Your Questions

Q: Dr. Eppley, I have some eyebrow asymmetry that I wanted fixed by a browlift. Can this be done through a incision from the eyelid? Also what can eh done permanently remove the deep vertical wrinkles between my eyebrows? I have attached some pictures to provide a clearer understanding of my concerns.

A: Thank you for sending your pictures. When you mention the left eye, I assume the pictures are mirrored images since that is the eyebrow that is lower than the other side.

If that is the case, that degree of brow ptosis can not be well corrected by a transpalpebral approach as that browlift approach only affects the outer half of the eyebrow. All other methods of browifting, which are superiorly based, are more effective. Technically the direct browlift method with an incision at the top of the eyebrow is the most effective but the fine line scar is always a potential aesthetic concern.

Treating frown lines is one thing but they can never be permanently eradicated particularly when they are as deep as the two glabellar furrows that you have. They are so deep that direct excision of them with a broken line closure and dermal graft placement would be need to provide the best and most sustained improvement in their appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of a chin reduction. My chin is fine at rest but when I smile it sticks out and looks very unflattering. What do you recommend?

A: Thank you for your inquiry and sending your pictures. I assume your concern is the chin protrusion that occurs when you smile. The chin at rest or non-smiling position shows a normal chin. That is what is known as a hyperdynamic chin ptosis problem. It is an ‘excess’ of soft tissue chin pad that protrudes downward as the chin tissues pull back across the end of the chin bone.

This is a very challenging chin protrusion problem to improve as almost all chin reduction surgeries are designed to treat a static problem and not a dynamic problem. That means that trying to improve a dynamic problem may cause an adverse effect in the static position.

Having treated hyperdynamic chin ptosis cases before, the only effective approach is a submental approach where the end of the chin bine is reduced and some soft tissue chin pad is removed and tucked to decrease the dynamic protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been 5 years using cocaine mainly through the left wide of the nose and that area of my face it is a little bit sunken and the part of the maxilla that makes the lateral shape of the nose it is more retracted than on the other side. Also the right alar sidewall is more elevated compared with the left side. I would like to know if its is possible to make a custom implant to reestablish the shape of my face and nose in a natural way. 

THANKS! 

A: By description it sounds like building up the bone would be helpful in the improvement of your nasal base asymmetry. I would need to see some pictures of your face that show this nasal/midface asymmetry to provide a more qualified answer as to what may be able to be done. But by description you are referring to the medial maxilla or the paranasal region. This can certainly be built up by a customized paranasal implant. While a a custom implant made from your 3D CT scan would be ideal, even a hand carved one made from ePTFE could be done at the time of the surgery and would be of good aesthetic benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For my cheekbone implants, I would like them to be placed high on the cheek and to stretch around the length of my zygomatic (like the implant on the right in the first picture attached) and to create an ‘ogge line’. One thing I’m kind of nervous about though is the possibility of having my cheeks augmented too much and looking very weird as a result. I see a lot of women on the streets who have fillers which make them look ridiculously bloated around the zygomas.

A: The key to having a natural looking cheek augmentation result, regardless of the style of implant used, is to not overdo it in terms of size. The cheek is a very sensitive area in terms of volume and a little bit does go along way particularly in small female faces. But this is an issue I am well aware of and I will know during surgery if such is the case and can make the necessary implant adjustments if needed to avoid that exact problem.

In addition injectable fillers notoriously can make the face look bloated because they are placed in the soft tissues and being a soft material they can make the cheeks look puffy and full. Fillers can not create a well defined cheek in most cases. Bone-based implants are different because they push the soft tissue away from the bone in a defined manner based on the shape of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a setback otoplasty seven years ago and have been bothered by how far back they were set. My surgeon released the sutures and scar tissue several months after surgery but it did no good. Can a reverse otoplasty help bring my ears partially back out and by his much? Could it be as much as 1 or 1.5 cms?

