Your Questions

Q: Dr. Eppley, I am interested in custom jaw angle implants.  I’m finding out that standard implants (i believe 10mm) are not as strong as I would’ve hoped and not providing me the stronger look i seeked. 

I would like to find out if I can make my jaw stronger with bigger or custom jaw angle implants and whatever else needed or if that result is not possible I’d get my current ones removed since the current result is an improvement on the right track but still does not provide enough strength in my jaw I desired to balance out my face. At some points early in the recovery though swollen my jaw seemed a lot fuller and stronger than now. I believe increased height as much as feasible and a bit wider. 

This after result below seems strong I would like to see if I can reach this point by whatever means and I believe at some point in recovery with swelling my jaw was in fact that wide in proportion to my face.

A:Thank you for sending your before and after pictures. As you have now discovered, the final result of any facial implant augmentation is going to largely reflect the size and surface area that the implant covers. In the end you have more defined jaw angles which is exactly what the size of the implant does. What you have also learned by going through the process is that the overall jawline fullness that came from the swelling is more of your desired jawline look. That is going to take an implant design that covers more of the jawline from the angles the chin…which can only be done by a custom jawline angle implants design.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin asymmetry augmentation. I have an uneven chin, where the right hand side has less horizontal projection, and more vertical projection than the left hand side. I would like to improve that symmetry as much as possible and perhaps add a minor amount of projection to my chin. Is this possible? Would you recommend a genioplasty or implant?

A: Thank you for your inquiry. For an uneven chin in which you want to improve its symmetry and add a little more projection, a custom chin implant would be the ideal way to do it. Only through the use of computer designing could you be assured that all chin dimensions are adequately made symmetric. Using standard chin implants and ‘eyeballing’ them during surgery for placement or hand carving them in trying to compensate for the bony chin asymmetry is fraught with not only not solving the asymmetry but even making it worse. Because the chin is a projecting structure even subtle amounts of asymmetry are hard to hide. Thus the use of a custom chin implant made from a 3D CT scan is the best way to avoid this aesthetic problem.

I would need to see pictures of your chin to give a more qualified answer.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some cheekbone reduction questions. I’m already quite dissatisfied with the droopiness of the lower third of my face and along my jaw. Hence, I’m extremely worried that the cheekbone reduction would further worsen this droopy look. I’m sure you’ve heard about the “falling tent without its support” metaphor, to describe what happens to the surrounding skin when the cheekbone is reduced. I’m hoping to gain a more balanced midface without this happening.

While you mentioned that I may be too young for any lifting, I would be very interested in any lifting/liposuction procedures to effectively ameliorate the droopiness that I’m seeing, both in my midface and my neck area.

A: Any time you disrupt the attachments of the cheek, there is always the risk of some soft tissue sag. As I stated in my prior email this has not been an issue that I have seen from cheekbone reductions due to fixation of the osteotomized bone segments in their correct anatomic position. But that being said, the only way to have zero risk of that not happening is to not have the procedure.

When I mentioned that you are too young for any lifting procedure, it is important that you understand what I mean by that statement. All facial lifting procedures have as their origin the treatment of tissues that have dropped or sagged due to aging. Thus there is tissue laxity by which they can be moved. Young people, however, do not have any tissue laxity and thus any true lifting procedure can not really be done. You can not move someone’s tissues into a ‘super normal’ anatomic position. While it is possible to re-establish normal tissue positions AFTER they have dropped, you can’t really lift tissues that have not dropped. In addition, and equally importantly, any effective lifting procedures require scars. In the midface that is going to be eyelid, temporal or both scar locations. This is always a potential aesthetic concern in young people, particularly in thicker Asian skin. My point being is that you have to have a really good reason to do these lifting procedures as you don’t want to trade off one aesthetic problem for another.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask about forehead osteoma removal. I have it from about 8 years. It is very good visible in direct light. As an attachment I have some photos of my forehead. I also have attached  x-rays taken a few years ago.I see it on your website that I will need a CT scan anyway.

I have few questions:

1) What is the procedure, step by step, with a forehead osteoma of this size? 

2) Will it be done under local or general anesthesia? 

3) During the operation I will breathe by myself or with the respirator? Or you will find it after CT scan and with the knowledge if the oeteoma is only on the surface of skull or it is also inside the skull?

4) Can you remove the osteoma with endoscopic method with the drill? The endoscopic method would be the best for me because it leaves no visible scar and it is less invasive.

5) Can we consult by Skype?

6) Before the surgery I will need some relaxing medicines.

