Your Questions

Q: Dr. Eppley, I am a 32 years old women coming from France. I ‘m interested about the rib removal surgery. Since 5 years ago I am focused on my large waistline. I have tried corset, diet and exercise but no result. I think is because I have a athletic body shape and no much fat in my body. That’s why I come to you to narrow my waist, the only way is the surgery. I would like to know the price of this surgery all inclusive and how long I have to stay before returning in France. As requested you will find my pictures. 

1) I have also heard that rib can grow back so it’s reversible it is true?
2) I have a thick skin so would it impact the result of my waist?

Thank you in advance.
A:Thank you for sending your picture. In answer to your questions about rib removal surgery:

1) In an adult removed portions of ribs will NOT grow back. Regrowth of surgically removed ribs is an urban myth.

2) Your thicker skin will not negatively impact the result. I always combine waistline liposuction with rib removal to maximize the result.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in teenage gynecomastia reduction. My 14 year old son has gynecomastia and is very embarrassed about it to the point he doesn’t take of his shirt in public to swim and he wears a tight shirt under his t shirts to hide it. I was not sure if you would perform surgery on him since he is still going through puberty or if insurance would even cover the procedure? Thank you

A: Thank you for sending pictures of your son’s chest. This appears to be a ‘soft’ type of gynecomastia which should respond well to liposuction reduction. His skin and areola will shrink back down with the fibrofatty breast tissue removal.

When it comes to his age, the ‘standard’ thinking it is that this type pf gynecomastia will go away on its own and that he is too young to have surgery. In my experience I find that thinking of early juvenile gynecomastia completely flawed. It will not go away on its own and he is at a critical psychosocial point of development. I would choose to have it treated and reduced now so he can feel a lot better about his chest appearance. Whether it will regrow in the future is unknown but, even if it does, there will still be self-image benefits to having the surgery now.

As for insurance coverage, they would require a complete endocrinological workup to prove there is not a hormonal basis for his gynecomastia (and there is a 99.9% chance there is not) and the gynecomastia would have to be much bigger than his. They would view his problem as cosmetic and deny coverage for it.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I initially consulted a doctor for orthognathic surgery for treating obstructive sleep apnea. He gave me the option to do the orthodontics and straighten the teeth before surgery or just do the surgery and only fix the apnea. The only instruction that he ever gave to my orthodontist is to maximize the overjet. My orthodontist is currently trying to move it into two defined arches as per his plan.

I reached out to you as I have been researching orthognathic surgery and other things related to it. My major concern is appearance and elimination of sleep apnea. Reading around I saw that cheek implants and jaw implants could enhance the appearance and started wondering if that would be something that I could do to have a great aesthetic outcome in addition to the functional improvement. I could certainly use some guidance here.

A: What you need to focus join first are the maxillomandibular advancements for the treatment of your sleep apnea. This will involve moving the underlying bones and it will change your appearance. But implants can not be put in at the same time for a variety of reasons. You need to fix the bone first, see what you look like after and then consider any aesthetic changes that may, if any, be determined to be beneficial. In short you can’t perform orthognathic surgery and facial implant surgery at the same time for functional and aesthetic reasons.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry surgery. I have been diagnosed with a mild version of hemifacial microsomia. My asymmetry of the face seems to be more a soft tissue involvement. after some CT scan, the bone asymmetry is not as bad. I would like give my face symmetry with either fillers or fat grafting, what would you recommend?

A: Given the two facial asymmetry surgery treatment choices you have provided, you would never use injectable filler unless you just wanted to do a test to see if you like the result. Injectable fillers are temporary and will take a fair volume of them to have any facial augmentative effect. Injectable fat grafting would be the better soft tissue augmentation/reconstructivhe technique since the volume able to be injected is limitless and some of the fat will likely survive and persist.

I would also have to see your 3D CT facial scan to see his significant the underlying bony deficiencies are. Augmentation of any bony deformities, particularly along the jawline, can often be very beneficial and is an assured permanent volume result.

Many congenital facial deformities are often best treated by a combination of hard and soft tissue reconstruction techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in migraine surgery. I have had migraine headaches for years and receive Botox injections for relief. My neurologists injectes them all over my head every four months from which I get good relief. My question is knowing that I get Botox placed all over my head, does that mean I will need surgical decompression of all four nerve zones?

A: Nerve decompression surgery for migraines works by treating the known area(s) of nerve impingement. While Botox has been effective for you, its injection all over the head does not provide a clue as to whether any of the known three migraine nerve sites (supraorbital, zygomaticotemporal and occipital) would be effectively improved by the surgery. In migraine surgery you never just decompress every available nerve site as that may end up doing unnecessary surgery.

