Your Questions

Q: Dr. Eppley, I am interested in a jaw angle implant revision.I want to remove both pairs of indwelling jaw angle implants and replace with new true vertical lengthening jaw angle implants. 

In your website, I saw the vertical lengthening jaw angle implants. I am not sure if they come in different sizes. I am positive that Vertical Lengthening implants are what I should have had implanted in the first place.The trick would be deciding on the size. From the profile view, you can see that the vertical length isn’t bad. The bottom part of the implant does go vertically far enough, but there is no mass at the bottom. This makes me wonder about the size we would have to use.  

The first Medpor implant did not have any effect from the front view. It did make a difference from the side view, though.  In my opinion, the picture where I’m sitting in the car, it shows that a could use some vertical lengthening and widening in the lower part of the face. I am not looking to have a very strong jaw, but in my opinion, it makes a big positive aesthetic diferrence when the angle is visible from the front view. It defines the face. 

A:Thank you for the additional information. Not knowing exactly what style and size of Medpor jaw angle implants you have in and where they really are sitting on the bone makes it very hard to know whether this is truly an implant style/.size problem or whether it is more of an implant positioning issue. A jaw angle implant can look quite different based on where it sits on the bone. You can’t tell just by looking on the outside either of those important issues which play the determining role in what new implant may be needed in your revisional jaw angle implant surgery. Therefore I would recommend you get a 3D CT scan so you can really know what you have in, where it is on the bone, and then know why it looks like it does on the outside. Just guessing on the implant exchange is a sure way to end up with another aesthetic problem…and the next surgery will likely be just as traumatic as the first as getting those Medpor implant out is never easy.

You also have to consider one potential reality is that maybe no jaw angle implant shape or size can give you that exact look you have imaged. While I would agree that is a good look, actually getting there may or may not be possible.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a reverse browlift. Seven years ago I had an endoscopic brow lift that left my medial brows too high. I had a brow reversal done (coronally) to bring my brows back down to my natural position. My brows were brought down 3-4mm but only lasted roughly 48 hrs before working their way back up again. Apparently the tacs that were used for this surgery did not hold.The Dr thought it would be ok to give it another try- I was super excited and couldn’t wait for my revision.. Although I had stitches from ear to ear and two pumps hanging down my head for a couple of days the surgery itself was practically pain free. Needless to say the second surgery (3 months later)left my brows on top of the bridge of my nose instead of on the inside where they sat naturally.

I look very unnatural still- my eyes have taken on a roundness and I feel I’m a bit cross eyed and my eyesight has suffered not only from an overly aggressive browlift but at the same time seven years ago I had an overly aggressive blepharoplasty as well. My lower lids have retraction. The Doctor who performed my brow reversal also did a canthopexy which has failed as well. So if you could just imagine my medial brows raised and my lower eyelids dropped.

I am asking you this question: could it be possible to place eyebrows back down on the inside of the nose with a device to keep them there? Thank you for your time.

A: Thank you for your inquiry and detailing your browlift history. When it comes to trying to reverse a browlift, a superior (coronal) approach is never going to work. That could have been predicted beforehand. It is not a function of the ‘tacs not holding’, it is a function of that it is impossible to get a downward pull on the eyebrows from above. It is a little like saying you want to lift your eyebrows from below…this is simply not going to work. To get the proper inferior vector you have to come from below (upper blepharoplasty incision) and put your point of fixation on the BOTTOM side of the medial brow bone. This provides the proper vector of pull. This also explains why the last effort created ‘left your brows on top of the nose’ as the pull could only created an inner or medial pull not the needed downward pull.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I am 7 mos post-op from a primary rhinoplasty and hoping to have a revision as soon as possible. I have heard great things about you and your practice. My surgeon did not correct the profile and make it straight as we had talked about. The objective was just to lower/ straighten the bridge and do minimal narrowing to the supra tip without touching the tip. The only difference I saw after the cast came off was that he may have narrowed the supra tip slightly. I couldn’t smile initially, but as I began to get more movement back I noticed a crease that looks like a mustache when I smile. I asked him if he released a muscle at the base of the nose and he said no. It was an open rhinoplasty though. 

I just visited another doctor who who saw me before the procedure as well. He was not very encouraging about whether the crease could be eliminated, and saw no difference in my before and after images besides 2 bony lumps where it was broken and not rasped at all. These were more obvious after my surgeon used steroid shots 3x (I don’t have pics of this.) We did not continue with the shots since since I didn’t want to thin the skin further. My surgeon didn’t know what could be causing the crease, but acknowledged the bony lumps as “irregularities which may eventually warp the nose.” He said “time will tell,” but would not comp any part of a secondary surgery even though there was no positive change to my profile. I’ve attached before and after pictures for your review.

