Your Questions

Q: Dr. Eppley, I am interested in forehead augmentation to create a wider, more masculine forehead with a custom implant. My forehead is very narrow and convex for a male. From my research I’ve come to realise that my limiting factor is the positioning of my anterior temporal lines. They are too close to the centre of my forehead. I know that designing an implant that extends beyond these lines may be aesthetically problematic. Is it possible to design an implant that covers both the temporal and forehead areas to sidestep this issue? How important is the ‘crossing the anterior temporal lines’ issue? Is it a completely preclusive one, or may the patient insist on going through with widening the forehead regardless?

A:When it comes to forehead augmentation, crossing the temporal lines with the traditional use of bone cements was always problematic because it was impossible to get a smooth transition into the the temporalis muscle area. (which is what lies on the outside of the temporal lines) But with the use of today’s custom forehead implants made from a 3D CT scan, where the edges can be made very smooth, such transition concerns are now minimized. This creating a wider or more lateral anterior temporal line demarcation can now be reliable done in an aesthetic manner.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jawline reshaping. I had a chin implant two years ago but it did not help me with the desired look which is not my chin but a weak jawline. I have since tried Kybella but had minimal results. I think jawline implants would possibly address the issues I have with my jawline area. I attached some pictures I pointed to the areas that bug me the most. The fourth pic is how I would like my face to look more tight and defined. I would love to know your thoughts.

A: Thank you for sending your pictures to illustrate your concerns. You have several different jawline reshaping approaches to consider for an improved jawline.

1) Jowl Tuckup procedure. What you are illustrating with your finger is jowling, the development of a soft tissue sag in the middle of the jawline. A mini-lower facelift or jowl tuck is what really solves that soft tissue drape issue hanging off of the jawline by pulling tissues back along the jawline towards the ear.

2) A weak jawline is often perceived as a lack of defined jaw angles, which you are illustrating in one of your pictures. (technically you are illustrating both a jowl tuck and a jaw angle implant(

3) The combination of #1 and #2 is also a possibility.

Dr. Barry Eppley
Indianapolis,

Q: Dr. Eppley, I am interested in cheek implant revision. I had cheek implants put in in ten years ago by a local plastic surgeon.  I originally went to see him because I had puffy cheeks and I did not want that baby-face look, so he suggested putting in submalar-malar cheek implants. The look I was going for was not achieved as it made my face look more full instead of narrow like I told the doctor I wanted.

The left implant either shifted up or was not put in correctly which caused one side of my face to be uneven with the right.  There was also some type of nerve or muscle damage because my smile on the left side would droop down, almost like I had a stroke.  There is still a little scar tissue that has formed around the implant.

I am considering the following options to achieve the look I’ve wanted from the beginning:

Option 1:

Slightly lower the left implant so it looks even and contoured to my face, like the other side.  Have some of the fullness in my cheeks taken out by removing the fat.

Option 2:

Remove the implants and have the fat removed from the cheek area.

Option 3:

Have new implants put in and have the fat removed from the cheek area.

I know option 3 will most likely be out of range for me to afford, and option 2 will most likely leave my face looking flat and my skin sagging where the implants were.

A: Thank you for your inquiry regarding cheek implant revision  and sending your pictures of concerns. First, the concept of putting in combined malar-submalat cheek implants was never going to make your face more narrow or sculpted. They are a cheek implant style that will give you an ‘apple cheek’ effect, an area of midface augmentation that appeals to some women but very few men in my experience. Second, cheek implant asymmetry is very common as the placement of any two-sided implants in the face or body is very difficult to achieve perfect symmetry particularly through the limited access of an intraoral incision.

That being said, my comments as to your listed options:

1) While cheek implant adjustment can be done, these existing implant styles do not appear to be achieving your initial objectives. Thus adjusting the left cheek implant may improve their symmetry but would not may the overall desired look any better. Whether taking out the buccal fat would be helpful remains to be seen. This is an approach that offers the simplest and least risky choice but also one that has the least aesthetic gain.

2) Without some cheek prominence removing buccal fat would provide little if any aesthetic improvement.

3) This would offer the best chance for real change and to get you closer to your aesthetic midface goals. The key is the cheek implant styles…which was the same important issue prior to your first surgery.

Since you mentioned cost, Option #1 would definitely in my option be better than Option #2.

