Your Questions

Q: Dr. Eppley, some doctors in the USA do Sculptra. it is FDA approved for hip augmentation and can you do it in my hips to get more volume to my hips? 

A: Sculptra is FDA-approved for use in the face in the United State. specifically for facial lipoatrophy. Using it for hip augmentation is an off-label use but can be done. The key with Sculptra injections, which makes it very different than any other injectable filler other than silicone oil, is that it takes a series of treatments to achieve its maximal effect. This is usually done up to three injection sessions spaced about 6 weeks apart. It is the scar tissue response to the injected PLLA particles which is how it works. If you try and put in too much of it at one time, adverse tissue reactions can occur. (inflammation, nodules) Thus it is a delayed response to the injected material that occurs and not the immediate result that is seen from most injectable fillers or injected fat.

The amount of injected volume of Sculptra (it is mixed into a solution at the time of its use) would be considerably more than that used in the face. As a result its cost would be also higher.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My concerns and questions have to do with my chin. I had a chin implant removal procedure done over a year ago because I disliked they way it look. The capsule was left to give me some augmentation. However I still dislike it. I also have mentallis muscle strain and have gotten Botox to help with it in the past. Overall, I’ve been told that cutting the mentalis muscle will help the way my chin looks because now it kind of looks like a ball, really round especially when I smile. I would like another opinion and to consider my options. 

A: With the tissue expansion that occurs from a chin implant, chin implant removal surgery results in an overall soft tissue chin pad excess. It is not just the mentalist muscle alone that creates the redundant so tissue chin pad. I have also never heard of leaving the implant capsule because it would create an augmentation effect as it ends up getting resorbed.

The direct answer to your question is that unraveling the contracted and stretched mentalist muscle MAY improve the ball shape that now exists with your chin after the implant removal. But there is no guarantee that it will be completely successful. That can not be accurately predicted before surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 32 year-old male who has a flat back of head and consider doing a flat back of head augmentation surgery with you but I have a few question which be thankful if you can answer to those 

1_. Do you use implant for these type of surgery? And if so which type of implant silicon or saline? 

2. Can you please explain what a bone cement (PMMA) is? Is it implant or? 

3. If you use implant how do you secure the implants in place do you screw the implant in to place? 

4. Does the surgery result permanent? I mean do I need to do another surgery to replace the implant in future? 

5. If you use implant how big is the risk for implant to rupture and leak and what should I do in this situation and how do I know that the implant is ruptured? 

6. How much does it cost totally for surgery and hospital? 

7. How long do I need to stay in touch with you in Indianapolis?

A: In answer to your flat back of head augmentation questions:

1) A custom solid silicone implant is used, made form the patient’s 3D CT scan.

2) Bone cement is another skull augmentation material but requires a full coronal scalp incision to place it.

3) The implant result is permanent.

4) The implant is secured by tissue ingrowth and a few small microscrews.

5) This is a solid silicone implant, not a gel filled implant like that used in breast augmentation surgery.

6) My assistant Camille will pass along the cost of the surgery to you tomorrow.

7) You would retain home 2 days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read quite a bit of informative material on your website. I am particularly interested in a procedure that you offer that is skull shaving. (skull reduction) I have always had a big wide head (wide, but short, I am brachycephalic.). Does it really make a different your procedure of burring into the diploic space? I mean, the cranial vault bone is 7mm thick, at most, I don’t see how it could make a difference visually. Do you have pictures I can see? Also, the docs I spoke to said that the bone will grow back. 

A: In my experience in the properly selected patient when a large enough surface area is covered visual differences do occur from skull reduction surgery. This is most commonly done by skull bone shaving which is achieved by high speed rotary burring using  carbide burr.. The question is not whether external changes occur, but whether the amount of change that occur meets the patient’s expectations. That must be determined in an individual patient basis. Also all in my experience, and I have done lots of skull reduction procedures, bone does not grow back in an adult nor is that biologically possible. You mist guard against excessive scar formation but not bony regrowth

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I have some facial surgery recovery questions. I’m in my early 20s. I came across your profile on RealSelf and was impressed by your experience across a vast number of procedures. I could not find any answers on the website to my problem and thought you could hopefully help me answer some questions about some recovery problems I have been experiencing. 

I underwent multiple facial procedures in Thailand and now I’m really really worried about my decision and hope you can put my mind at rest or guide me in the right direction. 

I underwent a silicone chin implant, breast fat grafting, double chin liposuction, endoscopic/intraoral cheeklift, and tiplasty. I am currently 2 weeks post-op.

(1) I had a winged silicone chin implant put in via the mouth. I believe I can feel the wing on the left side riding up so that the implant as a whole does not look symmetrical. How long should I wait before I have a revision for this if it truly is asymmetrical?

(2) My chin area is lumpy and red from the double chin liposuction. Is this normal at more than a week out or is there hope for the lumpiness to resolve further over time?