I would very much appreciate any suggestions you may have. Thanks and hope to hear back soon!

A:Thank you for sending your pictures. I think it is very clear that you got no reduction at all in your dorsal line/hump…which seemed like it was the major point of the rhinoplasty. Not sure what was done in the surgery that did not make that happen. But that is irrelevant now and could definitely be done at any point.

As of your upper lip crease, an open rhinoplasty incision by itself does not cause that issue. Modifying the caudal septum with depressor muscle release can but that does not appear to have been done. (particularly since even the bridge was not lowered) How to improve that now is vexing since its origin is not really known.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty 1.5 years ago and though it was predicted I still see quite large “edges” on one side, but actually both side of the face around the edges needs some kind of filling. My other issue is the deep mentolabial fold which is not the result of the surgery as I always had it, but I’m wondering if this can be addressed with some kind of further surgery or fillers etc. Also notice the “curved” end of the chin, I’m wondering what causes that?

A:You have all of the classic minor aesthetic issues that come from a sliding genioplasty of more than a few millimeters of anterior movement. Stepoffs at the back end of the osteotomy, deepening of the labiodental fold and a rounded anterior projection of the chin.  These are all due to the U-shape of the anterior jaw being pulled forward into a more narrow u-shape. There are a variety of augmentation strategies for the back of the osteotomies an the labiodental fold. The curved end of the chin can only be proved by placing an implant in front of the bone. These are all strategies to use in a sliding genioplasty revision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question about midface lift surgery. I read an article which described the following technique…’it returns facial volume to the upper cheek and lower eyelid area without the need for skin incisions (the two short scars are located within the scalp and mouth). Imbrication means “stacking,” as the deeper tissues of the lower cheek are stacked higher beneath those of the upper cheek. Midfacial suspension is accomplished by a single absorbable suture (this time a heavier “2-0” vicryl) positioned through the mouth incision, again without tension. Impressive improvements typically follow to the cheek, lower eyelid region, and mouth. Performed alone, however, any midface lift brings only limited improvement to the jowl complex, jawline, and neck, where most established aging resides. Therefore this “scarless” internal facelift becomes appropriate only in selected patients with earlier aging and fewer concerns about the jowl and neck region.’

My Questions: The last paragraph alludes to “limited improvement to the jowl complex, jawline and neck……”.  And that makes sense because you are pulling a lot of tissue/skin straight up, a long distance.  I was wondering if you would agree that a “short scar” traditional facelift might be the final piece of this puzzle?  It has been about 17 years since my original facelift so maybe there is merit to a vertical midface lift and traditional facelift.

A: Thank you for the additional information. While it is true that a midface lift does not have the greatest influence on the jowl area (it is  sheer function of distance from the point of pull), the author’s technique would be particularly limited because it is a midface lift that is done completely from inside the mouth and from below. (in effect a push technique) Thus it is really a very limited midface lift that is very different than the more traditional midface lift with cranial suspension. (a pull technique) These two types of midface lifts are not really synonymous/interchangeable in terms of their effects.

That being said, if one wants to cover all their bases so to speak adding an additional component of a tuck up lower facelift at the same time as the midface lift will provide some additional improvement along the jawline as well.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty. I am 18 years old and male. Although I am an adult it is pretty young to be getting cosmetic surgery. I have a weak chin that is probably caused by a recessed jaw also, but I really do not want jaw surgery cause my bite is good. The problem is since I am young I am worried about bone erosion. Do you offer any procedures/osteotomy that can square the chin? I like the benefits of a sliding genioplasty because it can help with breathing. But it makes the chin look more narrow. My chin is rounded. Is there any way to square the chin and bring it forward with bony tactics? Since I want other implants such in the future I would like to avoid it on the chin. So basically my question is do you preform or can you preform any osteotomy that will bring the chin forward and give it more of a square shape? Like width wise and not pointy. Thank you doctor.

A: A sliding genioplasty can be performed where the down fractured bone segment is split in the middle and expanded within an interpositional bone graft. This will create some degree of wideness and maybe a hint of squareness. But it will not create the square effect that a square chin implant can create. An alternative sliding genioplasty strategy, and a better one, is to place carved ePTFE implants that had squareness to the corners of the advanced bone. This is a blended strategy of osteotomy and implant that uses the best of both of them for a more square chin effect in a male.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making the ears more prominent (reverse otoplasty) from the front. My ears are barely visible, hiding behind my face at an odd angle and have always been insecure about it. I was wondering if it might be possible to to maybe build up the bone underneath the ear or any other method to make them come out farther than my face to an ideal angle? Thanks in advance.

