Your Questions

Q: Dr. Eppley, Orthognathic surgery is a more dangerous and time-consuming surgery than jawline augmentation and if it’s possible to have an ideal aesthetic jaw without going through the more complicated surgery, that would be nice. I do have an overbite but I was under the impression (although this may be wrong) that it could be corrected/compensated for with just braces/invisalign attachments and bands without surgery. I’ve never had any pain or other functional issues from my jaw alignment, so it’s mostly an aesthetic worry.

If orthognathic surgery is the only way to get an ideal jawline and chin with my current bone structure, (and perhaps getting implants afterwards) then I’ll do it, otherwise getting just a wraparound jawline implant would be ideal. I’ve looked at before/after pictures of jawline and chin implants and it seems as though there’s a limit for how much projection can be added, and I’d also like a natural look. 

Is there any way I could get a consult with my pictures to see what my projected outcome would be with just jawline implants? Are jawline implants never recommended if there’s any overbite?

Thank you.

A: You have thus answered the question about the need for orthognathic surgery…it is not for you as your primary problem is the aesthetics of the jawline and not its function. That is good because orthognathic surgery in most cases can not approximate what a custom jawline implant can do.

You are, however, inaccurate about the limits of a custom jawline implants. The aesthetic risk with their use is far and away that they can easily be created too big rather than being too small.

I would need to see your facial pictures as well as have an idea as to what your jawline goals are to answer the question of whether a custom jawline implant would be aesthetically effective for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m an out of town patient looking to surgically enhance my jawline. I’m not sure if a wraparound custom jawline implant or even a genioplasty would be enough to have an aesthetic jawline and chin or if I should be pursuing a bilateral sagittal split ramps osteotomy (BSSO) or other orthognathic surgery. Is there any way I could see an approximation of what my jawline would look like with these augmentations and/or get a professional opinion?

A: The answer to your question about orthognathic surgery vs. jawline bone augmentation is fairly simple…orthognathic surgery is only indicated when you have a malocclusion. If you don’t a bite issue that needs to be corrected then only jawline augmentation will work to achieve it. The most effective form of jawline augmentation, if it is more than just a chin issue, is a custom jawline implant. In general orthognathic surgery and custom jawline implants are not equivalent procedures, they have different jawline effects. But orthognathic surgery should never be considered a jawline enhancement procedure even if it can create some greater chin prominence. But it certainly does not improve the shape or size of the jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had custom jawline and cheek implants placed about five weeks ago. I have noticed some asymmetry of my cheeks and chin although my doctor said the implants are positioned perfectly. How soon would you recommend to revise it and how can I tell the exact location of the implants? I am wondering if the asymmetry of the chin is due to the lack of any screws used to secure it.

A: In answer to your custom jawline and cheek implant questions:

1) First and foremost every patient needs to wait until three months after the original surgery before ever doing a revision. It takes a full three months for all the tissues to settle and you want to give the tissues to to recover. Too early intervention may result in an incision that does not heal so well the next time.

2) If you want to know the precise location of your implants, and not guess about it, get a 3D CT scan. That will end all the speculation about it. It will provide unequivocal visual assessment of their placement.

3) As for your chin I usually place two screws to prevent rotation. But I defer to #2 above which will answer the implant positioning questions, screw location etc.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been considering facelift surgery for two years. I have done extensive research and have had consultations with local doctors. While I think I need both a mini facelift and neck lift, I am very uncomfortable/scared to do both at one time. I am a 57 year old female and honestly believe that I look 65 due to a lifetime of sun exposure. My thought of starting with a neck lift is that it will give me an introduction to facial surgery and help to relieve my angst of cosmetic surgery. I would love to have your thoughts. (is the neck lift the right procedure for me)? Thank you.

A: I believe you are confusing several ‘facelift’ terms and procedures. Technically a traditional facelift affects the lower face and neck and is best known as a jowl-neck lift. (this is what you are calling a ‘necklift’) This is the foundational procedure in the treatment of facial aging/facial sagging and is absolutely what you should do as the first and most basic procedure. This will help immensely by cleaning up the neck sagging as well as the jowls along the jawline.