(3) My endoscopic cheeklift swelling was very extensive. Though there was no eyelid incision, my eyes blew up like balloons by day 3 and I was near-normal-but-puffy by day 6. Day 7 however took a turn for the worst. My right eye blew up again in the morning, and has stayed that way for the last couple of days. At the very outer corner of my right eye, there is a hard lump near the eye socket and a little pocket of air or fluid which is very tender. The little air/fluid pocket area is around the size of a quarter. From the 45 angle view, it is at the very top of the ogee curve and makes my cheeks look square. Could this be a possible seroma? Do I need it drained or will it go away? I’ve read that untreated, there can be consequential scar tissue and irregularities. 

I am very worried about my healing and cannot communicate with my doctor as he is overseas and I have no translator with me.

A: In answer to your facial surgery recovery questions:

1) That certainly sounds like chin implant asymmetry which is much more common when placed intraorally.

2) The contour results from submental/neck liposuction takes 8 to 12 weeks to fully realize.

3) I can not speak to your cheeklift issues since I have no idea how it was done and what lies underneath that was used to perform it…but this sounds like a possible infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a second opinion on my custom jawline implant placement. I’ve attached a few pictures I took today. One of the front facing photos is a duplicate with some arrows pointing to the four issues I have mentioned below. In addition, I’m attaching a PDF case report which was given to me shortly before my procedure done last year. It contains images of my jaw and the implant design.

For the reference photos:

1) The imbalance on the chin where I can feel a separation/shifting of implant.

2) This is harder to see, but I have a gristle-like mass along my right side of the middle jawline (under the skin, but over the implant). I makes the lower right jaw area look bigger than the left side.

3) Especially when flexing/biting down you can see the right side muscle seems much bigger.

4) The profiles show how the back edges of the jaw go behind the ear farther than I would like.

Let me know your thoughts. 

A: Thank you for sending all of your pictures. What I can tell from them is the following:

1) The jaw angle implant portion extends posteriorly beyond the posterior ramus of the jaw angle and its natural curve, hence ‘being too close to the ear’.

2) There is masseteric muscle sling dehiscence which is why there is a bulge way above the inferior border of the implant in the jaw angle area.

3) What the mass represents in the middle third of the jawline can not be determined by your pictures alone.

4) Like #3, what the imbalance of the chin represents is impossible to know from your pictures alone.

The next important step in the diagnostic process is to get a new 3D CT scan and compare your current implant positioning on the bone to what you see on the outside as well as where it ideally should be. I don’t really see any design flaws in the initial implant with the exception that when you make the angle portion of the implant go beyond your natural bony jaw angle that is what can happen….the implant gets back too far and sticks out behind the muscle. This issue is magnified when the masseteric sling gets separated doing placement. This is not a criticism of your surgeon, these are just pearls that I have learned by doing hundreds of custom jawline implants. It seems straightforward on paper but there is a steep learning curve to doing the actual custom jawline implant procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing with hopes for more information on jaw angle implant removals. It seems jaw angle implants are relatively rare compared to other facial implants so it is difficult to find any information or cases online regarding them let alone their removal. I have seen that you have experience working with this type of procedure. I would be extremely grateful for any information you can provide relating to my case. 

I have always had a weaker mandible and likely should have received orthognathic surgery for this when I underwent orthodontics many years ago, as had been recommended by my orthodontist at the time. As I got older, however, the main concerns were the significant amount of mentalis strain that caused my chin to ball up when I closed my mouth and my moderately recessed chin.

My concerns led me to a consultation with a maxillofacial surgeon as I believed I needed to either get orthognathic surgery as had been previously suggested by my orthodontist or a genioplasty to move my chin into better position to address my concerns. The surgeon told me I could undergo a ‘masking’ procedure that would make it appear as if I had the correct orthodontic treatment done, which was a genioplasty in conjunction with a complete jawline build-up with Gore-tex material. I was told that the jaw implants were necessary to do in conjunction with genioplasty to achieve a ‘balanced’ jawline.

I decided to undergo the masking procedure and had a maximal advancement genioplasty with approximately 5mm hand carved Gore-tex jaw angle implants as well as Gore-tex strips in the mid-jaw region to connect the genioplasty with the jaw angle implants. There is also a small Gore-tex strip that was placed across the front of my chin for additional contouring in the labiomental fold.

Due to various concerns, I am adamant to just have the implants removed. The original surgeon refused to do so.

My main questions are:

– What would be the likely consequences/risks of removing 5mm Gore-tex jaw implants, if any? I am a young woman and the implants have been in for about a year. Would there be risk of skin sagging/facial deformity or would my skin likely bounce back similar to how it was pre-op?

– If it is likely that my skin will contract normally, how quickly would it take for my face to return back to normal and what changes could I expect in the shape of my face from the tissue changes caused by the implants?

– Most importantly, what would the impact of removing jaw implants that were placed in conjunction with a genioplasty be? It is difficult to imagine what the outcome would be since the procedure was not isolated. Would it make my chin look very disproportionate to my face?

Thank you so much for taking the time to review my case and questions.