A: Ears that naturally are back too far (minimal auriculocephalic angle) or those that have had an otoplasty that is overdone are treated in a similar manner. A reverse otoplasty technique is used where an interpositional cartilage graft is placed between the released antihelical fold cartilages. (cadaveric rib cartilage) This will push the outer helical rim outward and make the ears more noticeable from the front view.

This is an ear procedure that is done by making an incision on the back of the ear and exposing the curved cartilages. The cartilages are then scored to release them and a cartilage is placed between them to push the outer half of the ear outward. The key to success with this procedure is the interpositional cartilage graft. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a skull reshaping procedure. I have an odd shaped head that is long from front to back. I think I have a form of craniosynostosis that went untreated as a baby. What can be done now for it? I have attached pictures for your review.

A: Thank you for sending your pictures. As you know your head shape is a direct reflection of having had untreated sagittal craniosynotosis. This is why the back is so long and the forehead is slated backwards. While you did not include a front view, it is also likely that your head is fairly narrow in width as well.

What you may know is that it is no longer possible to treat your skull shape like is done in infants…a total skull reshaping by bone removal and expansion. That is done done in adults as that approach is reserved for when the bone is very thin and malleable.

This leaves you with several options. First, can the back projection be reduced enough to make a noticeable difference? The answer as to whether that is an option is how thick is the bone as this will require an x-ray to answer. Other options include upper forehead augmentation and skull widening but these may be not as important as reducing the projection on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wanting to know if you procedures for the upper eyelids (upper blepharoplasty) would qualify for insurance coverage. My insurance company said it should since it’s affecting my vision. I just wondered if you accept that. Just for the upper of course. Thank you for your time.

A: Whether insurance would pay for an upper blepharoplasty can not be determined by the patient asking them. It requires a complete written predetermination process submitted by the surgeon which must include visual field testing by an opthalmologist/optometrist that clearly shows visual field impairment as well as pictures that show sufficient hooding of upper eyelid skin. As a general rule it is very difficult for patients under age 65 to qualify today for what was once a common insurance coverage procedure. Only the insurance company can actually tell you based on the submitted information whether they would cover it or not. Talking to your insurance agent or the benefits office does not constitute an approval or whether it will actually be covered. They always say it will be covered ‘if there is a medical reason for the surgery’ when the patient calls and asks. But only the predetermination department of the insurance company can answer that question based on submitted information.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants. I’m looking for a small width increase to my ramus/jaw line and possibly a genioplasty. I feel that my chin is under projected for a male but I dont want to overdo anything either as I want it to look natural which is what I’m more interested in bone fusion than implants. In terms of implants, is it a a high risk procedure for the jaw implants? 

A: When it comes to creating width to the jawline, there is no other method than to use implants. Jaw angle implants pose similar risks like that if any other facial implant, they have no additional risks than the standard risks of infection and aesthetic concerns. (asymmetry and size issues) that all facial implants share.

 The one issue that makes the different than some facial implants (nose and chin), although the same for other facial implants (cheeks and temples), is that there are two of them as they are placed in pairs. Thus they have double the potential risks as that of a chin implant for example. This is most notable as it relates ti symmetry between the two implanted sides.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been wanting breast implants for awhile now. My family all have bigger breasts than me and I’m the one with nothing. I don’t want really big breast but big enough for me to have my self esteem high. And I wanna feel good about myself. I’m 19 years old. I am a young mom. I plan to have not in the future. I wanna still be able to breast feed and look natural. Any suggestions will you help me?

A: At 19 years of age you can certainly have breast implants and they can even be silicone  implant if so desired. What determines a natural look is based on the patient’s interpretation of that term but generally that means not too big for your body. What that would be for you I can not say since I don’t know what you look like or what your breast size goals are. I would need to see pictures to help make that determination. And then ideally you should be sized before surgery using volumetric implants sizers.Breast implants, regardless of their size or shape, do not interfere with the ability to breast feed. They are placed under the muscle, way away from the ducts of the nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty. (I think) Please see attached pictures of my frontal and profile view. In the first three pictures, I am pushing my lower jaw out forward, which is normally how I rest my face to create the illusion of a stronger profile/jawline. The next 3 pictures depict what my jawline looks like if I bite down normally. The end look that I desire is a masculine/defined jawline. I wanted your insight on what would be most aesthetic for my face/what would make me look the most ruggedly handsome. I look forward to hearing back from you soon.

