Your Questions
Your Questions
Q: Dr. Eppley, I recently consulted with another surgeon about facial reshaping surgery and his recommendation was to 1) shave down/narrow the chin (as I find it to be too broad) 2) insert implants to create a more angular jawline (in addition my left side is noticeably undeveloped and 3) fat transfer to my cheeks to create more fullness. I am very much at the stage of booking the procedure but i have read a lot of reviews about Dr Eppley (most particularly in regard to these specific procedures) and I would be very keen hear his thoughts..Looking forward to hearing from you.
A: While I would largely agree with those general facial reshaping concepts I would do some of the three procedures differently. Chin narrowing can be done by either shaving or t-shaped intraoral osteotomies. Depending on the type of chin change you are seeking, the latter is usually more effective. Jaw angle augmentation depends on whether width, vertical lengthening or some amount of both are needed. That determination can not be done based on a frontal picture alone, it takes oblique and side view images as well to see who such jaw angle changes would look. I would not use fat for your cheek augmentation. You are too thin to have that work very well. Cheek implants are more predictable and long-lasting. What style and size of cheek implant depends on the type of cheek augmentation change you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering breast implant removal. I have bilateral breast implants and now they are encapsulated the left is going under my armpit when I lay down. My insurance is paying for removal of implants and encapsulation removal. My Dr said it would cost $7000 to have new ones put it. I can’t afford that as I’m on Medicaid. I can afford the cost of implants themselves but not for the surgery room, anesthesia and the drs work even though I’ll already be having the other surgery paid for by insurance. My question is how bad will I look after this surgery. I’m so depressed and scared that I’m going to look deformed again.
A: I can not really answer your question without seeing pictures of your current breast situation. But it would be fair to say that the removal of breast implants does not usually return one to their pre surgical breast look. One’s breasts will usually appear worse than they originally were due to the stretched out skin and loss of further breast tissue. This if you felt that your breasts were deformed before the implants were put in then it is very likely that you will feel more so when these implants are removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast fat transfer. I am average in weight and size (5″8 and 137lbs), but seem to develop fat around my obliques (stomach and lower back) and arms much more than the rest of my body; plus I have very small breasts and buttocks. I am very healthy and no matter how much I work out and eat a great diet, those areas of fat won’t budge. I would like to transfer fat from my stomach, lower back, and arms toward my breasts (and possibly my butt depending on the cost). How experienced is your team in breast fat transfers, because I know that it takes multiple people to keep the fat alive while transferring it?
A: While any fat harvested from liposuction can be used for transfer, it is not likely you will have much to actually put into the breasts. And most certainly there would not be enough for both breasts and buttocks. Thus you would need to concentrate any fat harvested for your breast fat transfer.
To give you some perspective on what success breast fat transfer may achieve in breast augmentation, it is important to understand the ‘halfing’ rule. The relevance of this is in getting a visual idea of how much breast size increase may realistically be obtainable. To start let’s make the basic asssumption that it takes about 150cc of fat (or an implant) to make a cup size difference. I will assume based on your description that between the stomach, arms and lower back you may have 1200ccs to harvest. (and that may be a generous estimate but I will use this number) When this amount of liposuction aspirate is then concentrated during surgery (and it is not true that it takes multiple people to keep the fat alive), it usually amounts to in women that around 40% will be end up being concentrated fat and available for injection. This leaves 480cc to be evenly divided between the breasts or 240cc injected per breasts. Then one can estimate that only 50% or half if the injected amount will survive or 120cc per breast. (the percent survival could be higher or lower…but it is almost always lower and rarely higher)
In conclusion you may be able to get a 1/2 cup size breast increase and that is if you can get 1200ccs aspirate and 50% of what is injected survives. The point being is that you might as well take whatever fat is harvested and use it for transfer into the breast but at best the breast augmentation result will be very modest in size. It is important, therefore, to have very realistic expectations. I would consider your procedure as liposuction first and anything that comes of the breast augmentation efforts as a bonus result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about rib removal surgery:
1. Is the surgery life threatening?
2. Is the surgery considered major surgery?
3. Once the ribs are removed, what negative aspect does that subject your body to, if any?
4. What is the procedure as far as surgery, hospital stay, aftercare, and recovery time?
5. Is the surgery performed in a hospital or the doctor’s clinic?
6. What is the price of the surgery? Does that include aftercare?
7. Are there any additional costs and what would they be and if applicable what would they be
8. How many rib removal surgeries has the doctor performed?
9. Looking at the before and after photos I provided, does the doctor feel he can achieve the result provided in the after photos with the rib removal surgery?
