Your Questions
Your Questions
Q: Dr. Eppley, Zygoma reduction was a major surgery for me, and as much as I put my faith in my surgeon, I understand that there’s no guarantees with any surgery. I would like to keep a back up plan handy, in the case that things weren’t able to end favorably. In the case that sagging happens, I’m interested in getting cheek resuspension surgery or Endotine cheek lifting to lift the cheek tissues back up higher. My surgeon does not provide cheeklifting or endotine lifting surgeries, so my ultimate plan is to fly to your practice in Indiana.
However, I’ve read on your blog, of someone else’s experience of zygoma reduction. (http://eppleyplasticsurgery.com//can-a-cheek-lift-fix-my-sagging-face-after-cheek-bone-reduction/) With this individual’s experience, you stated that their tissues were scarred and atrophied from their cheekbone reduction, cheekbone reduction reversal, and endoscopic midface lift surgeries.
What do you mean exactly when you say their soft tissues have been ‘scarred’ or ‘atrophied’ from the surgeries?
I was wondering if this case would apply to me as well. I’ve already undergone zygoma reduction and lifted the cheek tissues up once. If I were to get the titanium screws removed (ideally I would), the cheek tissues would be lifted twice. If I were to undergo a third surgery (cheek resuspension) and lift the cheek tissues off the bone a third time, would this result in atrophied and scarred cheek tissues as well?
When the tissues are atrophied and scarred, what effect does this have on the external appearance of the face?
A: All surgeries in the face cause tissue damage and some degree of scarring and tissue atrophy. How relevant this effect is depends on many factors but is of greater relevance in facial bone reduction surgery than facial bone augmentation surgery. (unless you remove the augmentation) With less bone support the overlying tissues will contract as a natural part of healing. While everyone thinks that the tissues contract in a 3D fashion around the reduced bone (in, down and up, they may not and the tissue contraction may be more of a 2D effect. (in and down) The young age of the patient and good tissue elasticity makes it far more likely that a 3D tissue contraction effect will occur but this is not necessarily assured.
The more times you enter a surgery site the more scar that is created. Whether this scar is detrimental depends on what is being done. For plate and screw removal this dissection is such more limited so it is less likely to have any cheek sagging effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 9 months post operation from a zygoma reduction and jawline reshaping surgery with a surgeon in Korea. I am 23 years old, soon going on 24, and I’m finding that I’ve developed a double chin. I exercise 3 times a week, am a normal weight for my height, and this double chin was definitely not there prior to my surgeries. So I’m suspecting that the surgeries instigated this double chin, whether its excess skin/tissue or the fats from my face sliding downwards.
From touching the area myself, I’m unsure whether what I’m feeling is fat or tissue. Could you please help me on what I should do next to eradicate this problem?
Why did this double chin slowly start to appear over time? My jawbones weren’t over-resected and my zygoma reduction wasn’t over-resected either. As I am young, I was expecting for my skin and tissues to redrape themselves over the new structure.
Is this a common occurrence from jawline reduction and cheekbone reduction? What should I do!?
A: The simple answer to your jawline reshaping surgery question is that the loss of bone support from a projecting facial structure (like the chin) can eventually result in a submental tissue sag or even chin ptosis. While such a biologic effect is more commonly seen in the cheeks, it can also occur at the chin and along the jawline. And such an effect is well chronicled in the jaw angle region.
It takes a fairly long time after facial bone surgery to see the extent of the soft tissue effects due to he slow resolution and the how well the overlying soft tissues have contracted around the reduced bone. This is why it is often not apparent for 6 to 9 months after surgery.
There are limited number of treatments for these soft tissue redundancies such as liposuction or limited soft tissue tucks. I would need to see pictures of your face to provide a more qualified recommendation.
Dr. Barry Eppley
Indianapols, Indiana
Q: Dr. Eppley, thank you for reading about my request. I am a Korean female.
In Korea, as you already know, many Korean girls desire to have a very heart shaped face – Just like the one I have sent in the photo.
My situation is very different. I was actually born with a heart shaped face. Many of my friends say I was very lucky to be born with this shape, as the taper chin and slim face is very desirable in my country. But…
I desire a more oval face. I feel as if it makes a person look younger, cuter, and more feminine. I do not like my face when I smile, because my chin is so tapered it looks sharp and pointy and makes me look old. More oval face is plump, cute like a baby.
Doctors in Korea do not do jaw implants. When I tell them I want to change my heart shape face, they think I’m crazy and reject my request because there is nothing they can do.
For me to get oval shaped face is important. Do I need jaw implant or can I get some small improvement from chin widening surgery as I really hate my small thin pointy chin. I am very afraid of jaw implant because it is very not common in Korea – the doctors here don’t know how to put in or fix if something goes wrong. Would chin widening surgery give me more rounder bottom half of the face?
A: While it may be common for a Korean female to seek chin/jaw widening, it can certainly be done. There are two fundamental approaches, each with their own degree of effectiveness.
While osteotomies work well for chin narrowing as part of V-line jaw surgery, they are not quite as effective for chin widening. This is not due to the central chin widening effect but out at the sides of the chin where it has to blend into the jawline to make it wider as well. This can be an area of step-off or irregularity.
A extended special designed chin implant works the best because it provides a smooth widening effect back along the chin into the jawline. As the effect you seek is probably more than just an isolated central chin widening. But you would have to clarify that for me.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 24 years old and I underwent zygomatic reduction and V-line jaw reduction surgery for cosmetic purposes around two months ago. I was wondering, is it possible that jaw reduction surgery can cause sagging around the neck area? I ask this because I’ve started noticing that I have am getting a double chin, when I did not have one prior to the surgery. I know for sure this was not caused by any weight gain, as I have actually lost quite a bit of weight since the surgery due to being on a strict liquid and soft foods diet.