A: Thank you for your inquiry. Based on your pictures I would recommend a sliding genioplasty combined with small widening jaw angle implants. That will accomplish what you are showing by thrusting your jaw forward for the chin as well as add some complementary width to the back of the jaw. I would prefer a sliding genioplasty in your case as the chin augmentation increase you are demonstrating by a jaw thrust create both a horizontal and vertical chin change. This is best done by moving the chin bone down and forward. While that does not widen the chin, that does bot appear to be a chin dimension change you are seeking since a jaw thrust does not widen it either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reduction. I wanted to inform if it’s possible to help me with the following. I have a bulged forehead, that looks bigger than the one’s of people I generally see. Maybe it’s scaphocephaly, I’m not sure. I’ve attached a photo. Is it possible to reduce it to a more normal appearance? You mentioned a  ‘conservative change’, would it be possible to go even further? Would an operation cause a large scar? How much recovery time would be neccesary? What would roughly be the costs for such an operation?

Thanks! 

A: Certainly some reduction of the forehead bulge with or without some brow bone reduction can be done. (forehead reduction) I have imaged a conservative change to see if I am going in the right direction. When I do computer imaging I like to demonstrate what I feel is the minimum amount of change that will occur. More may be possible but a patient’s decision for surgery should be based on the least amount of change they can accept.

To do forehead reduction an incision has to be made somewhere and this is actually the biggest decision in the surgery as to where to place it so it the most aesthetically acceptable.

Most of the recovery (swelling) should have resolved by 7 to 10 days after surgery.

My assistant will pass along the cost of the surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have seen before and after of paranasal implants and it seems the goal is to make the face look less flat? I do plan on getting these done. Also I have recessed jaw and my maxilla is basically normal and my bite is fine but I am going to get it checked with an jaw surgeon. So no type of midface implants makes your maxilla look more forward?

A: Looking vertically longer is one thing, having more horizontal projection is another. Your original inquiry asked the question of a longer maxilla which is an increase in the vertical dimension…which is not possible. Many types of implants give the midface more horizontal projection or bring it forward. You have been using confusing terms in your descriptions. It is now clear that you mean increased horizontal projection of the midface. This can be done using a variety of midface implants including paranasal implants, maxillary implants, premaxillary implants and combinations of any of these midface implant styles. The best way to bring the midface forward is through the use of a custom midface implant which augments the entire midface bone above the maxillary teeth level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in shoulder width reduction. I wanted to consult you for a surgery which I still do not know anything about and, as much as I researched, I have not found much about it. I am a transgender girl and I have a big complex with respect to my wide shoulders. I have a female body but still my shoulders look broad (not muscular but really broad) and I think it is the part that is disproportionate to my body. I have been researching about surgery to reduce broad shoulders but can’t find any information on it. I heard that you performed a complicated rib reduction intervention on a model and wondered if you could intervene on my bones. But this time on the collarbone to get it to look narrower. Is this surgery possible? Do you know if it is available in America or anywhere else? Here in Europe nothing is known yet. Thank you very much for your attention. 

A: What you are referring to in regards to shoulder width reduction is to shorten the clavicle, the bone that runs between the sternum and the shoulder. By removing a segment of this bone, the shoulders will move in a bit and create more of a rounded shoulder look. This requires an incision over the clavicle on each side and the use of a metal plate to hold the bone back together as it heals. It would also require a prolonged recovery as one might predict considering that it creates a controlled clavicle fracture on each side.

While such a surgery can theoretically be done (it is just a spin off of the treatment of clavicle fracture), I have never performed it nor have I ever heard of it being done anywhere in the world. It would take an extremely motivated patient to undergo his surgery on an aesthetic basis considering the scope of the procedure, the creation of small scars in a visible area and the recovery involved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have the problem of mentalis muscle strain and distortion after a sliding genioplasty advancement. I want to improve it by the mentalis resuspension method but only by an intraoral incision. Because I did the sliding genioplasty surgery my mentalis muscle is strained and looks distorted when I close my mouth or pout my lips and also there is too much ower teeth show. My doctor who performed my surgery will improve my mentalis muscle strain by cutting some muscle at my chin. And then he said that the mentalis muscle resuspension is not suitable for me. Is that true?? When I rest my mouth it’s normal and my lower teeth show but but when I try to close or pout my lips my mentalis muscle strain appears and my chin looks distorted. Which method is suitable for me? Should I allow him cut my muscle?

A; It is correct that a mentalis muscle suspension procedure is not what you need to improve your mentalis muscle strain. Rather you would likely benefit from a mentalis rmuscle elease and dermal-fat grafting procedure to prevent recurrent muscle contarcture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from midfacial hypoplasia. I am currently scheduled to undergo a modified LeFort III and I anticipate undergoing bimaxillary advancement in the future. I am fully aware of the risks associated with the procedure.