FYI a minifacelift is a watered down limited form of a lower facelift that is not appropriate for you. It is indicated for younger patients with more limited facial aging issues or as a secondary procedure years after a primary facelift

Because you also have some midface sag (and central facial hollowing/gauntness) I believe term you are referring to is a midface lift…not a mini facelift. You have multiple options here as this requires some additional work from that of the lower facelift. You could defer it to later you or you could treat it at the same time with either a midface lift or more simple malar-submalar implants. (which create the same effect as a more extended midface lift) The timing and technique to treat it can be debated and each approach and technique as their own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old and have a very low-riding scrotum. I am wondering if you have operated on someone my age before and if you are able to perform a scrotal reduction procedure.  Also why do you think that my scrotum hangs so low, could it be a sign of a connective tissue disorder? Thank you.

A: Thank you for your inquiry. Scrotal reductions are typically done in older men who develop sagging due to age and gravity and in some younger patients who can develop a scrotal sag after large amounts of weight loss. While these are the typical patients that have scrotal reduction, the surgery can be performed on any patient regardless of age that has a scrotal sag and desires a scrotal lift. While I can not answer the question why your scrotum hangs so low, it is unlikely it would be a connective tissue disorder as this would affect other bodily areas as well and not be just isolated to the scrotum only. Most likely it is just your natural anatomy and does not represent a deformity other than its aesthetic appearance. But a scrotal lift can be successfully performed on a a very young male.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone augmentation. Last year I had a hairline lowering procedure. Apart from some minor shock loss, the surgery went well. I had planned to have additional hair transplants to round out my hairline in the next six months. But I have been researching brow bone augmentation and it appears that the incision is usually near the hairline. I would like to consult with you about the feasibility of a 5mm brow bone augmentation. My ideal augmentation would add 5mm projection at the outer corners of my eyebrows and gradually slope towards 0mm projection as it approaches the center of the brow bone. Complicating all this is some asymmetry–my right eyebrow is higher than the left, and the eyelid on that side is more prominent, although I cannot tell if this asymmetry is due to the underlying bone. 

If I am a candidate for augmentation, it appears to me that it would be optimal to have the augmentation first, and the transplants second, in order to conceal the scar. Would love to hear your thoughts on this.

A: Thank you for your inquiry and sending your pictures. You are precisely correct in that if your were to do brow augmentation it should be done before the hair transplants as the hairline incision would be used for access to the brows. For the sake of shape precision and with the underlying brow asymmetry, the best approach would be a custom brow bone implant made from a 3D CT scan. That is the best method to ensure the desired implant dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation surgery with an implant. I don’t know if I may need a scalp expansion first or not. I think a little less skull augmentationresult will be OK for me. How is a scalp expansion done by the way? 

Would you tell me about how the procedure is done? Where will the incision be and how big will it be? Are there any possibility that I will get loose hair where the scar is made? Are there any possible complications with his surgery? How will the recovery be?

Thank you again.

A: A scalp expansion is done by the placement of a scalp tissue expander under the scalp. It is then slowly inflated over 6 weeks in preparation for the second stage placement of the skull augmentation implant.

A scalp incision of about 9 cms is made across the top of the head near the crown area to make the pocket and place the implant. The incision nor the underlying implant will affect hair growth. There will be a resultant fine line scar but it heals very well and usually is barely detectable.

Like any other implants the body there is always the risk of infection, but the good blood supply of the scalp and skull bone makes it a very low risk. Having done hundreds of skull implants. I have yet to see an infection. (this does not make it impossible however)

Recovery is usually much quicker than one would think since it is just an implant in top of the head. There are no after surgery restrictions. Most of the swelling is gone in 10 to 4 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw you on Real Self answer questions regarding to cheekbone reduction complication treatments. 

I had my cheekbone reduced and very unhappy with the results. If i was to attempt to reposition the cheekbones to the original anatomical position would that require a coronal incision across the scalp? Or is there a less invasive method? If i choose to bypss all that and choose cheek implants, would that help with midface sag or do i still need a coronal incision to lift the muscles back up? or would a SMAS  facelift suffice? Thank you.