There is also an Option #4. Treat both existing cheek implants (as well as adjust the left cheek implant and the buccal lipectomies) by getting rid of the submalar portion of the implants which is not helping your facial aesthetic goals.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am 32 years old woman. I am interested in skull reshaping surgery because my head is very flat on top. I want to ask if PMMA is also Osteobond? How does Osteobond differ from PMMA? And is it possible for Osteobond to give toxic reactions to the body in future like 40-50 years later? Because I have read somewhere that some Osteobond in orthopedic surgery caused arythmia, blood hypertension and heart attack for old patients. And what will be the approximate price for top of the head augmentation? I will be looking forward to your reply. Thank you for your time and consideration 🙂

A: Thank you for your inquiry. PMMA is a generic name for polymethylmethacrylate, a well known material used in orthopedics as a true bone cement to hold in place joint replacements and is also used as an onlay contouring material in the skull usually under the name Cranioplast. Osteobond is one variation (copolymer) of PMMA but it is a polymethylmethacrylate material. Do not confuse what can happen when such borne cements are injected under pressure inside a long bone with applying it softly on top of the skull bone. Such bodily reactions as you have described do not occur in cranioplasty use.

That being said I have largely abandoned the use of PMMA bone cements for custom silicone skull implants which offer superior shape, smaller incisions for placement and no potential adverse effects on the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 36 year old female with a pretty flat jawline and chin. My chin is a little short face on, and from the side it’s probably in the acceptable range (and not weak). I am interested in making the lower third of my face less “flat” looking. I’ve had fillers before in my chin to elongate my facial look and I really liked it – but of course, those dissolve. My back teeth don’t occlude (the only teeth of mine that touch are the front teeth). I would love to send some pics and hear what Dr. Eppley thinks can be done about this. I am particularly interested in doing less invasive procedures (i.e., a chin implant v. a genioplasty). I look forward to hearing from you!

Kind regards,

A: Thank you for sending your pictures. You have a vertically short chin and near flat mandibular plane angle. Placing fillers in your chin looked better because it provided increased lower facial height. The correct surgery procedure to create this same effect is a vertical lengthening genioplasty. This is where the chin bone is cut and dropped down. Adding about 8mms of vertical chin height will create the right amount of vertical lower facial elongation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Pixie ear correction surgery. I had a facelift done two years ago and my earlobes have gotten longer as you can see in the attached pictures.How extensive is the corrective surgery and since I scare easily, will it take long to heal? Thank you for your time with this matter.

A: Thank you for sending your picture. Pixie ear correction surgery can be done by two different methods. The ‘simple’ method is a direct release of the earlobe from the side of the face with reshaping of the earlobe (shortening) and closure. This can be done in the office under local anesthesia. This will, however, leave a vertical scar line running below the newly shortened and reshaped earlobe.

The ‘complex’ way is to redo part of your lower facelift and get the earlobe shortened and the facial skin advanced up under it. This is the scarless way but requires a limited facelift approach under Iv sedation or general anesthesia. Whether thus would be effective would be based on his loose your facial skin is now and how much it will mobilize when undermined again. 

While most patients would like the results of the complex approach better, they really only want to undergo the simpler approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m writing you about a chin implant revision surgery. Previously I had Conform extended anatomical implant XL size and I liked it very well but I decided to get a revision and have the vertical lengthening chin implant size L and it looks monstrous on me. I had my surgery on 04/15/17, I know it is too early with the swelling, but the results I’m seeing right now scare the hell out of me and I don’t remember feeling this way, or even close, after I had the conform implant put it. I would like to have a revision ASAP and have my old implant put in because I don’t want this one to stretch my tissue even further. I saw you once in the past for an unrelated complaint. I was wondering if I can come see you again at your earliest convenience because this issue is causing me a lot of distress. Thank you.

A: I would suggest that you get a chin implant revision as soon as you can. Given your prior chin implant history you are well aware of how the recovery process looks. And of it looks too big right now then it is and will be until you change it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have suffered with acne for around 10 years and the aftermath has left me with some facial and body scarring. I took a course of Accutane around 2 years ago which cleared the acne. I also have two facial scars from childhood injuries, both of which required stitches. I’ve heard some amazing things about the abilities of Acell. I have a question about Acell and I’m also reaching out to you for help. I’m aware that Acell can be used for scar revision. But Can Acell be used to treat acne scarring after some kind of abrasion like laser resurfacing? I’m really desperate to resolve my scar problems and I’m willing to be experimental.

A: Acell is typically used as an interpositional or internal graft material to aid healing in surgically closed wounds. It is not traditionally used as an onlay or topical wound healing agent although it can be done so. Whether it would have benefits to lessen scarring as an immediate topical agent placed on laser resurfaced facial skin is not known. I have not used it in such a fashion nor do I know of any others that have. At least it would not be harmful or impede wound healing in any way. Whether it will improve the results of laser resurfacing of acne scars can only be conjectured. But it does have theoretical appeal in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interrested in chin augmentation but I already have a deep labiomental fold and weak chin. If I move my chin forward with it would look very unusual. I can’t have my chin moved vertically downward because i already have a long face, and I cant afford to make it any longer. Is there a way to move the chin 1 cm forward while at the same time addressing the really deep lm fold?  Fillers/Fat graft maybe before/after the chin surgery? Thank you for your guidance. 