I have considered going for the ‘camouflage’ approach, consisting of implantation, and thus I am drawn to you given your experience and presence. What will be crucial in making my decision is whether there is anything that customized implantation can achieve in the upper midface that a modified LeFort III procedure cannot, and vice versa. Initially I was curious as to whether the soft tissue response would be different. Is there anything that you can envisage an osteotomy involving the upper midface achieving that a custom implant cannot?

The main point of my email though is with regard to something more specific. My surgeon informs me that the cut will be made in the lateral orbital wall above the lateral canthus. The lateral orbital wall will be moved forward,along with the lateral canthus. This is important to me because my lateral canthus is very far back relative to my medial canthus and the anterior surface of the eyeball. In fact, this is probably my most pressing aesthetic concern. So my surgeon assures me that it is solveable. However, if there is another way of achieving this aim without undergoing a risky procedure such as a modified LeFort III, I would be eager to undergo it. 

Which brings me onto my question. I know that it is possible to replicate more anterior projection of the lateral orbital rim with implants. What I would love to know is whether the lateral canthus may be brought forward in the way that it would with an osteotomy? Perhaps through disattachment of the lateral canthus and replacement in another part of the newly constructed lateral orbital rim? 

Another brief question that I have is with regards to the appearance of the lateral orbital rim without movement of the lateral canthus. I struggle to envisage how the lateral orbital rim would appear if it is given anterior projection past the position of the lateral canthus. Would the lateral canthus become invisible in this situation or how would it appear?

Thank you for your time.

A: In short, you have correctly surmised that the position of the lateral canthus inside the lateral orbital rim can be repositioned either onto the bone or onto an implant rim. (lateral canthoplasty) One would certainly not choose a modified LeFort III procedure if that issue was the primary objective of the surgery. As there is an easier way to accomplish that goal. 

Be aware that in the execution of any form of a LeFort III ostetotomy the later canthus has to be detached and then reattached once the bone is moved. It does not really ‘move’ with the bone as it comes forward

Whether you should do the LeFort procedure or onlay implants depends on how much forward movement of the midface/rims you need to accomplish your aesthetic goals and what other midface needs are to be addressed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I m interested in migraine surgery. I will try to be brief about my migraine history. Twelve years ago I was in an auto accident. I had/have hereditary stenosis of the C-spine. Things in my neck shifted enough that I needed a vertebra removed. I had a vertebra and disk ripped apart in my lumbar spine. I have mild tingling and numbness in my hands. I have chronic pain in my neck and lumbar that like my head never goes completely away. From the beginning I received epidurals in my lumbar and neck, although the full pain was never covered up. In 2011 I had a new pain management Dr. who had just done a  nerve block in my neck and asked how I felt. I said much better, now if you could get my head to quit hurting… He took my head PAIN seriously. Everyone before thought I just had a headache. He did nerve blocks on the outside of my skull, at the nerves. I almost cried. For 7 years I had… you know what it feels like to smash your thumb? That’s how my entire head felt for 7 years, my knees almost buckled from relief. He learned, on my behalf, how to do Occipital RFA’s.

I’m tired of fighting insurance and government procedures. I hope to have 20 or 30 years left, and I want something more permanent. It not only affects me but everyone around me. My wife deserves better and the best I can be. With blocks and RFA’s the chronic pain becomes less. I would love to be able to get off of the pain meds I’m on. At least reduce the levels. I am tired of being treated like a criminal because some people abuse their drugs and others who suffer from extreme pain are called druggies for over dosing when it’s cleaner than other ways and doesn’t involve others. I don’t like being in pain.

Please consider me for migraine surgery.

A: Thank you for detailing your history. The critical question, as in all chronic migraine patients including occipital neuralgia, is whether occipital nerve decompression would be effective. While you have some suggestion that it may have some benefit (positive response to nerve blocks and RFA), there really is no way to know with any certainty unless some simply does the procedure. The main qualifier for me as to whether one should undergo external occipital nerve decompression surgery is two-fold; 1) the patient accepts the uncertainty of the outcome and 2) Should the procedure not be effective there is nothing else surgically I can do to try and make it work better. In other words I do the maximum extent of the surgery knowing that this is a one time short for relief.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision surgery. A little over a year ago, I had a pilonidal cyst removal surgery and it left me with a disgusting scar in an intimate area. The doctors told me that the scar would no be very noticeable, but it is in fact very noticeable and ugly. This has really hurt my self-esteem and made me feel disfigured. I would like to see if making it less noticeable is an option. Please let me know if you think there is anything you could do.