A: Thank you for your inquiry. Reversal of cheekbone reduction osteotomies are done the same way the original operation was performed…which I assume intraorally for the anterior cheek osteotomy and a small preauricular skin incision for the posterior arch osteotomy. (which is how I do them) I would need to see x-rays, however, to see how yours were done. But most certainly you would never do a coronal approach to reverse it from above. (While effective it would not be worth the tradeoff of that operation for it) 

Alternative approaches are to use an implant to create some soft tissue cheek lift. A facelift helps with any sag along the jawline but less so of the cheeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in multiple facial reshaping surgeries for my nose, cheeks and jawline. I have attached my pictures with morphs of what I want to achieve. I want to see off these type of results are possible.

A: Thank you for sending your picture and providing a detailed description of your facial reshaping goals. To summarize that list it includes the following: rhinoplasty, cheek and jaw angle implants and chin reshaping. The rhinoplasty is straightforward as you seek a more swooped or concave dorsal profile and a more refined and upturned tip. Your jaw angles need a little more definition as it is yet to be determined whether that is primarily a width or vertical lengthening cap implant but either way such implants would come from preformed standard styles and sizes. The cheek augmentation, as defined by the outcome you have drawn, does not come in any preformed style that fits that exact shape. But it is a design that goes back along the arch from the main body of the cheek and I have some special design styles that would work. You appear to want the chin vertically reduced but I not clear about the other shape change. (narrowing?)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know how to get information about secondary rhinoplasty with Dr Eppley. I have seen some approaches to correct upturned noses, and I am interested in knowing the options Dr Eppley offers.

A: Thank you for sending your pictures, x-rays and a very detailed description of your surgical history particularly as it relates to your prior rhinoplasty. Your prior nasal concern, and the most difficult challenge to correct, is that of the over rotated nasal tip. There are two fundamental approaches to driving down the tip of the nose, 1) stack caritlage grafts on the infralobular side of the tip while reducing tip length (push the tip skin down using the existing nasal cartilage as the floor) or 2) place an interpositional graft between the septum and the nasal tip to push it down from behind it. Each approach has its merits but with either technique the key is having good cartilage with enough rigidity to create the effect. I will assume that your septal cartilage has been harvested for the original rhinoplasty as well as having one ear harvested as well. This limits your cartilage donor options to either rib cartilage or cadaveric cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to get an injected skull implant revision, but I have a few concerns/questions.

1) You mentioned removing and replacing the implant as being the preferred method. What size scalp incision would that take? What material would you use to replace it?

2) You recommended not doing the burring only. Is it because of the potential unfavorable results or is it another reason? How long would that incision be?

I’m nervous to go under the knife again after the results of the last skull implant procedure. My main concern is the resulting scar length and width.

Thanks

A: While I don’t recall what the material that was injected (t would be very helpful to see the operative note from that procedure), I assume it was bone cement or PMMA. The ability to give it a better contour by contouring what is already there is nil. That is why it is better to remove and replace it by:

1) 3 cms scalp incision over it. Such scalp scars heal really well with minimal width. The aesthetic result of such scalp scars is all about how they made and then closed with protection of the hair follcicles.

2) Probably replace with new bone cement because it can be better contoured under direct vision. But this would depend on the size of the defect of which is not known to me yet.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested ins time head augmentation. I have a generally small head and wonder if it is possible to add some volume to the skull to make it a bit higher and wider. Have you performed this kind of surgery before? How is it done? Are there any possible complications or dangers with this surgery?

A: Thank you for sending your pictures and the morphed head shape images. What they show is a crown and side of the head augmentation effect. A custom skull implant can certainly be designed to achieve that type of head shape change. This is not the question. The only question is whether your scalp will stretch enough in a single procedure to accommodate such an implant. The amount of augmentation you seek is right on the edge of whether your scalp will allow for the implant to be placed and a competent scalp closure achieved over it. Generally thin Caucasian females have the least amount of scalp flexibility due to its thinness. In other words do you need a first stage scalp expansion or not? If you can accept a little less of a result then you would not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have concerns about chin implant bone erosion. I have noticed the bone holding my lower teeth appear to be eroding somewhat from an overlying Gortex chin implant. Can you remove it and put something in the correct place that will not erode bone.