A: Thank you for your inquiry. While the use of ePTFE (the contemporary name for Gore-Tex) for jaw angle augmentation is very rare, it has a long history of use all over the face. In my experience I will occasionally use it to supplement standard or custom facial implants if needed and hand carve ePTFE blocks for some facial augmentation procedures. (I believe your jaw angle implants are probably ePTFE blocks)

While ePTFE does have more tissue adherence than silicone, for example, it can be removed if one is experienced in doing so. While I have no idea what you looked like now or before your surgery, 5mm thick jaw angle implants are not very big and, unlike facial implants in other facial areas where soft tissue sagging may be a potential post removal issue, this has a very low likelihood to occur in the jaw angle area. This is because it is the only facial implanted area that is placed under such thick muscle and the attachments to the skin lie above the muscle and not below it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about back of head augmentation reshaping surgery? 

What is process and how long does it take? 

What is the recovery time frame? 

How long before one can get back to work? 

Can you fly and when after surgery is that possible? 

Also what is the cost of this procedure and related procedures? 

A: In answer to your back of head augmentation surgery questions:

1) The implant is made from the patient’s 3D CT scan and takes 30 days to do from time of design to manufacture to be shipped and available fir surgery..

2) Most patients recover fairly quickly and are back doing most normal activities in 10 days after surgery. The recovery us usually less than most would think for ‘skull surgery’. But this is because patients understandably confuse intracranial skull surgery with aesthetic skull surgery…which are two completely different types of skull surgery.

3) Most patients return home 1 to 2 days after surgery. In recovery it is relevant to really that no physical activity can adversely affect the skull implant as it is resistant to displacement or material disruption.

4) My assistant will pass along the cost of the surgery to you later this week.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had under reye fat injection surgery four months ago. But I think its is overcorrected. Is there any way to remove these fat cells or make them go away? For example, with radiofrequency or laser or warm compress or sauna or pressing the area or using corticosteroid injections? Please help me as I feel so bad about myself. I don’ t like my under eye area now as it is unnaturally even with cheek. It’s awful, I don’t even look at mirror. It’s 4 month passed now since the surgery and it still looks like extra fat.

A: An under eye fat injection result that is undesired can not be reliably removed by any of the methods that you have described. I would definitely avoid steroid injections. After 4 months the injected fat has survived and integrated into the tissues. In some cases I have used BBL (broad band light) therapy or radiofrequency treatments to lessen their aesthetic effects. This can be effective but will require multiple treatments to achieve a visible effect in under eye fullness. The most effective one time method for under eye fat removal is a lower blepharoplasty approach for direct excisional removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reading online about rib removal and came across Pixie’s story. I am considering rib removal. I was wondering how many patients (in addition to Pixie) have you operated on that have had ribs 10-12 removed and whether any have developed flank hernias? That is my primary worry and I was wondering if you have any information you can share on that risk. Thanks very much! 

A: A flank hernia is a defect in the posterolateral abdominal wall which is s risk in certain of abdominal and spine surgery.. Since rib removal surgery does not involve the abdominal wall, as the ribs are located outside of it, a flank hernia is not a potential risk of this type of body contouring surgery used for a smaller horizontal waistline.

It is easy to understand how one might think this is a surgical risk because rib removal surgery is not well understood by patients and doctors alike. What is really being done is removal of the outer half of the ribs 10, 11 and 12. Total rib removal is not done nor is it necessary to do. Thus the supportive part of the rib closer to the spine is maintained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am six months post-op cheekbone reduction surgery. I am happy with the results from the bony perspective as my face has been effectively narrowed, but there were some trade offs. I have some slight sagging of the midface which is evident in the form of hollower eyes and deeper nasolabial grooves. 

I’m 24 years old and I’m booked for a cheek lift procedure in ten days. It is an understatement to say that I am absolutely terrified about the uncertainty of the operation and its outcomes.

My surgeon will be taking two 2-3 cm incisions in the temple, and reusing my oral incisions from the zygoma reduction. He will lift my cheeks off the bone and suture them to the temporal muscle. 

However, I haven’t read a lot of good things about this procedure. Most people seem to have complaints about looking too pulled up or cat-like or too full in the cheeks after the operation. I asked my surgeon not to make the eyelid incision as I am still young and of Asian-descent. 

My sagging was only slight and I would hope that I just get a slight lift of the cheek tissues. I am deathly afraid of looking too full or too pulled or my cheeks changing their shape dramatically.

From your experience of midface lifting in young individuals after cheekbone osteotomies, what kind of results can I expect? I just want a conservative redraping of the tissues slightly higher but it’s just so hard to communicate to my surgeon what “conservative” means. 

I’ve read about an 18 year old removing implants and getting the same type of midface lift to correct sagging, and she mentioned it warped the shape of her cheeks. Please provide any insight you have about my situation.

A: The fundamental problem with a temporal cheeklift is that the vector is oblique while the direction of the cheek sagging has occurred in a vertical direction. Thus a swept back look is possible based on the direction of the pull. To make a vertically directed cheek lift a cranial suspension technique is needed. This is similar to the temporal cheeklift but the incisional access and the suture placement is directly upward in the scalp.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have braces on my teeth and although they will probably be off by the time I have surgery with you, would there be any issues if I still had them on? For example, damaging the implant or braces during placement?  Also, could the movement of teeth alter my bone structure? Is there a risk that the implants will not have a perfect fit if the movement of teeth has altered the bone after CT scan and implant design?