A: I would estimate you can move the ears back out by 5 to 7mms with a reverse otoplasty.

While it is true you can place any amount of cartilage grafting behind the ear to push them out quite far, large cartilage grafts will result in not being able to close the skin incisions behind the ear used to place them. An often overlooked part of a setback otoplasty, when done in the traditional manner, is that a large segment of skin is removed from behind the ear. This has been an historic part of otoplasty for the past 100 years. It has been proven to be unnecessary, as it does not help create or maintain the setback ear position, but it is still commonly done today. As a result a skin ‘deficiency’ now exists on the back of your ear and this prohibits the amount of cartilage ideally need to be placed to push the ears back to their initial preoperative position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few more questions before I make the decision on the custom infraorbital-cheek implants.

1. From my research on silicone implants, I’ve read from one surgeon that they cannot be screwed in because the silicone is too soft and would risk rupture over time. But from my understanding you plan to screw in the implant, so how would it not rupture? is this because we are using “hard” silicone?

2. The same doctor told me that the “pocket” that encapsulates the silicone must be exact, or the implant risks micromoving and eroding the bone due to the friction. Is this because off the shelf implants do not fit exactly? 

3. I’ve also read about capsular contracture with breast implants due to scar tissue forming over time around the foreign silicone. What confuses me the most about this is the prevalence of silicone implants in Asia, especially for rhinoplasty. Seems like a bad idea if it is used so often. Is this an issue?

It’s very confusing getting different answers from every doctor…the medical papers provide me a better understanding but unfortunately they mostly talk about chin implants, but I guess the general concepts apply to all facial implants.

A: In answer to your custom infraorbital-cheek implants questions:

1) There has never been a problem with screwing in silicone implants, I have done so in thousand of silicone implants. Solid silicone facial implants are solid enough that they can be securely fixed with screws. The surgeon making that statement is inaccurate.

2) That is another inaccurate statement that has no biologic basis.

3) Capsular contracture is a unique phenomenon that has relevance to a soft tissue implant that is intended to feel soft and move around. That is obviously the opposite of what facial implants are indented to do….remain firm and not move.

4) In reality the basic concepts and biology of facial implants is not confusing. But most surgeons will little clinical experience except maybe with one type of implant or one specific implantation site make it very confusing by promoting statements that have no sound biologic basis. (as in # 1 and 2 above)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a mentoplasty to shave done a bone (almost spurlike) in order to lessen its size and pointiness. My chin now is a little more square due to scar work, age and tissue. I am interested to see if fillers/botox can soften my jawline with a little less squareness to the chin..

A: The squareness of a chin is not going to be improved by Botox (a muscle relaxant) or injectable fillers which will just make it bigger by adding volume. When you just depoint a chin it will, by definition, become wider…unless the depointing procedure also made an effort to desquare it as well.  Desquaring it secondarily requires tapering the sides of the bone….another surgical procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hope you are doing well! It has been a long while since we’ve talked. A couple of things happened and I would like to inquire with you before finally signing up for my surgery. 

Basically I am using a palate expander, I am hoping it would not be a problem for inserting paranasal implant? 

I also would like to know if you do any incision around the nose area during the fixation of the paranasal implant. I am scheduled for a corrective septoplasty in order to help my breathing in August and I am worried about the prior paranasal implant interfering with that procedure.

A: Good to hear from you. In answer to your questions:

1) The intraoral use of a palate expander has no adverse effects or connection with the paranasal implantation site.

2) The intraoral incision location is different from the intranasal location for a septoplasty. There is no anatomic ccommunication between the two sites and paranasal implants in place are not in the way or restrict access for performing a septoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there a difference between a diced ear cartilage graft wrapped in a fascial graft and diced ear cartilage graft that us glued together? My surgeon used the glue one. Will it be more difficult to remove than the fascial one? Is there any special techniques required for such removal? Is there any complication associated using the glue in mixing the diced ear cartilage? 