A: Thank you for your inquiry and sending your pictures. Your forehead osteoma is very evident. The very pertinent question is whether this is an osteoma that is an outgrowth of the outer cranial table or whether this is an osteoid osteoma that invades the full thickness of the cranial bone. This distinction is critical as their treatment differs radically. I will assume for now that you have the more benign and common outer table osteoma. In answer to your questions:

1) Endoscopic or hairline incisional approach for removal.

2) Full anesthesia

3) A CT scan must be done to make the proper preoperative diagnosis.

4) An endoscopic approach can not use a drill or any other power equipment, it uses an osteotome or chisel.

5) A virtual consultation is done before surgery.

6) Sedative medication can be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip asymmetry correction. My lips are thin and uneven and I would like to get it corrected. It’s so awful that I don’t want to have a picture of me taken with family. Five years ago I was diagnosed with a brain tumor. The surgeon operated through my eyebrow as the tumor was behind my eye.  This surgery left me with a mouth droop. I have attached pictures for your review and recommendations.

A: Thank you for sending all of your pictures. It is clear that the neurosurgery procedure created some facial nerve weaknesses which has resulted in your upper and lower lip asymmetries. The right upper lip is weak and does not lift up as much as the other side. Thus it rolls in and is smaller. The right lower lip depressor is weak and this makes the the right lower lip elevate (rather than being pulled down) when you smile.

While the facial nerves can not be made to work more normally, the lips have to be adjusted at the vermilion-skin junction to create more symmetric vermilion show. (lip asymmetry correction) These are known as vermilion advancements. The right upper lip needs a vermilion advancement to  create greater vermilion show to match the opposite side better. The same is needed for the lower lip to bring out the the vermilion edge to match better to the left side.

These vermilion advancements can be combined with a subnasal lip lift to shorten the distance between the nose and the upper lip at the same time.

All three lip procedures can be performed at the same time under local anesthesia as an office procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had lower jaw surgery (Sagittal Split Osteotomy) done a few years ago to correct my bite, and believe I would benefit from a jaw angle implant to improve my jaw angle. From what I read, it seems like this a a procedure that has a relatively high rate of failure. I would like to discuss and determine if this procedure would be recommended for me.

A: Thank you for your inquiry. I have an extensive experience with jaw angle implants and they do not have a higher rate of problems than any other facial implant. But because they are bilateral, implant/angle asymmetry is not rare. This is not only technique-related but also because many patients have natural jaw angle asymmetry which becomes magnified with implant augmentation. Such jaw angle asymmetry most certainly applies to you since you have had ramus osteotomies whose healing always creates some bony asymmetry.

I would need to see pictures of your face for an assessment and computer imaging as well as current x-rays (at least one year after your surgery) to see what your jaw angles look like. It is a question to determine what style of jaw angle implants you aesthetically need as well as whether standard or custom implants would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I has a temporal artery ligation procedure done by a doctor in Beverly Hills who performed 2 point ligations on each side and double tied) a little over 6 weeks ago.  The left side did not work – the pulsation is still there – and the doctor is going to go back in a few months to retreat it.  On the right side, the pulsation is gone, however, I worked out very hard today, and the artery swelled up and the zig zag that was previously there (and previously had the pulsation) is back – but this time with NO pulsation. Has this happened to any of your patients (where the pulsation went away but the outline of the artery is still there)?  My doctor here has not seen this before.  And if so, what can be done to further correct it? 

A: In temporal artery ligation If you don’t strip the artery of blood before you tie off the ends, blood will stagnate in the vessel and its appearance may remain… albeit with no pulsation. But the most likely reason is that not all contributing feeders have been ligated. I have found that rarely does just two point ligation work well. Without knowing what the specific ligations locations are or what your arterial pattern was before surgery, I can not provide any further meaningful insight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making my face look better, some sort of facial rejuvenation surgery if you will. While I am only 50 years old, I feel like I look much older. Here are some starting pictures of me for your assessment.

While I’d like to fix the “bag” effect under eyes, the depressions in my cheeks, and the acne scaring…I’m looking at all possibilities as well. My nose has a slight hump in it (might be called a dorsal hump from looking online) and my nose seems a little wide at the top (I have no idea what the proportions of a nose should be relative to my face).

You can see the skin wrinkling in front of my ears, I’m guessing some sort of facelilt procedure to fix that as well. Another doctor told me that the bags under my eyes might go away with a full or advanced facefilt as well.

I don’t care for my smile and would love to have a bigger smile that shows more of my teeth.

A: Thank you for sending your pictures. You really don’t have herniated fat under your eyes, what you have are alar festoons. These are bags of tissue that appear over the highest part of the cheekbones. They are not easy to eradicate but are treated through a lower blepharoplasty procedure not any form of a facelift.