A: Thank you for sending your picture for consideration for intergluteal scar revision surgery. Your intergluteal scar can be improved and will require complete excision of the scar and the recreation of the sacral cutaneous ligament. (this is what creates the intergluteal crease) Such surgery is very familiar to me since this is the exact approach that is used to place buttock implants and is how the intergluteal crease must be put back together.

This scar revision procedure can be done under general anesthesia as an outpatient surgery. It ail likely not widen again after this type of scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about bimaxillary surgery.  I’m very confused on what the answer is. I have a recessed lower jaw but my bite is fine. So I was thinking about getting bimaxillary surgery for my maxilla as well. 

However here is what I’m inquiring about. I have prominent/wide cheekbones that protrude laterally. I notice though my cheeks look a little sunken in from the front anterior wise. I have those nasolabial folds. This is something I find a rare problem. I don’t see many people who have this issue when their cheekbones are prominent wide. 

So basically will advancing my maxilla through bimaxillary surgery help with this? Are there any implants that would help with making your maxilla look more forward? If I’m getting jaw surgery anyway should I skip the implants? Thank you

A: The answer to your concerns is very straightforward and not confusing. While you can do bimaxillary surgery with a good bite relastionship this would be uncommon. Such surgery, short of sleep apnea treatment, is done when the bite is off. But if both the upper and lower jaw is horizontally short, then skeletal correction keeping the same bite would be fine.

Bimaxillary surgery will not help with wide cheeks. The bone cut at the LeFort 1 level is done below the cheeks so it does not affect their appearance in the long run. (when the swelling resolves)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may be interested in getting a tip rhinoplasty. Should I consider just getting a tip refinement? I’m not really happy with the “box-like” bulbous tip I have naturally. However, if surgery wouldn’t offer me a great advantage, then I wouldn’t risk it. I don’t mind the the rest of my nose. I do like my profile very much. I’m insecure when people see my face front-on due to the width of my nose. I have more photos to send if you would like.

A: What you have is an isolated boxy nasal tip due to the size and separation of the domes of your lower alar cartilages. Your nasal tip could be nicely reshaped through an isolated open tip rhinoplasty. That would solve your nose appearance concerns on a permanent basis.Whether you would consider this type of nose change offers a ‘great advantage’ remains to be determined by you. Based on your stated concerns I would think it would. I will have my assistant pass along the cost of that type of rhinoplasty surgery to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old and am interested in chin scar revision. When I was a child I slipped and fell on my chin resulting in one big visible white scar on my chin and two small ones, and another one on the bottom of the inside of my my mouth in front of the teeth. The cut inside my mouth healed absolutely perfect without even using stitches but the same can’t be said about the scars on my chin. Now eight years later I really want to get something done to minimize the white scars, as it really affects my confidence and my ability to be happy with my appearance immensely. 

The medical report from the incident reads as follows: “Cut on inside of mouth (1 cm deep) that seems to be connected to external scar on chin. It was judged that it didn’t need to be sutured but the chin is taped up and back. The tape will sit until it falls of. On the chin (external injury) scar that is 1.5 cm long and relatively deep; local anesthesia with carbocaine-adrenalin. Sutured with single sutures 5-0 Ethilon, which are to be removed in 6 days time. Otherwise there are some excoriations on the lower lip but no other cuts.”

Now the texture of the skin beneath is kinda hard and it feels like the area is slightly raised. I also think that as a result of the trauma the surrounding skin changed texture to become more bumpy and depressed in some areas. Can something also be done about the lack of hair growth in the scars? I am open to anything that can be done and I’m price insensitive as long as an improvement can be achieved.

A: What you have is a typical white scar line that runs perpendicular to the relaxed skin tension lines of the chin. Given where it is oriented it has healed better than one might have anticipated. But that being said it is still noticeable and it has a residual appearance that bothers you. It can be improved through a chin scar revision procedure where the scar is completely cut out and then closed in a geometric pattern to break up the straight scar line. I would use Acell particles to plant into the car to help lessen how much scar would form the second time around. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead injectable fillers. I had a PMMA forehead implant placed last year, but I’m not entirely satisfied with the results. The biggest issue is that the implant doesn’t extend all the way to my hairline, and there is a slight notch near the top of my forehead where the implant ends. Moreover, the implant did not adequately augment the central brow region.

Hence, my questions are:

1) Can filler be used to augment the areas circled in the picture?

2) I’ve read about necrosis and blindness, which is the main concern I have. Would it be safe to inject fillers into these areas?

Thank you!

A: I would definitely not put injectable fillers down by the brow area. This is a danger zone in injectable fillers whose risk may be increased with a forehead augmentation underneath it. I think the upper forehead region is safer as it is not near the vascular pedicles that exist down at the level of the brow bones.