My surgeon had told me prior to the surgery, that because I am in my 20s, my skin and tissues would be able to shrink and redrape themselves to the new bone structure. But I am just really annoyed by the gradual appearance of this double chin. My chin used to have no signs of a double chin pre-surgery, unless I was smiling very widely or looking downwards.
Now I just have a double chin even if I am just looking at my side profile! What can I do about this?? What options do I have when this may be excess tissue and not fat?
A: The elevation of tissues off the chin and jawline to perform V-line jaw reduction v-surgery, with the loss of bone structure/support, always has the risk of creating a soft tissue sag later. This is a well known risk of the surgery and could be the aesthetic tradeoff of this type of facial bone surgery. Since it is only two months after surgery i would give a lot more time to healing and to see the full effects of tissue contraction which could be up to six months or longer after surgery. I can not say whether your condition will improve or not but your tissues need adequate time to fully heal.
If it persists there are options for treatment including liposuction that can be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the approximate cost for rib removal without fat grafting?
This is a rare procedure, and I imagine a fairly traumatic one, considering how the muscle tissue clings to the bone of a BBQ pork rib. What are the potential consequences for mobility and activity? What is the aftercare protocol? Can you connect me to other patients who have worked with you who would be willing to talk about their experiences?
Where will the scars be located, and how large will they be?
Would deliberately fracturing the bones and wearing a corset as soft cast while they heal be a realistic alternative to resection?
A: In answer to your rib removal surgery questions:
1) My assistant Camille will pass along the cost of the surgery to you later today.
2) Rib removal surgery, while providing as expected some after surgery discomfort, has not had any morbidity othethan the scar that I have seen. Patients recovery quicker than one would expect.
3) The surgery is done through oblique 5 cms long back incisions.
4) Rib resection offers a more effective waistline reduction with a quicker recovery than rib fracturing. Such rib fractures would not go on to heal and would be a source of chronic pain.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am from China an am 23 years old. Please read my story and give me advice.
One year ago I went to Korea for V-line surgery and the cheek bone reduction surgery because Korea is very famous for Asian small face surgery. My face before was very not symmetric and very ugly and not like a girl !! I have put old photo of my face in the email. If you see photos, you can see that my cheekbone was very very big. My old face – one cheekbone very bigger than the other cheekbone and more meat on the face if you look at the photo carefully.
My Korea doctor used very popular technique called 3D rotation malar reduction. This technique uses L cut in front of cheek bone and cut the back in the hair. Then push the bone in and fix with the use of titanium plates and screws. I do not know how many mm of bone were taken out.
My face after surgery got very smaller and I was very happy. The result very dramatic and my face very likeable. But one year after surgery, I have a big problem.If you look at after photos in the email, the meat of my face drooping. There is too much meat on the face and it makes my face look old, chubby, nasal labia lines! I was very angry!! Doctor said 3D rotation malar reduction have little chance of cheek drooping because of plate fixation and bone rotation and because I am young.
I flied back to Korea this month and he say thread lifting is good solution. I was very angry again because thread lifting is not permanent fix and only last very short time. I can’t pay for thread lift over and over until I die. Korean doctor then refused to fix my drooping face, and now I do not know what should I do.
My big problem is the extra meat on the nose making nasal labia lines. What is your advice on how to fix? I try skin tight laser but no effects… What can I do to fix?…
Should I do face liposuction to get rid of the extra meat or redo surgery? Can I do cheek lift to move cheek meat up high when I am still young? Is it possible?
I want to hear your reply soon, thank you.
A: What you have experienced after such cheek bone reduction surgery is not rare and is what can happen when there is loss of bone support. The overlying soft tissues may or may not contract down completely in a 3D fashion. Such effect can take up to a year after surgery to see whether it fully does or not.
The cheek sagging to which you refer/have is not an easy problem to fix. Nothing non-surgical, like lasers or any other device is going to work. Liposuction will largely be ineffective and threadlifts have a temporary effect at best.
Some form of a cheeklift is needed or resuspension of the tissues. An intraoral approach is one option with Endotine fixation. Other superior options are through the lower eyelid or temporal scalp incisions to do the lift. My personal preference is for a cranial suspension technique which pulls the cheeks vertically upward, which is the best direction for resuspension as that is how they have fallen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial feminization surgery. Based on my pictures what are your recommedations?
A: Thank you for sending your pictures. As an older facial feminization patient, the effects of aging must also be considered as part of the facial procedures .My recommendations would be the following:
1) Browlift and Upper Blepharoplasties with Tail of the Brow Bone Reshaping (I don’t think a central brow reduction is that useful)
2) Rhinoplasty
3) Upper Lip Advancement
4) Lower face/necklift
While there are many other potential facial feminization surgery procedures that could be done, I consider these four the most effective and the best value.
The biggest challenge for the browlift is where to place the incision to do it.
In many older facial feminization surgery patients there is a concomitant need/benefit for facial rejuvenation procedures as well such as brow lifts, blepharoplasties and face and necklifts. These are done at the same time as the more traditional facial reshaping procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m very sorry to take up more of your time, but I just had a couple questions about my surgery path and I wanted a second opinion. By a local surgeon, I was referred to a plastic surgeon who uses hydroxyapatite granules for facial augmentation. I was wondering, what are your thoughts on using this method to add the missing width to my chin. I’m not looking to project it further outwards, but as I had said earlier, just to increase the horizontal width.What problems or benefits are there? Or would a reverse t-osteotomy technique be best.
A: I have had to revise a lot of hydroxyapatite granule augmentations of the face. They often end up irregular and lumpy. Hydroxyapatite granules for facial augmentation is an old method from the 1980s, which does have some clinical successes in small areas of facial bone augmentations. But it is a fairly uncontrolled pushing of hydroxyapatite granules blindly into a subperiosteal tissue pocket and hoping it will end up perfectly smooth. Sometimes it does and sometimes it doesn’t.