A: In answer to your questions about rib removal surgery:
- The surgery is most definitely not life threatening.
- It depends on how you define major surgery. Compared to surgeries like breast augmentation it would be considered major. But compare to surgeries tummy tuck and BBL surgery, it would be considered less severe.
- I am not aware of any negative aspect of rib removals other than the fine line scars it takes to do perform the procedure.
- This is done in a private surgery center under general anesthesia as an overnite stay.
- It is done in neither a hospital or a clinic but in a surgery center.
- My assistant will pass along the cost of the surgery to you tomorrow. Whether you need any aftercare or not depends on whether you are traveling along or with someone.
- The surgical quote will be all inclusive of the surgical experience.
- I have removed hundreds of ribs for a variety of body contouring and recostructive surgeries.
- I do not think the result you are showing is realistic unless you do a lot of additional waist training after the surgery. By itself it can produce about half of your imaged result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had contacted you about a year ago about my occipital knob reduction surgery. I have since been saving money for this procedure with you. I have also been following procedures you have performed and posted on your website. One that I found very impressive was the occipital implant with knob reduction using a custom implant. I have taken some more profile pictures and played around with possible outcomes. I have attached those to this email. If you could please give me your suggestions and opinions on this that would be great.
A: Good to hear from you again. What you have shown would be a beautiful addition to your occipital knob reduction since you really have a combined occipital problem of a lower protrusion (occipital knob) and an upper deficiency. (occipital flatness) Normally an occipital implant is done by a custom approach using a 3D CT scan. But I have done so many of these occipital implants that in some cases, to save money and still get a good result, I will use another patient’s occipital implant design. (this is known as a semi-custom implant) That saves a fair amount of money and the shape of the flat back of the head is only minimally different amongst most patients as long as there is not a significant occipital asymmetry. The implant is also flexible so there is a lot of give for its fit onto the bone. (once on the bone it feels hard just like bone however)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for reversal jawline reduction surgery to undo my prior V-line jaw reshaping. I have sent you a 3D CT scan. Cal you tell me what procedures I need to get back the jawline that I had?
A: I have reviewed your 3D CT scan and I can now report on what was done on your jawline reduction procedure. You had a straightforward sliding genioplasty of maybe 5mms advancement. (very small) There were three plates used for its fixation. No width reduction as done on the chin, it was simply brought forward. There are no appreciable changes to the rest of the bony jawline. The jaw angles remained structurally intact (no amputation of the angles) There may have been some burring done for a little width reduction but not much.
In conclusion your reversal jawline reduction procedure to return you as close to where you were before would consist of the following:
1) Reversal setback genioplasty
2) Width only jaw angle implants of a small size. (3mm)
Based on the 3D CT scan I do not see the benefit of making custom implants. The chin needs to be set back and performed srandard jaw angle implants can be used too restore the jaw angle width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been researching Kybella treatment for my moderate jowl laxiity. I consulted with a plastic surgeon and he rejected me suggesting that I lose weight. I am 53 years old, 5’6″ and weigh 150 lbs. I averaged 127lbs through my 40’s to the present. I have great confidence in my dermatologist and she has recommended two treatments of Kybella,and has told me there is a 4% chance of a temporary drooping of the mouth. Most of my research says that Kybella is not recommended for the jowls. I am writing to you because you are the first I’ve come across to suggest that it can be effective for that area. Could you tell me with your experience to this date, if you still think it can be relatively safe and effective in smoothing a mild/moderate jowl sag? Many thanks in advance for your response.
A: The concept of injection lipolysis (Kybella is the one brand name for now) can be done anywhere there is fat. It is not a question of whether it can be done but whether it will be effective and has a low risk of problems in doing so. Thus the jowls can be injected and some mild improvement may be capable of being achieved. It will not be as effective as small cannula liposuction or even a small jowl tucked however. The risk of injecting the jowls is injury to the marginal mandibular branch of the facial nerve. Such injury will not cause month drooping but rather will cause lower lip elevation and smile asymmetry. Such an injury can occur from the intense inflammatory reaction that the injected deoxycholic acid solution causes. Such a reaction occurs in a 1 cm zone around each injection site. As long as one stays well away from the marionette line area of the chin this complication can be avoided. I have never seen it occur in the patients I have injected.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial fat grafting. Can volume loss in face due to no back teeth for a number of years be restored for a fuller face by the use of fat grafting?
What method of fat removal do you use?
What harvesting method do you use?
What is the cost?
