Your Questions

Q: Dr. Eppley, I am interested in Medpor facial implant removals. I had a Medpor chin implant and angle jaw implant done ten years ago. Is there a way to have the implants removed or shaved down to be smaller? I would prefer removing. The jaw implants has two screws and the chin implant one screw. I have read that Medpor is challenging to remove because of potential sagging but suspension can be done. I wear a beard and don’t know if this could be hidden behind beard. Both were done through the mouth not externally. Thank you.

A: Medpor facial implant removals are challenging because of the significant tissue adherence that they have. But they can be successfully removed and I have removed many of them. An important issue with any chin implant removal, particularly when done from inside the mouth, is the risk of chin or lower lip sag thereafter. Even with good muscle suspension this is still a potential issue because what the implant has done is create an overall tissue expansion effect. When you remove the support (chin implant) there is a relative soft tissue excess that may not be overcome by an form of tissue suspension. This depends to some degree on what size the original implant is. But knowing this is a Medpor chin implant, by definition, this is a larger implant with long wings on it. So this issue is probably very relevant to you. This why ideally such implant removals should be supplemented with some residual chin augmentation whether it is a much smaller implant or a small sliding genioplasty subtotal replacement.

Such issues are less pertinent to jaw angle implant removals as they are not anterior projecting structures.

It is best to think of total implant removals, not in situ implant reshaping. This is a recipe for facial asymmetries and implant irregularities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was diagnosed with Congestive Heart Failure at 19. I’m now 29. I’ve had 3 defibrillator surgeries, the last one being the 2nd of this month. They implanted a subcutaneous defibrillator which goes in your side and the lead runs under the breast and up in between. It does not have contact with the heart it is like a camera that just watches it. My defibrillator has only ever went off once in 2010, it’s pretty much just a precaution. My ejection fraction is low, like 20%. I’m 90lbs so this particular defibrillator is VERY noticeable and makes me very self conscious. I have like no boobs lol, literally. I’m hoping to possibly get a breast augmentation to make me feel better and make my machine and lead less noticeable. Do you think it’s safe?

A: The two relevant questions are whether breast augmentation is both safe and effective given your medical condition and very thin frame with little body fat. From a safety standpoint this is really a question for your cardiologist and whether he/she would ever give medical clearance for this surgery. The safety of surgery relates to whether you could have general anesthesia which is typically how breast augmentation surgery is done. Another consideration would be to have the surgery under local anesthesia with the breast implants placed above the muscle.

The other question is whether breast implants would provide some camouflage for your debrillator. I have done a few breast augmentations in defibrillator patients and it has been helpful.

Lastly it is important to know where the leads run so they are not damaged during surgery. A chest x-ray is needed before surgery to accurately know their location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I love the rhinoplasty imaging predictions, they look great!  I was wondering however if you could possibly send me a few more.  I know I asked for a concave look, but could you show me what it would look like if my nose were made to be a little less concave.  Also, what do you think about possibly shortening my nose and nostrils?  Would it become too short for my features then?  I’m nervous and want to ensure I love the end results, so could you show me a few possibilities for what these two separate end results might look like, one with my nose just a little less concave, and another with my nose a little less concave and shortened. 

A: Thank you for your feedback on the rhinoplasty computer imaging. What is important to remember is that computer imaging is just a prediction and and not an exact replica of what can or will be the outcome. It is a good goal and a road map for the surgeon but no one ends up looking exactly like the imaging. It may be close but never exactly like the prediction imaging shows. Rhinoplasty surgery is not ala carte. You can’t dictate the fine details of the change to your nose like getting your coffee at Starbuck’s.

That being said, you should decide to have rhinoplasty surgery based on what you have already seen. If that is enough then the surgery will not disappoint. But if you have to have some change this is more than what is shown then you will find fault with any rhinoplasty surgery and will end up disappointed and always finding fault with some aspect of the result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a facial slimming surgery revision. I had cheek bone and jaw angle reduction six months ago in Asia. This seemed to result in cheek bones that dropped, became assymetric and disjointed. As for the jaw bones, the left mandible broke and seems fixed with screws. Could these screws be affecting my nerves and affecting my smile because now when I smile, my smile is crooked. I also have dental maloclusion and cannot chew normally. Please can you look at my CT scans:

1. What has happened to my cheek bones? What needs to be done for corrective surgery?

2. What has happened to my jaw bones? What needs to be done for corrective surgery ?

3. Please give me feedback or input as to what could be causing the problems I am experiencing regarding my crooked smile.

A: Thank you for your inquiry and sending your pictures and x-rays as well as telling your surgical history about cheekbone and jaw angle reduction. In reviewing your CT scans, the answers to your questions and facial slimming surgery revision needs are as follows:

1) The front end of your cheekbone was plated in an inferior (low position) rather than being put back at the correct horizontal level, albeit in a more inward position. I have never seen such a bone positioning of the cheekbone. But this would explain why your cheeks sag.