There is nothing wrong with using an implant material to augment the width the chin bone. But I would favor a more structured or rigid material that could be shaped and fitted without the risk of distortion.
And then there is, as you have mentioned, the chin widening osteotomy method as well. But I would still favor an implant material as it is more predictable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I went to my birth country to get double eyelid surgery. I underwent a procedure called non-incisional double eyelid surgery or suture double eyelid surgery, of which I hope you are familiar. It’s currently holiday period in Korea so I have been unable to contact my surgeon. It’s been over 4 weeks since my double eyelid procedure, and my right eye has healed very well.
However, on my left eyelid. There is a tiny but clear bump from one of the suture puncture holes. The skin is a darker brown color, which is not the case with every other suture hole, and the feel of the bump is more noticeable. My left eyelid has also started twitching very regularly, and I’m not sure if it’s because of the suture bump or if something has gone wrong with the surgery.
I don’t mind the feel of the bump from the suture or puncture hole, but the twitching is driving me mad. Every hour or so, my left eyelid will twitch or throb for a couple of seconds. I know there’s botox to stop this twitching but I’ve also read it needs to keep being repeated every couple of months.
1) From your medical knowledge and experience with surgery on east asians, is it normal for the eyelid to be reacting like this so long after the surgery? This was not happening the first couple weeks post surgery, and has started becoming more frequent in the last week.
2) If the twitching will eventually subside, how long should I wait for it to subside as it is actually driving me insane!
3) Is the twitching an effect of the thread lump? When I feel the other puncture holes, they do not hurt when I touch it. But this particular one on my left eye is still a bit sore when I touch it even though it’s almost been a full month.
As I am an international patient, would you advise me to fly all the way back to have this revised?
A: I am very familiar with the suture or non-incisional method of double eyelid surgery even though this is is not my preferred method for double eyelild surgery.
The bump to which you refer is undoubtably the knot from the underlying suture. It is apparently right under the skin and is more prominent than the others. This accounts for the bump that you feel and the skin discoloration. It is likely this is the source of your blepharospasm as well. Such events when they occur often do not occur for 4 to 6 weeks after surgery when the initial swelling has subsided and the tissues try and return to normal.
If this issue has no resolved in the next few weeks you will need to have that suture removed/replaced for a resolution of your symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my surgeon told me that when he degloved the chin and removed the titanium screws and plates from the sliding genioplasty (which was performed last year by another surgeon) he found granulomatous tissue in the area of the screws and plates. Where the screws were attached there was now diseased bone which he removed. According to the surgeon, he removed all dead tissue and cleaned up the area with an antiseptic solution. It seems as if I have had a major infection/inflammation around the screws which has killed off the surrounding bone.The strange thing is that I never noticed any puss, swelling, redness of the skin or even any real sensation in this area. Many months after the sliding genioplasty when I pressed on this area, I felt only a slight tingling sensation and absolutely nothing that would have alerted me to the gravity of what was happening. Furthermore, the sliding genioplasty was only performed 11 months before this latest implant surgery so the process seems to have been quite aggressive. Due to the nature of the placement of the plates and screws, the problem was restricted to the middle of the chin. At the epicenter of the problem, there is a wide hole in the middle of the chin where most screws were placed which according to the surgeon may surpass the cortical bone in depth.
What worries me is that it took almost four weeks for the sutures inside the front of the mouth to fully close from this last surgery. This observation is of course only based on what I noticed inside the mouth, which means that the incision may have closed up further down leaving only the top part unhealed for a longer period of time. I did not poke inside the incision to see if it was unclosed all the way. Since he put in an implant, there are new screws attached to the remaining chin bone, which may serve as a foundation for a further infection that may have taken hold if indeed the sutures did not close up quickly enough. Luckily, I did take antibiotics in a moderate dose for 3 weeks after the operation. Since I did not notice anything unusual after the sliding genioplasty, I do not expect to see any clear signs of problems now either. Still, it may be worth mentioning, that there is no redness or puss in this area. The chin is somewhat swollen though, especially the top part where the problem area is, even after more than 2 months and 1 week since surgery. I do have some shooting pain coming from the area a few times a day, otherwise, I mostly feel a faint tingling sensation. If I press the area, I get kind of a mild cold sensation but no immediate pain. The thing is that the implant used by the surgeon had about twice the projection I asked for, subsequently, my chin is very tight and I am still numb in most of my chin and lower part of the lip area. There is also an overall burning sensation in the whole chin area. I suspect that all of this is masking some of the sensations from the problem area in the chin.
I have decided that I will not seek a revision by the surgeon and will most likely ask you to replace the jaw implant and possibly the cheek implants also. The surgeon also agreed that he was not the right person to deal with either the problem in the chin or the implant revision for numerous reasons. The insertion of a new jaw implant is, of course, complicated by the state of my chin. Assuming that you want to take on this case, what do you think is the appropriate action?
1. To wait 4 more months and hope that new bone has formed to fill out the holes and then replace the jaw implant? My main problem with this is that I do not know what is going on in my chin and I do not trust that the surgeon did a good enough job cleaning up and thus I might have a new infection brewing which is impairing any healing process of the bone or even worse, extending the holes in my chin. The surgeon himself said that he was unsure if he did enough. Up until the last surgery, the problem was confined to the middle of the chin, leaving me with an intact outer border. But if bone starts breaking down around the new screws, maybe I will end up with a hole extending all the way to the border of the chin. Another problem with this approach is that the soft tissues will adapt even more to the faulty design of the current jaw implant, which I would like to avoid if possible.
