Your Questions

Q: Dr. Eppley, I am getting closer to making a decision about extra large pectoral implants. I currently have Implantech’s Power Flex Pectoral Implants. (ACPI-4, 17.6 x 13.4 x 3.2cms) I am looking for something much larger, particularly in projection…hopefully at least double or much larger with greater upper fullness and deeper separation/cleavage. I know my pecs will be out of proportion to the rest of my body but that is OK. ou sid I could get pectoral implants as large as possible that would fit in the tissue pocket. How would you be able to judge their maximum size. Didn’t you say you had used custom implants as big as 6.5 cms projection? Thank you so much for your kind attention to this matter.

A: When designing custom pectoral implants, several considerations go into considering their dimensions based on the restrictions of the submuscular implant pocket. First and foremost you have indwelling implants which have created a solid surrounding capsule. Unlike submuscular breast implants, the capsule of pectoral implants is harder to release much because of the limited access from the remote axillary incision from which the implants were initially inserted. The one area that most needs to be released is the sternal or medial edge of the pocket as well as the superior edge of the pocket since this is where you need the most expansion with new pectoral implants.  Because you have the Powerflex pectoral implants (ACPI) that are more oblong rather than rectangular (PowerFlex II, ACPI2), your greatest area of ‘aesthetic’ deficiency is closer to the sternum. Any new pectoral implants must have a shape that is more like the PowerFlex II rather than the PowerFlex I that you have now.

Changing the height and width of your indwelling pectoral implants to 19 cms x 14.5 cms would be what I would advice. Any increase in pectoral implant surface area is going to come in the sternal side. Unlike the height and width of the existing pocket the ability to stretch the projection is more generous. Thus doubling their projection should not be a problem from a tissue stretch standpoint.

The only issue that bears consideration, and a possible limiting factor, is the insertion process of  large custom pectoral implants. Pectoral implants are inserted through an axillary incision and are done so because they are folded onto themselves. The thicker the implant becomes the harder it is to roll it (fold in half) for insertion. This is why in very large pectoral implants the concept of double stacking implants rather than one single large implant is often considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to ask, in a Lefort 1 osteotomy, is it possible to lengthen the nose along with that part of the maxilla. Part of my problem with my midface is a nose that is short vertically compared to the distance between eye to eye horizontally. So is it possible to lengthen the nose within the Lefort 1 osteotomy? I am asking because I saw this Lefort 1 osteotomy example, and wanted to know if the bone grafts also applied to lengthening the nose vertically? And if so, by how much?

A: While diagrams and actual LeFort I osteotomy down fractures (vertical lengthening) do show the pyriform aperture (nasal base) being opened up and/or bone grafted, this will not vertically lengthen the nose. The shape of the external nose is largely controlled by the cartilaginous support system. (septum, upper and lower alar cartilages) This to vertically lengthening the nose cartilage grafts must be placed on TOP of the existing cartilage support. Nothing done underneath it will lengthen the external nose shape. In fact, vertical lengthening of the midface will actually create a relatively greater deficiency of the nose, more of a potentially saddle dorsal line appearance rather than the opposite effect which you desire.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a chin reduction three weeks ago. My chin always made me feel self conscious because I felt it was too long and wide for my face. Also, I had a dimple in the center of my chin that also really bothered me. My surgeon preformed a sliding genioplasty and shortened by chin 5mm. I was also concerned of the width of my chin after surgery so he tapered the sides of my jaw/chin to create a more narrow appearance.

I understand that there is considerable swelling still but I am so unhappy with how I look at this point I can’t even leave my house. The first thing I noticed was instead of dimple being in the middle of my chin, it’s at the very bottom and looks much deeper. I thought my dimple would be greatly diminished if not gone. This is what he told me. Also, my chin looks incredibly round. I feel like he should have addressed my skin and tissue instead of just addressing the bone alone. The sides where he burred to make it more narrow have this big hard knot or bulge on each side. What is this? When I smile I feel like I look awful. My lower lip looks thinner and is still numb. My lips when I smile look lopsided as well. I absolutely hate everything about my chin. I want a v shape appearance with my dimple gone or at least diminished. Now I feel like he made everything worse.

I want you to preform a revision but how long would I have to wait? I have included some pictures from 2 days ago. I would love to have a skype interview with you ASAP.

I appreciate your time and I look forward to hearing from you!