2) As you had previously stated, you sustained a fracture of the mandibular ramus during the jaw angle reduction procedure. (this also I have never seen before) There are plates sand screws at two levels to fix the fracture. It is possible that the screws from the lower plate could be impinging on the mental nerve which could cause numbness of the lower lip. The fracture could also be as source of bite issues since fixing jaw fractures are a well know source of postoperative malocclusion. (bite is off) Your smile is crooked because your have sustained an injury to the marginal mandibular branch of the facial nerve. This is the nerve that controls the depressor movement of the lower lip. When it does not work the lower lip on he affected side elevates when you smile rather than being pulled down. This is the source of your crooked smile. If the function of this nerve has not returned in one year after the injury, it will not recover.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in having a chin implant removed while having a genioplasty in its place. However I noticed your article in which you state that the genioplasty can be altered through a midline incision to narrow the bone. Can this midline incision also be used to widen the chin? Therefore augmenting my chin forward with the genioplasty while making it wider with the midline incision? 

Thank you

A: A sliding genioplasty can be done where the bone is expanded through a midline sagittal bone cut and the placement of an interpostional bone graft. (allogeneic bone is usually used) This requires more than one metal plate for fixation because of the two independent bone segments (unlike a typical sliding genioplasty which just uses one central plate) but such a widening bony geniplasty can be done. Whether it can achieve the exact effect you are trying to accomplish in the amount of chin width expansion would require computer imaging assessment before surgery. The amount of chin bone expansion by this technique is limited to 1m or less. This would not be enough to replicate what the width of a square chin implant could achieve in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to receive male model cheek implants. The type of cheeks that I would like to achieve are the high cheekbones that are visible on male models. Now my issue is this: my zygoma is set too low on the face. I believe that this is a particular growth pattern because the same is true about my infraorbital margin. When I trace the infraorbital margin with my hand, it feels too low relative to the position of the centre of my eye. 

So my issue is that my zygoma is too low, which has two salient aesthetic consequences: 1) that the malar prominence is too low relative to the rest of the midface, and 2) the lower border of the zygoma is situated too low. My question to you is whether we can manage this issue and replicate a higher zygomatic bone with implants. My thoughts here are that we would: a) reconstitute the malar prominence with the shape of the custom implant, placing it higher on the face. And b) bone reduction/burring of the lower part of the zygoma, thus raising the lower border of the zygoma. 

The reason why I believe that this particular part is important is because faces with high set zygomas tend to have a ‘hollowed out’ area that starts where the zygoma stops. Unfortunately the lower part of my zygoma sits too low, meaning that this area is ‘filled out’ in a feminine way rather than the masculine ‘hollowed out’ appearance. 

c) My only other question is whether the actual infraorbital margin can be raised as part of an infraorbital extension to the same implant? My thoughts here are that we would both raise and bring the infraorbital margin forward, causing the ‘mew’ margin to sit both higher and more forward relative to the iris.

Thank you for your time, Dr. Eppley

A: I can’t ever say that I have seen anyone whose zygomatic body sits too low with the exception of certain congenital craniofacial deformities. (e.g., Treacher Collins Syndrome) But that comment aside, with custom implant designing you can make infraorbital-malar implants anyway you want. How to achieve the desired external cheek appearance (so called male model cheek implants through such designing, however, remains an art form and not an exact science. Also, It is not rare that such custom infraorbital-malar implants raise the level of the inferior orbital rim.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I lost a fair amount of weight a few years ago after giving birth to twins, and suddenly my superficial temporal artery on the right side of my face started bulging. Now, 5-6 years later, I have another one on my left side. They are bothering me on a daily basis even though I’ve just cut my hair to cover them. I am wondering if anyone has ever experienced permanent hair loss or scalp problems as a result of ligating these arteries? I had a dermatologist tell me once that there was nothing you could do to them without “going bald”, which obviously caused me great concern. But from all that I’ve read in my research, I have never heard of this happening. I really appreciate your response. Many thanks.

A: In my experience with the temporal artery ligation, I have never seen any adverse scalp effects….nor would I expect that to happen. The scalp is a tremendously interconnected vascular system that it would be very difficult, if not impossible, to cut off the blood supply to any one area without long incisions. I do not consider scalp or hair loss a risk with the procedure. But if or really wanted to ‘hedge your bet’ so to speak about the potential hair loss concern, just do ligation on one side at a time.

On a side note, of all the temporal artery ligation patients I have treated they have all been men. I have yet to see a wome

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheekbone reconstruction. I had an injury to my right cheekbone 11 years ago it left my face asymmetrical. My right cheekbone is flatter now than the other side. It’s appears to be protruding at one point. The orbital looks out of place. I didn’t have insurance or money at the time to fix it so I allowed it to heal on its own. It obviously healed very poorly. I have not been happy with my appearance ever since. I was wondering what can be done to fix this and achieve a natural symmetry to my face I once had. I fear I may have broken the my zygomatic arch and since I didn’t fix it right away stuck with there results. I have gone to a few surgeons that recommended fillers although my cheekbone it flat in some areas that may help I’m concerned where it appear to protrude will upset that balance. I already have fairly large cheekbones and I don’t want them to appear larger. This is my concern about the filler. Most of the surgeons I went to downplayed the injury and were more interested in convincing me to live with it. This is not an option I’ve tried for 11 years and there hasn’t been a single day that I’ve been overcome by the disappointment in my appearance. This was never the case before the injury. I’m always researching and looking for surgeons that may be able to help. I saw you website and decided to make an inquiry. Thank you.