Will my face be widen from this procedure?
Can a brow lift be performed at the same time or will fat injections serve the same purpose as a brow lift?
A: Thank you for your inquiry. In answer to your questions:
1) The area to which you are referring ( the soft tissue trampoline area between the cheeks and the jawline) can only be augmented by facial fat grafting. This is a non-bony supported area so only soft tissue augmentation will work.
2) and 3) There is only one method of fat graft harvest and that is by liposuction aspiration.
4) My assistant will pass along the cost of the procedure to you tomorrow.
5) Your face will become fuller/more convex in the soft tissue area between the cheek and the jawline.
6) Facial fat grafting is not a substitute for a browlift. Adding fat to the brows will not lift them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested midface implants. Two years ago, I had a Lefort surgery to advance my upper jaw. I plan on getting a rhinoplasty at a future date. At the present time, I am only interested in getting facial implants to augment the tear trough/cheek areas and the midface. Specifically, I am interested in knowing if I am a candidate for a premaxillary implant and if premaxillary implants are often used on patients who have already had orthognathic surgery. Thank you for your time.
A: In my experience it is not uncommon at all to have patients who have undergone a LeFort osteotomy to subsequently want midface augmentation with implants. This is because, as you have experienced, the Lefort I osteotomy essentially moves the teeth and the lower nasal base forward (or upward) but leaves the rest of the midface ‘behind’.
The key question about midface augmentation is whether standard preformed midface implants will suffice or whether a complete custom midface implant is needed. Standard midface implants include cheek, tear trough and paranasal/premaxillary implants which augment the respective names areas. A more complete total midface implant is designed to create a total augmentation from the infraorbital rim/cheeks down to the lower level of the pyriform aperture/maxilla.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know that the Hydroxyapatite in the world using only a few professional surgeons. But I know that it is difficult to remove if something goes wrong. PMMA bone cements is more cheap than hydroxyapatite but how much it’s better ? I do not like silicone implants. Their many uses silicone implants since it is easy for surgery but I do not feel that it will give a nice aesthetic effect. And now I am confused choosing between hydroxyapatite or PMMA bone cements.
Could you explain please what is better to use and advantages and disadvantages between . I still do not really understand A: You have several misconceptions about the materials. Hydroxyapatite is fairly easy to remove just like PMMA and silicone implants. In the brow bone area PMMA produces a better aesthetic shape and is easier to place in that area to create the effect. Regardless of the material used, the aesthetic result is based on its shape not the material composition. Quite frankly the best way to brow bone augmentation is a 3D silicone implant made from a CT scan. It is best because the shape and dimensions of the brow bone augmentation is designed and controlled BEFORE surgery. The surgeon’s job then is just to place the implant correctly. All other materials, such as hydroxyapatite and PMMA, require intraoperative shaping and that is far less precise.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal artery ligations. I am talking to a couple of consultants here also and plan to make a decision once I have all the information I need. It appears that you are the most experienced on this procedure – would you mind informing me how many you have done on the past? My main concerns are around potential scarring and hair loss.
I first noted the prominent temporal arteries appeared about six months ago – first on the left side and most recently on my right temple. No idea what is causing them and have not been able to find out but I do get a throbbing/ shooting sensation in them most of the time.
Would the surgery eliminate the throbbing sensation I get as well as the appearance? I have attached pictures for your reference.
A: In answer to your temporal artery ligations questions:
1) I now perform about 1 to 2 temporal artery ligations per month from patients all over the world.
2) The incisions to do the procedure are very small (around 5 to 7mms) and usually heal imperceptibly. Whether you need just one proximal ligation (one point) or a combined proximal-distal ligation (two point) can not be determined until during the procedure. (The vast majority of patients receive a proximal and distal ligation) I have yet to have a patient have an issue with the scars. (at least a patient that has ever told me so)
3) Hair loss is not an issue with this procedure. It has not been seen or reported.
4) With a reduction in the temporal artery flow I would think that the throbbing sensation would decrease or be eliminated. That is what most patients who have these symptoms so state afterwards
5) Your pictures show a classic pattern of an enlarged anterior branch of the superficial temporal artery with its typical snakelike pattern coursing towards the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a subnasal lip lift. I’ve measured my philtral length from the base of the nose to the upper vermillion border and it is 16mm. I know this isn’t a great distance but it looks large on my small face. I suppose following the 25% rule, 4mm of upper lip shortening would be germane. Am I correct in saying that making the philtrum 4mm shorter will result in 4mm of extra upper vermillion pout to make up for the distance? This does appear to be a lot, but I am not sure how it works. The examples I linked appeared to show very little increase in vermillion show compared to the reduction in upper lip length.
