Your Questions
Your Questions
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
Q: Dr. Eppley, I have looked at the first draft of my custom jawline implant design. I would like the jaw angles to drop down further. According to my measurements I need about 31mms downward. What do you think?
A: Thank you for your input on the custom jawline implant design. The only tricky part of your jawline implant design is the vertical increase of the jaw angles. While any increase in the vertical length of the jaw angles can be designed and made, the critical question is whether the overlying masseter muscle will follow the implant downward. If it doesn’t the implant sticks out ay the bottom but the masseter muscle sits above it like a ball…this is probably not the look any patient is going for. There is no exact formula as to how much the vertical length of the jaw angle can be dropped in any patient until this occurs. What I do know is that I have never dropped a jaw angle past 20 mms and even that is risky. Your drawings are probably inaccurate from the standpoint that the measurement of 31mm doesn’t account for the thickness of the overlying soft tissues. So 31mms is probably closer to 25mms. I have started out with a more modest drop of 12mm on the higher side and would be willing to increase it to 18mm. But I think once you go last that there is a real risk of masseteric muscle dehiscence. (there is one at 18mms too but we have to take some risk to get closer to the aesthetic goal)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was told a cheek implant is necessary to elevate the lower eye lids to shape it more lateral to create this look. I am not sure how this makes any sense. While some also suggest that throwing in there a mid face lift can push the eyes as well to give such results. Another oculoplastic surgeon said that he likes to use grafts either from the mouth or alloderm as such drastic lateral canthoplasty will take more than a canthoplasty and also he mentioned the orbital bone and cheek / facial structure needs to be assessed in order to create such looks that my cousin and I are seeking. Something about how the cheek implant can create a desired look of this.
I am not sure if the photos were attached however I will attach them again. I hope this is something we can potentially convince you to do as we wish to boost our potential as models in our hobby. We would love to visit you personally but we are dispersed around other states as college students. So if possible let me know if the results are permanent and if this is something relatively easy fr you to do and if a cheek implant is necessary.
A: A cheek implant has nothing to with influencing the position of the repositioned lower eyelid. What is more useful is an interpositional graft like Alloderm as the eyelids need more tissue internally. Just stretching them upward alone with a lateral canthoplasty will develop some relapse because a truly elevated and sustained eyelid position ultimately needs more tissue.
While a cheek implant has nothing to do with the sustained position of the outer corner of the eye, it is needed if one wants a higher cheekbone look which is a separate but related aesthetic issue by proximity. The only implant that can help the position of the lower eyelid is a true infraorbital implant. But it does not negate the need for an interpositional lower eyelid graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for solutions to improve my paranasal area. I have quite chubby cheeks for my age and with my paranasal area slightly sunken in, it gives the illusion or shadows of nasolabial folds, thus making me look quite older.
Where I live, fillers are quite expensive compared to that of Asia and the US and it’s a maintenance cost I can’t afford forever. Mores o, I have heard many nightmare stories regarding the more “permanent” or “long-lasting” fillers, so I would like to stay way way clear of those.
In regards to paranasal implants, I’m not interested in having any foreign materials in my body as I am scared of infections. I have also heard that they can augment a person’s smile due to their rigidness. These honestly are not common in my country either. Moreover, fat grafting in areas of movement in the face don’t seem to last long at all.
Then I came across a dermal fat grafting post on Real Self by you, while I was surfing through Q&As regarding the matter. With your experience of the surgery,
1. What are the pros and cons of using dermal fat grafting to project the paranasal area and get rid of nasolabial lines?
2. Is this a more long lasting and permanent solution to my matter?
3. I understand that some tissue needs to be harvested from somewhere, and that’s something I’m okay with if this is a good solution to my matter. Is the buttocks the only viable area of harvest for someone of my age or is there a more hidden area of harvest available?
