything beforehand and afterwards?? 

A: You certainly can have root canal work done. I would inform the dentist that there is a jaw angle implant in there which is relevant to the local anesthetic injections….although the nerve block will likely be done on the inside of the lower jaw (inferior alveolar nerve block) and not the outside of the jaw.

I would also take a preventative approach and take Cindamycin beforehand as well as for two days after the root canal procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am someone who has an extremely long

midface (long nose length) distance between the eyebrow and bottom of the nose, which makes my face extremely long and thin looking.

I also have a severely recessed chin (about 11 mm deficient) 

I have been looking up procedures to give more horizontal projection to my chin and also widen my chin, and give it a more masculine and square look. However, my biggest fear is that a sliding genioplasty of 11-12 mm would elongate my already tremendously long face. 

I am wondering, if someone were to want to completely avoid elongating their face, and wants to add horizontal projection to their chin, and square width to their chin, without adding any vertical height to the chin, should they opt for a genioplasty or a chin implant?

I was initially leaning towards a genioplasty, but fear of elongating the face, caused me to research other options, but I also have heard that chin implants erode the chin bone under the implant etc.

Which would you recommend for a 25 year old male? Really insecure about my recessed thin width chin, but keeping my face as short as possible is definitely a priority.

Thank you!

A: In answer to your long midface treatment questions:

1) Only a sliding genioplasty can bring the chin forward AND vertically shorten it. A chin implant can’t have that dual effect.

2) Chin implants do not cause bone erosion, they are only associated with self-limiting implant settling.

I would need to see pictures of your face to provide a more qualified chin augmentation recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implant replacements. My current cheek implants are a medium combination submalar and malar midface implant. It’s opaque, blue and a rubbery material. The side that is placed on the bone has small tentacle like projections. 

I’m not sure if it caused by improper placement, sizing, implant shape or a combination of both, but my smile is restricted compared to before I had the implants (as in I cannot smile as wide after getting the implants).  My surgeon insists that it’s due to my facial muscles and maybe I’m the small percentage whose facial muscles cannot glide easily over the implant (he’s also blamed it on the fact that I’ve had a child but my smile was completely normal after delivering my daughter), but I’m having difficulty believing that is the case.

In any case, I have attached a few images for you to review. The first two images are pre midface implants. The last two are after implants (one before I delivered my second child and one after). When I am thinner, the implants look to large and I have a hollow under   It in the cheek area.  When I have more weight, I just look completely overdone and the issue with my smile is exacerbated. The other surgeon said the weight from pregnancy would fill in the hollows but either way… to put it plainly… it looks like crap and everyone I know can tell I’ve had work done. Needless to say it’s been an unpleasant experiences and I just want to get it fixed.  

Let me know if any other info is needed on my end! Thanks!! 

A: What you describing is a Conform malar shell style of cheek implant. (a blue implant is the sizer not the actual implant) In reading your concerns the most likely explanation of your symptoms is that of implant size and/or style. It is very easy in the cheek to get implants that are too big. If they were too big when you were thinner that will not change and mag even be exacerbated with more weight in the face. Cheek implants are a great example of less is usually better. Benefits ma y one obtained by either downsizing them or changing to a smaller and different stye. ideally a 3D CT scan should be done to also check their position on the bone which may also be too anterior.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One year ago I had a sliding genioplasty (along with LeFort 1) that horizontally advanced my chin 6mm. Although the projection of my chin improved, I was still unsatisfied by it, so on Friday, I was scheduled to have another 6mm genioplasty (for more horizontal advancement), as well as wisdom teeth extracted. When my surgeon went in, he saw that the plate and screws from the first genioplasty were completely overgrown with bone so he opted to place a 5.5mm implant instead. Naturally I was very upset when I found out upon waking up. I’m 100% I’ll be removing the implant. In a case where the plate and screws are overgrown with bone, is it truly that risky to cut or drill through? Can a 4mm genioplasty at minimum possibly be done at the time of implant removal? 