A: Thank you for sending your pictures. If I understand your concerns using the pictures as a guide, you have three right zygomatico-orbital concerns:

1) Right mid-zygonatic arch depression

2) Right posterior zygomatic bump (may just appear this way because the arch is indented)

3) flatter right inferolateral orbital rim-anterior zygoma

These three areas could be treated by cheekbone reconstruction consisting of the following :

1) small ePTFE zygomatic arch implant (max 3mms thick)

2) rasping down posterior zygomatic bump

3) small hand carved ePTFE inferolateral orbital rim implant

All done from inside the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom orbital rim implants. What is the amount of depth, in mm, that you would consider going for the orbital area as this area, in my opinion, would need more than a few mm? Also if it is a combined orbital rim-submalar this can also include the paranasal area too? I have seen on your blog the custom midface implant  and they look great.

Please would you have your secretary send me prices for custom orbital rim only and also for the combined orbital rim-submalar-paranasal implant.

Many thanks,

A: With a custom implant design you can make it cover whatever areas the patient wants or even the entire midface as you have seen in other patient implant design examples.

For the orbital rim area its thickness would vary based on where on the rim it lies. But as a general rule it is thinnest in the tear trough (2-3mms) and thickens as it goes out into the cheek region. (5-6mms)

The actual implant cost of a custom facial implant is the same no matter how it is designed to the surface are it covers. Where the cost varies is in the time it takes to surgically placed. I will have my assistant Camille pass along the cost of the two different options to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about bicep implants on both of my arms as a result of two traumatic injuries from playing football. Several years ago I suffered a left distal bicep tear and had unsuccessful surgery to repair it. Then, my right bicep–the short head muscle–suffered what my surgeon called a rare trauma (partial tear) one year later and subsequently was unsuccessfully operated on. As a result of these injuries, I feel and look “deformed” and would like to cosmetically improve this since I am still relatively young and tend to my health very well.

I am able to provide current pictures of both of my arms as well as a “pre-trauma” one. To note, my entire life, aside from OTC supplements, I have been 100% natural and aside from limited alcohol use, never have either tried or experimented with tobacco or illegal drugs. While there are other doctors in various parts of the country who do this type of surgery, after researching you it’s apparent you are one of the top ones. 

A: While I will ultimately need to see pictures of your arm, both flexed and extended, what you undoubtably have is muscle atrophy from the tears from the bone. They may be different, one proximal and one distal, but their treatment is the same…the placement of subfascial subtotal bicep implants. Most likely the incisions used for your unsuccessful muscle surgery could be used for their placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several questions about the various precedes we had discussed for my skull and nose.

1) For my skull, you are saying you are able to fix and address all my skull irregularities entirely with just that one incision, correct?

2) Will my skull look more symmetrical than my nose? I ask because you have made it clear for my nose to not expect a perfectly straight outcome. Does the same apply to the skull even though it is not a smaller centered human feature?

3) If I do both the skull reshaping and the nose surgery at the same time does that make it easier for you to give me the best symmetrical outcome or does it not make a difference?

4) The only part I am not clear about when it comes to my nose is the curve on the bridge on my nose that I can feel right now when I run my finger down my nose. Once my finger reaches the bridge I can feel the raised right side and the left side cave in and curve and it is no longer flat and straight. Will this remain after surgery or will the bone structure feel straight and even to my hand touch? This is hard to explain with words but it’s what I have been worrying about all along.

5) You did not answer the last time I asked. I am very curious is it possible to see imaging predictions of how a full skull reshape would turn out with the nose job?

A: In answer to your questions:

1) If you are including the forehead as well as the back of the skull as the totality of your skull irregularities then no one single incision, short of a full coronal (ear to ear) incision can address all of them through a single point of entry.

2) Skull symmetry is usually defined a smoothness of shape between the two sides. I would expect it to be a lot better. But perfect asymmetry, like that of the nose, is probably never achieved.

3) The issues with perfect shape and symmetry with any shape changing face or skull surgery are independent variables and are not linked. Each area poses its own challenges which do not change whether they are done together or separately. If you think about the challenges it is one of open access. Through the incisions used for rhinoplasty or most limited incision cranioplasties the surgeon does not have unlimited visual access. If you have no skin on your nose or your skull it would be a different story.

4) While your nasal bone asymmetry will be addressed in your rhinoplasty through osteotomies and nasal bone repositioning, it is not always predictable that the edges will feel perfectly smooth.

5) In regards to imaging, with the right picture angles it may be possible to show some skull reshaping changes with that of the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Due to the risk concerns of silicone facial implants, I am starting to reconsider the surgery. I am afraid that since it is a foreign object there may be long term effects I would rather avoid such as ALCL cancer. Is it possible that cancer cells could develop in scar tissue pocket?  I am just not feeling confident anymore and there aren’t a lot of studies done on this topic.

A: It is a very good question but the biology of that reactive process is understandably not clear to you. You are confusing gel-based breast implants with solid silicone facial implants. ALCL is a very rare lymphatic cancer that has been reported in a handful of cases of silicone breast implants, all due to the textured surfacing on the breast implant and how it was manufactured. Conversely, facial implants are solid smooth silicone implants from which no such issues have ever occurred. Given that the origin of ALCL is due to the textured surface of the breast implant, there is no correlation between a facial implant that you are considering having implanted and what is going on in these rare breast implant cases. Solid silicone implants have been placed all over the body for almost 50 years from which not a single such reactive tumor has ever occurred…nor would it be expected.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a zygomatic arch implant. I am 25 years old woman and three years ago I had my right arch of my cheek broken (zygomatic arch). After three weeks it was placed back into it’s ‘right’ position. Fortunately the scar is on my ear, but I have a little asymmetry which bothers me. I wish to have both sides of my cheek bones symmetric again. The damaged side of my face is flatter than the other side. I read on your website and in a lot of your comments in Real Self, that you are able to carve unique implants,that fit to the zygomatic arch and that might can solve my problem. Would you please send me how this surgery goes step by step and what results can we get from it? The surgeon, who placed back my zygomatic arch, suggested to rasp the healthy side. What do you suggest for me?