A: While I lack some specific information about your exact chin reduction surgery (type of osteotomy), I can tell you some very specific information about the recovery process from any type of reductive chin surgery. While three weeks seems like an eternity, the full recovery from chin reshaping takes a full three months, The swelling from chin osteotomies can be massive and, at three weeks, I would expect considerable chin distortion and roundness and it may not even be back to its normal size yet. Between resolution of the swelling AND soft tissue contraction back down to the smaller reshaped bone, it really does take a full three months. Other issues such as hard knots/spots, lip numbness and abnormal lip movement and smile are also normal at this point and will take the three months or longer to completely resolve.

If I am to interpret your pictures correctly, I believe some of them are before surgery (glasses) and the after surgery are those without. Based on these pictures I see a chin that do not considerable abnormally enlarged at this point after surgery.

From a chin dimple standpoint, No bony surgery is going to change the dimple. Its location may change because of the bone reduction but it will not go away. This is due to the fact that a chin dimple has a soft tissue etiology not a bone one. To decrease its appearance requires soft tissue management such as fat grafting.

The type of osteotomy used will determine whether a more v-shape will be the final result. This almost always requires a combined horizontal osteotomy and vertical ostectomy to achieve that change. I obviously have no idea what type of chin osteotomy was done in you although I am suspicious that it may have been a horizontal one only with some shaving on the sides. This does not usually work that well to effect that change. A simple panorex x-ray would answer that question.

Based on the chin osteotomy type and the presence of the chin dimple would determine whether staying the course until complete swelling has resolved would be best or whetehr earlier intervention would be more appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For purely cosmetic reasons, I wanted to know if it was possible to lengthen my midface by performing a 1-2mm dual sided vertical ramus distraction of the mandible? Also a 1-2mm LeFort 1 osteotomy vertical elongation similar to the fashion of that provided in the attached photo that had featured the osteotomy and bone grafts. And if so, what would be the likely maximum cost after taxes and hospital bills?

A: What you are  seeking is vertical elongation of the maxillomandibular complex. If all that is needed is a few millimeters of vertical lengthening of the maxilla and mandible, there would be no reason to undergo any form of distraction. This can be done by using conventional orthognathic surgery operations such as a LeFort 1 osteotomy with interpositional bone grafting and a sagittal split osteotomy of the mandible. I would not do a LeFort 2 osteotomy as this is associated with an incraesed difficult factor that requires a coronal scalp incision to complete. Whatever aesthetic benefits that may come from a LeFort 1 osteotomy vs a LeFort 2 osteotomy, the added surgical risks and effort are not worth it. Such bimaxillary orthognathic surgery will cost in the range of $40,000 to $50,000 to undergo.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in tummy tuck surgery. Can you please tell me the cost of tummy tuck surgery in your practice? Also what is the recovery time from tummy tuck surgery?
A: Thank you for your inquiry. There are eight different types of tummy tucks with differing associated costs. I would need to see some pictures of your abdomen to give you a very specific cost figure. Most women are type 4 so I will have my assistant pass along the cost of that version to you. That may or may not be the type of tummy tuck that you need. There are three different levels of recovery and it depends on what you are defining as your recovery point. (up and about, back to work, working out, final recovery) Since full recovery from a tummy tuck takes a complete eight weeks, I am assuming you are referring to some level of incomplete recovery where you can get at least back to that type of activity. Working backwards then it would six weeks for working out/running, four weeks for any job that has a significant physical components to it, two weeks for a sit down job and seven to ten days to be more up and about.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I hope you will respond to my question. I am scheduled for temple augmentation with your designed temporal implant and was curious to know the recovery time? I have had cheek augmentation recently(2 months ago) and found the swelling stayed longer than anyone explained. Should I expect the same swelling with this implant? How long? Are there any photos of temple implant recovery?? Is this a new type of implant?

A: Since you are not my patient, my first answer to your temporal implant augmentation question is that these should really be answered by the surgeon you are trusting to do the procedure. He/she should be able to fully explain these questions if they have had experience with the procedure.

That being said, temporal implant recovery will be quicker than that of cheek implants. As you have now learned, full recovery from any type of facial skeletal augmentation will take a full two to three months. Your surgeon should have made that clear before your surgery. Any form of facial implant surgery always takes longer than any patient believes or is told. However since temporal implants are not a bone-based surgery but a muscle one, the recovery is much quicker with a faster resolution of swelling and to get to the point of seeing the final result.

Due to patent confidentiality, patient photos are not shared.

The temporal implant is not a new implant as defined by just coming out. It has been commercially available now for over three years.