Thanks!

A: I can only speak from personal experience but I have yet to see a chin plate that could not be removed…and I have seen many with partial or near complete bony overgrowths. I more informed answer would require review of an x-ray that shows your plate and screws. Sometimes the screwheads are stripped and the shaft of the screw(s) can not be removed but the plate can always be with some bone drilling and effort. Once the plate is removed a secondary sliding genoplasty can be performed for an additional 4mm movement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently got Medpor jaw angle implants (1 month ago) 7.5 mm but already I wish I had went larger to the 1cm ones to have more flare. Would it be possible say in a year or so time to place a small custom silicone implant over the polyethylene implant without removal , and if not what would the reasons be.

A: You are referring to the concept of a jaw angle implant overlay. It can be technically done but would require lag screw fixation to they underlying implant to prevent impact migration. The best jaw angle implant to use for that effect would be the vertical lengthening style.

The only potential downside is the risk of massteric muscle disinsertion as it would be necessary to break through the overlying capsule to get the overlay implant down over the existing jaw angle implant. But I have done it more than once successfully.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am curious about custom titanium facial implants. Seeing a lot of fear mongering on the internet regarding bone re-absorption, infection, etc. Can you update me with the latest information on risk? How long do titanium implants last before complications are possible? Possibility of muscle or nerve damage, or large scarring? Is titanium truly the best material for safety and longevity?

I’ve attached front and profile pictures as well as imaging I’ve done on them for how I’d like to look.

Is this a realistic expectation? The skin around my jaw is rather loose so I believe it could accommodate the size of the implant without over-stretching.

My under-eye area is a minor concern but I’m open to suggestions. It will probably get worse as I age.. runs in the family. I’m 25 now. Filler should work fine there but I haven’t tried fillers before.

Overall I want bigger zygos, a more pronounced, wider and straighter jaw line, and a more pronounced chin that closer lines up to my lips. I feel these changes would improve the harmony of my facial features such as my somewhat over-projected nose.

How close can you get me to the imaging and what is a ballpark price range I should expect to pay?

Thanks for your time. Looking forward to working with you.

A: The reality is that titanium as a custom facial implant material in the U.S. is not a viable option due to:

a) It’s tremendous cost (it would cost about $20,000 just to have the implants made) and

2) surgical placement. This is relevant to the jawline were the rigidity of the material will require it to be sectioned into four pieces and the need for larger incisions for placement

The risks of placing titanium implant in the face are identical to any other material from which custom facial implants are made. The material does not change those risk factors.

I see nothing unrealistic about the facial imaging you have done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m emailing you regarding coral hydroxyapatite/Interpore. 

It is a porous, non-degradable granular mixture of hydroxyapatite from coral in the sea. It is perfect for facial augmentation, I believe. 

Do you use this material or happen to have any of it on the shelf? I don’t like the idea of a traditional implant in my face so if you know anything or anyone who has this material it would be great if I were notified.

A: I am very familiar with hydroxyapatite (HA) granlules for facial augmentation and have used it many times in the past. While it still has a useful role in small areas of facial augmentation it has issues with contour irregularities since it is applied as a paste/gel and rarely heals in a smooth and linear fashion. Due to this contour unpredictability it is an inferior facial contouring material compared to the smooth and predictable contours of preformed facial implants.

Hydroxyapatite granules are becoming increasingly hard to find as the number of manufacturers has become limited.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had mandibular body implants, placed bilaterally without complication, around 20 years ago. The projection of my chin was also reduced at that same time. There  were no screws, the mandibular body implants were the largest size available. 

At  that time it was very uncommon to lower the mandibular jaw angle , so I only enhanced the mandibular body without  lowering  the height of the jaw angle. I am interested in utilizing the better technology which exists today, in order to  possibly replace the jaw implants.  

I’d hope to focus specifically on lowering the mandibular angle, and give the jaw angle a more defined  square jaw appearanc , instead of the high angle tapered appearance . 