2. To deglove the area and fill out the holes with a bone graft (I assume that you do bone grafts) and maybe remove the current jaw implant and then put in a new jaw implant further down the road? My main problem with this is the blood supply from the soft tissues to the problem area. If this is interrupted again so close to the recent degloving, may I then face the risk of avascular necrosis of the chin? Or is the internal blood supply from the inferior alveolar sufficient. Also, if there still is an infection in the area, a bone graft may not be possible to perform, or am I wrong? Maybe, if you clean out any infection before inserting the bone graft?
3. Do the same thing as in 2. but also replace the implant with one of your customized silicone implants at the same time. The problems I see are the same as in 2., I guess. This seems to be the most desirable option for me, but maybe not the most prudent or even a possible option.
4. Replace the jaw implant after maybe cleaning out the area again if necessary but without any bone graft. Problems are the same as in 2.
I am really shocked that this has happened. The surgeon could not give an explanation what went wrong with the sliding genioplasty. I have not been able to reach the surgeon who performed the genioplasty yet. I am otherwise a very healthy individual with a great immune system which means that I am almost never sick. I also had great results on my recent blood tests and I eat very well, including lots of natural supplements, and have absolutely no deficiency in micro- or macronutrients.
A: Thank you for sending all of your pictures and detailing your most recent surgical chin history. Bone loss/instability around the plate and screw fixation from a sliding genioplasty is very rare. However I have seen it twice before. It most likely occurs, not from infection, but from some localized bone necrosis from the drilling of the screw holes. Remember that a high speed drill is used to make the holes in the bone and this generates heat. If overheated the bone around the screw heads dies and micro motion of the screw develops. This can result is sequestrum of bone around the site which is usually on the downfractured or inferior plate and screw segment. This does not create enough instability to lose projection of the chin but does cause a localized area of osteonecrosis and granulation tissue. This is what I believe has occurred in your case.
I would allow this area to fully heal over a period of six months before ever reopening the area to place any type of a jawline implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about cheekbone reduction recovery. I’m a lady in her 20s who is six weeks out from v-line surgery and buccal fat removal. I’m very worried about the progress of my recovery.
When I smile, my right cheek seems to jut out sideways a lot farther than the other and look very uneven. It looks a lot more fatty, while my cheeks were perfectly even prior to the surgery.
To the touch, my left cheek is a lot more softer and flatter. My right cheek is a lot more full and feels more firm/thick.
When I pinch my cheeks, to feel the thickness of the tissue (one finger inside mouth), the tissues of the left cheek are noticeably thinner whereas the right cheek tissues feel noticeably thicker.
Could this be an effect from uneven buccal fat removal?
Or could this still be an effect of swelling? However, I read somewhere on your blog that the bulk of swelling from this type of surgery would have dissipated by now, and am worried that I’ll have to deal with uneven cheeks. I’m not sure the little swelling that I have left to wait to subside will decrease the size of my right cheek enough to make them even.
A: To clarify a point of misunderstanding on your part, the full recovery from facial bone surgery takes a minimum of three to four months for all swelling and most of the tissue contraction to occur. (6 to 9 months or even longer is really the full process) You are currently not halfway to that point yet. I would wait until at least that time period before I would be doing any critical analysis of your cheekbone reduction recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Aesthetically, my concerns about hip implants are coming from the perspective of a late transitioning transgender woman. So my pelvic bones developed in typically male fashion, giving me basically no hips,and none of the anterior pelvic tilt that’s typical for a woman. As a result, in profile my butt appears flat with relatively little projection and seen from behind the shape appears long and narrow – no curves. It seems like hip implants might provide a more typically female shape, but would they appear imbalanced without butt implants also? Can one do both? For trans women, do you typically get better results from an under or over fascia placement? Where do you place the incisions, and how extensive is the scarring?
Realself.com shows many before/after photos of breast and butt implants, and some results look very good, but to my eye, in the majority of cases, the results appear noticeably unnatural and I often feel like the before photos looked better with the larger volume implants being more likely to appear disproportionate or even to present visible contour around the perimeter of the implant. Is it possible to simulate the likely results of various sizes, shapes and placements on my own body? Most of the results I’ve seen were for cis women and due to skeletal differences it’s impossible to infer much from their photos how similar implants might appear on a trans woman’s frame.
I also have questions about function. I enjoy yoga, running, hiking, and cycling. Would hip implants restrict my range of motion in yoga? Would the repetitive impact of running cause them to move? Would the pressure from a backpack’s hip band be a problem? In a bike crash, the soft tissue over the trochanters and iliac crest are often points of impact and abrasion – would hip implants make such injuries worse?
For one reason or another, it seems like many women who get breast implants end up needing follow up surgeries for removal, repositioning or repair. You mentioned that hip implants are relatively new. How many have you done and what’s been your experience with follow up so far? What types of complications have you encountered? Should one expect to need more surgeries over years and decades to maintain or remove hip implants?
A friend who got hip implants said the recovery was fairly arduous. She said the pain was worse than sexual reassignment surgery, liposuction or breast augmentation. That she couldn’t really sit down or lie on her back and that she could only sleep on her tummy. How long is it before one can sit or sleep on one’s back or side?
Finally, I wonder what you think about the iliac crest extensions these guys are experimenting with in Korea? Considering the relatively tall and narrow shape of the male illiac crest in comparison with typical female development, I might guess that making the area appear wider at the top without also doing something down the sides over the trochanters could yield a disproportionately top-heavy shape for trans women, but that doing both together might work really well. As far as I know, they’re not doing these for the general public yet, and apart from their press release claims, there’s very little information available about their technique and outcomes.
This e-mail turned out much longer than I expected – thank you for reading all of it!In closing, I’d like to thank you for the work you do – never before have trans women had the opportunity to make these sorts of changes to our bodies – it’s pretty awesome and amazing what you’re providing with the procedures you offer.