A: I would like to see the x-rays from which you have determined the occurrence of any bone erosion from an overlying chin implant. What sort of symptoms are you experiencing from it? Almost all chin implants will develop some natural passive settling into the bone which is often interpreted as ‘chin implant bone erosion’. That phenomenon becomes most apparent when the chin implants sits high, above the thicker basal bone of the chin and on the thinner alveolar bone closer to the tooth roots. But this is not a true progressive active inflammatory condition.

That being said it is clear that you also have does aesthetic concerns about the location of the chin implant and maybe even its outward aesthetic augmentation effects. The existing implant can be removed and a new chin implant placed lower over the basal bone. But all types of chin implant materials (silicone, Medpor, Goretex and Mersilene) can develop this passive bone remodeling effect. I have seen it radiographically as well as clinically during chin implant replacements and adjustments. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need a question answered about facial fat atrophy prevention. I am 29 years old and have been using tretinoin cream (0.05%) every evening and sunscreen with SPF 30 (Mexoryl) every morning since the age of 20.

Therefore my skin has visually not aged since I was 20 years old and looks even better, firmer and tighter.I would also like to prevent the age-related loss of facial fatty tissue. As a sunscreen from inside, I also eat 2 tablespoons of tomato paste together with olive oil every day, because lycopene is a powerful antioxidant. Now I have read that lycopene also accumulates very strongly in the fatty tissue.

Could lycopene prevent or slow down the age-related loss of facial fatty tissue, because of its antioxidant effect? Could it also protect the connective tissue of the deeper tissue layers of the face? What do you think? Thanks in advance for your reply!

A: I think there is no scientific evidence that taking or consuming lycopene is a useful compound for facial fat atrophy prevention. Such an approach is a theoretical one but no clinical or animal trial has ever proven it. But there is n harm in its ingestion so I would continue to make it as it appears to make you feel more comfortable in doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My questions are concerning what skull reshaping procedures could be combined under a single operation. My skull deformity isn’t localized, the result of untreated craniosynostosis. I have the typical trigonocephalic skull, which is narrow in the front, and wide and tall in the back.

I believe that for an augmentation covering such a large area of the forehead, a preformed silastic implant is preferable.

1. Can a silastic implant be combined with burring of the forehead? How does that affect the printing of the implant, since you’re modifying the bony contours the implant is based on?

2. Can the posterior temporalis muscle be resected in the same operation?

3. Can the saggital ridge be burred down a couple millimeters in the same operation?

4. Would it make more sense to make a number of smaller incisions versus a large coronal incision when combining procedures?

The contours of my skull cause great psychological distress, so I have no particular concern for scarring.

Thank you.

A: Thank you for your inquiry. In answer to your questions:

1) Skull implants combined with skull bone reductions are common. The bone reductions are factored into the implant design process.

2) The posterior temporals muscle can be removed in the same operation as #1.

3) The sagittal ridge can be burred at the sam time as #1 and #2.

4) If the hair density and hairline permit, it is always ideal to use a coronal incision. But I regularly seek how to limit the scalp incision as much as possible in skull reshaping surgery. I can certainly envision for #1 to #3 above that a complete coronal incision would not be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in your custom jawline wraparound insert, largely for the sake of vertical facial lengthening but have a few questions. First, what is the maximum vertical height that can be added through these implants, would anything in the 15-18mm range be completely out of the question? What is the recovery time for this procedure, generally?

A: In theory a jawline implant that provides vertical lengthening (inferior border elongation) can be designed to any length. But the limiting factor is the ability for the soft tissue of the chin to stretch down and the masseter muscle in the back to similarly do so without disruption of the masseteric sling. As a general rule 10mms or so is what these tissues will usually tolerate for alloplastic vertical facial lengthening.

Recovery from a custom jawline implant is largely about swelling and it takes a good 2 to 3 weeks for a significant part of the swelling to go down to look more ‘normal’. Although a full resolution of the swelling and a completely normal appearance to occur will take a full six weeks after surgery. Tyoucally the complete resolution of the facial swelling takes much longer than most patients think.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was diagnosed Linear Scleroderma at the age of 7 years old. Due to this disease it has created a bald spot that I am able to cover with my hair on the top on my head. This bald spot is about two inches wide and five inches long. I also have a dent on the left side of my forehead. This is something that I have always wanted taken care of and just to look and feel normal. I am able to come to a face to face consultation or I can do a virtual one as well.