A: In answer to your custom jawline implant surgery questions:

1) Many patients for different  types of custom facial implants have braces on their teeth. This is extremely common. This is not an exclusion or limitation of doing the surgery.

2) Orthodontic therapy moves teeth, not bone, in adults. That is the fundamental principle of how orthodontics works in general and in particular in adults…the teeth move through the alveolar bone and thus change position, the bone does move to make the teeth change position. As a result whether one is in orthodontic therapy or is going to subsequently undergo or has finished orthodontics, this will not adversely affect a custom jawline implant design and its fit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The reason I am considering rib removal is I do not have a defined waist or a flat stomach. I do exercise and have worked out like a beast in the past and am still unable to obtain the results I want. I had three children. The only way I can get a super flat stomach is to almost weigh like 100-112 lbs. I’m 5″8  so it’s not ideal because I lose my butt and my breasts are smaller when I lose that much weight. I have small hips which also adds to the look of no waist line. I don’t want the scars a tummy tuck gives you and I think rib removal and some liposuction might work. I’m not overweight so I do not know if liposuction is an option either. Attached is a recent photo . The second photo is almost two years old which is me at 110-112 lbs and still no defined waist and my belly pooch is still there.

A: Thank you for sending your pictures. I can see why you seek this procedure as there is not much more you can do in making your waistline more narrow other than removing the last anatomic barrier. (rib removal) Every posterior rib removal surgery includes aggressive liposuction of the flanks as well as wedge removal of the LD muscle which collectively results in 1″ to 3″ average horizontal waistline reduction. So both by pictures and description you are a good candidate for rib removal for maximal walstline reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation. My forehead is very round in shape and I believe a forehead implant can greatly impact my profile. I also have a bent nose and want to go through rhinoplasty simultaneously. I just want the tip of my nose to be lifted very slightly.

What im curious to know is that, would it be possible to do nasal augmentation, through a coronal incision, and by doing so completely avoiding any scarring of the nose.

A: Thank you for your inquiry. Please send me some picture of your forehead, particularly from the side view, for my assessment and recommendations.

Whether it is to build up the radix or bridge of the nose to for nasal tip manipulations, you can not do that successfully from a forehead approach. This requires an open rhinoplasty for which the small columellar skin incision to fo do so heals so well it is virtually invisible afterwards. I have never in 30 years of rhinoplasty surgery had a patient request a columellar scar revision which speaks to the issue whether any adverse scarring occurs.

In addition most forehead augmentation proedures that are done with a custom implant do not require a coronal scalp incision to place them. That type of access scalp incision is only needed for bone cement forehead augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a Medpor jaw angle implant revision. Three years ago I had an operation to improve my jawline using Medpor implants. After the surgery i noticed a degree of asymmetry in lateral projection of my right jaw angle. Recently I went through a 3D CT scan to determine the source of this issue and the doctor stated my masseter muscles are not symmetrical and specifically the right jaw muscle is 1-1.5 mm thinner. I would like to know if I can fix this problem by removing the current Medpor implant on my right jaw angle and replacing it with another implant which can increase the lateral projection of my right jaw and consequently remove the asymmetry between my jaws.Thank you in advance and I will look forward to hearing from you.

A: Thank you for your inquiry and detailing your surgical history. While your indwelling Medpor jaw angle implant can be removed and replaced, the initial critical question is whether this is a true muscle asymmetry problem or one related to the implants. I assume you know this answer because you have seen the scan yourself and you have visual assurance that the implants are perfectly positioned and are not the underlying culprit of the asymmetry.

For the sake of discussion there are numerous ways to do a Medpor jaw angle implant revision for a mild jaw angle asymmetry of 1 to 1.5mms, regardless of whether it is of muscle or implant origin, which would not include having to remove and replace the entire implant. An implant overlay can be placed on top of the existing implant which would be far less traumatic to undergo. Of course the complete implant can also be removed and replaced as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Medpor chin implant placed several years ago but have never been that happy with it. I have always felt it was not enough and was too short even though the implant was a large. I am thinking of having it removed and replaced with a sliding genioplasty. Is this a reasonable plan?

A: The critical question in your secondary chin augmentation inquiry is whether you would leave the existing chin implant in place and do the cut above it and carry it forward with the sliding genioplasty or take it out and do the whole chin advancement with the sliding genioplasty alone. It depends on how much more your chin needs to be advanced over what you have now, what the thickness of your bone is and whether the bone alone can make the amount of advancement improvement that is desired. That would require a 3D CT scan to help make that determination as well as measurements of how much further your chin need to brought froward to meet your aesthetic goals. If the Medpor chin implant was a large one it may bee doubtful that a sliding genioplasty alone would be able create your ideal chin augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in a chin augmentation. I am 6 feet tall and somehow my chin does not harmonize with the rest of my face. It’s not that I don’t have a chin, but it just doesn’t seem masculine.