Looking forward to reading your consultation.

A: I don’t see any difference in removing either diced ear cartilage graft to the nose. Both can be removed equally well. Undoubtably what you are referring to as a ‘glued’ diced cartilage graft is one mixed with either platelet-rich plasma (PRP) or fibrin glue which are autologous sealants and can loosely be called a ‘glue’. It would not be a true cyanoacrylate glue which would be toxic to a cartilage graft and would cause it to be absorbed. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting paranasal augmentation with you, but I have one main concern. Basically, I’m worried that if I get paranasal augmentation, it will project too far compared to my mouth area and make my mouth look like it’s sunk backwards compared to my paranasal region. Now I’m not referring to premaxillary augmentation, I’m purely referring to augmentation of the sides of the base of the nose, whilst leaving the premaxillary area as it is.

Am I right in saying that if you augment this area, it can cause this part of the face to stick out relative to the mouth? I’m just confused as to how that would work if the centre of the nose base (the premaxillary) around the anterior nasal spine isn’t moved forward.

I guess I’m asking for your general experience on whether purely paranasal augmentation can negatively affect how the mouth appears, or whether that’s something mostly applicable to moving the anterior nasal spine forward when the nasolabial angle is optimal to begin with? To be clear I’m not asking for specific comments about my own case, but rather your opinion on how this thing works.

A: I think your  potential concern is with premaxillary augmentation which is a central midface procedure. The paranasal region lies to the side of the midline and no matter how much it is augmented it can never make the mouth area look recessed. Unlike the premaxillary area which is a projection or structural convexity, the paranasal region is naturally recessed or has a  concavity surface contour.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m aware we have a virtual meeting soon to discuss a few things regarding the implants. I just had a question that I assume would be easier to answer via email since there are photos involved. I’ve attached an unaltered image of myself as well as an altered ‘morphed’ image similar to the one you provided a few months ago where I’ve extended the cheeks and jaw. I tried to make an after photo of what I could potentially look like following the implants. Would the current implant design achieve this look/size or would the implant need adjustments?

In short, what implant size would most approximately get me from the before to the after photo?

A: While the fundamental question you are asking is very relevant, it is a question which defies a predictable answer. As there is no exact mathematical or precise method to know what any dimensional element of a custom implant will exactly create in one’s external appearance, this remains the ‘art’ form of custom implant design. Fortunately having done many hundreds of custom facial implants I have developed a good, albeit not perfect feel, for what any dimensions of such implants may do. 

In that regard your own morphing is tremendously insightful as to your goals and they would be considered very ‘modest’ cheek and jawline changes to which the initial design draft was intended to create. While this is open to further discussion, your imaged result shows the importance of in your case of a ‘less is more’ implant design approach.

Dr. Barry Eppley

Indianaplis, Indiana

Q: Dr. Eppley, I am interested in butt and hip implants, liposuction to the arms, back, abdomen and inner thighs and possibly tummy tuck and rib removal. I would like to set up a in person or phone consultation. I have attached some pictures for your preliminary review and suggestions.

A: Thank you for sending your pictures. There are several ways to approach your body contouring with the following observations:

1) While the fat harvested from the abdomen, flanks, arms and inner thighs is useful for buttock augmentation it is unclear yet as to what your buttock augmentation goals. While it is most likely would not be enough for your buttock augmentation goals (yet to be defined)it it still useful to place around an intramuscular buttock implant if implants should be needed.

2) I do not see a need based on these pictures for a tummy tuck.

3) Rib removal MAY be useful if one is trying to maximize waistline reduction and wants t make every effort to do so.

4) Implants are the most effective strategy for hip augmentation as fat injections almost never work in that area and you don’t have enough to do it anyway…unless you want to invest all the harvested fat towards hip augmentation.

When you put all of these observations together the following is clear:

1) Liposuction of all involved areas is a foundational body contouring procedure for you.

2) The harvested fat can be placed into the buttocks OR the hips but not both.