A: Thank you for sending your pictures. You have a classic case of linear scleroderma that involves the first division of the trigeminal nerve. Thus its effects go from the eyebrow straight up in the scalp along the pathway of the nerve involving atrophy of bone and soft tissue.. I would treat your case with a two-stage approach that includes the following:

1st Stage = Placement of two scalp tissue expanders on each side of the wide scalp scar with fat injection grafting to the foreheads/brow.

2nd Stage (6 weeks later) – Removal of tissue expanders with excision of scalp scar and advancement of hair-bearing scalp flaps to cover it and placement of custom forehead-brow bone implant

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eye asymmetry surgery. I was born with congenital torticollis. The torticollis was not caught early and resulted in me sleeping exclusively on my tummy with the left side of my head smushed against the mattress as a newborn/infant which resulted in the asymmetry in my face. My head/neck as a baby would not turn to the left due to the torticollis. I had a plastic surgery consult when I was 12 and we decided to correct the torticollis (by releasing my left side sternoclatomastoid muscle) but the other facial reconstruction freaked me out too much. At that time, it involved significant intracranial work and taking bone from my ribs and raising eyeball …in short it was overwhelming to a 12 year old so I told my parents I didn’t want to do it.

I now feel that with age my right side has become too bulky and my left side seems to be sinking in more which is causing the eye asymmetry to be more noticable.  When I was younger, you didn’t notice as much, as the baby fat was more evenly distributed in my face.  

When I saw your case study with the Hydroxyapatite cement, it gave me hope that there might be a less invasive fix to even out my eyes?

A: Thank you for sending your pictures and detailing your history. The treatment of eye asymmetry or vertical orbital dystopia (VOD) that has a 5mm or less discrepancy can be done through orbital floor/rim augmentation as well as some surrounding ancillary procedures of the eyelid, cheek and brow bone. (eye asymmetry surgery) A 3D CT scan is very useful in determining the vertical discrepancy and how much orbital floor augmentation would be needed and/or can be done. In many cases of VOD my preferred method is a custom designed implant that covers the orbital floor crosses over the infraorbital rim and onto the cheek…all orbitofacial skeletal areas that are deficient in all cases of VOD.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a transgender male to female who is investigating how best to further reduce the masculinity of my face. Overall, my face has a width problem with wide temporal muscles, laterally protruding cheekbones, and a wide chin. I spoke with you on the phone a few months ago about the temporal reduction which I still plan on doing with you later this year.

However, I am also concerned about my chin. I had a chin reduction with another surgeon, and he used a submental burring approach. This was effective in making my chin more rounded and less square, but it’s still a wide chin. And considering the fact that I am looking into doing temporal width reduction and cheekbone reduction one day with you, I realize that if this wide chin issue isn’t dealt with it will look even more disproportionate.

1) What do you think is the best way to deal with a wide chin? Would I be correct that a wedge osteotomy to remove a center wedge of bone and pushing the two sides together would create the narrowed chin shape that I desire?

2) Can temporal width reduction, cheekbone reduction, and a chin reduction procedure all be done together?

Thank you!

A: I am not sure why with a submental chin burring technique you did not get enough width reduction. That technique can create as much narrowing as an intraoral wedge reduction chin osteotomy. They are just two different ways to achieve the same result. I suspect your surgeon was simply not aggressive enough and may not have been comfortable doing so. A wide resection of the side of the chin can definitely make it more narrow and probably more so than an intramural midlne wedge osteotomy.

Temporal, cheek and chin reduction surgeries can all be done together and would make the most sense to do so given the overall objective of a total facial narrowing effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Pectus Excavatum implant surgery over twenty years decades and have had any problems with it and have been happy with the results. This past fall I got struck on my chest on the right edge of the implant. Quite quickly a bulge appeared but there was no skin break. I saw my doctor within a few days later and he drained the surface fluid. However fluid had formed under the implant. My doctor referred me to an interventional radiologist whom aspirated the fluid under the implant using ultrasound. The fluid returned. I have had 3 subsequent aspirations.I have had a CT scan. At this point what are my options. Can the implant be saved?