A: Two approaches to help lessen the depth of the labiomental fold in a chin augmentation procedure:

1) Graft the step-off in the sliding genioplasty during the initial procedure and

2) Place a dermal-fat graft between the muscle and the skin through an intraoral approach secondarily if needed.

The deep labiomental fold poses a challenge in chin augmentation. Grafting the step-off in a sliding genioplasty is helpful but not a complete solution. I have found that the best treatment long term is to perform a secondary intraoral release and place a dermal-fat graft. This pushes out the fold most effectively because it provides a direct approach to it as the level just under the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been following you for quite a long time and am impressed by the exhaustive list of procedures you are capable of performing well.

I am a 25 year old male who is interested in increasing all three of the bony dimensions of my face for a more masculine and attractive appearance. I have a decent base to start with and have already undergone eye reshaping procedures (bilateral canthoplasty, lower lid retraction, tear trough implants, and orbital decompression). For this reason I am very happy with the shape of my eyes and am concerned that any extensive procedures I am about to undertake may remodel them.

Anyway, I would be very interested in knowing whether you’d be able to widen, project forward, and increase the height of my facial skeleton to my happiness with implants/cement/genioplasty/fat alone, or whether any of the procedures I’m going to undertake can be done better with an osteotomy. 

I would like to explore getting with you a jaw implant that lowers the ramus quite a bit, flares out the gonion, and lowers/flares the entire jawline, with a genioplasty (or combination of genioplasty and implant, deferring to your expertise when we meet) that lowers the chin, expands its width slightly, and gives anterior projection. Is this capable of changing my mandibular angle? How about my gonial angle?

Furthermore, I will potentially be pursuing a zygomatic sandwich osteotomy and zygomatic arch osteotomy where for the latter procedure 2/3rds of the arch will be moved laterally. Are either of these procedures capable of being pursued with just implants? I am hoping for 4 mm of lateral facial width at the arch (a total of 8 mm). Perhaps the arch is better done with an implant as well? 

This is where it gets tricky. I would also like my zygoma and infraorbital rim (along with the orbital floor on the left eye for asymmetry) raised. I know the orbital floor can be done with an implant, but I’m wondering whether there is a way to give the appearance of a zygoma and infraorbital rim that is higher on the face and closer to the orbit?

Afterwards I’d pursue a midface lift to redrape the soft tissue that is already slightly saggy and bloated looking on my face, and an extended midface implant not already covering areas of the face (mostly the maxilla and lateral orbital rim). I’d pursue skin tightening, buccal and perioral fat removal, micro lipo, etc in case my lower cheek still looks bloated or chubby.

Lastly, an extended implant, cement, or fat (deferring to you on this) for the temporal/forehead region to also widen this part in line with the rest of the face. Whether the onlay needs to go as high as the parietal bone to give a normal skull shape is up to your experience, though I’d expect it does.

There are two additional procedures I’m exploring that id like to ask about. 1: Is there a way to increase the width of my supraorbital ridge, perhaps by also placing an implant or cement on the very lateral side of my ridge/forehead? 2: is there any way to widen the maxilla above the lefort 1 line, or at least give the illusion of a wide maxilla (I don’t want to have wide facial width with a narrow maxilla as it may look funny). Perhaps by creating some kind of illusion with the way the implant is placed on the cheekbone?

I suspect I need one surgeon to carry out these procedures so my extensive surgical plan can be analyzed and understood accordingly. Please let me know what you think. Thank you very much.

A: All of the facial procedures that you have described can be done with various forms and designs of facial implants. This includes the zygomatic arch widening which can be done simply and effectively with an implant vs am osteotomy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m not familiar with the mucosal smile line lift. Is it necessary to do both a subnasal lip lift or can you just do the mucosal smile line lift only?  This would be the goal in picture form. 