I would be very interested in a chin implant and would also like to have the procedure performed later this year. I would also like my jaw to look more contoured. I had in mind filler + chin implant. Can fillers have the same effect as a jawline implant? In this part I’m not sure yet why a temporary solution would be good but with the chin I’m sure it should be permanent. My eyebrows are pretty asymmetrical, maybe you could fix it parallel. I would be very pleased about a cost calculation and would also like to have the intervention carried out with you.

A; Than you for your inquiry and sending all of your pictures. Doing a chin implant with injectable filler or fat is a good combination when one is uncertain as to the jaw angle effect that they seek or whether it would be what they want. The debate for a jaw angle fillers comes to a synthetic like Radiesse or using one’s own fat. There are arguments to be made on either side.

For the brow asymmetry what can be done is to lift the lower side of the eft inner brow area. It is not possible to lower a higher brow so it would be important to know which type of brow change you seek. I will assume the former for now.

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

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I can’t thank you enough for the time and effort that you put into answering patient enquiries. Although I may not be a direct patient of yours, your blog has helped me tremendously. Thank you for not beating around the bush, as many surgeons on RealSelf tend to do.

I’m a 24 year old recipient of cheekbone reduction surgery and had some mild midface ptosis, although I was happy from a bony standpoint. This week, I’ve undergone a temporal/intraoral incision cheek lift to hopefully alleviate the sagging. From your blog, it seemed like the most logical thing to do to directly address my cheek sagging post-op zygoma reduction.

How long after my subperiosteal midface lift should I be able to start seeing the final results? My surgeon mentioned that my temple area and cheek area would be hard and swollen. This is the case but my left nostril and lateral nose are also completely numb. I can flare my nostrils fine, but should I expect a full recovery in regards to this nerve disruption? My surgeon said a full recovery is likely but I just wanted a second opinion.

A: It is not rare to have some temporary numbness of the infraorbital nerve distribution after a midface lift which has a major access point intraorally. That should fully recover but will take 3 to 4 months to do so. Because of swelling it may be difficult to see the results of the midface lift initially but you should be able to see some initial results right after surgery. But the true and final assessment of the outcomes will be evident by six weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing with hopes for more information on jaw angle implant removals. It seems jaw angle implants are relatively rare compared to other facial implants so it is difficult to find any information or cases online regarding them let alone their removal. I have seen that you have experience working with this type of procedure. I would be extremely grateful for any information you can provide relating to my case. 

I have always had a weaker mandible and likely should have received orthognathic surgery for this when I underwent orthodontics many years ago, as had been recommended by my orthodontist at the time. As I got older, however, the main concerns were the significant amount of mentalis strain that caused my chin to ball up when I closed my mouth and my moderately recessed chin.

My concerns led me to a consultation with a maxillofacial surgeon as I believed I needed to either get orthognathic surgery as had been previously suggested by my orthodontist or a genioplasty to move my chin into better position to address my concerns. The surgeon told me I could undergo a ‘masking’ procedure that would make it appear as if I had the correct orthodontic treatment done, which was a genioplasty in conjunction with a complete jawline build-up with Gore-tex material. I was told that the jaw implants were necessary to do in conjunction with genioplasty to achieve a ‘balanced’ jawline.

I decided to undergo the masking procedure and had a maximal advancement genioplasty with approximately 5mm hand carved Gore-tex jaw angle implants as well as Gore-tex strips in the mid-jaw region to connect the genioplasty with the jaw angle implants. There is also a small Gore-tex strip that was placed across the front of my chin for additional contouring in the labiomental fold.

Due to various concerns, I am adamant to just have the implants removed. The original surgeon refused to do so.

My main questions are:

– What would be the likely consequences/risks of removing 5mm Gore-tex jaw implants, if any? I am a young woman and the implants have been in for about a year. Would there be risk of skin sagging/facial deformity or would my skin likely bounce back similar to how it was pre-op?

– If it is likely that my skin will contract normally, how quickly would it take for my face to return back to normal and what changes could I expect in the shape of my face from the tissue changes caused by the implants?

– Most importantly, what would the impact of removing jaw implants that were placed in conjunction with a genioplasty be? It is difficult to imagine what the outcome would be since the procedure was not isolated. Would it make my chin look very disproportionate to my face?

Thank you so much for taking the time to review my case and questions.

A: Thank you for your inquiry. While the use of ePTFE (the contemporary name for Gore-Tex) for jaw angle augmentation is very rare, it has a long history of use all over the face. In my experience I will occasionally use it to supplement standard or custom facial implants if needed and hand carve ePTFE blocks for some facial augmentation procedures. (I believe your jaw angle implants are probably ePTFE blocks)

While ePTFE does have more tissue adherence than silicone, for example, it can be removed if one is experienced in doing so. (jaw angle implant removals) While I have no idea what you looked like now or before your surgery, 5mm thick jaw angle implants are not very big and, unlike facial implants in other facial areas where soft tissue sagging may be a potential post removal issue, this has a very low likelihood to occur in the jaw angle area. This is because it is the only facial implanted area that is placed under such thick muscle and the attachments to the skin lie above the muscle and not below it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I sent you some pictures not long ago and you kindly recommended a full custom jaw implant because my jawline is vertically deficient.