A: The concept of altering a normal side to match an abnormal side speaks for itself…that is not the thing to do. The correct approach is to build out the flatter part of the zygomatic arch and that can be done most easily and effectively by making a zygomatic arch implant to augment the inwardly displaced portion of the bone. That is usually done from inside the mouth and the implant come from several different methods. A preformed nasal implant can be used since it is straight and curvilinear and is designed to fit on a straight linear surface, an implant can be hand carved out of a ePTFE block based on intraoperatve measurements or a custom zygomatic arch implant can be made from a 3D CT scan.

Regardless of the implant used, the surgery remains the same.

For further assessment I would need to see pictures of your face from the side with you having drawn the outline of the depressed area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I could schedule for a Skype consultation with you for getting large buttock implants? I’m from outside the USoriginally but I’ve had various surgeries in the states. I am after liposuction with buttock augumentation. However, the photos that I have seen online with the 700cc buttock buttock implants do not seem enough for me. I would like large buttock implants that are big and round to match my 2000cc breast implants. My boyfriend has told me you are the best in the business and we were hoping you would help us achieve our look? Also we are interested in multiple surgeries at once. Is this something you would be able to do?

A:When it comes to stock buttock implants, the largest standard sizes that are made are in the 600cc – 700cc range. If that is inadequate then custom large buttock implants can be made for increased dimensions and projection. While any size custom buttock implant can be made we always have to be vigilant to be sure that there is adequate soft tissue to cover them. Unlike breast implants, where just about size can be placed, the buttock soft tissues are not quite as forgiving. Also just like your breast implants, which I am sure you did not start out in your first augmentation with 2000ccs, extremely large buttock implants may require more than one stage to get there to allow the tissues to stretch to accommodate them.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I would like to know your opinion about silicone nasal implant for raising only the bridge of the nose. For instance an implant  from Implantech called Flowers Dorsal Nasal. I know there is a big debate about silicone versus Goretex where cartilage is much safer than the synthetic materials. I have done ear- cartilage nose augmentation and it is almost dissolved. I just need a little permanent elevation for the bridge of my nose, I don’t have any complain about other parts of the nose. I said I would order for 1.5mm or 2.5 mm. But there is 2 kinds of Flowers Dorsal Nasal Implant. One is made of the silicone and the other is made of ePTFE. I have a question here ePTFE is only Goretex or silicone covered by goretex. I have read also that in any complications after placing the implant silicone on the nose, it is easier to remove silicone unlike goretex which is difficult to remove as well as infection is also a potential risk for having it on the nose.
Please advice me of which material I should go for my nose surgery.

A: When it comes to nasal implants there are three fundamental types of synthetic implants; silicone, ePTFE coated (called composite nasal implants) and hand made pure ePTFE nasal implants (carved from a block of ePTFE)

All of these will work with similar effectiveness in my experience and I have used them all. Goretex has the advantage of some soft attachments but it is never so adherent that it is difficult to remove later if needed. Whether one uses a silicone vs an ePTFE nasal implant depends on how one emotionally feels about the material. (my preference is for ePTFE) Whether one uses an ePTFE coated silicone implant or a pure ePTFE nasal implant which is hand made one depends on the surgeons comfort and carving skill of making one out of a block of ePTFE.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Could you provide the service of creating a custom implant (or suggest someone who can)? I live in New Zealand and recently had surgery using off the shelf implants. They haven’t worked well and I would like to have them removed. Ideally I would like to replace the implants with a custom implant. I saw the custom implant in the case Study “Total Jawline Enhancement with Custom Implant” on your website.. Could you produce something similar if the required CT scans etc where sent to you?Is it possible to pay for just the custom implant (service) without the surgery? I thought the surgeon in Australia who put the implants in could replace them with the custom implant. Is that possible?

A:This is a question I have been asked many times. That request is not possible for two very specific reasons. First the designer and manufacturer for custom implants is not going to permit that to occur as it violates the import regulations for medical devices in many countries. Secondly and of equal importance, custom implants are larger and require considerable experience in surgically implanting them. It is not as simple or as easy as putting in standard implants. The best design custom jawline implant will be irrelevant if it is not placed properly.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have consulted with another surgeon about this procedure. I don’t really need a lower face lift. Is this done or can it be done under local? The cost of the general anesthesia and operating room is high and I’m intrigued by your price listed at this website. Thank you.

A: Thank you for your inquiry. A submentoplasty procedure is not a procedure I would attempt to do in the office under local anesthesia. While some version of it make be able to be done, it would not be the same version or achieve the same result as that obtained in the operating room under some form of deeper anesthesia. It is possible that maybe your neck needs are amenable to a more limited approach that may achieve acceptable results under local anesthesia. But I would have to see pictures of your neck to provide a more qualified answer to how to achieve the best submentoplasty results in your case.