A: The smile line lift procedure is really an upper lip reduction where the lowest portion of the upper lip margin mucosa is removed. It will create more tooth show but will also make the upper lip look smaller. Conversely a subnasal lip lift creates more tooth show but makes the central upper lip look bigger. Depending upon what you want to achieve the combination of a subnasal lip lift and a smile line lift will create the most upper tooth show but will also not change the size of the upper lip. (or may even make it look bigger)

The smile line lift is rarely performed alone and is often part of other combined lip reshaping procedures as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am asking to you about a procedure that you probably do not get asked about. So basically there is a plastic surgeon who advertises “shoulder widening” using the patients own bone. The technique is described as making an osteotomy in the bone and inserting a permanent titanium plate to stabilize the bone. I originally thought this was like limb lengthening but he seems to place a bone graft from another body part so it cannot be distraction osteogenesis correct? The technique involves a small incision in the skin overlying the clavicle; creation of an osteotomy (cut in the bone) and insertion of bone grafting material is performed, followed by fixation with a permanent titanium plate. Widening of the shoulders of up to one inch can be achieved.”

Would you ever preform something like this? I am interested in this and have done research on this. I understand even shoulder-shortening is possible. I saw someone ask you a shoulder shortening procedure question a few days ago so I just thought it was worth a shot to get your opinion and see if you would preform, thank you.

A: What you are referring to is a clavicular osteotomy with the placement of a bone graft and plate fixation for stabilization. You are correct that this is not distraction osteogenesis but a straightforward osteotomy and bone grafting. While I have never performed it I can not speak as to its effectiveness. But it would seem that it would provide a shoulder widening effect whose increase would be the separation of the bone ends and the width of the interpositional grafts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 42 year old male with very strong master muscles (on the right side of my face) that gives it an asymmetrical look. 

I have tried talking to several renowned plastic surgeons, but I am told that 

1. (I had a facelift in 2014) – since I am pretty skinny, another facelift is not an option/won’t help, 

2. Botox too won’t help much due to how big and strong the masseter muscle is, and 

3. Surgery might be the only option 

Then I came across your electro-cauterization method of masseter muscle reduction.

One more question please, I understand that more than one sessions might be needed, so what is the cost of one such treatment?

A: I have never heard that Botox can not make an impact on masseter muscle reduction. While it may not be permanent, I have never seen it not work and provide some size reduction of the muscle. I would first get Botox done and then only consider surgical reduction thereafter. Electrocautery reduction is a surgical method for masseter muscle reduction that is done through an intraoral approach. The inside surface of the muscle is treated. This causes some muscle fiver necrosis which ultimately accounts for a reduction in the size of the muscle.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Thank you for your reply. I am interested in modifying my cheeks and chin. My cheekbones are very prominent and a bit too wide. One cheek (the one without the mole) is particularly big. I am looking to see if cheek reduction would be a way to correct the size and asymmetry.

As for my chin. I would like to increase its vertical length to make it more proportional to the rest of my face. I would also like to even out its shape and make it more square.

I’ve attached a current pic of me and a morphed pic of me to illustrate what I am hoping to achieve.

Please let me if what I described is achievable, if you have past experience doing a similar case, and what the estimated costs would be to get this done.

A: Thank you for sending your pictures with the excellent imaging. What you are seeking to achieve can be done by the two procedures you have mentioned, cheek-zygomatic arch reduction and a vertical lengthening bony genioplasty. Having done a lot of both of those types of facial osteotomies I think you could come close to what you have imaged. The most challenging aspect of your case is to improve your cheek symmetry despite both being reduced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for the pictures and the consult on custom skull implants. I have 10 follow-up questions, if you don’t mind.

1. As you might be able to see in the pictures, the top of my head does not have a lot of volume either (relatively flat). In your professional opinion, do you think the top of my head will begin to look odd if we add volume to the back of my head and my forehead, or can it be smoothed pretty well?

2. How long do the implants last (will I ever have to repeat the procedure)?

3. Does this procedure affect my ability to get Botox or have other facial treatments done (micro-needling, lasers, etc.) – trying to understand if there’s anything I can’t do after the procedure?

4. Will the implants shift as I age, if so, how does that affect the overall look?

5. What is the risk and pain involved in this procedure?

6. Will I need someone to come with me, or can I do the procedure and recover on my own?

7. How soon would I be able to fly home after the procedure?

8. Will I have any loss of feeling in my face or head long-term?

9. What is the success rate of these types of procedures, and what if I am unhappy with the result?

10. Finally, I think I’d like more volume than shown in the picture. Can you help me understand the cost difference and the process for doing the tissue expander first?

Overall, I am very interested in your expert opinion, to ensure I can achieve the best balance/look.

A: In answer to your questions:

1) Ideally you would have the whole head augmented from front to back. But as long as the back and front of the skull is not overly augmented the top of the head will not look too vertically short.

2) The implants are permanent devices that ail never breakdown or need to be replaced due to implant failure.

3) Skull implants do not affect the ability to get any type of skin treatment. (other than forehead Botox injections should not be injected too deep)

4) The implants will never move from their surgically placed position.