A: In a subnasal lip lift, It is not a direct correlation between the amount of skin under the nose removed and the amount of lip increase that occurs below. Usually it translates to less than 50% and often just 25%. This means that about 1 to 1.5mms of central pout lip increase occurs for a 4mm or 25% vertical lip length reduction in your cases. It is important to remember that tissues do not respond like a block wood. They are elastic and stretch which is why it is not a 1:1 correlation as one would understandably think.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in numerous facial augmentations particularly brow bone augmentation. I saw your work and thought you did an amazing job on your patients. I have struggled with my eyes my whole life and I am trying to obtain a more “masculine” look. I put a word file together to so you what I am trying to achieve. There is this male model who I think has similar features to me and I would like to have some of his features (especially in the eyes). I was even thinking I need an infraorbital rim implant. Hope to hear from you soon!
A: Thank you for your inquiry and sending your pictures. In comparing the two pictures, what you ‘lack’ is a downward brow bone protrusion, fuller supraorbital sulcii, broader cheek/zygomatic arches and a less recessed infraorbital region. There are two fundamental strategies in making these facial changes:
1) Fat injections for all of the above facial areas, or
2) Brow bone/cheek/infraorbital implants for augmentation with fat injections to the supraorbital sulcii.
Facial augmentations can be done by these two methods and each has its own advantages and disadvantages which are well known and come down the degree of invasiveness, amount of recovery and potential permanence of the results. My preference is usually for implants because they offer permanency and can be custom made to fit the patient, which are both major advantages even though they are more invasive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been made aware of the upper subnasal lip lift, and its ability to make the upper lift shorter. I know that this is a commonly performed procedure. However, as far as I understand, it mainly performed on women who desire increased upper lip pout. In my case, I am looking for a decrease in the distance between the base of the nose and the upper vermillion. My aim here, however, is to minimise the amount of visible pout of the upper lip. To that end, Dr. Eppley, are there any techniques forming part of the lip lift that you aware of that can minimise upper lip pout whilst reducing the philtral length as upper lip pout is not attractive male trait? This aim seems to have been achieved with stunning effect in the attached images. In both of these images (one being your own of course), the philtral distance was reduced, with very little change to the overall shape of the upper lip itself (of course some upper lip fullness is visible but it is not very noticeable and doesn’t detract from the overall result in any way).
A: While there are more women than men that get lip lifts, men do get them as well. It is inevitable that there is some change in the upper lip pout with any subnasal lip lift. The key is what percent of the total vertical lip distance is removed that determines how much the lip pout is changed. As long as the vertical lip distance is not reduced more than 25% the change to the central lip pout is minimal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m so glad that I found your website because I’m searching for a surgeon who can answer me this question.I’m a skinny person and I have a 17 inch neck and it looks very thick on me and I don’t like it. It’s just naturally that thick. I don’t know my body fat right now, but I don’t think that I have a lot because I’m already skinny and there is no fat around my neck, it’s all just muscle. So is there a surgery or anything else that can shrink my 17 inch neck to a 16 size?
For example is it possible to shrink the sternocleidomastoid muscle on both sides by 1 cm? I saw a before and after picture on a website of a woman who shrank her trapezius muscles through Botox injections. If Botox can shrink the trapezius muscle it should also work on other neck muscles like the Sternocleidomastoid muscle. But using Botox on large muscles to shrink them could be dangerous. I really want to lose at least 2 cm from my neck muscles. I know it sounds crazy but it’s really my biggest wish to have a thinner neck. So is it even possible to shrink my genetically large neck muscles?
A: There is no surgical technique to reduce the size of the neck through removal of part of the muscle. While Botox can be injected into any muscle, I have no experience with injecting it into the sternocleidomastoid muscle. Like all other muscles treated with Botox, muscle mass will shrink at least temporarily provided the dose of Botox administered is adequate.. I see no reason why the sternocleidomastoid muscle would be any different in this regard.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom cheek implants. I have attached a photo of how I am right now and a photo that shows how I want to make my cheeks look like. I was wondering If I can achieve this look with these implants that you are offering. Also I was wondering if these implants also cover the area of the infraorbital rims because I also want to achieve more squinty eyes. What other surgery do you suggest that I do based on my before picture in order to achieve the best look?? I will definitely be visiting you in the next year because I have heard very good words about you…thanks in advance Dr. Eppley.