3) Combining buttock and hip implants with rib removal is a pretty tough combination and is not advised from a recovery standpoint.

4) You can only combine two of three from #3 so you have to prioritize.

5) You could make an argument for liposuction, buttock implants, fat injections to the hips and possibly rib removal.

Buht as your exact goals are to yet clear, these are just some preliminary thoughts to consider.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my cheekbone and jaw reduced a few years back. If I was to use bone grafts to push the cheekbone back out…would it be best to wait 6 months to a year before I consider a cheeklift? Or can cheekbone reconstruction and a cheek lift be done at the same time?  Thank you.

A: Since it has been a few years since you had cheekbone reduction surgery, there is no reason to wait any longer if secondary cheekbone reconstruction is desired. Treatment options include an anterior re-osteotomy with an interpositional bone graft, a cheek lift or a combination of both done at the same time.

The question you may be asking is whether you should wait to determine if you need a cheeklift after cheekbone reconstruction. It can not be determined beforehand whether tech cheekbone reconstruction will negate the need for the cheeklift or not. Thus you can argue to have the cheekbone reconstruction first and then see if the cheeklift is really needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, after skull reshaping surgery is the ear asymmetry also corrected?

A: Skull reshaping surgery alone will not correct ear asymmetry. That would need to have a specific ear procedure that can most likely be done at the same time as the skull reshaping surgery. Associated ear protrusions are common in skull asymmetry and can be addressed with otoplasty setback surgery. If, however, the ear issue is that it is set further forward or back on the side of the head from the other ear, that is not a fixable issue. The actual front to back position of the ear on the side of the head is fixed by its cartilaginous attachment to the ear canal. Only ear protrusions or an increased auriculocephalic angle can be improved by setback otoplasty surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I stumbled upon an article on this site regarding removal of Medpor chin implants and I have some questions. I had a Medpor chin implant made nearly 20 years ago, but very shortly after it was done, I changed my mind and decided to get rid of it again. I only had it for three weeks or so before it was removed/explanted. 

Since then I’ve been struggling with severe autoimmune issues and I’ve always felt that there is still something left inside my chin. Something remaining there and every now and then the chin gets a little inflamed. 

I went back to the doctor who performed the surgery and he claims that Medpor always comes out in one piece and never breaks off and that all I can possibly have left inside my chin is some kind of harmless body tissue. 

Is it possible that he is wrong about this? 

Would my body really produce so much tissue in such a short period of time? And shouldn’t that tissue be gone by now then if there’s no implant left to create it? And does Medpor break off easily even if it’s only been inside for a few weeks? 

I would really, really appreciate an answer to this. Thank you so much. 

A: While I obviously have no knowledge of your chin implant and the details of its removal surgery, the easiest time to remove a Medpor chin implant is within the first few weeks after surgery before any significant tissue ingrowth has occurred. Thus it is more likely than not that the implant was removed in its entirety. But that is a general statement based on my surgical experience with the material and not a definitive answer to your specific case in which I had no participation.

While all surgery produces scar, such scar tissue after twenty years would have been completely absorbed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had already double jaw surgery which improved my jawline as well as my chin. I really look good in the side profile. However, my mid face is not sharp. I would like to have model looks i.e., high cheek bones. Is it possible to achieve the look in my face, considering my face is chubby not slim. If cheek implants can be done in my case, can you let me know the cost?

A: Thank you for your inquiry. There are many different types of cheek implants but for the ‘high cheekbone’ look that requires a true custom cheek implants design t that wraps around from under the eye all the way back along the zygomatic arch. That would help create the distinct line of the midface that would be compatible with that of your jawline. If you combine that with buccal lipectomies you would definitely help create a less chubby looking face. I will have my assistant Camille pass along the cost of such surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question. I found this fantastic site that distributes custom implants and CT-Bone via 3D printing.