A: Thank you for you detailed description of your history and recent event in regards to your pectus excavatum implant. At the least your issue requires an open procedure to clean up the pocket, resterilize the implant and place a drain. While this is not a guarantee that the implant can be salvaged, this would be the best approach to try and do so. Because the implant has done so well over many years I would be optimistic that it can eb salvaged from this traumatic event.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have  a deep vertical groove in the area between my eyebrows. I have tried Botox injections but it didn’t do a thing. I even tried injectable fillers but it also didn’t improve it. What do you think about a glabellar implant to help push it out and make it smoother? I have attached some pictures which show how deep the groove is between my eyes.

A: Thank you for sending your pictures. What you have is a very deep glabellar furrow on the left side as well as other less deep wrinkles lines on the right side. When a glabellar furrow gets this deep it will not respond to any neuromodulating agent (Botox) or injectable filler. It must be treated like a depressed scar, which in many ways it is without the traumatic injury history. In these deep glabellar furrows, which occur more frequently in men, I treat them directly by furrow excision, glabellar implant augmentation down at the bone level, muscle release and excision and geometric skin closure. This comprehensive approach to deep glabellar furrows is the most effective strategy that I have found to be effective. It is the only way to change a deep V-shaped skin and soft tissue groove betwee the eyes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want like to have a sliding genioplasty to bring the chin forward to balance my facial profile. I also thought of another option to have a solid hydroxyapatite chin implant (not paste) with hydroxyapatite screws, is this possible? I have some questions.

-How long does a sliding genioplasty take to perform?

-How much projection can be achieved with a genioplasty?

-I understand that it is not necessary, but I want to remove the metal plates some time down the line and have any irregularities smoothed out if there are any.

-Can bone removed from my ridge reduction and used for a bone graft to place where there would otherwise be a step to add better form to the new chin?

A: In answer to your sliding genioplasty questions:

1) It takes one hour to perform a sliding genioplasty.

2) How much horizontal projection can be achieved depends on the thickness of the chin bone. But, on average, 10mm to 12mms can be obtained if not more in a male.

3) You can have the metal plate and screws removed 6 months after the surgery when the bone is well healed.

4) Bone grafts from the tibia can be used to fill in the step of your sliding genoplasty if desired. This would be a good use of ‘recycling’ of the removed bone from the tibia.

5) Making a chin implant out of hydroxyapatite is not possible as no U.S. manufacturer will do so. But even if it were possible, such a chin implant would be fairly brittle and hard to place due to its stiffness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get a chin reduction, I have lots of soft tissue and bone that sticks forwards when I smile. However when I don’t smile my side profile looks slightly weak due to the way the soft tissue sits. I also have a small overbite.

My face structure becomes very witch like when I smile. I am hoping to achieve a more symmetrical v-line chin, I quite like the shape of my chin from the front but I would like to remove the part that sticks forwards. 

I have a very petite face and don’t really want to loose much vertical length, it’s more the way it sticks forwards from the side that bothers me. 

My face is also asymmetrical, I have TMJ in the left side of my jaw, this side of my face is more rounder & wider than the left side of my face. 

I have attached lots of photos to give you a good idea of how my chin looks from different angles. Would a simple chin reduction be able to fix my problem? I would like to avoid implants and adjust the bone and soft tissue if possible. However I worry that reducing the bone would result in a weak side profile when not smiling as it only sticks forwards when I smile. 

I feel like my chin ruins my whole face and I would be much prettier if I could fix it. 

A: Thank you for your inquiry, detailing your objectives and sending your pictures. With a hyperdynamic chin protrusion but a weaker or more normal chin shape at rest, that makes can reduction more aesthetically precarious. Chin reduction surgery reduces soft tissue, bone or both but the most effective chin reductions remove both bone and soft tissue. But no matter what tissues are removed it will have different effects from smiling to non-smiling. If the reduction improves how it looks when smiling there is the risk it may adversely affect how it looks when not smiling. (as you have astutely mentioned) Thus it is not likely possible that any chin reduction procedure will produce the desired chin shape from any angle regardless of whether one is smiling or not. That is not a completely realistic and achievable aesthetic goal.