It is important to realize that a submentoplasty is an upgraded version of neck liposuction that includes additional fat removal as well as platysma muscle work. With this understanding it is easier to appreciate why local anesthesia may not be the most comfortable way to have it done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am seriously considering having orbital rim implants and submalar implants done by you. I have deficiency in the under eye and lower cheek area and would like them filled out. I regularly read your blog and see that you can create custom infraorbital and cheek implants. Do you think it is necessary to go the custom route or can you still get good results with off the shelf implants ( especially orbital implants). Also, could a custom implant be created that covers the infraorbital area and also goes all the way down to below the cheek to the submalar by a once piece implant?

A:Good to hear from you again. As you may recall we have communicated in the past and I have all of your pictures for reference. The fundamental question you are asking is whether using standard orbital rim implants (tear trough)  and submalar implants would produce a similar result as that of a custom orbital rim-submalar implant. The answer is probably not the same aesthetic result because the two areas would spill not be connected while the underlying bone (albeit deficient is) The other way to answer that question is which is least likely to have other potential aesthetic complications (asymmetry, implant malposition) to which that answer is more obvious. When you have two single piece custom  implants (orbital rim-suibmalar implants) versus four standard implants that are not connected which is superior is that regard is much more obvious.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m about to order chin implant for my surgery of chin augmentation from your representative in Tehran. But my query is I have already chin implant on my chin. I had it done 15 years ago and it is in a very good condition I had no any complications. But this implant did augment my chin vertically but what I’m looking for now is I need my chin to be more forward projected I feel it is flat, do you recommend that I leave my old chin implant as it is and I put on the middle of my chin an implant from your Catalogue which is Curvilinear silicone chin implant. So I will be having two implants on my chin. Or shall I remove my old chin implant and please another one which will augment my chin vertically plus giving it a forward projection. For the same inquiry, I’m looking as well for a chin implant that has a dimple on it at the lower middle. I would be grateful if you could answer my inquiry as soon as possible.

A: Please be aware that I do not work for or am employed by any facial implant company. I am just a plastic surgeon that happens to have a large facial plastic surgery practice in which we have a lot of experience in all types of facial implants.

That being said, for you chin implant replacement it is almost never a good idea to stack chin implants. It can be done, and I have done it, but it requires multiple screw placements for stability. It is always better to have one single implant that can meet all of your chin dimensional needs. Whether this would be done using a standard vertically lengthening style chin (which also adds horizontal projection as well) or whether this will require a custom chin implant I can not say just based on a description. An externally visible chin dimple does not come from it being placed as part of the implant design. That will never work. A chin dimple has to be created through soft tissue manipulation which can be done at the same time as the placement of a new chin implant. Dr. Barry Eppley Indianapolis, Indiana

Q: Dr. Eppley, I am wanting a rhinoplasty and subnasal lip lift and don’t want to do both at same time so I wanted to ask. Do you recommend getting a lip lift first before rhinoplasty as it can distort nostrils or should I get it done after?

A: A well done subnasal lip lift will not distort the nostrils so this is a misconception. That being said the order of a rhinoplasty and subnasal lip lift does not matter from an anatomic standpoint. Doing one does not affect the other in a negative way either in terms of aesthetics or being able safely perform it.

You do the nose or lip procedure first that is of greatest aesthetic significance. Because most patient’s rhinoplasty surgery produces a greater aesthetic change and can potentially have some impact on lip length, it would be most common to do the nose surgery first.

The other way to look at it is to assume whichever one you do first, the other one may never get done. (for a variety of reasons) Thus if you prioritize the surgery based on if you could only ever do one of the procedures and not both, which one would it be?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Unfortunately, I come to you with an issue of a previous jaw implant surgery. The whole situation has been a mess. When you combine my ignorance on the procedure and the lack of explanation from a surgeon, bad things happen.There is a reason why I went to my previous doctor, and I can explain it to you, but I am afraid it’s too long.

I had 7mm Medpor jaw angle implants done. For some unknown and unexplained reason to me,  my previous Doctor shaved off the outer part (lateral) of the implants. I had no lateral augmentation at all. This is not just my opinion, but the doctor agreed to this after the fact also. He told me he had shaved off the outer part of the implant. He never told me he would do this though. 

I had the original procedure done six months ago. Three weeks ago we had a jaw angle implant revision. I reminded him over and over and over again that my original need was the vertical length and just a bit lateral. 

He said that he was against silicone implants because, in time, silicone implants erode the bone. But he said that since I now have Medpor implant installed, he could place silicon implant on top of it. I told him that that would be ok with me as long as it gave me a little vertical length. He told me he could achieve that. I did ask him how many times? 

We decided to go ahead with the surgery. He installed the Implantech contour type implant on top of the shaved off 7 mm Medpor implant. I never could understand how that would give me vertical length!! I felt as though I didn’t know what I was talking about and I agreed with him. (big mistake)

The first Medpor implants did make a minor positive change in the original first operation. From my profile view, it looked “better”. My natural jaw bone starts right under the ear. With the Medpor implant, it went to the back of the face a bit and it elongated the vertical line a little less than half of an inch. From the front view, there was no change at all.  The round oval shape of my face didn’t change at all, and there was no lateral augmentation from the frontal view.  Even if he hadn’t shaved off the outer part of the original 7mm Medpor implant, the angle would have still been above the line level of my mouth. (not ok)

The revision plan was to replace the 7mm with 11mm Medpor jaw angle implants. Upon consulting with him and after I saw the difference between the 7 and the 11 mm implants, I knew there was not going to be vertical length. The angle would have still been above my mouth line.  I had no way of assessing or imagining how lateral the 11 mm would look on me since he had shaved off the original 7mm ones. So we decide to leave the 7mm in place and to add a silicon implant on top of it. I told him 100 times that the angle should come down vertically at least down to the level of my lips and that didn’t need much lateral length. 