The skin wrinkling in front of your ears would be treated by a limited form of a lower facelift.

The mouth area would be treated by a corner of the mouth lift that turns up the corners as well as makes the corner to to corner mouth distance bigger.

Your nose could be improved any a hump reduction and shortening and lifting of the nasal tip.

All four of these facial rejuvenation procedures could be done at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, . I have a multitude of facial asymmetry issues stemming from a mild Kaban/Pruzansky birth defect. I have a confirmed hemifacial microsomia that has primarily affected the eye, orbit, and cheek regions and ramus of my jaw. They really bother me and I want to fix some of them. I am not sure whether to go for orthognathic surgery and a custom cheek implant. Or to do all implants on the affected side. If you place an implant in the cheek (malar-ygomatic arch), will this also make the affected eye and brow look more bizarre as it will look even further back with the projection of the cheek? How do I improve my facial asymmetry without looking even more bizarre in other words. I also have a skinny face with the cheekbones projected like you see in fashion models (though I am no model!). Will custom implants look bizarre as I do not have a tremendous amount of overlying fat? I have dealt with this for almost 30 years as I am almost 29 and I want to move on with my life.

A: Thank you for your inquiry about facial asymmetry correctiobn. There is little I can tell you by your description alone. To be most helpful and to properly treatment plan, I would need pictures of your face and bite and a 3D CT scan.

With this information meaningful recommendations can be made. In short, if your bite is fine and your occlusal plane is reasonably level, custom implant augmentation of the smaller side would be appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek scar revision.  I have got scar tissue in my mouth and cheeks from multiple cheek procedures. cheek (implants, cheek implant shave down, cheek implant removal, revision implant placement). I also had jaw and chin work done two times. It caused lots of scar tissue. My lips move weirdly now and is thick in my cheeks. Can scar revision be done to cut out the scar tissue? Can anything can be done to reduce it or remove it? Thank you for your time.

A: I would not think about scar tissue removal as that would just make things worse. You fundamentally have a tissue deficiency (which is really what scar tissue really is) which is why your lip vestibule is tight and tethers your lips from a normal outward movement and stretch. What you really need for a cheek scar revision is scar tissue release and the placement of small interpositional dermal-fat graft to help restore lip flexibility and prevent recurrence. The placement of an autologous tissue graft between the lips and the underlying maxillary bone fills in the tissue gap that is created by the scar release and returns needed healthy tissue to the area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to do multiple surgeries to correct issues with my face structure. I have a receded chin and a round, weak jawline. I’ve seen a few pictures of a custom jaw angle wrap around, and think this might be ideal to fix these issues. How much would this procedure improve my chin projection, would I be able to have the chin in front of lips? Looking at my photos, is it possible to get an angular jawline?

My nose has a low radix, and looks very off to me. I don’t really know if anything can be done, what are your thoughts?

I’m not sure about this, but it seems I have a recessed mid-face and very recessed under eye area. Would a custom midface implant be ideal for me? Would I get enough projection to have a positive orbital vector? Would this implant do anything significant to orbital rims?

A: Thank you for your inquiry and sending your pictures. I would agree that a custom wrap around jawline implant would make a big difference for you. Custom infraorbital-malar implants could be designed to give you a positive orbital vector and higher infraorbital rims. A custom paranasal-maxillary implants would add projection to the midface. The nose could be improved by dorsal augmentation to build up the bridge and low nasal radix.

I will have my assistant pass along the cost of the procedures you on Monday

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correction of  numerous facial deficiences which all are located on the left side of my face. Attached are 3 pictures of my face that show the areas of concern. I took one straight-on picture and another two pictures each showing one side of my face.

When looking at the straight-on photo, you can see that my jaw is skewed to one side with the right side being fuller than the left. You can also see that my chin is tilted to one side as well. What is slightly harder to see in the photo is that there are some soft tissue discrepancies between my cheeks and if you can see, there is a slight “indent” on my right side that isn’t there on the left. I thought that this could be because of the prominence of the mandible underneath and the prominence of the cheekbone above that creates this indent but I would love to hear your opinion on it as well. The deficient cheekbone that I mention is on the left and it may be difficult to see without being in person or taking a picture at a very specific angle. However, you can easily see that the zygomatic arch on the right is more prominent and that holds true to the entire cheekbone as well. I cannot wait to hear your opinions on these pictures. Again, thank you for your time.

A: Thank you for sensing your pictures. I can not disagree with any of your observations about your face. What you really have is a near total left-sided facial asymmetry which affects many structures from the ear to cheek and down along the jawline. The facial asymmetry is greatest at the jawline and lessens as it ascends superiorly towards the eye. Undoubtably, as is often the case, they are heavily bone-based with some soft tissue component to them.