I am no doctor but it seemed absolutely amazing to me, and I was wondering if the custom implants you provide would be able to be made with such versatility?

CT-Bone for facial asymmetries (Xilloc)

I am very interested in skull reshaping surgery, and I would love to work with implants that are this customly designed. Would it be possible?

I am not sure how distribution works for implants among surgeons, but this site has impressed me wildly.

A: There is nothing unique in the world of 3D implant designing that this manufacturer does. That is common technology today. The designer and manufacturer that I work with on all my custom skull and facial implants, 3D Systems, has capabilities that exceed the company to which you refer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been doing a lot of research on my procedure with you. Just a reminder. I want a custom made wrap around chin/jaw implant, zygo/cheek implant. I’m thinking about having my forehead reduced aka hairline advancement. I also feel like my forehead has a nice brow bone but feel like my forehead is rounded and not flat. I was curious when you do your hairline advancement where the incisions are placed? Can you also reduce the rounded bones surface to be flatter. I was talking with a surgeon currently. He does a incision horizontally and two vertical incisions at the temple/recision area.  I was curious what your incisions are. Does the scar heal lumpy or smooth? Is the scar “almost” invisible?  I like this guys profile of his brow bone to hairline. 

A: By definition a hairline advancement has to have incisions at the hairline….there is no other place to put them. How far down it extends into and along the temporal hairline is an individual decision. And no hairline incisions heal ‘invisible’ no matter what you are told

But the incisions aside you are not a good candidate for this procedure. You have too far a distance to move the hairline if your goals are the pictures you are shown. You simply can not move your hairline far enough forward to help create a straighter or flatter forehead. In addition you can’t reduce our forehead to make it flatter, it is too round and the bone is too thin. You can only add to the forehead to increase its verticality and flatness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, We had a skull reshaping video consultation two Saturdays ago about my cranial abnormalities resulting in asymmetry and sagittal ridge deformity. I apologize that it has taken me so long to get photos to you as you had requested. Rather than taking new ones, I wanted to rectify that situation as I felt the photos I have attached are indicative of the oddities of my skull.

Thank you for your time that morning. I feel that working with you could pave the way to a brighter future for me.

A: Thank you for sending all of your pictures which show the combination of a sagittal ridge and asymmetry.

With the skull reshaping goal of a smoother rounder head shape you have two options:

1) Sagittal ridge burring reduction and augmentation of the asymmetry….while this is a logical approach the dilemma is that this will requires a significant scalp scar whose aesthetic trade-off may not be worth it.

2) The other option is to make a thin custom implant that covers the ridge and the asymmetry. This is more appealing from a scar standpoint as the incision to do so would be smaller.

As you can see each skull reshaping option has its own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I am a 57 old male with untreated scaphocephaly. Do you operate on old people like me to fix the shape of the head?

A: I have performed skull reshaping surgery for a wide variety of shape deformations on patients well into their seventies. So you are still young at age 57 by my standards for this type of surgery.

Please send me some pictures of your head for my assessment and recommendations.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about revision to my lower buttocks. I had a BBL in 2015 and since then I feel as if some of the fat dissolved. I now have a little bit of saggy skin I never had prior. I am not looking to add more size or fat grafting. (I’d like To avoid that if at all possible) However I am interested in fixing the bottom shape of my rear if possible.

A: Thank you for sending your pictures….that was tricky to do but you did a good job with it!

I can see that you have a very long buttocks and some loose skin at and along the ill-defined infragluteal crease. The only way to improve that area is with a lower buttock tuck which is done by excision of the loose skin and placing the scar along the infragluteal crease line.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting my jawline asymmetry, it is very bothersome I was curious if anything can be done to address it? I had a CT scan taken recently, I am not sure if it is 3D though.