I’m sending some pictures in the hopes that you might be able to tell me if the  current results can potentially be safely improved on.  My impression is that the left jaw has always been comparably weaker.

I should add that I had a neck lift and fillers over the past several years, also without any complications.

Thank you in advance for any opinions you may have. 

A: I would need to see a 3D CT scan of the current position of your long-standing jaw angle implants. In the face of well encapsulated implants I would be cautious about trying to open the capsule and drop the implant borders down with a vertically lengthening implant. That is not a complication free procedure which can result in masseteric muscle dehiscence with indwelling jaw angle implants. But seeing the scan would help me determine as to the advisability of this procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 22-year old male. My temporalis muscles bulge at the sides which makes me look like an alien. Because of the my protruding posterior temporalis, my hat size is 58cm, and even that feels a little tight. 

I heard that you’re one of the few surgeons that can surgically excise the muscle. You’ve mentioned in your blogs that a 7-9mm width reduction each side can be expected from the surgery.

However, I’d like to try out botox first to see if I’d like the final look. However, since botox only shrinks the muscles and doesn’t remove it:

1. How much width reduction per side can I expect from botox? Will it be considerably lesser than the 7-9mm through surgery? Is 4-5mm reduction per side through botox possible?

2. How many units do you recommend per side? I’ve seen doctors quote a range from 25 units to even above 50 units per side.

Thank you!

A: In answer to your questions:

1) The effects of Botox compared to surgery would be less than 20%.

2) You would likely need 100units per side to get a really noticeable muscle temporal reduction effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just would like to know if you can help me with a procedure. So, I would like to have a silicone implant in my head to grow 2.5 cm for my job and my career. My career requires me to have at least 166, but my size is a 163.5 . I know that this procedure is common in Spain. People do it to grow taller. Please let me know if you can help me. Thank you very much.

A: Skull augmentation with a custom implant can be done to increase your height by 2.5 cms. But this will require a first scalp expansion as no one’s scalp has enough flexibility to permit such a large implant to be placed without it being stretched first.

With the immediate insertion of a custom skull implant one’s height can be increased by about 12mms or 1/2 inch due to the limits of scalp stretch. With a first stage tissue expander the thickness of the implant can be extended to 25 to 30mms (one inch) due to the scalp stretch obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long face, it’s actually long through out and while i am looking into hairline lowering/hair transplant , and have already had a chin reduction , the mid face and the part of the lower face that is between the lips and the nose appear to be harder to address. Can a Lefort 1/maxillary impaction help to reduce the vertical length of that part of the face between the lips and nose? Also, I am thinking the impact to the mid face (brows to the tip of nose) would be minimal, but some doctors says optically the surgery has the potential to make the mid face look shorter, what are your thoughts? 

Also, will shortening the maxilla actually shorten the vertical length of the nose on the frontal view? Or is there any surgical maneuver at all that can reduce the length of the nose (frontal view) when the tip is already at a good position and not drooping? I think we are constrained by the nasal cavity here. 

Thanks for your time. 

A: In short, there is no effective procedure for reducing the middle third of the face unlike the forehead and chin. No bone shortening procedure shortens the visible midface, it only affects the amount of upper tooth show. A lip lift, which shortens the distance between the base of the nose and the upper lip is the only procedure that provides some vertical midface reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had decent results from Botox to correct temporal hypertrophy, but the results are always temporary unfortunately, so I’m looking for something more permanent. I have a few questions please .. .1) I think the muscle is thickened in both anterior and posterior aspects, but I think in my case its more an anterior problem, it actually aches in that area at times. I see Dr Eppley’s approach for Anterior is “high temporal release”. Could you please give me a ballpark idea of total cost of that procedure alone. Cost is unfortunately a fairly big issue. So that’s probably a good place to start. 2) Could you please also give idea of cost for posterior approach? 3) The last time I had general anesthesia I had a bad experience from the anesthesia and I swore to never have general again, at most conscious sedation. So, is it at all possible for Dr Eppley to do any of the procedures with local anesthesia/conscious sedation?