A: Thank you for your detailed description of your body shape concerns. In answer to your questions:
1) Hip and buttock implants can be done together but great care must be taken to ensure that their two implant pockets do not merge into one.
2) Hip implants can be done alone without the use of buttock implants. It all depends on what shape and size hip implants that are placed to keep it in proportion.
3) Whether one places hip implants above or below the fascia depends on implant size and what area of the hip needs augmenting.
4) Hip implants are placed through 3 cm long skin incisions just above or slightly back from the upper hip prominence.
5) It is important in reviewing before and after pictures to realize that those results may have been exactly what the patient wanted and they may think it looks quite good and natural. The fact that many do not look good to you speaks to what your goals are and how the choice of implant style and size are of critical nature in achieving your desired results. The key in buttock and hips implants for the most natural look is implants that have larger diameters with lower central projections and very feathered edges all the way around the implant. That often requires the use of custom made implants.
6) Hip implants do not restrict one’s physical activity. Although I have never placed them in a patient who cycles so I can not speak as what the level of activity means for them.
7) Because all hip implants are ultra soft they are actually protective from traumatic injuries rather than placing one at increased risk of injury.
8) Unlike breast implants which are fluid filled sacs which are designed for eventual failure and the need for replacement, hip implants are a very soft but solid material and will not undergo the need for replacement because of implant failure.
9) Your friend’s description of her implant recovery is far different than in my observed experience. It is not nearly as arduous or difficult as that description or comparison.
1) Iliac crest implants are the newest body contouring implant the I am working on both in design and surgical technique. They also are soft solid silicone implants that are placed just along the iliac crest from a posterior incision. They are a far easier and less arduous recovery than any other body implant that I have ever placed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am three weeks out from facelift, necklift and chin implant by a very experienced plastic urgeon. My chin and lower lip continue to be totally numb. In the first week, my surgeon touched the sides of the implant and I did feel the shock pains, but the area is no longer as sensitive, just numb. Should I seek the 3D CT scan you mention? Do you have much experience removing chin implants? Thank you.
A: Having bilateral lower lip/chin numbness is unusual from a chin implant particularly those used in facelifts which are often more modest in size. The key about whether you should evaluate the position of the wings of your chin implant this early after surgery depends on the progression of your nerve symptoms. If you remain totally numb with no improvement then I absolutely would check a scan to be certain that the wings of the implant are not up against the mental nerve. But if the numbness is improving and the pain is less then I would give it a few more weeks time healing and see how it feels then before considering such further evalutaions..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you so much for responding to my question on potential chin implant malpositioning! I was prepared to give a lot of time to healing, as I understand everyone recovers at a different pace, but then I started researching the numbness because it is so numb and unchanged in first three weeks after surgery. The impression I got from reading a lot of articles is that if the implant is causing the numbness by pressing on the mental nerve then there is a clock ticking to remove the implant before permanent damage may result, no more than 2 months. I understand you cannot diagnose my situation but do you believe there is a time when I really should consider removing the implant? I miss my smile. Thank you.
A: While to some degree this is a decision between you and your surgeon since you are still under his/her active care, the relevant question is how much aesthetic value is the chin implant producing. (may be hard to tell exactly given that it is just three weeks after surgery) If it is of a minimal nature then the risks of nerve injury and recovery make it not worthwhile. If it is adding tremendously to your result then a less ‘drastic’ approach should be taken with more due diligence given to the actual position of the chin implant to rule out chin implant malpositioning. (3D CT scan of it)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in vertical higher ear repositioning. You have replied to a relevant question at Real Self. Therefore, I would like to enquire whether you perform such a procedure, and how much the ears can be vertically lengthened.Looking forward to your reply.
A: I am not sure where you got this information that the ears can be vertically raised higher to any significant degree. While minor amounts of change can be done, the ear is attached to the side of the head by the cartilaginous external auditory canal which prevents it from being lifted upward more than a minor amount. While it is easy to grab one’s ear and pull it upward, this should be confused with true vertical repositioning of the ear. This is nothing more than putting stretch on the more flexible external ear cartilage. Thus vertical lengthening or more accurately, vertical ear repositioning, is not a highly effective procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a middle-aged male who is generally happy but the expression on my face gives a different impression. My eyebrows are very low and they slope downward in the middle to the nose. There is a very deep crease across the nose where my brows hangs down. I know I need a browlift of some type but I don’t know what my options are. I have attached some pictures of what I look like normally and what I would like the result to be.
A: Thank you for sending your pictures. They clearly show your low brow position concerns, much of which is in the the inner half of the brows more than the tails. As I indicated in my initial response, the challenge in men is where to place the incision to do the browlift. You need a superior type of browlift as inferior ones (transpalpebral brow xlifts) only produce a modest change in the tail of the brow position by pushing up from below. Given the three superior-based incisional choices (transcoronal scalp, pretrichial or frontal hairline mid-forehead wrinkle line) your best option is probably the mid-forehead incision placed in a horizontal wrinkle line. While this places the incision in the most visible location, it is the only one that uses a natural skin crease area to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had zygoma reduction surgery over 1 year ago in Korea. The method was L osteotomy cut with posterior bone cut, and then push the bone forward with screws. This was all done through intraoral incision method because I did not want scars on the face.
Unfortunately, there has been signs of skin sagging since 4 months after surgery.
My eyebrows have lowered, I have deep forehead lines when I try to open my eyes very wide.The cheek sagging is very obvious from side view, even though I see positive bone contour change from the front view. I am only 25 years old.
I am all healed but the negative effects very much bothers me. Excess skin folds run vertically on my side cheek. It is very obvious when I smile or wear makeup. I don’t know what is the cause and want to fix it.