While you could do forehead injectabale fillers, it is safer and more effective long term to have your forehead implant modified or replaced. Your existing PMMA forehead implant can be supplemented to improve your aesthetic concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is outer corticotomy method for jaw angle reduction? Is it just cutting the jaw slightly from the front view? Another thing I don’t necessarily want is screws to hold bones together. 

Also, what is muscle reduction by electrocautery? Isn’t that dangerous to the muscles? Wouldn’t cutting a part if the muscle be more effective?

For my chin, I had attached 2 more pictures. One with Botox into the jaw with NO filler to the chin and another with both Botox and filler. The one you saw before in the first email was without any procedures done. I just want the sides of my chin narrowed not necessarily broken and attached back together with screws if that makes sense. 

Anyway we can cut the muscle and jaw and narrow the chin without any screws and long terms affects? Thank you!

A: The outer corticotomy jaw angle reduction method removes the outer cortex of the jaw angle.  It leaves the shape of the jaw angle but makes it thinner. This is in sharp contrast to the more traditional full-thickness amputation method of jaw angle reduction.This creates the appearance in the front view of some slight narrowing. It does not require plates or screws as the bone is removed.

You never want to cut on or try to take out portions of the masseter muscle as this will lead to visible irregularities on the outside. In addition it can result in both intraoprtstivr anf postoperative bleeding. Electrocautery more uniformly shrinks the muscle and has no risk of bleeding.

The sides of the chin can be narrowed through an intraoral approach by just removing portions of the sides of the chin.  (known as lateral tubercle ostectomies) Like the jaw angles it is done by removing the outer layer of the bone and does not require any plates or screws.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the look from V line jaw surgery. I currently receive Botox injections into my jawline to narrow my face and I have a filler for my chin. I am of Asian decent but I find that some surgeons in Korea overdue it and some faces look too overdone and I want a more natural look.

I want the look that I currently have. I am looking for a more permanent solution. I would prefer not to have my jaw shaved since I’m satisfied with the look I have now with just having my masseter muscle reduced from Botox.

Since I have success with the Botox into the massetter muscle would you be able to reduce that muscle permanently without complications later on? My filler will also be gone soon, would you be able to narrow the sides of my chin because I don’t want an implant.

How long until I will be presentable to go back to work? How long do I have to stay in the area? Can’t wait to hear from you soon. Thank you.

A: The reason you don’t like Korean jaw angle reduction results is because they amputate (cut off) the entire jaw angle in most cases. While that can have a radical effect on facial width in the front view, it artificially raises the jaw angle and thus can look overdone. (because part of the jaw is missing) That is just one way to do jaw angle reduction. The other way, and the more common and better method that I use on many non-Asians, is the outer corticotomy method. This preserves the jaw angle shape and just makes it thinner. The width reduction may not be as dramatic as the amputation method but it looks more natural (not overdone) and keeps the shape of the existing haw angle which prevents complete soft tissue collapse inward. This form of bony jaw angle reduction is what would be appropriate for you along with some muscle reduction as well. This might be something to consider as muscle reduction by electrocautery usually doesn’t produce as much reduction as Botox does.

For your chin I am assuming you added filler to the central part of the chin to give it projection and make the chin appear more narrow or v-shaped. Thus the bony reshaping method would be an intraoral t-shaped chin osteotomy technique. This narrows the chin in width and also give it some slightly increased projection.

Having both of these surgeries, you could go home in a day or two. Be aware these type of jaw surgeries cause considerable swelling and would take 10 to 14 days before you look presentable for work. (although what defines presentable will vary from person to person)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve talked to one plastic surgeon about doing a lower facelift, but cost and time make that impossible for now. I’ve been reading about fat transferring and it sounds less invasive and as I understand there is less downtime.  Also, I’m not quite ready emotionally for a facelift if it can be put off for now.

I’ve considered having injectables, but too often see unnatural looking results and do not like the idea of having to do it every 6 months or so.

Thanks in advance for your consideration.

A: Thank you for sending your pictures. While trying to circumvent a facelift, or delaying to for awhile, is understandable, no non-facelift procedure is going to produce the imaged results that you have provided. I assume that you recognize that issue since only more aggressive skin removal can create that degree of jawline and neck definition.

That being said, there are more limited procedure with less recovery that can be beneficial. Fat injections to the cheeks/midface as well as sub mental/neck /jowl liposuction would provide some aesthetic benefit and would help defer a more formal facelifting procedureuntil a later time. At the least it would be far better than using injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about Occipital Bun Removal. How much does the surgery costs; what is the recovery time; how prominent is the residual scar; how long before I can return to work? I am bald. Additionally, what are the risk of the surgery itself? Thank you.