I wanted to ask your opinion about a genioplasty to obtain an increase in vertical height on my chin. Would this be a viable route to take ? And would it also decrease the mentolabial fold ? I understand you can only tell me so much from these pictures. I appreciate your answer Dr.

A: If you are looking only for a vertical lengthening of the chin, then an opening wedge intraoral genioplasty with an interpositional graft would achieve that nicely. This would probably be in the range of 6 to 8mms of vertical chin lengthening although it can be even greater up to 10 to 12mms. It can achieve an anterior vertical elongation of the chin just as well as a custom implant. It may not decrease the depth of the labiomental fold but at least it will definitely not make it any deeper. Be aware that a vertical lengthening genioplasty affects the chin and the chin only. It will have no effect on the jawline behind particularly that of the jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley: Over the last few years I’ve been intrigued with the idea of customizing implants to fit an individual’s face, and I’m looking into getting a customized implant for my cheekbones. My cheekbones are quite flat but also quite low down my face. Meaning the main part of my cheekbones seem to sit well below my lower eyelid. My first question is whether this can be addressed with a customized implant? Can my cheekbones be brought higher???? 

The other question that I have is whether it’s possible to order a layered-segmented implant from the implant company. I’m scared about getting an implant too big, but also too small. So I had this idea: could we order a single implant that can be ‘layered’, meaning can we order a single segmented implant where the implant is essentially in two similar layers, one over the top of the other. My thoughts were that I could have the lower layer implanted and then reassess whether I want more, and if so I would get the second layer implanted over the top of the first, thus avoiding the need to order two seperate implants from the company. 

Look forward to hearing from you 🙂

A: When it comes to custom cheek implants they can be made just about way we want. One of the most common reasons for custom cheek implants is to get the higher cheek look which standard cheek implants can’t do. Attached are a few examples of the many types of custom cheek implant designs that I have done.

As for making a layered custom cheek implant, that can be done. They concept of secondary placement of the second layer if need, however, is the reverse of what you have mentioned. It is far easier surgically to slide a second implant layer under the first one than it is to secondarily place it on top of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant replacements surgery. I had three spontaneous lung collapses and video assisted lung surgery followed by talc pleurodesis to correct the issues about a year ago. I have breast implants placed yeas before these lung problems and now I want to go bigger. Do any of my lung surgeries prevent me from having another breast implant surgery? 

A: Your description describes a pleurodesis procedure which by your description was done with your current breast implants in place. While on the surface there does not seem to be a contraindication for replacing your breast implants, the following would be the appropriate questions to preoperatively consider. (in essence will breast implant replacements cause recurrent lung collapse)

1) What was the origin of your original lung collapses? 

2) Where is the incision site for the previous lung surgery?

3) What does your pulmonologist say about having a general anesthetic and the breast implant surgery?

With an established breast implant capsule, replacing breast implants is far less traumatic than making the initial implant pockets. If necessary it may be possible to do your breast implant replacements under a local anesthetic if your pulmonologist is apprehensive about a general anesthetic.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want a chin reduction and already had one 5 years ago through under the chin. I feel its still too long and broad and pointy. It needs 6mm vertical reduction and 6mm horizontally reduced and tapered to narrow it. Is it best to perform a osteotomy reduction or burring it instead? Also I have muscle that pulls down the soft tissues when I smile still even though its less than previously. Also is sliding genioplasty the same as osteotomy reduction?

A: When it comes to a combined 6mm vertical reduction and a 6mm horizontal reduction, the submental approach is essential because it can manage the resultant excessive soft tissue that will result from such soft tissue deflation from the substantial bone removal. While sliding genioplasty can effectively reduce the vertical height, sliding the chin backward will create a submental fullness as the excess soft tissue must go somewhere. A submental approach is always the most effective for a 3D chin reduction. When you slide the chin bone back, two negative aesthetic consequences occur…the back ends of the genioplasty stick out below the inferior border (creating a bump) and the attached muscles bunch up. (which is why liposuction won’t solve it)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in weird head shape surgery. I’m 24 years old. I have thinning and receding hair which I have come to terms with. However I can’t come to terms with my weird head shape. I will include pictures below as well.

Picture 1:

Left and right arrows show dips in the sides of my head which gives the skull such an uneven look and very coney. This goes back quite far as well but not far enough to get to the back of the head.

The middle arrow shows a coned look, however it may be because it goes so thin due to the dips in the head which makes it seem worse. 

It’s a slightly better picture of the dip on the side of the temple specially on the left side. You can see it looks like it’s on another platform. 

I have looked at a lot of the surgery posts on your site and feel encouraged that you can assist me I just hope I’m correct in assuming this to be honest. I would love to have a normal smooth rounded head shape rather than dippy lumpy and coney.