He told me that the contour silicon implant would give me vertical length naturally, but I asked him repeatedly as to how was that even possible???? He said he was sure. I felt I was already too deep into it to say no. I had paid two weeks in advance to replace the 7mm for the 11mm Medpor implants but we ended up going with a 10mm contour silicone on top of the shaved off 7mm. 

Obviously, it didn’t give me vertical length, and now my face is too way too wide. Sure I would like some lateral augmentation, but not right under my ears. I looked better with the shaved off 7mm medpor implants than now.

As you can imagine, this has been a nightmare for me. I hate to come to you with this crap. I “believed” against all my intuition and common sense that those implants would give me some vertical length and some lateral.  He said he would refund me the cost because it was a revision and it took him very little time. I was just supposed to pay for the costs, but he has disappeared. I came to him because he was recommended to me by other plastic surgeons.  The original 7mm implant was not terrible; he just shouldn’t have shaved them off.  When I compared the medpor 11mm to the 7mm, I realized that the only difference between the two was laterally and not vertically.   This is the reason why I didn’t want to replace the 7mm for the 11mm ones. 

The Idea of having the shaved off medpor 7mm ones plus the 10 mm silicon ones made sense to my uneducated thinking at the time. He said that that would give me what I was looking for. I do not look terrible per say, but I feel that I went backward to my original vertical length look, except wider. 

I want to talk to you via Skype so that you can see me. I wonder if by taking out the current contour silicon implant and replacing it with a vertical length silicon implant would be a solution for me?  

I did not need much at all!!! Just a tiny bit of vertical length. That’s all. I was not looking to have a huge strong jaw. I just wanted the angle to look a bit as if coming from the back of the face at about the level of my mouth.  Just some symmetry and nothing major. All the forums and guys whom I had been talking to previously to the surgery agreed that I just needed a little bit vertical length and lateral. They are all disappointed and are furious to see what has happened to me. They did tell me to come to you, but I went for a revision. The original idea was to replace the 7mm for 11mm.  Once I was in it, it seemed too late. It’s just a bad situation overall. 

 I hope this helps and I hope to talk to you soon.

A: Thank you for detailing out your jaw angle implant and jaw angle implant revision surgical history. While it is seemingly complex and I have not seen any pictures of you, the answer as to who to proceed is much more simple. You have but three options:

1) Remove the overlay silicone implants and live with the result of the first surgery. You now have a better perspective on what that outcome is. This is an assured approach since you already know that result.

2) Remove both pairs of indwelling implants and replace with new true vertical lengthening jaw angle implants. While I don’t know the exact implants you have had placed, I am certain they are not actual vertical lengthening jaw angle implants. (as they are not yet commercially available and only I have access to them)

3) There is, of course, always the ‘nuclear’ option which is just remove what you have and return back to your original jaw shape.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Thanks so much for agreeing to do a revision rhinoplasty consult with me, I’ve followed you on Realself and I’m excited to get a professional opinion from someone who seems to be as well educated, concise, and thoughtful with answers as yourself.

I am a young female and in 2013 I had a primary septorhinoplasty to address some septum issues as well as improving aesthetically the dimensions of the nose. Pertinent to this first surgery, it might be noted that I have thicker and sebaceous nasal skin,and my septum was not visibly deviated prior to this first surgery.

Immediately following the operation, my nose was crooked, septum was deviated to my left and a year following that, my doctor recommended a revision in order to straighten it. That took place in 2015, and the goal for that surgery was primarily to straighten my septum and refine the tip/cut out some of the scar tissue that had formed.

After my revision which would’ve been close to two years ago now, my nose seems to have formed a significant amount of scar tissue and though I often use tape still for compression, my nose seems much larger, thus looking a bit more amorphous as well as still being deviated to my left side. Corticosteroids injected into my nasal tip were used about 3 times, starting 4 or so months after my revision up until about a year post-but none were used after my primary. I also did not realize this before a few months ago, but it shows in my operative notes that I had a graft placed.

My doctor has recommended a second revision full septorhinoplasty and suggested that he wanted to submit everything for insurance. A few months later I saw him again and during that visit he told me his plan for the revision was to straighten the septum and cut out scar tissue, which was basically the same goal as the first revision. I asked him what his thoughts on the use of steroids post op were and if he would be able to possibly trim the graft that he had already placed in the tip of my nose. He seemed particularly impatient about speaking with me and he just gave me a flat “no”. Further, I brought up something that he had actually told me before which was that my nostrils seemed a bit crooked, except this time he said that my jaw is crooked, not the nostrils. He recommended that in addition to my revision septorhinoplasty, he could do a reduction genioplasty to make my chin look more proportionate to my face. He told me that may help with the fact that when smiling, my upper central incisors don’t show, which makes my smile look not as full and suggested that he thought it would improve the aesthetically the proportions of my face.