On a practical basis one starts by addressing the skeletal issues and the use of 3D CT scanning and the design of custom jawline and cheek implants is really the only way to effectively treat it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in jawline augmentation. I had a chin implant placed several months ago. I have attached my before and after pictures. As you can see, the chin augmentation is an inadequate improvement –  I have basically gone from having a recessed chin to having a weak one. I want my chin to line-up with my lower lip. I suspect I would need a genioplasty + implant to attain this.However, I do like the height the implant has given to my chin, it has given me a stomion ratio of 2.00 and this is a feature I would like to retain. I also like the enhanced lateral chin width and the squarer shape. Square chins look better than round chins on men in my opinion. My gonial angle I would like reduced to 115-120° range, I’m unsure whether this is a realistic goal though. What is the maximum possible jaw angle augmentation with implants? I’ve read that it is 12mm. 

A: Thank you for sending your pictures of your chin augmentation results.. For a large anatomic chin that is not much of an improvement. Based on your pictures and goals, I can make the following jawline augmentation comments:

1) It is rarely a good idea to combine a chin implant on top of a sliding genioplasty in an effort to substantially increase its width. That works best when the goal is merely to ensure that the chin is more square or to cover the back ends of the osteotomy cuts.

2) A sliding genioplasty may provide the greatest horizontal projection but in doing so will make the chin less square and potentially even more narrow.

3) Based on #1 and #2, the best choice is a custom wrap around jawline implant alone. Your existing chin implant has help to serve as a chin tissue expander which allows for greater horizontal projection than otherwise could have been achieved initially.

4) Vertically lengthening the jaw angles (decreasing the mandibular plane angle) in theory can be done any amount, particularly when it is a custom implant design, and can even be surgically placed. But the greater the implant drops down the jaw angle the risk of the muscle not following the implant edge increases. (masseteric muscle disinsertion) Such an aesthetic complication is very difficult and in many cases impossible to correct secondarily…so it is a problem best avoided. It is impossible to predict before surgery what patient may experience this potential problem. I have dropped jaw angles down 25mm and not seen it…then I have seen it occur in drops as ‘minimal’ as 10mms. As a general rule it is best to not get ‘greedy’ and keep a reasonable amount of vertical jaw angle lengthening in the 8mm to 12mm range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead rejuvenation surgery. First, I have deep horizontal wrinkles across my forehead and vertical wrinkles in the corrugator area. These wrinkles have been effectively controlled with Botox for many years. The only thing is that if Botox is not done properly, I get pointed eyebrows and a Spock type look.  This is the reason why I’m interested in a brow lift and corrugator resection – to eliminate the wrinkles, precisely place the eyebrows, while providing a more permanent solution to the wrinkles.

On top of the wrinkles caused by my powerful brow muscles, I have numerous shallow boxcar acne scars in the upside down triangle area of my corrugator area (with the apex of the triangle meeting with the bridge of my nose directly between my eyes).

Several years ago I had fat grafting to the entire forehead and for a while (due to both the fat graft and swelling from the procedure) all of my forehead issues, including the boxcar scars, were greatly smoothed out. But the swelling went down and my powerful forehead muscles eventually eliminated the fat that was grafted. This is why when I saw that you do forehead implants, I got interested.

My hope would be that a properly placed forehead implant would have the same effect that the fat grafting/swelling initially did from the fat grafting procedure, which was to raise and stretch to skin thereby smoothing the scars.

A: Thank you for the forehead rejuvenation surgery clarifications and let me provide some commentary about them.

1) A brow lift is not a cure for horizontal forehead wrinkles. Its effect is that of a brow lift not a wrinkle reducing operation. There is no surgical equivalent to what Botox does in terms of muscle deanimation. While it may have some temporary benefit in terms of lessening the depth of the wrinkles, it is most certainly not a permanent solution for them. (for which there is none) One undergoes a browlift for the goals of lifting the brows as that is the one assured benefit of the surgery.

2) Corrugator muscle resection through an upper blepharoplasty is best approach to do it, not through a superior browlift. Again it will help with the glabellar furrowing but it will not completely eliminate the furrows and it is not a permanent cure or solution to them.

3) A forehead implant will help stretch out the skin and provide some smoothing effect. But this is completely dependent on its size and thickness and there is a delicate balance between forehead implant that provides the best smoothing effect and one that makes the forehead look too big.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came across this website and saw some before and after images of craniofacial surgery. (forehead horn reduction) I was hoping to get some more information on this surgery. I’m very uncomfortable going out wearing my hair off my face as my forehead appears to have two bumps on and if I do I’m often asked if i’ve hit my head, which I get quite embarrassed by. It would be great to get some advice and what actions I can take. I look forward to hearing from you.