In hyperdynamic chin protrusions like yours some horizontal bone and width reshaping (not vertical length reduction) with a submental soft tissue excision/tuck is the likely effective approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just had some concerns regarding the silicone skull implants. The first concern I have read about are possible issues with erosion of the skull over time by the implant.The second is something about water collection within the implant over time.What are some adverse side effects that may be possible due to the use of silicone skull implants? 

A: In answer to your silicone skull implant questions:

1) Bone erosion is not an issue with skull implants. I have never seen it nor is the general concept of bone erosion around any craniofacial implant accurate. Such a phenomenon, outside of an infected implant, does not really exist. There can be passive setting of the implant into the bone by a millimeter to two common in high tension situations like chin implants, but that is a passive and self-limiting natural biologic process.The broad surface area of a skull implant does not even allow that to occur.

2) I have never heard of ‘water collection’ around any craniofacial implant. There can be small serous fluid collections right after surgery but they are limited and self-absorbing and are common in any surgical implant site.

3) I have never seen any adverse effects with any skull implant material. The issues are always the same regardless of the material…how well did the shape of the implant achieve the desired aesthetic effects.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you also use Allofill? And if so, what experiences did you make with it?After two cheekbone augmentations with Medpor implants (after the first augmentation with Medopr Malar Shape implants, another Medpor implant was placed over the lateral part of the cheekbones, which was carved from a Medpor block), one can now see a transition between the first and the lateral cheekbone implants. Is Allofill suitable for correcting this transition of the cheekbones? Is the result really permanent and does the replenished amount correspond to the new tissue growth?

A: In treating facial implant edging or transition areas, I would not recommend Allofill injections for it. There is little clinical evidence yet that its effects are permanent. While there is no harm in dong so, its effects do not offer proven persistence beyond other types of synthetic fillers or fat injections. Other options include an overlay of ePTFE sheeting which would be better and more assured of a long-term solution mask the transition areas. Your case illustrates the potential pitfalls of having two implants right next to or over each other. Some palpable and even visible implant transitions areas can frequently result.

Dr. Barry Eppley

Indianapolis, Indian

Q: Dr. Eppley, I am very interested in the tear drop breast augmentation procedure. I am currently a small B and would like a small change to maybe a full C. I really want a natural look and a small implant so that my breasts still look natural and do not stick off my chest or look high up, so i am interested in the teardrop shape implant.

I also am interested in a chin reduction since mine is very long and prominent and protrudes significantly when I smile. I would like it to be shorter and narrower/ pointier. Another thing is that my face is rather narrow and long and I desire a rounder face and more full look, what procedures could help with this? I want my cheeks to be wider in diameter if that makes sense? thanks!

A: While you have mentioned tear drop implants for a natural look in breast augmentation, be aware that the same effect can likely be achieved using low profile round implants which often create the same look. In the upright position tear drop and low profile round implants have been shown to look the same. I mention only because the cost of tear drop breast augmentation is higher.

Otherwise a submental approach to your chin reduction is the best method to address both  bone and soft tissue excesses.

The one procedure that is most effective at helping widen a face are cheeks implants. But not just any cheek implant will create that effect. It takes a special design cheek implant that specifically focuses on adding width back along the zygomatic arch.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i had a few quick questions about Medpor chin implant removal in advance so that I can speak with you with a clearer understanding of surgical possibilities next week.

1) If an implant is placed via an intra-oral incision, can it still be accessed via a sub-mental one?

2) Instead of removing a Medpor implant and replacing it with a different shape or size, can it be edited / cut down whilst still attached to the chin?

3) In my case my lip function is perfect. However the position of the lip is not correct; it feels like my lip is being pulled downwards by the weight of my mentalis muscle which (i believe) was not reattached successfully. Can the reattachment be made without further risk to the muscle-lip function?

Of course our conference call should give you a better visual idea of my situation and whether or not i have correctly identified the problems i am noticing. 

I look forward to your thoughts.

A: In answer to your Medpor chin implant removal questions:

1) A chin implant that was placed intraorally can be subsequently accessed from a submental incision.

2) It is almost never a good idea to modify a chin implant in place as the amount and type of modification is very restrictive…and thus limits what can be effectively done.