5) There will be some temporary swelling and discomfort from the procedure. The only medical risk is implant infection…which I have never seen.

6) It can be done either way.

7) You should be able to fly home in a few days.

8) There should be no long-term numbness in the scalp or the forehead.

9) The success rate is very high. One can always have the implant taken out but I have yet to see that be requested.

10) To get ore volume than that shown you would need a first stage scalp expansion, making it a two-stage procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 25 year old male and I’ve been following your blog for some time. I am interested in the ‘male model’ cheek implants that you have discussed a few times. As far as I am aware, this involves augmenting the zygomatic process of the temporal bone (the zygomatic arches) along with the zygomatic prominence. One particular question posted to you blog caught my interest and it was with regard to raising the position of the zygomatic prominence. You said that it could be done by placing a customized implant higher on the zygoma and performing an ostectomy on the lower part of the zygoma.

This is suitable for my needs, but I was wondering whether a similar thing could be done with my zygomatic arches. In other words, I would like to actually move the position of the zygomatic arch upwards by creating a custom zygomatic arch implant to literally sit higher on the face (compared to the old zygomatic arch). I am assuming some form of bone reduction would be performed on the older, lower zygomatic arch. What do you think about this? I feel as if it is very important because raising the zygomatic prominence without raising the arch will look disharmonious.

The other question that I have is with regard to the efficacy of silicone v. Medpor. I have consulted with another doctor and he informed me that in terms of soft tissue response, Medpor performs better than silicone (1:1.5 v. 1:.7 in terms of soft tissue movement relative to the implant dimensions). Is this an accurate approach?

Thank you.

A: One can not raise up the bony position of the zygomatic arch for one very distinct reason. Along its inferior edge is the attachment of the masseter muscle. This is not going to let the arch raise up any higher without complete disinsertion of the muscle…which would not be a wise anatomic thing to do.

As for the effects on soft tissue from an underlying bone implant placement, the body does not care what the material is that it doing the pushing. It will respond the same regardless of the material used as long as they are of reasonable stiffness. It makes no sense to suggest otherwise and there is no clinical or biologic proof that would remotely indicate that is true. What does matter is the implant shape and thickness, not its material composition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to remove my jaw angle implants. I really don’t like the results, but I want to know if my skin its getting back to normal after this. Also what is going to happen with the pockets where the implants are? The doctor told me they are médium size silicone implants. Thanks.

A: Since I did not do your surgery and have no idea what you looked like before or now, I can not tell you what will happen when you remove your jaw angle implants. YOur tissues may or mat not completely return to normal.  But on the other hand, what difference does it make if you do not like the look they have created. Just like in placing the implants it is a gamble that the result will be good. Int taking them out there is a similar gamble of whether you will return completely to what you looked like beforehand. But if you really don’t like the look (and 9 weeks may be too early to really judge the final result by accommodating to the new look) then I don’t see that you have much choice but to undergo jaw angle implant removal. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Three months ago I had a forehead reduction. The forehead reduction made a big difference. However, ideally, I wish my hairline would be just a centimeter lower and start exactly where my scar ends. Would you advise me to get the forehead reduction done again to lower it just that extra bit, or would hair transplants be a better option? 

A: I am not sure why the frontal hairline is not at the scar line exactly but your scalp must have been was very tight so there must have been some separation. Given the tightness of your scalp, I don’t think it will ever move any lower than it is. Or at least not much lower like a centimeter. For your forehead reduction revision It would be best to have hair transplants done to fill in the difference between the hairline and the scar and this can also be done up over the scar line. This would produce the most natural looking result and be assured of getting the final frontal hairline position that you desire. I would let the scar heal until the three month mark and then have the hair transplant done. In the end yow will have a great forehead result and a very natural one as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Well I had some work done on my ear as a child (Microtia Reconstruction Revision) but I didn’t like the work done so I want to consult with another doctor to see if I can get better work done.

A: Thank you for sending your ear pictures after your microtia reconstruction done years ago. Microtia reconstruction using ribs grafts is a very challenging and humbling surgery for which it is hard to get good and pleasing results every time. Your ear result looks fairly typical to me and generally can be summed up as…not bad but there is room improvement.

The general outline of the ear and its projection from the side of the head is adequate but it lacks the ear details that the underlying framework probably has carved into it. To make improvements I would do the following microtia reconstruction revision:

1) shorten and smooth out the earlobe

2) Create the concave details of the antihelical fold, crus and concha through excision of skin and scar with the placement of small split-thickness skin grafts

There is definite room for improvement in creating some better ears details which is what your ear lacks currently.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, We had a Skype call a few days ago regarding forearm implants. You asked me to draw the part on my forearm where I would like it to be augmented. Please see the attachment and let me know what your opinion is.