A: Custom cheek implants can be designed based on the effects one wants to achieve. Just like make the back part of the cheek implant go back close to the ear, the front part of the implant can be extended to go across the inferior orbital rim as well. I believe that such an implant design can create the facial effects that you have shown by your own imaging. I think this one implant deign would be all that you would need to create your desired midfacial improvements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. I have a silicone nasal implant and a PTFE forehead implant. While I like the improvement from my forehead implant, it has the unintended consequence of making my nose look too sunken in.
As such, I’m looking at a revision rhinoplasty to give me a higher bridge. I’m also looking for some extra glabella augmentation. After doing some research, I have narrowed it down to either a rib graft or GoreTex. However, this is where my dilemma arises, and I have a few of questions:
– Are you comfortable with using either of these materials for a revision?
– Between a rib graft and GoreTex, which implant material do you think will provide the best aesthetic outcome?
I have read a few people comment that GoreTex can provide more customizable results – do you think this is true?
– Lastly, would there be any issue if either nasal implant material overlapped with the current forehead implant?
Thank you for your time!
A: While both a rib graft and Gore-tex material can be used to augment the radix/glabellar region for your revision rhinoplasty, it would make the most sense to use an alloplastic material since a portion of it will be resting up against the forehead implant material and the lower portion on top of the silicone implant. It would also offer intraoperative adjustability, permanency and the best chance for a smooth transition of the lower forehead into the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have prominent ‘ridges’ in the temporal region of my forehead (see example in attached image). Please could you advise on my options for reducing the prominence including thoughts on best method for a good outcome, either as a one off long term correction or ongoing ‘management’ and associated costs, and the degree of confidence in achieving a good outcome.
A: What you are referring to are the anterior temporal lines along the sides of the forehead. They are the near 90 degree transition between the sides of the bony forehead and more vertical temporalis muscle. They represent the attachment of the temporalis fasica and muscle to the side of the forehead. Temporal reduction in appearance can be done by either direct reduction by bone burring or augmenting the upper temporalis muscle with either injectable fillers, fat injections or temporal implants. The choice between reduction vs augmentation depends on how you want the contour of the side of the forehead/upper temporal region to be.
It would be easier to reduce the appearance of the temporal lines by augmenting the upper temporal region by either fat injections or extended anterior temporal implants. Bone burring will require an incision for access which is hard to hide in the forehead/frontal hairline region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a few questions regarding jawline augmentation. I’m looking for a custom wraparound implant to enhance my lower third, and and give me that sought after “male model” look. Angularity and sharpness are very important to me, and from my research online I was hard pressed to find very many implant results that showed the angularity/sharpness that I was looking for. My question is if an individual had an acceptable body fat (8-10% or lower), and started off with an average jaw/chin could something like the two photos I have attached be reliably achieved by a skilled surgeon like yourself. Secondly, are implants the best route to achieve this look, or should should other procedures be considered. Thanks and have a wonderful day.
A: The key to getting great jawline angularity from jawline augmentation is that one has to have the right kind of face for it…meaning a very lean face with little fat….just like the two pictures that are have attached in your email. A custom jawline implant, whether it is three separate implants or a single piece, is the only way to achieve this degree of jawline angularity since no standard chin or jaw angle implants are designed to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Eight year ago I had a sliding genioplasty, and it left me with an unpleasant rounded shape in the center of my chin. Six years ago I had the plates removed, and the chin’s unpleasant shape remained as it was.
I have contacted local doctors about correcting this shape, but none seem too confident that it could work. From doing research online, it seems like I may have chin ptosis (I certainly have the same droopy look) although I’m not sure if that’s accurate.
I am wondering if you who has expertise in this type of issue, believes that it can be corrected with a high chance of success.
I have attached some photos for illustration. In the picture with 3 images, the first is before anything, the second is after the sliding genioplasty but before the removal, and the third is current.
In the picture with two images, both are current and show the chin dimpling that I have.
I would greatly appreciate it if you could let me know if you think there is a good chance that I could return my chin to the pre-surgery look (in other words, where the base is flat).
Thank you very much!
A: You do not have chin ptosis. The chin shape you currently have is that of the bone which now appears more narrow/tapered because of the forward movement of the chin bone. This is a very common aesthetic sequelae of a sliding genioplasty…which is usually fine for a female but may be bothersome for some males. The only way to treat this shape is to round off the front of the chin to be flatter.
The chin dimpling issue is difficult to treat but it is best done by release and fat grafting at the same time as the chin shave.