A:Thank you for your inquiry. Unfortunately I can not be of assistance in your case. I do not have a reliable way to reduce the anterior temporalis muscle like I do for the posterior temporalis muscle. Furthermore even if I did this is not a procedure that I would do under anything less than general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am searching for a doctor well experienced in sliding genioplasty revision. I had a sliding genioplasty reduction 6 months ago as I wanted to reduce the protrusion of my chin when I smiled. I am happy w the results, the problem is the dynamic ptosis my chin manifests every time I smile. My chin also looks flat and without form when I smile on top of having the tissue/muscle pulled down. I am wonder if this is a matter of mentalis muscle resuspencion or if I can simply have my original surgeon move my chin more forward? Will that fix the hanging tissue or do I truly need a resuspension? 

A: Thank you for your inquiry. As expected when you slide the chin bone back for horizontal reduction you are going to develop dynamic chin pad ptosis. (and in some cases submental fullness as well) This occurs because a purely bone-based procedure does not account for the soft tissue excess that is also present. This problem is not going to be solved any any form of muscle suspension as it is a tissue excess probpenm. Your options are to either slide your chin back out to pick up the loose tissue or have a submental chin pad excision/tuck done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been following a lot of your work and you seem to know a lot about computer imaging. I think I will have to go with you for my next procedure because my current doctor doesn’t seem as informed as you.

I had off the shelf cheek implants inserted by a surgeon who put them in asymmetrically ( everyone makes mistakes, not a huge deal ). He wanted to see the asymmetry so he can better know how to fix it during revision, so he ordered an X ray for me, but the X rays only showed us the screws and not the implant. 

What type of imaging should we order so we can see the silicone implants and not just the screws? Would a CT scan work? I see in your writing here https://exploreplasticsurgery.com/category/custom-facial-implants/page/11/ that a CT scan works, but do we just order a regular CT scan or do we need to ask for some special CT scan that shows silicone?

Thank you very much for your time.

A: The short answer is that the implant images are in the CT scan, which I assume is a 3D CT scan which is the type of scan to accurately assess facial implant positioning. But if you don’t have special software to pull them out of the data, you will not be able to see them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been thinking about getting custom made jaw implants to compliment my cheek implants, but the ONLY thing that scares me is an infection. I am terrified of infections, which is why I had the cheek implants inserted through the eye lid.

Which brings me to this series of questions:

1. Would it be possible to have the jaw implant inserted from outside my face in order to dramatically decrease the chance of infection? 

2. Is this easier or harder on you compared to inserting from inside the mouth? I don’t want to make things harder on you since that increases the chance of things going wrong

3. Are there any risks associated with inserting them from the side of the face that I should know about? Maybe increased chance of nerve damage or something?

4. Have you ever done this before or would I be the first special case like this?

Sorry about all the questions, and thank you for your time.

A: I have done several times both primary insertion of jaw angle implants as well as secondary revisions of them through an external skin approach in men. In answer to your questions in that regard:

1) The external approach is done through a small skin incision right over the jaw angle area. See attached picture of scar.

2) Whether it is harder or easier than an intraoral approach depends on what material and implant style/size of jaw angle implant is being placed. To keep the incision small I would only use a silicone jaw angle implant for an external approach.

3) Other than the scar, the only other remote risk is marginal mandibular nerve injury. But the course of that nerve is lower than the level of the incision.

4) see #1 above.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been carefully considering everything and I think I am going to put off getting calf augmentation and custom infraorbital-malar implants until future procedures, if I choose to do so. I am still interested in the following:

-Custom Jawline

-Buccal Lipectomies with Perioral Mound Liposuction: Bilateral

-Septorhinoplasty

-Fat Grafting to: Labiomental Fold

I have some questions about those procedures and some others I’d like to consider:

1) If I got a custom jawline implant, would it be attached to my jaw bone with screws? If yes, would this affect my ability to have an MRI in the future if I needed one for any reason?