Best of luck with your surgery,

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested surgical reduction of the occipital nob. I have a large bump on the bottom of the back of my head that causes constant pain and headaches. It hurts to sleep on it and wearing protective head wear at work is almost impossible. I have read that you do a reduction of the occipital knob. Is this strictly a cosmetic procedure or can it be deemed a medical issue for insurance coverage?

A: The occipital knob deformity is an abnormally large hump of bone at the bottom of the occipital bone in the midline. Why it develops more prominently in some men than others is not known. It has become more of an aesthetic issue today since more men shave their head or have very closely cropped hairstyles.

Tthe size of the bony knob can be a source of discomfort when flexing the head backwards or in certain headwear/headgear.  This is also where some of the neck muscles attach and the large hump of bone probably signals strong muscular attachments as well. The occipital knob can be reduced by burring it down through a small horizontal incision over it. This is a cosmetic procedure and not one covered by insurance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two questions about rhinoplasty. First, is there any leeway in the 7 day recovery time? And the second one is I have seen that if you have trouble breathing, insurance may pay for some of the procedure. Is that true? I ask because my nose is a little crooked to the right and I feel like there is a big difference between the left and right side as far as breathing goes.Thanks.

A: Depending upon how one chooses to define recovery, only the first phase of a rhinoplasty is done at one week after surgery. That is when the nasal tapes and splints are removed. But that is far from when one has a full recovery from the procedure. But that is certainly the most obvious appearance part of it due to the external nasal dressing.

If one has breathing problems in which deranged anatomy is evident in a CT scan, then a predetermination with your insurance can be filed to see if they will pay for the functional or breathing part of the surgery. An insurance predetermination can not be filed without a recent CT scan report. The purpose of a predetermination letter is to provide your health insurance carrier with the information so they can determine if you qualify. But insurance does not cover any part of a rhinoplasty that changes the external shape of the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a rhinoplasty. I’m looking for mostly tip narrowing and some nostril narrowing for when I smile, and also don’t like how close the bottom of the nose is to my lip when I smile. I’m wondering what you suggest.

A: It is important to recognize that rhinoplasty, like almost every other facial plastic surgery operation, is a static and not a dynamic procedure. The rhinoplasty operation is designed to fix anatomic problems in the shape and function of the nose that exist when one’s face is at rest and not smiling. Thus your nasal tip can be significantly narrowed and shortened and the nostrils narrowed, and that will have some positive impact on the appearance of the nose when smiling, but not to the degree that you may ideally like. The distance between the base of your nose and upper lip when smiling is a dynamic one that rhinoplasty will not really improve per se. Lifting the nasal tip may provide some illusion that it is improved but not by actual measurements between the nose and lip. That area of improvement is not an achievable or expected outcome from any rhinoplasty surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question on upper lip lifts. A little of my lower teeth is already showing when my lips are slightly apart. This is probably due to a chin reduction I had via the intraoral approach. I am concerned that the show / visibility of my lower teeth will be exacerbated if my upper lip length is reduced further. Can the upper lift length be reduced without increasing the show of the lower teeth? 

A: I am not aware that a subnasal upper lip lift ever increases the show of the lower teeth. It can increase marginally upper tooth show, perhaps by a millimeter or so in some cases. The further away a structure is from the point of pull, the less movement effect it has on it. In most lip lifts any increased tooth show is only temporary at best.

But if one wants to avoid any risks of tooth show in a subnasal lip lift, either the upper or lower teeth, no more than 1/4 of the measured philtral length in millimeters should be reoved. That is how you determine the amount of skin under the base of the nose to remove in a subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in another revision rhinoplasty. Are some noses by virtue of skin thickness or other unfavourable pre existing qualities simply not amenable to improvement? I have had 5 rhinoplasties already (the last procedure was done using autologous rib cartilage for the tip and silicone for the bridge. This was in march last year) and have seen little (if any) improvement in the size of my nose (which has always been my chief complaint). After the last procedure, ironically, I seemed to have ended up with an even bigger nose than what I had to begin with. The tip is now also drooping and the nose is long and heavy looking. Is there any hope at all for a smaller and more refined nose? My ethnicity is Asian but I do not think my skin is thicker than what would be considered typical for my demographic. I am willing to treat my nose as aggressively as is required so I can obtain the best outcome. I understand this may include taping the nose every night for the first 3 months and also kenalog injections for swelling / scar tissue resolution. In your practice, how beneficial have you found these adjunct therapies to be? Will/can laser help in thinning the skin to obtain a better rhinoplasty outcome?