The doctor said during surgery because I am young, the skin should shrink to match my new bone shape. But why is there extra skin after 1 years?! I have attached photo.
Can intraoral incision method cause more sagging than intraoral and sideburn incision method?
What is the solution to my problem?
A: It is not rare that once cheek bone support has been reduced after zygoma reduction a soft tissue sag will appear. This may not develop for months after the surgery when all the swelling has subsided and the temporary support that it provides goes away. This is not really a biologic surprise as the trauma of the surgery to the tissues and the narrowing of the cheeks can allow for a downward drift of the soft tissues.
The corrective approach requires a soft tissue resuspension down through a combined endoscopic scalp and intraoral approach to allow for tissue mobilization and suture placement for suspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard that you are very famous for your knowledge of face bone surgery from my friends in China. I would like to ask you some questions. I posted my question on Real Self and a Chinese version of Real Self but got no response.
I got cheekbone reduction surgery in China 1o months ago. The doctor used L cut method and hidden hair incision to cut my zygoma bone and move the zygoma bones inward. Then titanium screws were used to secure it.
I was very happy with my recovery. I went to my 3 month and 6 month check up with no problems and that was the end of my meetings with my surgeon. I read on your website, that if skin sagging didn’t happen by 6 months, it should be safe to expect no skin sagging after. However, I’ve been having a problem this month.
It’s been just over 10 months since my surgery. BUT. starting from the 8.5 month time, I started realizing my face is drooping. I’ve attached pictures of my face now. My face was completely sag-free until the 8.5 month mark.
Now my cheeks are bottom heavy and fleshy and look swollen. There’s puffy flesh/skin around my nose which makes it look like I have a lot of fat and have nasal labial lines. I also have lines from my mouth to my chin area. This was not happening at the 6 month time so I thought the surgery was a success.
Can you please explain why this is happening so long after the surgery time. I was very very happy with the result after 8 months, and only then did my face start to droop. I am 24 years old. What can I do to fix this?
A: While most patients are ‘safe’ from tissue sag by the six month time period, the ultimate test is at the 9 month to one year mark. This is when the full effects of tissue contraction become most apparent. So to not have developed it until 8 or 9 months after surgery is not that rare.
It is important to remember that all cosmetic surgery has tradeoffs. While it is not uncommon, this is one of the tradeoffs of cheekbone reduction surgery. Soft tissue suspensions methods are now needed if you desire improvements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve recently (one month ago) undergone a horizontal chin reduction in my home country. I’m not sure what the technique is called exactly, but my surgeon cut my chin bone into a T sort of shape and removed a middle piece of bone via an intraoral incision. The horizontal length of the bone removed from the middle part of my chin was around 8mm. There was no sliding forward and backward of the chin itself.
Now I have this straining or tightness feeling in my chin, and I was wondering how long it would take for this feeling to subside? It makes it very hard to eat anything because it is so tight!
I was also wondering how long it would take for swelling to go down completely, as the fleshy tip part of my chin seems to protrude out slightly more than prior to my surgery. When I try to purse my lips, it creates a groove or dent underneath my chin. Hopefully this isn’t permanent.
A: My first comment is that these are questions that you should directed to the surgeon who performed the procedure. If you had the confidence for him/her to do the procedure then you should also trust what they have had to say after the surgery.
That being said, an 8mm horizontal chin reduction is a lot and what you are experiencing are the soft tissues straining to make the change to a loss of its bone support. This combined with the resuspension of the muscle, which had to be separated to do the procedure, makes for a lot of healing and soft tissue readaptation to occur. It is going to take good 3 to 4 months after surgery until the final outcome is realized. I can not say what you are seeing and feeling now will completely resolve, only time and healing will answer that question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about the custom wrap around jawline implant.
1/ What is the maximum horizontal projection (in mm) that (wraparound) custom jaw implants of ‘mimicking BSSO’?
2/ What other procedures or implants are necessary to mimic BSSO?
(other than custom jaw implants, custom midface implants, genioplasty)
3/ What is the approximate cost for the procedure?
4/ Can the chin be very square (front view) & slightly wider than the mouth/lips?
A: In answer to your custom wrap around jawline implant questions:
- A BSSO mandibular osteotomy and a wrap around jawline implant are not comparable procedures as they have very different effects on the lower face. From an aesthetic standpoint an implant is far superior to the BSSO because it creates a 3D augmentation of the mandible which a BSSO can not. A BSSO is limited in its forward movement by the teeth coming together, a custom jawline implant is not. How much horizontal projection an implant can create must be determined on an individual basis.
- A sliding genioplasty creates forward projection of the chin, like a BSSO, but is not limited by teeth contact like the BSSO is.
- My assistant Camille will p[ass along the cost of the procedure to you next week.
- In a custom wrap around jawline implant the width of the chin can be designed to the dimensions that it takes to meet the patient’s aesthetic needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a corner of mouth lift. I have tissue hanging over my mouth corners that makes a deep marionette line. What can be done to correct it? Have a attached an unflattering picture for your assessment.
A: Thank you for sending your picture. If you look closely what you have, it is not a true downturned corner of the mouth (only very slightly is the commissure turned down) but rather there is an overhang of facial tissue along the marionette lines. While there is some mild benefit to be gained by a corner of the mouth lift, most of the problem needs to be improved by a lower facelift to pull back the tissues that have descended and fallen forward. Thus a lower facelift with a corner of the mouth lift is what is needed for an ideal improvement. That is the only combination of facial procedures that would be worth the surgical effort. It is not uncommon to do a combined facial rejuvenation surgery of a doer facelift with a corner of mouth lift. This improves the shape of the corner of the mouth, reduced marionette lines and gets rid of jowling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was involved in a car accident a while ago that required my chee bone to be repaired. The surgeon that operated on me performed the surgery was a plastic surgeon, rather than a craniofacial or maxillofacial surgeon. My cheekbone fracture was secured together with plates and screws and was performed entirely through an incision in my upper gum.