It is important to realize that you are never going back to the chin the way it was before the sliding genioplasty. It is just a question of how much improvement can be obtained towards that goal. I can provide you no assurance of what the degree of success would be…the surgery should be viewed as a gamble and only undertaken with full acknowledgement of that aesthetic risk.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting deltoid implants. The look that I am going for is aimed at the appearance of wider shoulders to improve my waist-hip ratio, rather than increasing the overall mass of the deltoid muscle. So I have two questions with respect to that:
1) If a custom implant is used, what is the limit to how wide the shoulders can be made?
2) Is the width created by the implant independent from the width potentially created by muscle hypertrophy? In other words, if I achieve lateral deltoid hypertrophy through weight training after having the implant placed, will my ‘new width’ be the implant size + any new muscle size I have gained?
3) If a subfascial implant is used, will it a) show up unnaturally if I drop down to 8% body fat or so, and b) obscure any potential aesthetic definition (such as muscle striations) that I might otherwise obtain with low body-fat?
4) From an aesthetic standpoint, do you think that there can be too much shoulder width?
5) Another concern is that the implant may make the shoulder muscles look too big; so I think I am asking whether there any techniques that can be used to maximize the perceived width of the shoulders while minimizing the perceived size of the deltoid heads themselves, i.e. I want the width but not the unnatural and disproportionate deltoid size.
A: Almost all deltoid implants have to be made in a custom fashion since there are no true preformed deltoid implants available. When placing deltoid implants the limitation of its size is based on how much the overlying fascia can stretch as well as the length of the incision used to insert them. Any muscle hypertrophy added after the implants are placed will create a cumulative effect.
The deltoid area has a fairly thin subcutaneous layer so low levels of body fat may expose the outline of the implants.
I cam certain there is a limit to how much shoulder width is aesthetically pleasing. But the more important issue is having an implant that blends in well to the surrounding tissues regardless of its size.
I think when you are trying to create a distinction between muscle size and shoulder width you are trying to make a critical difference which does not exist. Deltoid implants, or any body implant for that matter, just isn’t that specific. Deltoid implants create a indistinct mass effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I will eventually be having a cosmetic surgery to correct my recessed chin and have started to look into the nearest and most reputable institutions that perform sliding genioplasty surgery. Yours was one of the most promising I have come across thus far and will likely be one that I consider. I would like to know, based on the two pictures I have sent (very limited information I know), what type of procedure you feel would be most efficacious. I feel that my chin is adequate in terms of height and structure and the only improvement necessary is postural. I would greatly value your assessment.
Thank you for your time should you choose to read and respond to this.
A: Thank you for your inquiry. Your chin is of adequate height but still a bit horizontal short because you have a fairly steep mandibular plane angle. The most aesthetic treatment would be a sliding genioplasty to bring your bony chin forward with a slight bit of vertical shortening. (which you can aesthetically tolerate. Computer imaging would confirm to you how that chin change would look so you could determine for yourself if such a change is beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been experiencing a feeling of discomfort and pulsation from the facial artery on the left side of my face for about 3 years now. I have been to vascular doctors and when they report nothing wrong with my blood flow they dismiss it like its nothing. I have been dealing with this problem for a long time and I feel like I can’t live my life or function because of it. Apparently most doctors see my problem as nonexistent. But i saw that you had a case study on “Facial Artery Ligation for Prominent Pulsations”. And all thesymptons you described are exactly what I am experiencing. The blood vessel is noticeable on my face. The pulsations are annoying, although not painful, and I feel like it also effects the way I smile. I need advice. You are the ONLY DOCTOR I have researched that seems to know about/ how to fix this problem. Thank you.
A: I certainly have treated multiple patients with prominent and/or symptomatic facial pulsations with facial artery ligation. The case study you have described is a good illustration. Please send me some pictures of your face where the location of the problematic facial vessel is. By your description it is located just to the side of the mouth, just as was described in my case study. That is the facial artery as it crosses up into the face and is the location where it usually bifurcates into the labial artery as it continues to head northward towards the nose. This is the facial artery ligation location that is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle implant removal surgery last year, and they were removed early this year. The biggest issue is the disruption of my pterygomasseteric sling which is most noticeable when I clench my teeth.
Anyway, after a fair bit of research online, I’ve since accepted that it is not possible to fully fix this. My question is – could fillers be used to camouflage or minimize the disruption? If so, would Radiesse or Sculptra be suitable fillers? Finally, what would be the longevity of these fillers and how much will they cost?
Thank you!