A: In consideration of weird head shape surgery, we first have to define the exact skull shape abnormality. The side dips to which you refer is known as the temporal lines where the top of the temporalis muscle meets the outer edge of the skull. While in many people this is a smooth transition as the muscle gets very thin in this area, there are men like you where the muscle actually remains or appears thick (or the skull bone is more narrow than normal which better describes your situation) creating muscle pseudofullness and making the normally flat temporal line look indented. The other indicator to your scaphocephalic skull shape is the high peak or sagittal ridge with narrow parasagittal sides creating what is known as the ‘roof’ skull deformity.

The effective treatment approach is usually a combination of sagittal ridge reduction combined with parasagittal augmentation that crosses the temporal line. Together this is the only effective way to reshape the current appearance of your head shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim implant removal. Is it possible to remove OMNIPORE Inferior Orbital Rims Implants? Will be an emptiness there after removing which has to be concealed? How to conceal? What is the earliest/best time to remove them after placing?

A: Omnipore facial implants is just a branded name for porous polyethylene. (Medpor) As such they can be removed just like any other Medpor facial implant. The time to remove them is when you have given the result long enough to really see the final result and have adjusted to it. (2 to 3 months after their placement)

You are correct in assuming that the lower eyelid/midfacial tissues may not return exactly to normal given that a subperiosteal elevation and tissue expansion has been done. Thus thinking about tissue management from the deflation caused by the implant removal is appropriate. What one would do depends on what you looked like before and what your original goals were for having the implants in the first place. Tissue resuspension and some volume coverage with allogeneic dermis is one approach.

I will have my assistant Camille contact you on Monday to schedule a virtual consultation time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eye asymmetry correction. I have also always been conscious that my right eye is slightly lower than my left. Looking at the CT scan, I can see that this could be caused by the bottom of my eye socket on the right side being lower than the left.Another thing I noticed on the CT scan is asymmetry of my cheek bones. The right one appears lower than the left, or at least extends lower. 

I did some research and mostly your articles came up. I found examples where you were able to correct all 3 of the above issues using custom implants. Therefore, I was wondering if you could recommend a solution to this? If it’s possible/feasible, I would likely look at getting it done after I recover from my jaw implants.

A: What you are describing for your eye asymmetry is a modest form of vertical orbital dystopia. (VOD) By definition, since the orbito-zygomatic bone complex is a combined unit, if the eye is lower so will be the cheekbone…the two go together since they are connected. Custom orbital floor-orbital rim-malar implants do offer the most effective method of VOD correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Sculptra injection reversal. I had Sculptra injections about 6 months ago and it has given me a square chin and is making me very depressed. The doctor is using an enzyme to dissolve the other fillers I had put into my face but, of course, the Sculptra won’t dissolve. Do you recommend trying to get rid of the dissolvable fillers anyway as there’s quite a large amount too? Would appreciate any help. 

A: As you may know Sculptra is not like the more commonly used hyaluronic-based fillers. It is composed of PLA particles (small bits of resorbable polymers) which create their effect by inducing collagen formation around them. Such PLA particles are not responsive to enzymatic digestion as they are a chain-liked polymer strand. Their resorption will eventually occur through a hydrolytic process (water absorption) but this is a slow process that could take 12 to18 months with the presumption that the reactive scar tissue will fade away as well as the stimulus is removed.

There is no known method to remove the Sculptra filler from soft tissues that would not potentially cause other long-term issues, particularly in the chin area. Steroid injections or liposuction should be avoided due to potential soft tissue deformities from them. 5FU injections are the only injectable strategy that would not cause a potential soft tissue problem but whether they would be effective in this situation is unknown. 

One other potential treatment option, if the Scupltra was injected down at the bone level (your injector would know this), is to remove the material from the bone surface through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in side profile enhancement. I am really insecure about my side profile, I know I want to do something about it, but I’m not sure what the best course of action is! I would like to have a less receding chin and defined jaw line (I’m not overweight). At the moment I’m leaning towards fillers in my jaw/chin and kybella but would it end up being more cost effective as opposed to jaw reconstruction or chin implant? Any advice or personal experience is greatly appreciated! 🙂

A: When it comes to side profile enhancement, you must define your profile goals as either chin or jawline augmentation because they are different. Fillers or a chin implant are the options for chin augmentation. Fat reducing by injection (Kybella) or liposuction can remove submental fat which will be a favorable adjunct to the chin augmentation. Thus the non-surgical approach of fillers and Kybella has a role in subtle to modest chin augmentation efforts. However neither a surgical or non-surgical chin augmentation approach will improve your jawline. That requires different procedures for which fillers, Kybella and even a chin implant will not achieve. To augment the whole jawline more defined (chin and jaw angles) it all must be augmented with implants. Whether this is using standard chin and jaw angle implants, a sliding genioplasty with jaw angle implants or a custom jawline implant requires a more in-depth discussion.

Dr. Barry Eppley

Indianapolis, IndianaSide P

Q: Dr. Eppley, Last year, I went to South Korea for a simple chin narrowing genioplasty. I consulted for a mini-vline surgery, which is what they call chin-narrowing surgery without the jaw bone shaving. 