A: A dermal-fat graft is a well known procedure that dates back over 100 years. While injectable fat grafting is better known today, there are still roles for dermal-fat grafts for small amounts of augmentation such as in the face. Dermal-fat grafts actually survive better than injected fat grafts on a volumetric basis as long as their size does not become too big. As long as the patient can tolerate a harvest site (the lower buttock crease is just one potential harvest site), such a graft is an option for paranasal augmentation. Given the restrictions you have imposed on material options (no fillers and no implants) fat grafting would be your only option. The debate then becomes should it be an injected fat or a dermal-fat graft? There are pros and cons for either fat grafting approach in the face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very appreciative of your insight, it is amazing to even get a glimpse into your wealth of knowledge of facial surgery.
Is there any particular reason why the potential negative effects of cheekbone reduction only become evident after 3-6 months? No medical education here, but why wouldn’t the sagging not be evident straight after the surgery is over, right after the tissues have been peeled off the face?
In regards to the sagging, apart from the wide dissection that is required for the cheekbone to be reached for osteotomy – Are there any patient characteristics that would contribute to potential sagging? (eg. thick/thin skin, facial flatness, etc.)
Thank you again for your time.
A: Healing after any facial bone surgery requites two stages, swelling/edema resolution (first stage which takes 6 to 8 weeks to fully resolve) and then tissue contraction. (second stage, what I call the shrink-wrap effect, which takes 3 to 6 months to fully occur)
As a result of the natural healing process around facial bone reduction sites, It takes that long because the swelling supports the tissue initially and masks whatever sagging may subsequently occur. When the second stage of healing occurs (soft tissue contraction and tightening around the bone) the position of the overlying soft tissue becomes revealed.
It is easy to see how the loss of bone support allows the cheek tissues to be contacted down in a lower position. What is a more interesting question is why it does not occur in every case of cheekbone reduction… which it does not. This undoubtably occurs because of the variations in each patient’s anatomy and differences in surgical technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal for body contouring purposes. I have the following rib removal questions:
1. Estimated cost for the surgery
2. Recovery period after surgery, especially if flying in for the procedure
3. Whether fat removed from flanks during procedure and can be transferred to the breasts
Thanks in advance.
A: In answer to your rib removal questions:
1) My assistant will pass along the general cost of the procedure to you on Monday. Only she knows the answer to this question
2) Most patients return home in three to five days after the surgery. How much more recovery is needed depends on what physical activities to which one is recovering. It is a gradual recovery and most patients return to full physical activities by one month after surgery. There are no restrictions after rib removal surgery so you do whatever feels comfortable. You should probably take two weeks from work or three weeks if the work is more physical.
3) There is never enough fat removed from the flanks to be enough for any appreciable fat transfer to the breast. It requires a lot more fat do so than what the flanks have to give.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 31 years old and I’ve been overweight for most of my young adult life. I’ve spent the last three years trying to lose weight and I’ve managed to lose a whopping 110 lbs.
I am proud of myself for what I have achieved thus far, but a problem remains. As I am still young, I was counting on my skin elasticity to bounce back and tighten up everything. It’s worked slightly for the body, and I’ve accepted that later on I’ll need a surgery to remove the excess skin if it doesn’t retract further in the future as I continue to lose weight.
However, my deepest concern lies with my face. Around the back end of my jaw especially, I am able to pinch and pull a lot of excess (of what I think is excess skin and stretched tissue?) The chin area has done better – I have no jowling of the noticeable sort.
My body does bother me but at least I can hide it under clothing. My face on the other hand, is a problem. I feel like a bulldog.
I feel as if there is too much excess to have any worthy outcome from any lasering or tightening treatments. Dr Eppley, what are my options here?
Is a facelift an option in my case? I have no medical knowledge of any kind but is there some sort of lift procedure for the face where the SMAS is left alone but the excess skin on top is cut off?
A: Thank you for your inquiry and congratulations on your efforts at weight loss. Any person that loses as much weight as you have will develop loose/extra skin around the jawline and neck. Such excess tissue is into going tor respond to any non-surgical tightening methods. Only a lower facelift (neck-jowl) lift will suffice to lift and remove what is likely inches of loose skin.
I would need to see pictures of your face to provide a more qualified answer as to your exact needs for improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your surgery expertise and I hope you can help me.