2) Can a custom jawline implant make snoring worse?

3) We talked in my consultation about submentoplasty, you considered it a bad return on investment because it was likely I would get the jawline definition I was looking for from an implant only. I am a little confused about the description of the procedure. Is it just fat removal/liposuction? Do you also tighten the platysma muscles? What I am trying to achieve with submentoplasty is to get a much sharper angle between my neck and my jawline as seen in the before/after picture I have attached. 

4) If I’d like to treat the my under eye hollows/bag with fillers instead of implants, what kind of fillers would you recommend? How long do they last, do they deteriorate slowly over time or all of the sudden? How many syringes of filler would I need?

5) I feel like I have some breathing difficulties and I know for certain that I snore loudly and would prefer not to. Do you offer somnoplasty/turbinate reduction? I’d like to get my soft palate/uvula and turbinates targeted to treat nasal obstruction and habitual snoring. If you do offer it, do you perform it often? Is this a procedure that I need some sort of medical evidence/sleep test results to show that I need it?

A: In answer to your questions:

1) All jawline implants are attached within screws. There are titanium so they are non-magnetic.

2) No.

3) A submentoplasty is a combination of liposuction, fat removal beneath the platysma and muscle tightening.

4) The only fillers that should be placed in the thin undereye tissues are hyaluronic acid-based of low viscosity. Most people need at least 0.5ccs per side or at least 1 syringe,may be 2.

5) I perform inferior turbinate reduction regularly and are part of most septorhinoplasties when there is breathing impairment present.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am an international patient and am interested in a custom wraparound jaw implant. I have a few questions: 

1. As I am an international patient, will it be possible for Dr Eppley to design the implant just off the 3D ct scans or will i have to physically be present for optimal results? 

2. Can a custom wraparound jaw implant add a slight amount of vertical chin length (roughly 4mm)? 

3. What would be the rough total cost of such a surgery? I understand this cost may vary from patient to patient but it would be great to get a rough range.

Thank you very much!

A:Thank you for your inquiry. In answer to your custom wraparound jawline implant questions:

1) Most custom facial implants are designed off of the 3D CT scan and picture imaging. The patient does not need to be physically present unless they want to be.

2) Custom jawline implants often add vertical length not which 4mms at the chin is no problem to do.

3) My assistant Camille will pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have really been mulling a facial reshaping procedure for some time. 

I am interested in getting a more heart shaped face. High, defined ogee curve – so delicate cheekbones and a V like chin. I am unclear on if I need to touch my chin at all. I am also unclear if my brow bone has anything to do with this. 

I have attached my photo and a few photos showing what shape I am aiming for. I do intend to do rhinoplasty next year but first things first. I am seeking definition that photographs well as well as looks nice in real life. 

I was really considering fillers to accomplish this look but my issue is I really want it to look like a change in structure, not fullness. I also want it to be permanent. 

Questions:

Will weight loss after surgery possibly change proportions in a negative way?

Would implants negatively affect my ability to smile?

Also, are my goals realistic at all? To be clear I know won’t like these models. Rather, is it possible to get closer to my ideal v like face shape without it looking fake? Is it possible for cosmetic surgery to achieve that facial harmony seen on actually attractive faces (as opposed to just placing features that still don’t show that balance?)

Sorry for the lengthy email. I just want to move forward and need to know if I found my solution.

A: Thank you for your inquiry. In trying achieve your facial reshaping changing the correct procedures are cheek implants, mid facial defatting (buccal lipectomies and perioral liposuction) and possible chin lengthening. (although I can not tell based on just a front view whether that is beneficial in your case or not) 

The question is not whether these procedures can be done but whether they can remotely achieve the type of facial change you are seeking given your natural facial anatomy with thicker tissues. In other words how realistic are these type of changes? There is no way to really know that answer accurately other than to say I suspect it is more unrealistic than realistic.

And to answer your two specific questions:

1) Weight loss will only help the result not adversely affect it.