There may be some clue as to whether you have specific trigger zone involvement by a description of your migraine pattern. Does it start in one specific area? It is on one side or both sides? Can you put your finger on an area that is most tender or where it seems to come from? Such information would indicate which nerve site(s) should be decompressed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have given up my search looking for a surgeon to preform distraction osteogenesis to widen my clavicle. I have heard you preform deltoid implants and have seen it on this website. Is it possible for the implants to add 2 CM of width on each clavicle and does it look natural for the most part? Also I can’t do fat grafting because I am not overweight at all. I just want wider shoulders in width and you seem to know much about this procedure. 

Is this procedure becoming more popular, are your patients usually satisfied with the results? 

Thank you doctor Eppley for reading this I hope to hear from you soon.

A: You are correct in that no one is going to perform distraction osteogenesis to increase your shoulder width. That is a concept that simply is not going to work for a number of reasons. While deltoid implants are your only option, the question is whether it is a good option.

Deltoid implants are not going to be able to increase your shoulder width by 2 cms or more per side. The skin over the shoulder is simply too tight to tolerate that amount of augmentation. There is also the issue of the incision/scar to place it which is usually done from the posterior axillary skin fold. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin implant revision. I had a chin implant done 15 years ago. The chin implant that was used at the time was too big, roundish and squarish for my heart-shaped face. I needed more chin projection than chin width. The chin implant was also put in crooked, one side was higher then the other. The doctor at the time also put in an additional implant shaped like a matchstick in the depression of my chin and at the bottom of the chin to offset the fact that it was crooked which I was not aware of until after the surgery. Within a week he took out the small implant from the center of the chin which then left a line scar. It was a terrible experience needless to say so I just left the big implant in and the scar until two years ago.

Finally I had the courage to get the chin corrected. I had several different consultations and finally decided on a plastic surgeon that supposedly had expertise in chin implants. We reviewed all the details with many photos and discussions. I finally had the surgery last year. Basically the plastic surgeon decided to use the original implant that I already had in instead of a custom one. He basically just went in and moved the implant downwards and that was it. The result was that it was still too round and big and now way too low. One side had already fallen after one week. The plastic surgeon said I needed a revision and they scheduled it a month later. I again explained to the plastic surgeon prior to the revision that the chin implant was too big and squarish for my heart shaped face. Again we reviewed photos etc…After the surgery the implant was the same. The plastic surgeon had just repositioned the implant slightly higher but it was still wide and squarish and very crooked. I was devastated to say the least.

One month later they scheduled me for another revision. I again voiced my concerns with the plastic surgeon and was assured that he understood what had to be done this time and that the implant had to be carved and shaped to my heart shaped face. After the surgery the implant had finally been reduced in size but was completely carved in a square shape and completely crooked. 

Finally I was again scheduled for another revision two months later. Again more photos more discussion etc…The plastic surgeob finally carved the implant smaller and narrower to suit my heart shaped face. However it’s been carved unevenly and positioned off center and there’s a lot of puffiness formed in a wave on the top of the chin and it’s spongy and puffy. It’s a year next month since the last surgery so not sure if this is all scar tissue.  I went for a followup last week out of concern with the total result and the plastic surgeon suggested cortisone shots which I did not want to do. I don’t believe that doing a patch up job of cortisone shots or fillers will correct this issue and it’s been very disheartening to think that this is the final result after all these surgeries. I am now considering doing another revision with a custom made chin implant to correct this once and for all. I came upon your profile on RealSelf and went through your website/blog/reviews and feel that you have considerable experience and knowledge in the chin area.

I have attached several photos for you to view and I look forward to speaking with you and thank you for your time in reviewing my situation.

A: Thank you for sending all of your pictures and detailing out your multiple chin surgery history. This is a tragic tale of chin implant augmentation surgery that was both ill-conceived and poorly performed. The fundamental problem, in my opinion, is that you really had the wrong type of chin augmentation surgery. When you have the natural chin anatomy that you have, placing an implant will be hard pressed to create a very satisfying result. Your chin is very horizontally short and subsequently vertically long. Your chin has a 45 to 60 degree angulation backward of the slope of the bone from it normal inclination. Any type of chin implant, particularly one that is placed low on the bone, is going to create vertical elongation and limited horizontal projection. This issue is compounded by the typical narrow width that such a chin shape will have in a female. Any standard chin implant that has wings will end up creating a long and wide chin. (squarish)  You have experienced every problematic variation of trying to make a chin implant work in an anatomic situation where it just won’t do well.

With regard to the labiomental scar that is not the approach I would have utilized in your or any situation for the placement/removal of any form of labiomental implant.