A: Thank you for sending your pictures and panorex x-ray. Your chin/anterior jawline asymmetry is caused by a lower inferior border which can be clearly seen on the rays. This can be corrected by an inferior border shave done from a submental chin incision under the chin. Measurements would be taken off of the x-ray to determine how far back the asymmetry goes as well as how much needs to be shaved off to match the left side.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m looking into getting a small to mid sized dent I have on the top left side of my skull fixed.

I’m unsure of the bone cement treatment as the three biggest worries I have about it is can the cement ever shatter once placed into the skull? I have read some articles online that this is a possibility.

Secondly, What effect can it have on day to day activities e.g. going for a run, playing soccer and other physical activities. Can such activities cause the cement to dislodge?

Thirdly, What kind of longevity does bone cement have and can it degrade? I have had no success in finding any articles online regarding this.

I would appreciate if you can take some time to answer these questions for me.

A: In answer to your skull dent correction questions:

The options to treat a skull dent are either bone cements or a custom skull implant. Hydroxyapatite bone cements are basically ceramic so they can potentially fracture of struck…although I have never seen it in 30 years of its use. PMMA bone cement is as hard as plastic and therefore is much harder to fracture Custom skull implants are composed of solid silicone and can never be made to fracture no matter how much force is applied.
No physical activity can make a bone cement or implant on the skull become displaced.
Bone cements and skull implants will last a lifetime as they do not degrade or breakdown…ever.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, My main concern now is that my jaw angle implant itself has become “colonized” with a layer of film due to the persistent incision opening. Based on what I have told you, am I at a high risk of that? 

And if that happens and the infection returns, can it still be treated by reopening and cleaning the implant? I guess I’m quite concerned as that side of my jaw has been opened four times now – one for my initial jaw surgery, one to remove the jaw surgery plates, one to insert the implant, and one to adjust it. Is there a limit to how many times we can open this, with regards to scar tissue etc?

A: If an implant is colonize it is by definition ‘infected’. Should treatment be necessary the procedure would be a combined procedure of removal, cleaning out the pocket, re-sterilization of the implant and immediate reinsertion…..with closure aided by a pedicle buccal fat flap over the implant.

You are correct in that the tissues have thinned out over the implant due to recurrent surgeries. I have learned that unless new tissue is added between the implant and the mucosal non-healing of the intraoral wound will continue to occur.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, The more I analyze my face it appears to me that my forehead slope is largely due to an overly prominent brow bone that exaggerates it- especially between my eyebrows the brow bone appears to be very prominent. Do you agree with this or believe it is something else? My goal it to have a less slanted and more flat and upright forehead that is balanced with the rest of my face like the pictures I shared bellow. The other area of my face I would like to draw attention to is my chin. Because I have an overbite in my jaw it seems to make my chin look weak throwing off the rest of my face. In pictures looking directly at my face overall I like the way I look, and don’t want to change the shape/positioning of my eyebrows or jaw line. However from a side profile the sloped forehead and the weak chin to me are very obvious. I attached a pictures of how I look and a few pictures of how I want my forehead to look.

A: Thank you for sending your pictures. While you are correct in that you have an overly prominent/developed brow bone, that is not the complete problem. The backward slope of the forehead is equally an issue if your goal is any of the ideal pictures you have provided. To achieve that type of forehead change you need a combination brow bone reduction and upper forehead augmentation done at the same time.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Roughly two years ago, I had a bullhorn lip lift which I’m very happy with. However, the lateral sides of my upper lip are still quite thin. The skin above my lip seems to push down, against the lip, exacerbating the thin appearance and making any filler placed in my lips look unnatural. For these reasons, I’m interested in a vermillion advancement on the lateral aspects of my upper lip. I’ve attached a few pictures at different angles and under different lighting for your reference. I look forward to hearing your thoughts!