2) Cheek implants will not affect your ability to smile normally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley, I am interested in custom infraorbital cheek implants. However, I have scleral show and don’t want to run the risk of amplifying it through insertion via the eyelid. Could the custom implant be inserted though the mouth? Thanks.

A: The intraoral route for custom infraorbital-malar implants can be used IF the implant is not designed to saddle the orbital rim and only provides some minimal anterior projection. If it needs to saddle the orbital rim to any degree, and most such custom implants do which is why they are custom, then a lower eyelid approach is needed ensure adequate placement.

Custom infraorbital implants that saddle the orbital rim and add height to the bone are actually an effective treatment for scleral show as they drive the lower eyelid upward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am two days after custom infraorbital-malar and jawline implants. I’m feeling OK, pain is tolerable. However I have significant facial swelling, right face greater than left (I notice that this is far more than what I had my Lefort 1 surgeries).

I have started medrol dose pack. Is this common to see this amount of swelling? Is there anything else that needs to be done? Should I take the bandage off?

A: Your surgery went superbly and your lower eyelids did not have to be disturbed from above. Coincidentally I also drained a large sebaceous cyst in the left cheek area the became more revealed from the perioral liposuction.

What is important to remember about the facial swelling is the following:

1) It will be considerably more than anything you have ever seen before. If you think about it your entire face was degloved off the facial bones with the exception of the nose. That is not remotely similar to anything you have ever experienced previously. So even though you may have been partially ‘prepared’ from our prior surgeries, that is the barometer by which to judge the swelling from this surgery.

2) Swelling will takes 2 days to maximize. So whatever we see today will be worse by tomorrow, this is normal. I would basically expect your face to look like a round pumpkin by tomorrow at the peak day. It is psychologically disturbing, as I mentioned before surgery, and it will take about1days until you feel better by the direction that things are heading….but a good month until things start to look close to what the final facial reshaping effect will be.

3) Even though the surgery was done symmetrically, the same things to both sides, they never swell symmetrically. One side will always swelling more than the other.This is normal.

You may remove the chin strap at any time. It is only there if it provides comfort. It has no role in stabilizing the position of the implants.

You may shower and wash your hair today as normal.

Despite all the thought that goes into these surgeries, this early recovery phase is the hardest for patients as only time, healing and patience are the ingredients for recovery.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I was thinking about brow bone reduction surgery and I have two questions:

1) Will the screw/plate/etc in my skull interfere with airport security?

2) Is the brow bone reduction surgery something that is often re-done or come with complications? I was a bit startled when the form said 15% of patients want surgeries to be re-done. If something goes wrong, I won’t have time to get surgery redone because I will have to go back to school.

A: In answer to your brow bone reduction questions:

1) The 1 plate and 4 small screws used to hold the bone flap in place as it heals are made of titanium, a non ferromagnetic metal. This will not interfere with airport scanners or having MRIs.

2) It is important to realize that any surgery has a risk of revisional surgery, whose percentage risk varies dependent on the type of procedure performed. The risks that we are mainly referring to are largely aesthetic in nature and are often issues that patients see and are not necessarily medically needed. For example such risks as asymmetry or a slight irregularity here or there. There are other more major risks, such as infection, although tis is to something I have seen in this type of facial surgery.

While revisional surgery in brow bone reduction is not common, it is wise that the patient be aware that it exists and it is a potential sequelae of this or any surgery. Surgery is not like putting puzzle pieces together. The factors of how human tissues respond and heal to surgical manipulation is not a completely predictable phenomenon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting cheek implants after unfavourable results from zygoma reduction surgery. I am very much interested in getting custom implants to get the most desirable results, but this would entail going overseas as no plastic surgeon offers custom implants for aesthetic purposes in my home country.

How often or what percentage of patients get an infection in one or both implants in the immediate post-op period? I have read that implants can get infected up to two or three months after the surgery, and I definitely cannot be overseas for that long. I am worried about getting implants put in and then returning to my home country and then getting an infection.