Moving forward you have two chin implant revision options. The best option is to convert your chin augmentation to a sliding genioplasty and abandon the implant approach. Your chin needs to come forward and up. (vertically shortened) This is not what a chin implant can do. (as you now know well) The other approach is to make a true custom chin implant BUT shorten the length of the chin bone at the same time so that you still create the important vertical shortening effect.

I am sorry that you have had the outcomes which have occurred and I remain sympathetic about your chin surgery experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had custom facial implants placed about 3 years ago and I am wondering if they may be too big. You can see in one photo that I have some trouble smiling. My cheeks just kind of bunch up. I am considering replacing them and I would appreciate your opinion. They are cheek implants that extend to the paranasal area, chin implant, and jaw implants. Thanks for your time. 

A: As I understand by your description you have custom cheek, chin and jaw angle implants. As the old saying goes…beauty is in the eye of the beholder. The fact that you ask the question indicates that you feel the implants are too big. In looking at the pictures you have sent with your initial inquiry, I think there is no question that the chin implant is way too big for your face from an aesthetic standpoint. If your smile feels stiff then the cheek implant size or style may not be quite right for your face also. The question now is whether your current existing implants can be resized or whether you would need new ones. There is also the question for some of them, like the chin implant, as to whether it is needed at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface shortening. I am interested in the LeFort 1 procedure. However I do not have a gummy smile, so would that be an issue? Perhaps there are better ways to solve the midface ratio by playing around with facial/jaw width. Is there a way to send pictures and get a professional opinion?

A: You are correct in that doing a LeFort I impaction without a gummy smile will have adverse effects on the upper lip-tooth relationship and is not a good idea. Burying the upper teeth under the upper lip has a negative facial effect and creates more of an aging appearance. Searching for other facial options would be what needs to be explored. Please send me some pictures of your face for my assessment and computer imaging of other potential facial reshaping options. Rhinoplasty, midface and/or jaw augmentation and lip enhancements can all be potential facial reshaping procedures that can change the disproportionate appearance of a long or strong middle third of the face.

True midface shortening can only be done through a LeFort 1 impaction as a vertical shortening of a bony vertical maxillary excess.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I consulted with a plastic surgeon in January and he told me that I have an unusually low set zygomatic prominence. He suggested a custom malar implant. From your response I understand that it is indeed reasonable to reconstitute the malar prominence higher up on the face using a custom malar implant approach.. 

What I want to clarify in particular is what happens to the current zygomatic prominence? As you know it is important to maintain a natural shape to the cheekbones to avoid them looking fake. Assuming that I am not looking for any alteration to the frontal and lateral projection to the zygoma, would two malar prominences not look odd on the face? If it is contended that the custom implant would taper into the former malar prominence, I can envisage this creating an excessively large malar prominence which would run counter to the objective of a sharp, high set malar prominence.

A similar concern arises with respect to the lower border of the zygoma which would ordinarily sit beneath the ‘old’ zygomatic prominence. Can we literally remove this part of the zygoma by burring/shaving in order to raise that border to sit directly under the ‘new’ malar prominence?

A: I can only tell you what I would do…make a custom malar implant that sits high with an anterior infraorbital and posterior arch extension combined with an inferior triangular ostectomy of the lower portion of the zygomatic prominence combined with a buccal lipectomy. This is the most assured approach to maximize the likelihood that an inframalar concavity facial contour is created along with a higher cheekbone appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in bicep implant revision. One of my bicep implants is outside the fascia and the surgeon only sutured it to other tissue as a solution. Can it be re-implanted correctly? My surgery was five months ago. It is too late to fix? What has been your experience with this problem?

A: Whether you can have a successful bicep implant revision depends on the reason your implant currently sits outside of the proper subfascial pocket. If the fascia has not been torn or disrupted, then the implant should be able to be placed into the subfascial position. This would presumably have occurred because the surgeon intentionally placed it above the fascia for whatever reason. This would be favorable for a successful subfascial repositioning. If the implant ended up outside of the pocket because the fascia was torn or disrupted during its initial placement, then repositioning would not likely be successful because surgical repair of the fascia is very difficult due to limited surgical access. This does not mean it is impossible but an intact fascia along the longitudinal axis of the implant location is important to maintain the implant in the pocket.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

Thank you

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Thank you for your time, Dr. Eppley

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

1) Right mid-zygonatic arch depression

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

3) flatter right inferolateral orbital rim-anterior zygoma

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

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

2) rasping down posterior zygomatic bump

3) small hand carved ePTFE inferolateral orbital rim implant

All done from inside the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Many thanks,

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

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

A: In answer to your questions:

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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