A: Thank you for sending your desired forearm implant location picture. While I was initially skeptical when you discussed forearm augmentation of where that location would be, the area you have outlined is in fact,very safe for the placement of an implant. It runs longitudinal to some of the extensor forearm muscles and stops short of the wrist crease. It is in a location where there are no motor nerves or blood vessels of concern. In addition, although perhaps in just one forearm, you have a scar through which the implant could be placed.

Such a forearm implant is custom made based on measurements of the outlines area that you have shown. I would have the implants made with about 1 to 1.5cm of maximal thickness and with feathered edges at the perimeter. The implants would be placed in a subcutaneous rather than a subfascial location as there is on one single large muscle in that part of the forearm.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question about deltoid implants if you don’t mind. Basically I have been doing searches for the right type of deltoid implants to achieve my goals. I currently understand there is a limit to how much shoulder width can actually be achieved, I have looked at many deltoid implants from the few surgeons who actually preform them and I realize that all of them seem different. Some add more width some add less width, some look noticeable some don’t look that noticeable. I am going to attach a photo of the deltoid implant goal that I would like to achieve. I understand there are different locations for where the deltoid implant can actually be placed I believe. But here is something that I would like to achieve. The claim on that augmentation is apparently 44cm to 50cm, which may or may not be accurate. Although it definitely did supply a noticeable amount of shoulder width. My shoulder width looks pretty similar to the guy posted in the photo on the left, I am also not thin. This one caught my eye due to the lack of you can’t really tell that there is an implant in his shoulder really. It’s not noticeable to someone who wouldn’t know that the procedure was done. 

How much width do you think this patient achieved if you had to guess? Is a result possible like this for me to achieve? Why I am pleased the most with this result is the fact that it makes the actual clavicles look a little longer in my opinion. Thank you so much for reading my email. 

A: Since I did not do the patient’s deltoid implants to which you refer I can not accurately tell what thickness those implants were. Beware that the photos you are showing is likely a small deltoid implant placed very high which may had about 1 cmof width. I would not assume that the outline of the implant is not seen just based on a front view picture. Its ‘obscurity’ can only really be determined from a side picture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young female with a weak recessed chin which is worsened by a skeletal overbite (by 50%). Jaw surgery is too extreme for me so i was thinking of a genioplasty. My main concerns are further elongating my face. I already have an extremely long face and wish to not further it anymore. Is this possible to do? I also want the indent between my bottom lip and chin to not be as noticable (huge indent because my jaw is pushed back from the overbite) thanks in advance!

A: While it is clear by your description that moving the entire lower jaw forward is the ideal procedure, the only skeletal alternative is that of a sliding genioplasty where only the chin bone is moved. When the sliding genioplasty is moved forward, it can also be shortened by a technique known as a jumping genioplasty. This is where the advanced chin bone is placed where in front of the superior segment. This not only provides maximum horizontal projection but also avoids any vertical lower facial lengthening. (and may even make the face vertically shorter) I would need to see pictures if your face to determine whether this is a good genioplasty option for you.

Be aware that your deep labiomental fold is a result of your bite relationship and will not be improved by any form of chin surgery. Only moving the whole lower jaw forward, where the lower teeth push out the labiomental fold, will make any improvement in that aesthetic issue. The labiomental fold is an anatomic area that lies above the chin and thus is not usually improved by any form of chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Facial Feminization surgery. I am 55 years old so I know that adds to the complexity to it. I have attached pictures for your review and recommendations.

A: Thank you for sending your pictures. Your FFS surgery is more challenging to image/predict because you have a major facial aging component to it. (older facial feminization surgery) The need to get rid of loose skin in the upper eyelids and the neck /jawline (upper blepharoplasties and lower facelift) as part of the FFS procedure makes looking at the skeletal changes more difficult. I think they are best illustrated in the side view picture.

FFS is a large number of facial reshaping procedures of which not all apply to every patient. What I look for is those facial procedures which I think would have the greatest impact on feminizing the face. These will be different for each patient. In looking at your pictures, I feel the following would be most beneficial:

1) Brow Bone Reduction/Browlift
2) Rhinoplasty
3) Upper and Lower Lip Advancements
4) Earlobe reductions

I think if you put these four facial reshaping procedures with the previous anti-aging facial procedures mentioned (upper  and lower blepharoplasties and lower facelift) as a combined FFS procedure. These would have the biggest impact on making a positive facial change.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, your internet page explains that back of head augmentation is possible by use of different kind of surgery. However, I have read a lot about different possibilities such as implants made from silicone or the use of Osteobond. I am struggling a bit by imaging what is best suitable for me and I have a couple of questions. I would be really grateful if you could give me some feedback.
 