If you could please provide any insight on your experience, it would be much appreciated. Thank you for your time.

A: In my vast experience with custom facial implants, infection of cheek implants is one of the lowest. So low that I can not recall a prior case in which infection resulted in implant removal. I do recall, however, several that were resolved satisfactorily with antibiotics alone.

Because I have so many international patients, I use a special antibiotic protocol as the stakes of having problems is so much higher when patients are far away.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What type of cheeklift did I have done when my Medpor cheek implants were removed?

A: Cheeklifts are done to either treat a difficult ectropion, as a prevention of ectropion or cheek tissue sagging such as may occur from cheek implant removal, or do a cheeklift for sagging from aging or as a possible substitute for cheek implants. While many different types of cheeklifts have been described, every cheeklift is some form of a subperiosteal technique which only differs by the way they are suspended upward. A direct cheeklift, which is really the most effective as it is done closest to the ‘problem area’ and also lifts the cheeks vertically in the correct vector, does so by attaching the suspension to the orbital rims. 

Because it is done through a lower eyelid incision it is not the most common cheeklift technique even though it is the most effective as many younger patients don’t want a lower eyelid incision. But in your case with an already existing lower eyelid incision with ectropion and wanting cheek implants removed, this was by far the most logical and effective approach. 

Dr. Barry Eppley

Indianapolis, IndianaC

Q: Dr. Eppley, I am interested in rib removal surgery for waistline reduction. I want to make way since I’m not near you for an in person consult and email should be enough for now.

1: Referencing the picture of the ribs in this reply could you tell me precisely what the surgery entails? Is it just cartilage or the entire rib? Making sure we’re on the same page the primary reason for this surgery is waistline reduction; so completely elective and doing it for myself only.

2: Regarding aesthetics/scars what are we talking here? Where or how will the cut be as I see the people on your site and some scars look fine. I’m used to various elective surgical scars over the years and have come to accept them. It also sounds like there are options in how extensive of a surgery I’m able to choose.

3: How much does this cost and what hospital does it take place at?

4: How’s recovery and should I know anything special regarding flying before/after such as how soon can I return to work or how much pain there’ll be? I’m only a few states away and my current job is very white collar low physical.

5: Will liposuction be performed or can that be done separately later on if I decide that’s something I want to pursue with a local center? I’m mainly interested in the core procedure since I’m already a twig to begin with. Weight gain has never been an issue of mine.

6: Figure I’d throw this out here, but should I bother making a claim to insurance to get it potentially covered in any way?

7: Assuming I’m ok with all this after having time to think some more, do you do a final in person consult before surgery to know precisely how much to take out? We’ve never met in person so you only know what I sent you pictures of.

8: Do you accept payment plans? Some plastic surgery centers offer cosmetic credit cards or payment plans to allow patients to get their procedures sooner and work on paying it off in their own time later.

Thank you.

A: It is not clear to me whether you are referring to anterior or posterior rib removals which are done for different reasons. Posterior rib removals is done for horizontal waistline reduction while anterior rib removals are done for verticals waistline lengthening and/or removal of subcostal rib protrusions. In answering your questions I will assume you are referring to posterior rib removals.

1) In posterior rib removals, the outer calfs of ribs #10,11 and 12are taken. (see attached picture)

2) These are 5 cm obliquely oriented scars on the back. (see attached picture)

3) My assistant Camille will pass along the cost of the surgery to you later today. This is done in my surgery center not a hospital.

4) Recovery is really about comfort and getting back to doing things normal which will take a few weeks. There are no restrictions after surgery. Most people can return to work in ten days after the procedure.

5) Posterior rib removal always includes flank liposuction as well as rib removals.

6) This surgery would not be able be covered by insurance, this is an elective cosmetic procedure.

7) The amount of rib removal is the same one each person, the outer half of the rib is removed back to the erector spinal muscle.

8) My assistant Camille can answer all logistical questions about the surgery.

Dr. Barry Eppley

Indianapolis Indiana