A: I will have my assistant pass along the general cost of the procedure to you on Monday for Occipital Bun Removal. I would need to see a picture of it to have her provide a confirmed cost of the surgery. This procedure is done through a 3 to 4 cm long fine line incision either right over the knob or in a skin crease (if it exists) above or below the knob. How the scar looks would be the only risk of the surgery. All such scars in my experience heal really well and I have yet been asked to ever perform a scar revision procedure on it. One could return to work within a few days after the surgery. There has never been a problem with getting the bump of bone completely reduced to be level with the surrounding skull bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in the early stages of investigating my abdominal liposuction options for reducing my stomach fat. I sent pictures to you as well and then discussions could continue as needed. 

I have attached 3 photos for review. A little background: I am 58, 5’8″, 160 lbs. I work out 5-6 days a week with both weights and cardio but I can not get rid of the so called “stubborn” fat around my mid-section. I am open to different procedures and I have investigated Cool Sculpting with mixed thoughts to that procedure. 

Thanks again and I will wait for reply.

A: You have the classic male distribution of fat in the abdomen and flank/waistline areas. You would not be able to loose that on your own unless you dropped your weight to about 140lbs, which is not a sustainable weight for you. You are an ideal candidate for liposuction as this is the most effective and efficient method of reducing it. Non-invasive methods such as Cool Sculpting, at best, will create only about 1/3 as good of a result over a long protracted time with multiple treatments. Most men are not very tolerant of a slow and incomplete treatment process for fat reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am touching base to let you know your response in dealing with my pectoral implants assisted me being successful in making a date to change my pectoral implants later this year. As you are aware I would like to get this right. However based on what has happened I wanted to run by what is going on. As you know I have had the Powerflex 1 271cc pectoral implants placed in my chest which has a projection of  3cm. What my doctor and I discussed is that we would like to change to the Powerflex 2 style implant in the 293cc volume which is the largest of the 3 sizes in a slightly lower projection of 2.5cm.  However these ones as you are aware are more spread out which will give me a more medial augmentation towards the sternum.

What I was wondering if you could help me with is that I noticed some surgeons place pectoral implants vertically and horizontally. i wanted to know what looks these two options give and the benefits they have. Secondly my concern now is that I am torn between the choice of using the 293 cc with a 2.5cm projecion or going lower at 203cc volume with a projection of 2.1cm.  I do trust my doctor but I don’t feel he has come across a patient like me. My aesthetic goals are to have a noticeable pectoral muscle but with more of a definition of muscle rather than a “busty” “booby”  body builder look. I  don’t wish to become a bodybuilder. I actually like being a slim and toned male but with muscles similar to when someone shreds or reduces their body fat . 

In saying that I might add that I personally find the Powerflex 2 style pectoral implants to look more natural over the anatomical ones. I don’t know if I’m saying that due to my ones being on the larger size but another key point in my current implant is that my implants don’t softely taper off into my real chest like a natural pec muscle would. That is why I am stuck between these two sizes as I want bulk in the lower area of the pectoral muscle and on the top area I would like the implants to taper off into my normal chest area without looking like two big solid implants glued to my chest.

A: Since you are having the original surgeon do your pectoral implant revision, then these are discussions you need to have with him/her. That is your responsibility as well as that of surgeon. Asking other surgeons to try and guide you as to the proper implant selection is both unfair to whom you ask as well as to yourself. Only your surgeon knows what you look like and has a vested interest in your outcome. You either trust your surgeon or you don’t. If you don’t then find another surgeon that you do. Standard pectoral implants come in certain sizes and the results they create are limited and do not work ideally for everyone. When one is seeking very specific results after a first set of pectoral implants have been placed, one should strongly consider having custom pectoral implants made. This will remove all doubt about size and shape concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal. I’m a thin girl, and I was considering removing four ribs to get a smaller waist. My plastic surgeon in my hometown said he punctured a lung while performing this surgery before and therefore does not do this procedure anymore. Is there anyway to eliminate this risk? Any other major risks and complications with this surgery? Can it be done under local with IV sedation instead of general anesthesia? Thank you for your time.

A: The best way to avoid such a complication as you have described for rib removal surgery is to have someone do it that knows what they are doing. That should be a complication that is easily avoided in experienced hands, particularly down as low as ribs #11 and #12 where the base of the lung does not extend that low. This is a procedure that can only be done under general anesthesia. It is performed in the prone position (with the patient face down) and Exparel long-acting local anesthetic is used for nerve blocks once the rib portions are removed. This is a very safe procedure when down by a surgeon with experience doing it.

Dr. Barry Eppley

Indianapolis, Indiana