• What is approximately the maximum thickness backhead augmentation you are able to realize without the use of an expander in advance?
• How can it guaranteed that the implants adhering over years and what will happen if they get loosen? Can the implant crack somehow?
• I have shaved skin on my head, a scar doesn’t cares me but can this being done in an asymmetrical way of cut to make the appearance more looking unintended?
• What is about martial arts fighting sport as an hobby, will it be still possible to do those sports or is it dangerous in case of too much force introduction to the implant?
• Can the implant be formed in a way that rim areas on the outer contour are not visible anymore (print through)?
• I read that Osteobond develops heat while curing caused by exothermic chemical reaction. How this will interact with my organism? What is about chemical reaction products – will this interfere somehow?
• In case of problems how easy the implant can be removed again?
• What does the surgery approximately cost? Is there a possibility to stay in your clinic for a couple of days?
 
I am looking forward to your feedback!

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

1) About 15mms is the maximum thickness that the scalp can accommodate.
2) Skull implants do not get loose, that has never occurred.
3) You can design the scarline anyway you want.
4) Having an implant on the back of your head is more protective than restrictive. It is like putting a layer of protection for the bone.
5) The implant is designed to have very thin feather edges to make the implant-bone transition smooth.
6) Osteobond is an inferior alternative to a custom made skull implant. I would never use it on a shaved head…or any head for that matter if I had a choice.
7) The implant is easily removed.
8) My assistant will pass along the cost of the surgery to you later today. You should be able to return home in a few days after surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, We have discussed using an implant for my infraorbital-malar augmentation, but I was wondering if fat grafting could be an option as well. I think I would prefer the fat grafting, it seems less invasive and more natural. I attached some photos of my face. Also, I saw that fat grafting could be used for the chin and jaw. I think having a chin that protrudes more would make my nose seem less prominent. I was also curious about having a wider, more square jaw with fat grafting. However, I am mostly concerned with just my cheek/eye area.
 
Thank you for your help,

A: Fat grafting is a natural body graft but has major issues of initial survival and long-term retention. In your face probably close to 0% of the fat would survive because you have very thin tissues. It is also prone to irregularities and clumping in the eye area as it does not get distributed in a smooth linear fashion. Fat also is a soft material so it does not give a hard push on the tissues and will just make everything more round and soft looking.

In short, fat grafting and implants are not interchangeable facial techniques. They not only are done differently but have very different aesthetic outcomes and long-term implication.

But there is no harm in trying fat first…then you will know for yourself.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m considering getting implants, but I’m worried about both bone erosion and infection. When it comes to bone erosion, I’m worried about how much bone will actually erode and will I have to eventually replace my implant in a few years time? Also, I plan on having some teeth removed and replaced with dental implants in a few years (after implants), will the implants get infected from this or would they remain infection free?

A: Bone resorption is not an issue I have ever seen with any custom jawline implant. There can be bone overgrowth sometimes back at the jaw angles and some mild implant settling into the bone (seen as an implant imprint on the bone) but not inflammatory bone erosion or any other tissue reaction that would necessitate removal of the implant. Teeth removal and the placement of dental implants does not jeopardize the implant per se…although the inadvertent injection of local anesthetic (dental infiltraion/blocks) into the implant may pose the risk of infection to the implant. For this reason full disclosure to the treating dentist is advised so they can appropriately adjust the depth of their needle penetration into the tissues.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have never had any work done to the chin area although years ago I did have a submental incision at the crease where skin and tissue was removed and lipo done. Here are my concerns:
1) Chin Ptosis/witches chin is potentially causing:
    a)  A deep submental crease causing an unsightly irregularity between the point of the chin and throat.  The excessive tissue that I can feel that has drooped down from the point of the chin seems to be part of the problem (chin ptosis).  The skin and tissue around the chin is very thick and dense.  The bone on the tip of the chin does not appear to be excessive but a profile x-ray would be needed to confirm this.  maybe.
    b) A very deep labiomental crease seems to have been caused by excessive mental muscle contraction.  The crease has worsened as I have gotten older.  I would like to have a smooth transition from the neck area to the tip of the chin.

Hope you have some positive things to say about you being able to help me with my profile. 

A: Thank you for sending all of your pictures and detailing your concerns. In regards to the potential witch’s chin, that is not what you actually have. A witch’s chin deformity is when the normal chin tissues have slid off the bone for a variety of reasons. This chin soft tissue malposition creates an overhang off the end of the bone which also leads to a deepened submental crease an undesireable chin-neck profile. What you have is a normal bony chin and the chin soft tissues in proper position on the pogonion point of the chin but with a deepened submental crease. The deepening of the submental crease has been exacerbated by the prior facelift both anatomically and visibly. 