It’s been a while since the surgery and I swear in my eyes, the cheek on the operated side looks different. My friends don’t seem to notice but I swear it looks slightly off. I think they just never notice because I’m always moving and they never just look at my face straight on.
I feel as if the cheek flesh/apple cheek underneath my eye has shifted downwards. I can tell because in my photos prior to the surgery, when I smiled widely, the bump of the cheek (the fleshy apple cheek bump) was a lot closer to my eye. Now it’s more in the middle of my face, noticeably lower than it was before. I don’t think any resuspension was done after the bone repair.
Since I am young a midface lift on one half of my face is just out of the question. Is it possible to relift the soft tissues and somehow have them heal and stick to the cheekbone higher?
Ideally I wouldn’t like any scars on my face, but hidden oral and scalp incisions would be alright with me. Also, are there any absorbable solutions, as I’m a little bit iffy in leaving permanent devices in my face.
A: By your description your cheek sag may be exclusively soft tissue or it ma be combined with some residual bony displacement as well. I would need to see pictures of your face to help make that determination. But a cheek lift can be done through a lower eyelid, temporal scalp incision or even an intraoral approach could be used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, ; I am a young male patient. I contacted you about a month ago asking questions about lip advancements. I just wanted to elaborate further.
I feel like my lips are a difficult case. Like I said previously, my lips are quite full already and I have 5mm Permalip implants in the top and bottom lip. The only thing I’m afraid would be a problem is that my lips are very close to my nose already, however I really would like bigger lips and increased vermillion height and size. My nose is really close to my lips due to a hanging collumela (a result of my nosejob). The hanging collumela is not very visible from the sides, but its very visible from the front view. It gives the look of a very droopy tip. I’m wondering if lifting my columella a bit would give some more distance between my nose and lips and, therefore, make a vermillion advancement more aesthetically pleasing?
I know that a collumelar correction is quite a simple procedure and I would eventually want to get both the vermillion advancement and columellar correction done together.
I really don’t like lip fillers and I really would want something permanent that would increase vermillion height. I am very aware that my lips fit my face well, however I have had them bigger and I really love the look of them larger.
I have attached a picture of my lips from front and side views. I have also attached photos of my desired goal.
A: Thank you for sending your pictures. In answer to your lip advancements questions:
1) I would not view a columellar reaction procedures as ‘ simple’. It may not be as complex as a full rhinoplasty but getting the columella up to any significant degree is not easy or predictable. And you do not have a true hanging columella so I would view that procedure for you as probably not very productive.
2) You have described your lips as a ‘difficult case’ and that would be correct given what you are trying to accomplish. You can’t have a vermilion advancement without shortening the distance between your nose and upper lip…and any significant columellar retraction is not likely to occur.
3) While it is important to have surgical goals, your ideal goals are not going to be achievable given your anatomic limitations. Something has to give so to speak.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a secondary rhinoplasty surgery. I was just reaching out in regards to a prior septorhinoplasty surgery I had done. I am now one year post op and am not happy with the changes hang have been done to my nose shape. The changes that were done made my profile different and my nose appears shorter in height and length and not as wide. Cosmetically I am not happy because it is smaller and does not fit my face. My concern is that my nose appears wider but its actually thinner by bridge and middle of nose, its length is shorter due to the upturned tip, the nasal base and tip is a little smaller, and height isshorter due to dorsal hump being taken down. My goal is to restore to original height, length, and width like it used to be. Can cartilage be added to upper and middle of nose to make width wider again? Can nasal bones be out fractured to help increase width? During revision can bones be reshaped? Is this possible if osteotomies were used previously? Can fascia be used to add some volume back to nose and appear softer? The goal is to have nose appear more natural and not such harsh lines to look like a nose job has been done. In addition my nose seems to be congested more now than before. Any recommendations for tests to see what is going on?
A: In essence you are describing a secondary rhinoplasty to build back out the nose making it closer to what it originally was with emphasis on dorsal and tip augmentation as well as nasal bone widening. While there is no ‘returning home’ in an exact way so to speak, improvements can be made to augment the nasal areas that were reduced as well as place spreader grafts in the middle vault to improve breathing.
The key to doing so comes down to one basic need…you have to have enough cartilage graft to do so. For this type of nasal reconstruction (rhinoplasty reversal) you really need a cartilage rib graft to do so. (aka rib graft rhinoplasty) That supplies all the necessary cartilage graft to build back out the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My three year old son has a high cephalic index around 88/90%. We are interested in early skull reshaping surgery and would like to have some volume added to the back to make it more like 83/85%. Hoping this could be done with 15mm or less. He also has some bossing over the ears that we would like to reduce if possible. Is there a best age to do this procedure. We are thinking of doing it sometime between now and 4 years old if possible. Also curious what material you would suggest or if it would be best to do a custom mold. We are planning to set up a consultation if this is something we could have done and we could get a few questions answered ahead of time.
A: Some general early skull reshaping surgery comments are as follows. At this young age the width of the head can not be reduced due to the thinness of the bone and overlying muscle. Occipital or back of the head can be done but the only material I would ever use at this young age would be hydroxyapatite cement. But the scalp is not likely to allow for a 15mm expansion of the outer contour of the bone. At best it may allow for up to 10mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some facial implant questions regarding silicone implants. It seems as if some “experts” on different forums believe that jaw iimplants and cheek implants with silicone are inferior to harder materials such as Medpor or PEEK due to the fact that silicone is softer and thus when subjected to pressures from soft tissues they may not retain the inteended sharp and angular look at, for instance, the edge along the mandible or along the lateral part of the cheekbones. (including zygomatic arch) Instead they claim that they may give a more rounded appearance that simply adds volume without retaining the sharp edges of identically designed implants made from hard materials.