My surgeon is a very well respected doctor in my area and specializes in septoplasty and rhinoplasty but I feel like it would do me well to get a second opinion from another physician to understand whether it’s worth having surgery and what my chances at success and options are. What I was hoping is that I could have someone look through all my pre/post op photos (I apologize for the quality, many were taken from my phone and many also have been redacted for privacy and taken from past posts in regard to my septum from the Realself website. I did, however, try to include a wide variety of photos in different lighting and angles to hopefully give a more clear visual), read the operative notes, and scan my xrays and help me understand

a. whether or not I’m a good candidate for either a secondary revision septorhinoplasty or
b. a genioplasty surgery, or
c. something else in addition or in lieu of those, that would in your opinion benefit my face aesthetically.
d. whether my jaw looks crooked and if it could be corrected
e. What your suggestion would be in regard to how to aesthetically improve the proportions of my face
Thanks so much for taking time to consider my situation and help me figure out the best course of action for deciding on my potential surgery. Looking forward to hearing from you.

A: Thank you for telling your surgical story and sending all of your pictures. In short, the answers to your questions are fairly straightforward.

1) Your nasal tip is crooked with nostril asymmetry. This is not going to improve without further surgery.
2) Your jaw, however, is straight.
3) Do not, under any circumstances, do anything to your chin. Your jaw is straight and you do not need a chin reduction. That will not aesthetically help your face. The focus needs to be on improving your nose through a revisional rhinoplasty.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, thank you for your time in creating these  rhinoplasty images.  I now feel a bit hesitant in performing the procedure though, because I just don’t see a very substantial result from the before and after pics.  I still feel like the bridge of my nose might be too broad, as well as the tip, and the nostrils.  I suppose that I am expecting an end result to be that I don’t have a big nose. Of course I don’t want to go the Michael Jackson route, but do want a bit more significant reduction. I am not sure if I am adequately expressing my interests, so please let me know if I need to elaborate more.  I also feel like the jaw line may not be what I was hoping for.  I really wanted a hypermasculine, chiseled jaw look, but I am not sure if that’s possible in my scenario.

A: The purpose of computer imaging is to serve as a point of discussion about realistic goals and expectations as well as the type of changes the patient is seeking. It is not necessarily an exact replica of what the final outcome may be. (it is just Photoshop and pushing facial contours around on the computer) That being said, it has served its initial purpose in regards to your nose and jaw as follows:

1) A reductive rhinoplasty result is always heavily influenced by the thickness of the skin on the nose. It is always going to be less than most patients want particularly in the thick skinned nasal patient like yourself. It doesn’t matter what is done to the underlying osteocartilaginous framework, those effects will be blunted by the thick layer of overlying skin. This is particularly true in the nasal tip. While you can achieve some further reshaping of the nose you have, it is not going to be dramatically different and you can not have much of a smaller nose. Therefore in any type of rhinoplasty you may undergo, the result is always going to less than what you ideally want. if you approach any further rhinoplasty with that concept in mind, you will not be disappointed. Any expectations higher than a mild to moderate reshaping result will be result in dissatisfaction with the outcome.

2) Conversely, any augmentation procedure like the jaw angles is exactly the opposite of that of the nose. That result is controlled by the style and size of the implant. Such a result can be modest or dramatic depending upon the implant chosen. For the sake of the initial imaging I have chosen a modest widening jaw angle implant. Much larger and more dramatic implants can be used. But it still remains unclear to me, at this point, what your visual representation of a hypermasculine jaw look is. What I do know is that you don’t have the face for a ‘chiseled’ result because that takes a very thin face with little fat which is not the type of face you have. That is likely not a realistic outcome.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I am interested in the custom jawline implant because I had a mentoplasty and I am still not satisfied with the result. I want to have a much stronger jawline and I think this is the way to go. or maybe just jaw angle implants might be enough so I would like to discuss what would be the best solution for my case.

You can see in the pictures even though they were taken after the mentoplasty my chin is still pretty weak and the jaw line is a mess. a weird bump formed because of the implant which is why I liked the idea of the full custom jaw implant.

I am also a bit curious about how that one is placed. I know the angular jaw implants and the chin implants are relatively simple procedures because it is a small incision inside the mouth in both cases. But with the bigger implant I’m curious as how you can get the whole thing in.

Thanks.

A: For your information even standard chin and, in particular, jaw angle implants are not simple facial implant procedures. Do not let the small size of the incision and or its location belie the challenges for a successful implant placement and outcome. That difficulty is ratcheted up for a custom jawline implant even though the identical incisions for standard chin and jaw angle implants are used. There are a variety of techniques for placing custom jawline implants that I have developed to keep the incision lengths down to acceptable size.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I asked question on Real Self and you gave me a response, I appreciate it. My question was regarding cheek augmentation as I wanted my cheeks to laterally protrude a few mm past the widest part of my forehead. You said that there was a special type of implant that would give me this result, but I can’t find any pictures online. I was wondering if I could see some before/afters so I can really gauge if it will give me the augmentation I want.

Again thanks for taking the time to answer my question on Real Self and actually answering my question. I feel like many docs don’t even read it with the answers they give.

A: The style of cheek implant to which you refer is a zygomatic archcheek  implant. The reason you can not find it online is because it is a special design facial implant of mine and no other plastic surgeons are doing it or even aware of it. Due to patient confidentiality concerns I do not pass out patient pictures. But to help you better understand what the implant looks like and the specific cheek area that it augments, I have attached an intraoperative image of the implant and its specific zygomatic arch location.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m not completely comfortable with the jaw implant width that I currently have. You mentioned that a custom implant was the only option to achieve the vertical 11mm and still add more width. I would like to talk about this option before you procure the other implants. Do they make semi custom jaw implants as well?