The difference between a witch’s chin and what you have is anatomically different and requires a diametrically different approach to effectively treat. A witch’s chin is treated by the excision/removal of tissue and resuspension because there is a relative excess of soft tissues that are malpositioned. A deep submental crease with normal chin tissues after a facelift has to be treated by addition and not subtraction. Your chin and neck tissues are likely too tight to be able to simply remove and tighten them and end up with a smooth transition on the underside of the chin into the neck. Conversely the submental indentation needs to be released and augmented. Whether this is done by a dermal-fat graft or an implant onto the bone can be debated, each with their own advantages and disadvantages.

As for the labiomental crease, that is a very difficult problem to improve without some potential aesthetic liabilities. It is very deep and is an inverted skin fold. Nothing simply placed under it (injections of any kind) will push it out. The dermal attachments of the crease have to be released through an incisional approach and a fat graft placed under it. This places a scar in the crease line. While admittedly your labiomental crease line is like a scar anyway, this is an aesthetic issue of which to be aware.

Dr. Barry Eppley
Indianapolisl Indiana

Q: Dr. Eppley, I have some inquiries regarding skull reshaping. I have a problem with the top of my skull, to be more preicise, there is a big “bump” (I can send you pictures if you provide me with your e-mail adress). It’s approximately 1 inch high, 1.5 inches wide, and about 2.5 inches long. I already have a big head, and this only makes it worse. This has caused me much anxiety throughout my life. I would like to know if you had come across with similar cases and if it can be fixed, shaped down to a normal shaped skull? Also, can you tell me what the cost would be of such an operation?
Kind regards!

A: Thank you for your inquiry. By your description I believe what you have is a sagittal ridge/bump. Please send me some pictures of it in a reply to this email for my assessment. It can usually be effectively reduced and I have done so many times. Whether the bony bump can be completely flattened (due to the thickness of the skull) and whether it is magnified by a parasagittal deficiency (whose augmentation may be needed to get a really normal skull shape) remains to be determined by the pictures your send. (and sometimes by x-ray assessment of the thickness of the bony bump)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am seeking brow bone recontouring from a brow bone fracture that I had two years ago. This was never fixed and had left me with a big indent in my brow. Can this be fixed?

A: Thank you for sending your pictures and the x-rays. What you originally had is a depressed frontal bone fracture that involved the frontal sinus and supraorbital rim. It remains as a displaced forehead fracture but a healed one at this point. It is no surprise that a neurosurgeon would want to do a craniotomy to lift out all the bone and get it back into anatomic position through a full coronal scalp incision. This would certainly be the standard neurosurgical approach. But I can understand why that would not be that appealing to you at this point. The alternative treatment strategy would be a brow bone contouring approach. Leave the bone where it is and apply an hydroxyapatite cement over top of the entire depression to recreate a much improved forehead contour. This is an appropriate strategy as long as there is no air leak from the frontal sinus or a CSF leak into the nose. (which I am sure there is not)(

The only debate about this contouring approach is the location of the incision. It certainly makes access easier and a more thorough recontouring can be done with the wide open exposure of the full coronal scalp incision. But that incision/scar may want to be avoided. The alternative incisional access is through one of your existing horizontal forehead wrinkle lines. This avoids the larger scalp scar. I have done this many times for forehead cement application and brow bone reduction in men. It is usually a scar that heals quite well since it is in a natural skin wrinkle which is only going to get more pronounced with time anyway.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I would be able to get an idea of what is able to be done about my face being completely asymmetrical. (facial asymmetry surgery)

This is something that has bothered me my entire life and is only making me more self concious as I get older. I feel as though one side of my face is drooped. It’s not just the eyes or just the nose… every single feature I have is completely different on the right side of my face in comparison to the left. This is made even worse by the fact I am an identical twin, only we’re not identical because I was born like this and she was born with a normal even face.

After plenty of therapy etc there is still no doubt in mind that I cannot keep this face for the rest of my life. Is it possible to get computer imaging of what my face would look like and what could actually be changed to improve it. It also seems as though my jaw is more prominent on one side of my face in comparison to the other.

Thank you 🙂

A: Thank you for your inquiry and sending your pictures. What I see that you need to improve your facial asymmetry is:

1) Right jaw angle implant

2) Right cheek implant

3) Right corner of mouth lift

4) Fat injections to the right face between the cheeks and jaw angle
Dr. Barry Eppley
Indianapolis, Indiana