I don’t know if things got lost in translation or if my surgeon just didn’t understand what I wanted. But my jaw angles did end up getting cut off. I strictly did point out I wanted my jaw angles left alone but when I saw the before/after CT scans, I was absolutely mortified. Only later did I find out, the Korean word for jaw and chin are literally the same.

In fact, a lot of my jaw bone was amputated off. I wanted a slimmer look but I didn’t want that egg-shaped face that Koreans strive for. I think around 2cm or slightly less of vertical bone was amputated. 

Now I find that my face is severely disproportional at the side view and the 45 angle view. And I can pinch a lot of excess skin and fat around the bottom/back area of my jaw. 

I am looking for solutions to remedy my botched surgery of which it appears only custom implants can successfully achieve V-line reversal. 

(1) Would it be ‘dangerous’ to try to restore my original jawline contour with a 2cm vertical implant. Or would I have to compromise and go for a smaller increase such as around 1cm? Ideally I would like to get my original contour but if the risks of complete masseter sling disruption are higher with a larger increase, I would rather opt to compromise. Are the risks of complete disruption high when my masseter muscle is scarred and contracted? My understanding is that the muscle can contract and be shortened, but it cannot be lengthened. 

(2) What would be the risks of using a harder material such as PMMA or PEEK to rebuild my jawline contour? Even if it requires larger incisions, if a person’s jawbone can be taken out, hypothetically, it can also be put back in? 

(3) How long would I have to stay in the US for this procedure to safely rule out the possibility of an infection?  Is it possible to get a delayed infection aside from needle penetration from fillers or dental anaesthetic?

(4) Would it be possible to have the implant extend into the pre-jowl area to give that area width?

I apologize for the long list of questions. I am quite distressed about the situation and really do look forward to your take on my situation

.A: I have heard your jawline surgical story many times. It is not really a language barrier, it is more of a cultural issue. They are simply going to do what they want to do. There is no such thing as customizing or doing an individual treatment approach. Regardless of language issues, it is seemingly hard to confuse a chin procedure with one where the jaw angles are completely removed.

In answer to your V-line reversal surgery questions:

1) Making custom jaw implants to restore your jawline is the only effective treatment approach for it. How much you should attempt to restore it is a matter of personal preference. It is very likely that the massteric muscle sling may already been disrupted as there is no emphasis in its preservation in a bone shortening operation where the muscle needs to contract anyway. That being said it is true that the greater the vertical jaw angle lengthening is after jaw angle reduction that risk is increased. But there is no known actual number of lengthening where the risk substantially changes. I would say that 2 cms is probably too much.

2) When it comes to the material used for custom jaw angle implant restoration, the body doesn’t care what the material is. That will all work the same. And the stiffness of silicone (durometer) can be made to almost match that of Medpor or PEEK. What matters most is whether any of the material can be designed appropriately, placed without trauma and incisional length and can be manufactured at reasonable cost.

3) Infection does not occur until 3 to 6 weeks after implant placement. So no one is going to stay here until that time has passed. The goal is to get home as soon as you can, often between 2 to 4 days after surgery. One does have to be vigilant ab outany injections therapies around the implants. (didn’t inject down into the bone) Such needle tract-induced infections are very rare but they have been known to occur.

4) The implant design can be made to what surface and dimensions one wants including a forward extension out to the prejowl area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, several years ago I had double jaw surgery plus a sliding genioplasty. The jaw surgery itself created what I believe to be alignment issues with my bite, and possibly TMJ and  tinnitus.

My major concern right now is that my lower lip and chin tightness, especially when talking or smiling. With my lips it’s like they were turned inward, and are stretched against my teeth. My chin was moved forward and up, and it feels as if the skin is being pulled taught against the new position of the bone and plate.

My question is, will getting the 7mm bent plate on the chin removed be enough to resolve this or should I get a revision of the chin surgery done? I don’t really care about aesthetics at this point. I just don’t want this tight feeling all the time.

My surgeon is concerned about going in and risking nerve damage. He’s not sure this isn’t nerve damage, but from what I understand nerve damage is typically numbness, not a thinner lip and tightness of the chin. It’s like wearing a chin strap when you talk.

Thanks!

A:  As best as I can tell from your description you had a combined lower jaw osteotomy with a sliding genioplasty advancement. (the maxillary osteotomy is irrelevant for this discussion) While you did not provide the specific numbers of movement for the mandible and the chin was brought  ‘up and forward’ (millimeters of movement?) I will assume that between the two there has been some substantial anterior bony movement and the chin was so done because of the severe retrusion you had where it was sitting down and back so to speak.  Given the tissue tightness symptoms you are describing it is reasonable to assume that the soft tissue chin pad is very tight which will also affect the lower lip position.

Without seeing pictures and the x-rays I can only make a general comment that it is not unreasonable to think that undoing some of the bony movement of the chin may be helpful (down and back a bit) for their relief. But without knowing anything else I am certain that just removing the metal fixation plate is not going to relieve your symptoms. This is not due to the metal plate, it is a soft tissue stretch issue from how the bone underneath has been changed.

Dr. Barry Eppley

Indianapolis, Indiana