A: Thank you for sending your pictures You have the classic limitations of a subnasal lip lift….failure to augment the sides of the lip and even exaggerating their thinness. You are correct in that lateral vermilion advancements are the only method to get more even vermilion show across the entire upper lip.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was looking into your custom made implants for both jaw and midface and had some questions. I saw from your RealSelf comments that you have experience with the chin-wing osteotomy. I was wondering in terms of chin-wing versus custom implants – would you say there is a trade off in terms of achieving angularity(given the difference between using bone versus silicone)? Also, in regards to midface implants, is it possible to have operations on the eye area following the midface implants (i.e sometime after, a year later or more)? Thank you for your time.

A: In answer to your questions:

1) A chin wing osteotomy is not remotely comparable to a custom jawline implant. A chin wing only provide horizontal and vertical projection of the chin but can not add any width to the jawline nor create any jaw angle definition. There are no comparable operations.

2) Operations on the ‘eye area’ can be performed anytime after midface implants. They are not restrictive to future surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in learning more about I am interested in learning more about revision genioplasty. I had a 6mm silicone chin implant placed under the chin which I had for 18 months. It was uncomfortable and so stiff. I had this removed and replaced by a sliding genioplasty of 8mms. This is also very very tight and all my teeth and gums feel tight and I’m in constant discomfort. There is a heavy feeling in my chin and a real tightness which is made worse when I talk. I have had 3 steroid shots in to the scar and it has helped a bit. Can you add any thoughts as to what’s going on here and any possible treatment? I have attached pictures and x -rays. It’s been 9 months since the genioplasty.

A: Thank you for your inquiry and sending your pictures. Having persistent tightness regardless of whether one has had a chin implant or a bony genioplasty was done may speak to the possibility that any type of chin surgery in you will create the same effect. So it is possible that no revision genioplasty procedure may provide relief.

But the one observation I can make from your x-rays is that your bony genioplasty was positioned very high….much higher than normal. This makes the whole chin tissues vertically shortened and compressed. I think that happened because they wanted to place lag screw fixation and they unintentionally ended up having the downfractured chin segment moved way up to do so. (plate fixation would have avoided that positioning) In effect you have had an unintentional ‘jumping genioplasty’ technique done. I could easily see how that could make you chin tissues tight.

The revision I would see is to move that bony chin segment vertically down to create a more normal bony chin profile and relief the tension on the tissues. (keep most of the advancement but ‘re-lengthen’ the bone) This can be challenging given that lag screw fixation is often not easy to remove but it can be done.

But as I said originally, it is unknown whether any chin surgery will relieve your symptoms. But that is an unusual bone position for a sliding genioplasty.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m 42 years old female and I just had a 3rd Revision Rhinoplasty to remove mersilene mesh implant but the surgeon inserted 12mm diced ear cartilage to have dorsal and bridge augmentation from one ear and made my nose misalignment, huge and high.

Is it true that it is hard to remove all those diced ear cartilages inserted into the nose after one year since I’ve got so many diced ear cartilage pieces and replace them with rib grafts? Will the surgery be somewhat messy and have unpredictable outcome?

Please help, thanks very much

A: I would not envision removing a diced cartilage graft to the nose to be any more difficult than that of mersilene mesh In fact mersilene mesh would be harder to remove. After one one year the diced ear cartilage graft is much more like a composite graft and may be able to even be shaved down. If reduction of the height is the goal I would think that reducing the graft you have would likely be what is needed, not necessarily total removal and replacement with a rib graft….uness there are some major irregularities or contour issues with it.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question about infraorbital rim implants. In addition to having hollow tear troughs, my lower lid is a bit droopy and I have scleral show underneath my pupils. I was wondering if infraorbital rim implants can help elevate my lower eyelids in addition to filling in the hollowness. I was also wondering if there’s an added cost to extend the infraorbital rim implants to the cheek.

Thank you

A: In answer to your orbital rim implant questions:

1) Orbital rim implants along with a lateral canthopexy can help raise up the droopy lower eyelid and decrease scleral show

2) The cost of manufacturing and placing custom orbital rim or custom orbital rim-cheek implants is the same.

Dr. Barry Eppley
Indianapolis, Indiana