A: Thank you for sending your forehead pictures. You have the classic ‘forehead horns’ that are benign paired bin bumps that appear on the upper forehead. They are development in origin and are actually not that rare. They can be successfully removed using of two approaches. The first approach is to simply burr down the prominences so they are more confluent with the rest of the forehead. (forehead horn reduction) The other approach is to build up the forehead area around the horns to make for a smoother albeit fuller or more convex forehead. The choice depends on the patient’s aesthetic preferences for their overall forehead shape

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. I have a very flat head from the back which makes my head look too small for my face and I need a big amount of augmentation to get the skull shape I’m looking for. After reading your blogs it seems that I need a 2 stage procedure using the tissue expander to get the maximal amount of scalp stretch needed for a good augmentation. I have few questions I want to ask you related to the 2 stage procedure

1.Are you the only one who preform skull reshaping 2 stage using Tissue Expander or it can be done by any skilled plastic surgeon?

2. Can an implant up to 3 cm be done if it was desired by a patient with a very flat back of head ?

3. Does this procedure performed by doctors in europe ?

4. My little brother has the same issue and his planning to get the procedure too when he will be able to pay for it. But he is very concerned if it’s gonna be available to him 10 years or 15 years from now?

A: Thank you for your skull reshaping surgery inquiry. In answer to your questions:

I can only speak for the procedures that I do on a regular basis. I can not speak to what surgeons elsewhere in the world may perform a two-stage skull augmentation procedure.
2) It is usually wise to stay in the 2 to 2.5 cm augmentation thickness range.

3) I would not know if any doctors in Europe perform these type of skull augmentation procedures.

4) I see no reason why such skull reshaping procedures would not be available in the immediate or far future.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I need a lot of nasal dorsal augmentation. I looked at your gallery and like your work very much. And I would like to know if you would recommend rib cartilage or donated cartilage or artificial material in patients with very low nose bridge. Looking forward to hearing from you. Thanks!

A: There are three material methods of nasal dorsal augmentation, each with their own advantages and disadvantages. A synthetic implant, like ePTFE, offers an off-the-shelf augmentation material that can be carved and customized for each patient and offers an augmentation method that is assured of a smooth contour and not to warp after placement. But it does come with some risk of infection being a synthetic material. Autologous rib grafts offer the most natural material and lowest risk of infection. But it does requires a donor site, costs more to do and has some risk of warping and asymmetry. Cadaveric rib cartilage is like an intermediary material between an implant and one’s own rib cartilage. It is not an implant but then again is also not like one’s own rib cartilage either.

As you can see there is no perfect dorsal augmentation material and rhinoplasty surgeons often use what they are most familiar with or have used in the past. Having used all three nasal augmentation materials, my preferred choice comes down to educating the patient and having them decide which nasal material is most appearing to them. The only caveat in your case in that you said you need a lot of augmentation. I would have to see what a lot means as that may sway the decision in favor of one of the nasal augmentation materials.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m quite interested in getting custom zygomatic arch implants from you, but I had one major concern. I am currently aiming for two cosmetic surgery procedures: zygomatic augmentation with you and eye reshaping surgery from another surgeon. As you can see, the eye reshaping procedure might require anything from lateral canthoplasty to midface lifting/fat grafting under the lower eyelid. Since the zygoma and eyes seem anatomically close, my main concern was that getting zygomatic arch implants would reverse or affect the eye work I’d have done. Do zygomatic arch implants tend to impact or affect the eye shape or any eye procedures done prior to implantation? In this case, do you think there would be any reversal/affect risk from having the two procedures done? Which order would you recommend I do them in? Thanks so much.

A: I am not aware of any adverse effects of zygomatic arch implants on the lower eyelid. The dissection to place them does not violate the lower eyelid tissues. That being said it is clear that the zygomatic arch implants should be placed first as this will eliminate any potential lower eyelid concerns you may have as to their potential adverse effects.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. Several years years ago I had a chin reduction (sliding genioplasty 4mm). It left me with a short face and excess tissue. I then had a small button chin implant (2mm) inserted to try and reverse the outcome. I still have a short chin and excess tissue under neath my chin. Also from a side view it looks like there is an indent where the scar is and then tissue/fat. Also I have formed a jowl on my left side. I originally had a smooth chin/neckline. I’m wondering if it’s possible to do a sliding genioplasty with the small implant still intact. (mainly vertically 2mm) to help the short frontal view. I’d like to look more like my original face (never should have started down this road). Will a sliding genioplasty help the excess tissue? Will it tighten my neckline? Is it possible to do a sliding genioplasty with an excision under the chin instead of intraoral to try to avoid complications with the lips? Thank you for your time. 