1. I had a “chin wing” osteotomy a couple of years ago. Can jaw implants be placed on top of this? And does it increase the likelihood of post-surgery complications?
2. I’m interested in custom midface implants, specifically to achieve what I refer to as the “high cheekbone” look you see on certain male models. So this targets specifically the zygoma prominence and the zygomatic arch. My question is my cheekbones have been described as medium, when I’ve asked different surgeons whether I have high, medium or low cheekbones, so can your implant raise the cheekbone higher? or can it only be placed simply on top of the existing cheekbone and thus increase lateral and anterior projection but not raise it in the superior direction?
3. What incisions are used exactly for the cheekbones? Lateral canthus? Or something else? Is it scar free or does it leave a permanent mark?
4. I want to reduce scleral show. I’m assuming the correct approach is a custom infraorbital implant in combination with a high cheekbone/zygo arch one?
5. My biggest goal with the jawline implants is to create a highly angular facial lower third when viewed front on. I want a somewhat square chin, that extends downward slightly but blends in with the natural curve of the face. I also want a sharp-ish jaw angle from the side, but not a ridiculous 90 degree one as it looks overly artificial. So I guess my desire is something that looks sharp, angular, well defined but not over sized or fake looking. To stress my biggest desire is the shape of the jaw front on. Tom Cruise in his 30’s had an amazing one in a million dynamite jaw in my opinion – a shape like that is what I want. But I don’t know if my face is too round for that to be achieved. What do you think?
6. What’s the waiting time for procedures?
7. Is custom midface implants too much in combination with jaw implants? Does it increase the likelihood of infection?
A: In answer to your questions:
1) I am very familiar with the chin wing osteotomy and have placed custom jawline implants in patients who have had the chin wing osteotomy procedure done previously numerous times. While the chin wing osteotomy has its benefits, it is not a total jawline augmentation procedure.
2) Custom made cheek implants can be made in any shape and dimensions desired. There are no limits as to how they can be designed. The key, therefore, is to determine what those implant dimensions are given what the aesthetic results the patient seeks.
3) The incisional access to the cheek implants depends on the style and dimensions of the implant. Unless there is an infraorbital component to it they are usually placed from an intraoral approach.
4) While adding support to the infraorbital rim is an adjunct to reducing scleral show, it is not usually completely effective as a stand alone procedure expect in the most minor amounts of scleral show. Usually an interpositional graft needs to be added to the lower eyelid to drive up the lid margin.
5) The aesthetic effect of a jawline implant is highly influenced by the face in which it is put. Thinner faces with smaller amounts of subcutaneous fat get the best results. Without knowing what your face looks like I can not tell you how realistic or unrealistic such facial reshaping results are.
6) Custom implants take about one month to designing fabricate for surgery.
7) Custom midface and jawline implants are commonly done together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Late last year I underwent cheekbone surgery on the left side of my face to correct some asymmetry. I wasn’t aware that this type of surgery was offered in America, so I had this surgery in Thailand. From my understanding of the surgery, I had an L shaped wedge of 5mm taking out of his front body cheekbone and the back thin cheekbone was moved inwards through a cut in the sideburn area. Everything was fixed with metal screws. Ideally I would have undergone the back cheekbone cut-only surgery to correct my asymmetry, but the doctors who consulted with me in Korea were too pushy on having additional surgeries and did not make me feel comfortable to have surgery there. The hospital in Thailand where I did the surgery did not offer this other type of cheekbone reduction either.
It’s been four months since the surgery now and much of his swelling seems to have gone down. Around the left jaw area, I don’t seem to have any jowling or excess skin happening which is a good sign.
However, the apples of my cheek now seem slightly lopsided, and it’s most evident when I am smiling. My cheek flesh seems tacked on but it has tacked on slightly more down than it was before, if that makes any sense.
It was an understandable risk. I have read through your blog after finding it online, and it makes logical sense that when flesh is taken off bone, it doesn’t stick back down to the bone (as much as we would love for that to happen.) It’s not an evident or drastic sag, but unfortunately it is quite noticeable.