3) I doubt very highly that the mentalis muscle was not reattached properly as there is only one way to do it…it is either done or it isn’t. It is important to remember that a chin implant displaces the muscle in an unnatural way forward. Your anatomy was not made to have an implant behind it. When this natural anatomy is changed and the muscle is dragged up over an implant, particularly one that gets a lot of soft tissue adherence, the risk is that it may feel stuck or being pulled down. That is why it feels the way it does, it has nothing to do with the muscle per se and messing with the muscle is going to create more problems not less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I talked to my surgeon and he explained some of the difficulties that may come of infraorbital implant removal. You see I had it done together with a SOOF lift and lower eyelid retraction surgery and so removing the implant might compromise the support of the lower eyelid area. I wanted to ask some tentative questions in case I go ahead with removal:

-How would you handle the risk of undoing the lower eyelid surgery I’ve had done and prevent any adverse effects that might require further surgery in the future?

-Is my surgical case very uncommon or something you have experienced before?

-If I am unlikely to return completely to my previous look, what type of change is reasonable to expect, or perhaps that’s impossible to say?

At one month after surgery there is still some swelling but I believe I am correct that the sharp edges I see below my eyes are indeed the implant as it’s quite palpable. Just to be sure though I’ve attached two recent pictures and two of my face before surgery if you have the time perhaps you could take a quick look and tell me if there is any hope at all that this issue will resolve itself?

You correctly assumed the incision method and the size of the implants should be relatively small but they appear quite prominent, maybe because of the thin skin in the area. I forgot to mention that these are “extended infra-orbital implants” so they are longer than is usual which I now think was a mistake.

A: Thank you for sending your pictures. The basic concept is that you are going to have to undo everything that was done to do infraorbital implant removal. In addition there is little guarantee that you will return to your preoperative eyelid shape state.

These two concepts should give you great pause at this early point after surgery in having a reversal/removal procedure. Any implant edges that you feel now with time will not likely become less. They over time indeed may become more prominent. But no one can predict how you will feel about it months from now…which is the time one should allow for full healing to occur.

The ‘mistake’ that is often made in infraorbital implants is using preformed implants. The tissues are too thin and the implants are standard shapes, a set up for implant edge capability and potential visibility. This is what I almost always use custom implants or ePTFE sheeting which allows for very feathered implant edges and a better blending into the surrounding bone margins.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, We spoke several months ago about my slipped rib and the possibility of having rib removal surgery for it. I’ve tried to manage things conservatively but my pain has not improved. In weighing the risks-benefits of an eleventh and twelfth rib resection, one of my concerns is the risk of a flank hernia. As you know, there is very little data on this in the medical literature. Most of what I’ve been able to dig up is in the context of rib resection to facilitate kidney removal. I would imagine that based on your extensive experience resecting ribs, you probably have more data than anyone on the potential risk of a flank hernia. In short, with the obvious disclaimer that you’re not giving me any formal medical advice, I would appreciate hearing your thoughts on the risk of a potential flank hernia from a resection of the eleventh and twelfth ribs. Thanks again for all your help. I really appreciate the time you’ve taken to answer my questions.

A: The simple answer to your rib resection question is that I have never seen such a complication or would I ever anticipate one. With preservation of the medial periosteal layer I can not imagine this occurring. This is quite different than opening up the peritoneal space for kidney removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came to your office back in August of last year. I had a temporal artery ligation on the right side of my head. The procedure went very well and is still holding up fine. I am planning to come back in the spring or summer of this year to have the left side done. My question for you is that I have some early stage pre-cancer spots on my head. This is from the result of being bald and exposed to the sun for most of my life. My Dermatologist has prescribed 5% Fluorouracil Cream to spread on my head twice a day for two weeks. This should help or take care of that problem. I just want to make sure that this cream will not affect the ligations when the outer skin peels off to replace the new skin. Thank You in advance for answering my question and I look forward to visiting your office again. Thanks.

A: Thanks for the followup and glad to hear that a good result has been obtained and is being maintained. 5FU is a strong chemical peeling agent that is commonly used in the treatment of superficial skin cancers. Its use will not interfere with the performance results obtained from a temporal artery ligation procedure.

Dr. Barry Eppley

Indianapolis, Indiana