A: The answer is you can do a sliding genioplasty with a chin implant in place, I have done it many times. This is the correct procedure to pick up the loose tissues and improve your jawline. Remember a sliding genioplasty setback (which never works satisfactorily for a chin reduction) got you where you are today…and only reversing it is going to help get you out it. (sliding genioplasty reversal) It will have to be done intraorally and not from a submental approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast augmentation  in 2006 in which round, saline, high profile implements were placed under the muscle. As you can see on the picture the implants are too narrow, too far apart from each other and not low enough which is one of the reasons why my nipples are too low. Also, when flexing the implants they move way too much (see pic) and when lying the left implant migrate externally (see pic). So what I’m looking for is a surgeon that could make do a breast augmentation revision as well as lifting my nipples of 2 cm whithout scaring the hell out of my breasts. So I was thinking that a capsulectomy with new lifting anatomical implants could be a solution? Or reducing my capsules In order to prevent the anatomical implant from moving could be an other one?

What do you think Doc?

A: Thank you for sending your pictures. I would agree that your breast implants are sitting too high and have a fairly narrow base. Because they are probably 100% submuscular you have a more complete expression of the implant animation deformity. (which every submuscular patient has to some degree) Through your existing inframammary incisions, new breasts implants that have a wider base (some increased volume as well) placed into new pockets which are lowered and with some partial muscle release, should address most of your concerns. The only one that would not be a lot better is the spacing between your breasts which is a reflection off your natural breast base spacing. I would avoid anatomic implants in a breast augmentation revision due to potential implant shifting. If needed I would also perform a superior crescent nipple lift as part of your breast augmentation revision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttock implant replacements. I have had two prior buttock implant surgeries The first was using 500cc subfascial implants which looked abnormal and then there were replaced with 712cc intramuscular implants which also do not look right and give me a lot of pain. What do you recommend for buttock implant replacements?

A: At 712ccs of volume I can assure you that your current buttock implants are in the subfascial location not the intramuscular location. My thoughts are as follows:

1) Stay in the subfascial pocket which is undoubtably where you are now with your 712cc implants.

2) Use a parasagittal incision approach rather than a single midline incision. This will lower the risk of wound separation after surgery and also prevent any communication between the two implants.

3) Round implants do not have the risk of rotation/malposition that anatomic or oblong ones have.

4) Your current 712cc implants have a 15.7 cm base with 6cm projection. That is too narrow an implant diameter for that much projection in a visible subfascial location.

5) New buttock implant considerations include either a) custom made implants with a 16.5 cm base of 500cc volume or b) stock oblong implants of 575cc volume with 20cm length and 15cm width.

6) Ideally you want new implants that can fill or stretch out your existing pockets/capsule so it does not need to be adjusted/reduced with less implant volume as this is an unpredictable and unstable maneuver in the buttock region which has to eventually be exposed to the stresses of sitting.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, at what time period can infection be ruled out in custom facial implants?  Like three weeks?  I am worried about second hand smoke from people causing infection, I’ve never smoked in my life but am worried about that. 

I was wondering what is done in the case of infection with custom facial implants, do they always have to be removed or do the infections sometimes clear up?  What can I do aside from taking the prescribed antibiotics in order to help prevent infection? 

A: The treatment of infection in custom facial implants is no different than that of any other implant placed in the body. The only effective treatment options s is to either remove the implant or clean out the wound, re-sterilize the implant(s) and immediately re-insert it. The infection never gets cleared up by any other maneuver. it is critically important that he biofilm layer on the implant be completely removed if any treatment is to be effective.

Second hand smoke is not a cause of infection. Other than talking antibiotics and using Peridex mouthwash, there is nothing else you can do. 

The risk of infection is never completely ruled out for 6 to 8 weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in your custom sternal implant surgery for pectus excavatum. How much would the surgery cost for a 3D computer design, compared to a silicone elastomer moulage technique? Also, what is the difference between the two?

A: To make a sternal implant in the contour treatment of precuts excavatum, the two approaches are as you have mentioned are a moulage and 3D CT scan design. In general a sternal implant designed from the patient’s 3D chest CT scan provides the most accurate implant shape based on the actual shape of the sternum and medial ribs. In contrast a moulage implant design is an external technique using the shape of the sternal depression. While not exactly mimicking the underlying bone shape it still provides a pretty good contour restoration.