Do you have any suggestions on what surgeries or alternatives I can pursue at this point to just slightly lift this cheek tissue a bit higher up? At a year post-surgery I plan on getting the metal screws out. When the cheek tissue is relifted to remove the metal screws out, is there some method to get the flesh to stick back down higher at the same time.
Or do you suggest that I just leaves the screws in? Would relifting the flesh to remove screws just result in making the drooping worse?
A: In answer to your cheekbone reduction sagging questions:
1) It is not an absolute necessity that the metal plate and screws are removed. While it is not likely to cause further soft tissue sag, there is always that risk.
2) The only reason to remove the metal hardware is if the primary reason for the surgery was to try and address the soft tissue sag through a lift or resuspension procedure or even the placement of a small implant. The hardware removal then becomes a coincidental part of the procedure.
3) Other non-intraoral approaches to managing the cheek sagging may be a cheek lift procedure done through a lower eyelid incision or even fat injections to add back some volume.
4) Each management strategy to sagging after cheekbone reduction (intraoral resuspension, implant augmentation, transcutaneous lowe reyelid cheeklift and fat injections) has their own advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what is rib removal recovery like? I understand it is two to three weeks, but is that time spent in bed, or is it closer to recovery the first week, then taking it easy for two more weeks or something different? i work at a job that is not too stressful physically, but it does require that i can stand, occasionally sit and move close to normally. Thank you!
A: The answer to your question is the latter in your description. It is a progressive recovery based on increased activity starting from right after surgery with the goal of being back to all normal activities within 3 to 4 weeks after surgery. In short there are no restrictions after surgery, you do what feels comfortable. It is important to remember that you can’t hurt the rib removal site no matter what you do. You can not hurt the ribs as they have been removed unliike a rib fracture where one is trying to get the bone ends to heal. The recovery is more about muscle and soft tissue healing. So as soon as one feels more comfortable after a week or so after the surgery, it is important to get moving and stretching to help one recover faster.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, From your blog, I’ve read that weak cheekbones can contribute to midface aging. Does this mean that with zygoma reduction, there could be potentially adverse side effects in the future, even if the surgery was a deemed “a success” say a year after the surgery? Would taking out a wedge of bone from the zygoma body and sliding the zygoma arch in be a catalyst for premature aging years after the surgery?
A: The potential negative effects of cheekbone or zyoma reduction, tissue sagging, is something that will become evident 3 to 6 months after the surgery. If has not occurred by then it will not. Whether cheekbone reduction contributes to premature aging is not known. There is no medical literature that supports this potential long-term concern in a zygoma reduction surgery where no after surgery tissue sag as observed. This is not something I would worry about if one has had a successful cheekbone reduction surgery at one year after the procedure and no such soft tissue sag ha occurred.
An interesting question is why soft tissue sag occurs in sone zygoma reduction but not all of them. In fact it appears to be a relatively small occurrence but one that definitely exists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have interested in some combination of cheek and jaw implants. Although I’m not yet 100% certain which procedures I’d like to have done, I have a few brief questions regarding these surgeries.
1) For jaw implants, do you think it is necessary to have custom implants created if a male patient wants to get the sharp “flare-out” at the jaw angles? Or is there an off-the-shelf implant that can create this “look?”
2) In regards to cheek implants, do you think it is necessary to use the custom-designed male cheek implants that you have written about on your website for someone who wants the sharp “male model” look, or can standard silicone cheek implants be altered to satisfy patients with this desire?
Thank you for your time and consideration, and I look forward to talking further with you soon.
A: In answer to your cheek and jaw implants questions:
1) I am not certain what the exact visual image of the ‘flared out’ jaw angle look to which you refer. It may or may not be able to be done with standard jaw angle implants but that would depend on what that look is and whether your facial anatomy will even allow that to occur. Many young male patients have an unrealistic or unachievable jawline reshaping goal.
2) Without question no standard cheek implant can create the so called ‘male model’ look because they all lack the necessary posterior zygomatic arch extension to create it. Either true custom or special design cheek implant designs are needed.
Dr. Barry Eppley
Indianapolis, Indiana