A: Reattaching a contracted masseter muscle after jaw angle implant removal is certainly a challenge and usually only partially successful. How well the masseter muscle can be pulled down is a function
Filling in the muscle defect below the new level of the masseter muscle can be done by injectable fillers or fat injections. The first thing you want to do is to use a hyaluronic-based filler (e.g., Juvederm XC, Voluma) as this has the least risk of irregularities and has an assured dissolution time or can be reversed by hyaluroidase injections in the event that you do not like the result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had orthognathic surgery last year. (LeFort 1 osteotomy) This has left me hanging soft tissue, no jaw line, crooked nose, enlarged nostrils, flared nostrils, toothless smile, thin bottom lip and can’t even close my mouth without feeling pain, as though someone is pulling my chin backwards through my skull.
A: While I am just looking at a front view picture, you have many of the potential sequelae from the intraoral incision used for a LeFort I osteotomy which includes flared nostrils, widening of the nasal base and upper lip sag. This occurs because of the degloving incision and detachment of the facial musculature to the bone…not because the bone was moved back too far. (although that may be a contributing issue of which I can not speak since I don’t know the skeletal movements done) The nasal asymmetry can arise from a septal deviation caused by the bony movement.
Given that you are nearly a year after this surgery the soft tissue changes are stable. There are a variety of procedures to deal with these nasolabial changes from nostril narrowing, lip lifts and rhinoplasty surgery. Unless there is a significant bite issue, I would focus on the soft tissue issues and leave the jawbones where they are.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been looking into various procedures for augmentation of the upper face as the area surrounding my eyeballs is recessed in relation to the eyes. It is my understanding that the area surrounding the eye is comprised of the brow ridge (superior orbital rim), the lateral orbital rim (bone that extends from the edge of the brow ridge) and the inferior orbital rim (area under the eyes). One area which I am not sure about is the boney area that stretches around the side of the eye before joining the inferior orbital rim area, what is this bony area called?
I know that this entire skeletal area can be mobilized with the Le Fort 3 procedure, however this is not something that I would like to pursue due to the risk factors involved. My question is to what extent the effects of a Le Fort 3 can be replicated by the use of custom made implants? I know that implants can be used for anterior projection of the inferior orbital rim and the cheekbones, and that custom brow ridge and custom lateral orbital rim implants can be made. However, is there any way to advance the area of bone directly horizontal to the outside corner of each eye, to ‘encapsulate’ the eye so to speak from that side? Also, to what extent can the inferior and lateral orbital rims be reasonably advanced without it looking unnatural or proving problematic? Finally, what is the most economical way of combining custom implants to provide a total augmentation effect? So can a combined brow ridge and lateral orbital rim implant be fashioned etc.?
A: The inner orbital area is not a rim area per se. Rather it is comprised of the nasal and lacrimal bones as well as the frontal process of the frontal bone.
A LeFort III procedure does not change the entire orbital rim area. Rather it is a naso-maxillary-inferior orbital rim skeletal advancement. While this can be good procedure for you get children and even some adults that are affected by congenital craniofacial conditions, it is not an aesthetic procedure nor appropriate at any age for non-craniofacial anomaly problems for a host of reasons including its risks.
Custom onlay orbital rim implants would be the only way to safely and effectively augment all of these facial areas. The design of these type of orbital risk implants must take into consideration primarily how they would be placed (access incisions) and to make the augmentation look natural. That usually means not having them too big and having smooth transitions to the surrounding bone off the implant edges.
Such a ‘mask’ custom facial implant would be put in a segmentalized manner. How that would be divided is based on the access by which they are placed. Thus brow bone/lateral orbital rim, inferior orbital rim-molar, and maxillary-nasal base would be a three-piece approach to such a custom facial implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis repair. I had a surgery for chin implant one year ago. It was a silicone implant and surgery was done from inside my mouth. I also had a dimple in my chin which I asked the doctor to get rid of. He put the implant, but it was too big for me so the wound from inside my mouth wouldn’t heal. I had to get the implant removed just after two weeks of getting it done. He said I would have to wait six months until I could put a new one in. Somehow the dimple i had in my chin is not there anymore and my chin looks completely different from what it was before. It has been a year and a half now and I’m not happy with it. But during this year and a half, it seems that it got uglier from what it was before from when i just got it removed.
I only had the implant for two or three weeks as the wound wouldn’t close. The doctor tried to stitch it back a couple times but the stitches wouldn’t stay and I could literally see the implant when I opened my mouth. I luckily didn’t get any infection. He told me that I could get a chin implant again in six months but obviously I never went back to him since then my chin keeps getting a worse look, I don’t know what to do.