I  have used both techniques and I can not tell you that one is absolutely superior to the other in terms of the aesthetic result. Thus the technique I use for sternal implants is based on the patient’s geography. If they can be seen in the office I will use the moulage technique as I can make it myself. If they are geographically distant I will either use a 3D CT scan design or have the patient make their own clay or silicone elastomer moulage of the sternal depression. ( I send a silicone elastomer kit to do it)

My assistant Camille will pass along the cost of the surgery to you next week. The only difference in the cost between the two custom sternal implant techniques is the cost of the implant fabrication.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Dr. Eppley, I am interested in flank liposuction. I had a tummy tuck ten years ago and have had these muffin tops since. I probably had them before but they have become more pronounced since the tummy tuck surgery. I’m otherwise very active and exercise regularly but these muffin tops are unrelenting and simply won’t go away. I hope that Smartlipo can get rid of them. I have attached some pictures for your review and recommendations.

A: Thank you for sending your pictures. The reality is that a significant portion of your muffin tops is caused by excess skin and not fat. While you can undergo liposuction that is very likely going to lead to a disappointing result as there is simply too much skin. No form of liposuction can shrink 10 to 12 cms of excess skin width. The only really effective procedure is going to be flank lifts where a wide excision of the skin rolls is done. You probably originally should have had an extended tummy tuck to address these rolls at the time off your original tummy tuck but either weren’t prepared to accept the extended scars or your surgeon never offered that as a tummy tuck option. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 35 year old man and I would like to make my chin area more developed to enhance my overall look. I believe the lower third area of my face isn’t very strong, This could be corrected in the form of a sliding genioplasty or a chin implant, your opinion on what needs to be done would greatly matter. 

I look forward to your reply.

A: Compared to almost all patients that I have seen for chin augmentation, you actually have one of the ‘stronger’ chins. Probably what you are seeking is both a horizontal and vertical chin change. Thus you could go either with an implant or a sliding genioplasty depending upon the following two considerations:

1) From the front view do you want to keep the chin the shape that it is or have it be more square which would require a square chin implant style

2) Your personal feeling about a synthetic implant or whether you feel more comfortable using your own bone for the chin augmentation

The answer to those two question will decide which chin augmentation method is best for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the flash recovery breast augmentation procedure. However, I have a few concerns: I have tuberous breasts, and I am transgender. Does Dr. Eppley specialize in tuberous breasts, and is it a problem that I am transgender? I have all the necessary paper work and documentation. My big goal is to be able to achieve “kissing cleavage” even without the need of a push up. I’m also wanting to go as big as possible, so how big can ideal implants get? A couple of surgeons suggested 800cc uhp silicone since I have a wide frae and it would eat it up easily, but when I tried on the sizers they just didn’t have that vavoom look I was wanting. I don’t really want to go saline because I still want that natural jiggle I have now. Thank you for your time!

A: Thank you for your inquiry. In answer to your breast augmentation questions:

1) I believe you are referring to a Rapid Recovery breast augmentation protocol as opposed to a Flash Recovery. While breast augmentation recovery can be expedited, it can not be instantaneous.

2) Whether one is a genetic female or male, breast implants can be successfully placed. There may or may not be size limitations based one the ability of the tissues to stretch to accommodate the implant.

3) Tuberous breasts are not an infrequent finding in prospective breast augmentation patients. Depending upon their severity they can impact how the breast augmentation procedure is performed and the results seen. No plastic surgeon ’specializes’ in tuberous breasts, they either have experience with them or not. Most plastic surgeons have.

4) Whether you can achieve cleavage from your breast augmentation depends on many anatomic factors and not just implant size alone. Implant size helps but one’s natural breast and nipple spacing plays a major role as well.

5) The largest silicone breast implants are 800cc. Only saline implants can go bigger. Depending upon your implant size needs, you may have no choice but saline implants ion 800cc is inadequate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a healthy 51 years old man and underwent a cheek implant procedure 15 years ago. The surgeon used Implantech´s Flowers Tear Trough implants, I am almost certain it was the size FTT-L  Large (4.8 X 2.6 X 0.5 cm).  He also suggested two nasolabial fold implants (those are quite small and he made them himself) and I accepted.

The problem is that, even though I have looked reasonably well up until now, the cheek implants where misplaced from the beginning.  The right cheek implant is too high, tilted and very close to the eye and the left implant too low.

The nasolabial fold implants are also misplaced (they were inserted through my nose, and I think it was the nasolabial implants that made recovery quite difficult due to extreme and swelling that lasted very a very long time).  Anyway, those implants go pretty much unnoticed and I only found out about their misplacement when I had a 3D face scan done recently.