1. Would you please comment on the above?
2. Are there any limitations on how you can customize silicone implants? For instance, can you customize them so they gradually taper off to 0 mm thickness, so they gradually blend into the existing bone structure around the eye area? Can you customize them to have a sharp, defined edge?
3. Some doctors claim that putting a screw through a silicone implant in the chin or jaw angles will eventually lead to the screw migrating through the implant because of the softness of solid silicone. Thus silicone implants may dislocate in the future when the screws no longer keeps the implant in place. Would you please comment on this?
A: In answer to your facial implant questions:
1) I consider the argument/opinion about the effects of available material compositions on the outer facial contours as lacking any scientific support. That is a discussion that has never made any sense from a biomaterial/biomechanical standpoint. One simply has to feel a silicone implant and wonder how it could ever be deformed from the overlying soft tissues. What effects the outer contours of the face is the shape and size of the implant not its material composition.
2) You can custom facial implants any way you want, there are not limits to their design. Whether the overlying soft tissues will allow the design to be fully seen and what the design should be to create the desired effects is a different matter with its own limits.
3) What keeps an implant in the placed position on the bone long-term has nothing to do with any screw fixation. It is the scar tissue/encapsulation that is eventually responsible for its positional stability. Screws are used in the short-term to maintain position long enough for this encapsulation process to occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an ear reshaping question about the procedure where the helical rim is folded in and it not being able to do be done at the same time as scapha reduction. Is that the case even if the scapha reduction doesn’t include an incision on the helix? I’ve attached an example to help me describe what I mean.
So basically, is it possible to have that kind of scapha reduction done and folding in the helical rims at the same time? I’m thinking that could be a less radical kind of reduction, while still reducing the size.
A: In answer to your ear reshaping questions:
1) What you are showing is a very limited form of a scapha reduction. It really folds the ear down a bit rather than a true vertical height reduction that requires a back cut cross the helical rim down at the middle part of the ear to create the reductive effect.
2) This limited form of a scapha reduction can allow a helical rim repositioning at the same time. Since there is no incision on the inside of the helical rim done at the middle third, an incision can then be safely made on the back of the ear in this area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip reshaping surgery. My main goals are to increase vermillion height and make my lips look larger and rounder (the shape of the lips in the pictures). I also would like to have a less prominent cupid’s bow to make the lips look rounder (like the pictures).
My questions are:
1. Would the vermillion advancement for bigger lips with increased height and roundness be out of the question? I’m not looking for the goal picture size exactly, but something somewhat close to the size and shape.
2. If I’m not a candidate for a vermillion advancement, what lip augmentation option(s) would you recommend to get results close to the ones I want?
A: In answer to your lip reshaping questions:
1) Only a vermilion advancement can increase the size of the whole lip and make a less prominent Cupid’s bow at the same time. It does so by removing skin above the lip to create the type of lip shape one desires. This would be of particular value in reducing the shape of the Cupid’s bow area where more skin would be removed compared to the sids of the upper lip.
2) A vermilion advancement is your only option based on your lip size/shape goals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m one month post operation from a jaw/mandible reduction and horizontal chin reduction surgery using the T-osteotomy method. I have some chin reduction concerns.
I’m loving the angle of my jawline but I’m very worried because it’s been 4 weeks and my chin looks very very pointy. My surgeon seems to have removed a lot more bone than I was expecting. I had a very very square face prior to the surgery and my surgeon said he removed a good 1cm wedge from the middle.
I made it firm in the consultation that I wanted a natural curve (U shape) to my lower face, and did not want a pointed v-line. I’m very worried that my surgeon still didn’t fully understand what I wanted.
I understand that there’s swelling but I read that the 3-4 week post op genioplasty look is usually similar to what you get. My chin looks like a triangle and my parents and relatives can instantly tell that it’s not a natural chin because it tapers in way too much. I legitimately told my surgeon I wanted a noticeable natural change, like as if I’ve lost weight – But I’m very afraid that he did not deliver and overcorrected.
What are my options here? Can I do a reverse T-osteotomy with a bone graft to widen my chin to the desired width? How much extra width can I expect from doing this?
Or will the look of the chin soften up over time? Though I highly doubt the change could sustain such a huge change. I have yet to face any friends as I am very afraid to face them like this.
A: At one month after this type of chin reduction surgery if you think it is too narrow then it is. The more typical concern is that it is still too wide and not narrow enough. Time and further healing will not make it more wide or less pointy.
The good news is that the chin can be re-widened by the placement of an interpositional cadaveric bone graft. That width can be any amount desired.I would not think you would take it back out the full 10mms that was removed but probably 5 to 6mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I messaged you about my jaw and cheekbone reduction enquiries not too long ago. I’m still early in the cheekbone reduction recovery stage but I was wondering about something else.
My doctor said it is good to practice opening my mouth as wide as I can after surgery. It’s barely been the start to my second month of recovery and I can open my mouth to fit two fingers.
However, I’m reading online that extensive mouth opening should be avoided for the first few months as the masseter muscle can pull down the zygoma body even if it’s fixated. Is it possible that I’ve done some damage to the fixation due to pushing myself to open my mouth widely every day?
A: My first suggestion is that you follow the instructions provided by your surgeon who you trusted to perform the operation rather than online commentaries of unknown expertise and experience. That being said, at this point in your cheekbone reduction recovery you should be working on getting your jaw opening rehabilitated back to normal. There is little concern about bony displacement with plate fixation, early after surgery or months later. Stretching your mouth open should be done freely at this point in your recovery.
Dr. Barry Eppley
Indianapolis, Indiana