A: Thank you for sending your picture. What you have is true chin ptosis as you initially suggested. You have four chin ptosis repair options at this point:
1) Do an intraoral chin ptosis repair. This is usually marginally successful because you have both detached and some stretched out chin tissues.
2) Do a submental chin ptosis repair. This is done from below by removing the soft tissue overhang. It is very successful because it removes loose tissue but does so at the expense of a submental skin scar.
3) Do a combined intraoral ptosis repair with a small chin implant. This is more successful than #1 because it adds support low on the chin bone for the resuspended chin soft tissues.
4) Do a sliding genioplasty. This is like #3 but uses your own bone and not an implant to create the support for the uplifted soft tissues. This probably offers the most successful outcome of all options listed but is the most ‘invasive’.
The reality is that it will be difficult to go ‘back home’…meaning going back to where you started before the chin implant was placed. That is probably a complete impossibility. Options #3 and #4 offer the combination of creating a chin augmentation effect that you were originally seeking and also solving the chin ptosis problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a L-shaped silicone implant rhinoplasty donea year and a half ago. There have been no major complications, but I’m looking for a revision for a better aesthetic outcome. My biggest issue is that the implant seems too ‘narrow’, and I’m looking for a new implant that’s wider and longer to give me a more masculine nose. My questions are:
– I know that many surgeons favor rib cartilage, but I’m honestly not fond of such an invasive procedure and lengthy recovery (especially the scar). If I only want a synthetic implant material, which one would you recommend (silicone, Gore-Tex etc.)?
– Apart from my bridge, I’m hoping for a more pronounced radix and glabella. Could this procedure be done at the same time as the rhinoplasty?
– Finally, I’m looking to increase my nasolabial angle. Could a small implant be placed under my nasal spine to bring the base of my nose forward?
Thank you!
A: In your revision implant rhinoplasty the question is whether any standard nasal implant would suffice for your needs or whether a custom nasal implant would need to be made. I would need to see some pictures of your nose to make that determination. I believe all of your revisional nasal objectives can be achieved with a new silicone implant that has the right dimensions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in bicep,tricep, deltoid and pectoral implants all done in one procedure. I have a couple of questions about these types of body implants.
1. Are the solid soft silicone implants you use “gummy bear” (cohesive gel) style implants or more solid than that?
2. In your experience approximately how long would it be before someone (including intimate partners) would not generally notice the scar? A week (after the hair regrows?) or many months?
Thanks,
A: In answer to your body implant questions:
1) Body implants are made from a very soft (low durometer) silicone that is in a solid implant form. They are not gel-filled like breast implants which is very low durometer silicone put into a bag because it can not maintain a solid form. Body implants feel just slightly firmer than a contemporary gummy bear breast implant but only slightly so, They are design in feel to be like muscle tissue.
2) While you will always have fine line scars from the insertion sites they do got through a period of redness from which it takes months to settle down and look their best. Thus you should think of it a several month process, not one of a few days or weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in sliding genioplasty revision surgery. I had a sliding genioplasty done five years ago for aesthetic chin contouring. A subsequent fat injection was done over the lower margin of chin for further chin contouring a year later. Afterward, I have functional disorder of the lower lip and chin so I took my doctor’s advice on removal of miniplate and screw via intraoral incision. The disorders of the lower lip and speech persisted. So I took my doctor’s advice on steroid injection for scar adhesion release which provided no improvement and made it even worse.
Now I feel tight while talking and eating. There is a line between my lower lip and chin. Muscle below the line will rise and stick to the line while talking, therefore I have difficulty talking smoothly. Some doctors said since I have had two surgeries via intraoral incision, there may be something wrong with my mentalis muscle and scar adhesion. Please diagnose my symptom. If there is something wrong with mentalis muscle or possible scar adhesion or else, please help me, because you are a master in this field. I need your help. In fact, I don’t know what to do next. I hope to talk smoothly. I pray to God for it. Hope you can help me. Hope to receive your e-mail as soon as possible.
A: While I have not seen any pictures of your chin, your story is not unfamiliar to me. This sounds like scar adhesion/contracture in the chin soft tissues. This is particularly evident in the tight and deep labiodental fold. This is a problem of both and now lack of supple tissues in this area. In my experience treating this problem, I advocate for your sliding geniplasty revision releasing the intraoral adhesions over the chin bone and muscle and placing a dermal fat graft. This now only releases the tight tissues but brings in new and unscarred tissue to make the tissues more supple/soft.
Dr. Barry Eppley
Indianapolis, Indiana