A: When it comes to any facial implant, determining the dimensions of the implant to achieve any desired facial effect is as much an art form as a science. There is no way to know beforehand whether any implant choice will create the external effect that you want or whether it is even capable of doing so. Computer imaging tries to help in that role but in the end it is still a judgment with the knowledge there are no guarantees about the outcome. The role of custom implants is that they exceed the style, shape and dimensions of any of the standard sizes. Whether you are better off with a custom, special designed or standard jaw angle implants I can not tell you with assurances. I have given you my best opinion in that regard already. All options for jaw angle implants are on the table.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just have a couple of questions about my jawline implant recovery. My swelling had been decreasing but has now been going back up and is at a peak high now and the pain is also increasing again at a high now (1 week post). I was just wondering if this is normal as I thought both swelling and pain would generally decrease over time?

A: Thank you for your very early jawline implant recovery questions. While it is true that recovery has a linear progression  (e.g., point B is better than point A, point C is better than point B etc), your understanding of the temporal sequence of this progression is inaccurate. The time points between levels of improvement occur by week of separation not days particularly in the early point of the process. It is very common for someone to have more pain at one week after surgery that the first postoperative day. You have incurred a major muscle injury to the face (the largest of the facial muscles) and it will take time to begin to have a real recovery. That has not really happened yet. Your symptoms would be more concerning if you developed a lot more pain and swelling three weeks or so after surgery when you had already had a lot of the facial swelling resolution. But at one week with less than 25% of any facial swelling resolved, your symptoms are common and not concerning based on your description alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was doing some research on skull reshaping surgery and came across this institution. The back of my head is very flat. It is from when I was a child, I was laid on my back too much before the human skill was done developing. I am 5 now. It really bothers me and I was 100% interested in a operation like this. I did not know that such a procedure existed and I was relieved that it does. It’s the back of my head. I had a few questions I was hoping to get answers. 

1. Is a material inserted in the back of my head were skull is suppose to be or is it injections were bone grows? 

2. Is this permanent? 

3. How long does the procedure take? 

4. What is the cost typically for such a thing? 

5. How much of a difference would it look from before and after? 

My goal is to have a normal looking back of my head.

A: Skull reshaping by occipital augmentation is best done by a custom skull implant placed on top of the flat bone. This is made from a 3D CT scan and is a permanent implant. How much the back of head can be brought out is controlled by how much the overlying scalp will stretch to accommodate the implant. This can be best shown by doing computer imaging on a side view picture of your head.

I will have my assistant pass along the cost of the surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an 18 year-old daughter who is a 36H cup. She has increased headache and back pain with rashes due to weight and size of her breasts. Would you perform breast reduction surgery at age 18? She has seen her pediatriciian and gynecologist who both gave me your name. Thank you in advance. I had my breast reduction and it changed my life for the better. I waited until age 26 but had issues for years. I would love to make appointment  but wanted to see if you had age limit or need to do a person to person case review.

A: There is no problem performing breast reduction surgery at age 18 or even younger. The surgery is performed when the symptoms warrant it regardless of age. It is well known that female breast size and shape will change throughout a woman’s life, they are not stable anatomic structures. While there is always the risk of potential regrowth when breast reduction surgery is done in teenagers, avoiding surgery for that concern dooms the patients to symptoms that could otherwise be improved much earlier.

Given the size of your daughter’s breasts and her symptoms, there his no question that breast reduction surgery can and should be done at her current age.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom jaw and cheek implants (the one that covers the entire cheek area to achieve the “male model” look. After extensive research I have decided that you are the best surgeon for these procedures so I will be definitely visiting you.

I would really like you to answer a couple of my questions about the procedure though.

1. What is the total cost. As far as I know a custom chin implant can be up to 9000$ and the cheek implant 15000$ for a maximum total of 24000$. Am I right?

2. I live in Europe so I would like to know about the entire travel. As far as i know I should visit you 1.5 months before the procedure to have the implants designed.

How long will I have to stay in the US for that first trip? Can I get the CT scan there?

3. For the second trip how long will I have to stay in the US? After the procedures what are the recovery times? How much time until I look normal again and how much time until I can see at least 90% of the final result, how much time until 100%?

4. What about the pricing plans? Can I pay over a period of 24 months? If yes will there be any interest?

A: Thank you for your inquiry. The first place to start is to see whether you truly need custom jaw and cheek implants or whether any of our special designed facial implant styles may suit your needs. Special design facial implants come from a inventory of many other patients who have had custom implants made and I will occasionally use them when what the patient wants to achieve can be done just as effectively in my opinion as a true custom implant. Thus I would like to see some pictures of your face for my assessment and computer imaging to see what is possible.

For custom facial implants implant designing is done from a 3D CT scan which you can get where you live and have it sent to me. You do NOT have to come here for the scan. That scan is then used to design the implants which is done online and a process that I do elicit patient input during the implant design process.

You would come here just for the surgery and could probably go home in a few days after the procedure. It will take about 2 weeks until you look fairly reasonable and will be more comfortable in public. The full facial recovery process is one that takes closer to 6 to 8 weeks.

For the sake of some cost information education, I will have my assistant provide you next week the cost of two custom facial implants performed during the same surgery.

Dr. Barry Eppley

Indianapolis, Indiana