I am in good shape, exercise, don’t drink or smoke, no heart or any other major issues whatsoever and have a normal build with about 20% of body fat.  I lost a lot of weight – 25 pounds, from 185 to 165 pounds, thus becoming quite skinny – a few years ago and I started feeling some pain in the cheeks.  I don’t know whether it was the cause, but when I regained my weight, the pain disappeared.  I thought that the loss of fat in my face was the cause.

Today I look younger than my real age, and I my cheeks look fairly good, but I fear that as I age, the asymmetry will become more apparent.  I was very interested on the idea of having customized implants that fit perfectly the shape of my cheeks and therefore will look natural no matter how thin my skin becomes in the future (or that’s what I guess).

I know that over the years, tissue grow around the implants and it becomes more difficult to replace them, so I don’t know how feasible my case would be or if you’ve had similar cases that wanted their implants replaced after so long.

Finally, I wonder whether having implants already in place would make more difficult to measure the cheeks and create new custom implants or if that fact is irrelevant to it. 

Also, I would like to know what the steps would be.  Could they be extracted and replaced in the same procedure?

A: Thank you for your inquiry and dealing your facial implant history and current concerns. In answer to your questions on your cheek implants:

1) Indwelling cheek implants do not make the surgery any more difficult regardless of the natural scar tissue which develops around them.

2) Indwelling cheek implants do not interfere sth designing custom ones as the existing implants are digitally removed. Actually they help in the design of the new ones since one can see where the old ones are and what they look like. When you know what doesn’t work well, it helps in making new implants designs to be better.

3) Cheek implant removal and replacement is always done at the same time.

If you have a current 3D CT scan please send me the actual disc as that is what is needed to make the new cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, ]I have pectus excavatum – I see on your site you mentioned the option of 3D implants to treat the sternal depression part of it. (custom sternal implant) Do you have any photos you could send me of your work with those? Have you ever done 3D implant on a female with Pectus Excavatum? The midline between my breasts is very narrow.. Do you think breast implants would be better choice? Do you have any pics you can send me of any patients with pectus excavatum that you placed breast implants in? Also where do we get fitted for a 3D implant?

Looking forward to your response.

A: Most cases of more minor pectus excavatum in females is adequately managed by breast implants. But it would depend on the depth of the sternal depression. I would need to see pictures off your chest to provide a more qualified answer as to what many be best for you. Breast implants work by making larger mounds and, as a result, the sternal depression usually looks less. The other treatment option is the making of a custom sternal implant designed from either a 3D CT scan of the sternum/ribcage or in office sternal moulages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had facial feminization surgery as part of my gender transition approximately six months ago. While I am very happy with the result overall, there is one problem: My lips do not meet at rest due to a labial gap of around 5.5 mm. 

Prior to my facial feminization surgery, I had double-jaw surgery to correct an open bite and a gap between my lips at rest. This surgery was 100% successful. I then had the feminization procedure which included jaw contouring, a sliding genioplasty, and an upper lip lift. While my lower lip is no lower than it was before the surgery (as far as I can tell) and I do not think anything was damaged, the upper lip lift is once again making it difficult to close my lips. 

I am trying to figure out if I am a candidate for mentalis muscle resuspension. (I know that it was not relocated as part of my genioplasty.) I spoke with a doctor here in New York and he believes it would help, but I’m not sure he’s the right surgeon for me and I’d like a second opinion. 

A: Just by your description it is not apparent that a mentalis muscle resuspension would be beneficial. Unless you have obvious chin ptosis, mentalis muscle manipulation is not going to improve lower lip incompetence in my experience. Unless the muscle is sagging (chin ptosis), you can’t lift the muscle past ‘normal’. Driving up the position of the lower lip requires multiple maneuvers and trying to change a normal muscle position is not one of them.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I have an interest in getting a mentalis muscle resuspension. I recently underwent a sliding genioplasty procedure and a few weeks later noticed that my lower lip began to be pulled down. I now have trouble keeping my mouth closed. I have been doing some research on mentalis resuspensions but it seems like most of the cases I’ve seen the lip position stays in place for a while but eventually falls back down. If permanent fixtures are placed and the mentalis is sutured to the fixtures, how can it fall back down? What causes this to happen? Also, what causes the sulcus to deepen and how can you bring it back to normal. Thanks and I hope to hear from you soon.

A: Mentalis muscle resuspension has a high incidence of ineffectiveness and lack of sustained long-term results. I would be particularly unenthusiastic about any success after a sliding geniopalsty where the tissues are already stretched. Deepening of the labiomental fold is an expected and natural sequelae of moving the chin bone forward.

The only surgical approach that I think has any merit is a dermal-fat graft to the labiomental sulcus placed intraorally and above the mentalis muscle.

Dr. Barry Eppley