A: Due to skin thickness, there are some noses where the ability to truly make it smaller or more refined is very limited. I would think after five rhinoplasties (four revision rhinoplasty surgeries) that has probably become true for your nose..even though I have never seen it. Regardless of what your nose’s original skin retraction capabilities were, that skin shrinkage capability is now probably lost. I do not know what the objective of your last rhinoplasty surgery was, but by adding rib cartilage and a silicone implant I can not see how it could have ever gotten smaller. By adding volume your nose would have predictably gotten bigger.

At this point I would not think that any amount of taping or steroids after a revision rhinoplasty is going to make your nose any thinner. That would be hard to imagine after so many revision rhinoplasty procedures. Laser is not a treatment for thinning the skin of the nose. There is no such procedure for doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. I want a slimmer waist. It’s something I can’t achieve with working out unfortunately. The more I work out the more boy like my body becomes. I look more feminine in my body shape when I work out less because when I burn fat my body becomes very straight. I have narrow hips and a small butt. I don’t have much fat on my belly so I know that is not the issue. My body shape is just very straight. I would like to have a more curvy body (I am also considering butt implants but that is an entirely different procedure). I don’t know how many ribs would be needed to take out in order to achieve what I want. I am not obsessed with a slim waist line I would simply like to narrow it somewhat. I think I would need your guidance to know how many and what I can achieve. I don’t want anything that would look unnatural, and I don’t want to risk my health. Being able to work out is important to me and I don’t want to be limited in any way. I don’t want to look like a Barbie, I simply want a enhancement to my body, to look more attractive and more feminine. Please suggest. Thank you and looking forward to your reply.

A: For your very straight torso, waistline narrowing by rib removal would likely be effective. Rib removal surgery of at least #s 11 and 12 would be needed and possibly a part of #10 as well. This is both safe, does not preclude working out afterwards and produces a very visible indentation at the anatomic waistline level. Since this type of rib removal surgery is done in the prone position, one may consider concurrent buttock implant surgery as well since that also has to be done in the prone position and any amount of buttock augmentation would contribute to your overall more curvy body as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would love to discuss getting breast implants, keloid removal, and possibly upper lip injections. My questions are: 1. Would all three of those procedures be able to be done during the same surgery andin the same anesthetic if I so chose to do all three? 2. The keloids are on my right ear are from botched piercings/healing. This a substantial keoid on my earlobe, a more minor one on the upper ear cartilage. 3. In your experience, what products are the most natural looking, safest, and have the most longevity in the human body for breasts and same question for lips. Again, I appreciate all insight and hope to soon be one of your patients.

A: In answer to your breast augmentation, ear keloid removal and lip augmentation questions, I can provide the following answers. It would most efficient and prudent to combine all three procedures during the same surgery. Ear keloids are common and their removal often involves the concurrent use of steroid injections to prevent their known high rate of recurrence. For earlobe keloid removal the use of a postoperative compression earlobe device is recommended. The most assured and effective method of breast augmentation is the use of breast implants. Silicone breast implants offer the most natural feel and longevity over saline breast implants. For lip augmentation one should take advantage of the operative location and anesthetic to do fat injections for the lip augmentation. While no method of lip injections is assured, the use of fat at least offers the potential, is natural and is best done in an operating room location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: D. Eppley,I am interested in a chin implant revision surgery. I had a chin implant placed through a mouth incision which has left me with a lot of issues. Will moving the chin implant to a lower and better location correct all the issues I’ve been having? Maybe even the dimpling. Don’t know if you can tell from some of the photos, but the doctor that put in the chin implant had also did a submental tuck. Will you be using the same implant or replacing with a new one? You mentioned moving it to a better location on the bone but you also mentioned that a new implant positioned lower may also be a possibility. I don’t  want my chin to look bigger. So will placing it right on the chin bone make my chin look longer?

A: Whether a new chin implant is needed or not for your chin implant revision is not absolutely clear to me right now. If you are happy with what horizontal projection it provides and are not unhappy about its width then I would say just use the one you have. When moving the existing implant it may be necessary to shorten its height so it does not create a vertically longer chin. That would be the only reason to consider a new implant to prevent that occurrence. Knowing what style and size of chin implant you currently have in place would be helpful in that regard but that is information you may not likely have. Thus that is a judgment that would have to be made on an intraoperative basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a 28 yo female who has a negative orbital vector bilaterally. I don’t have a history of zygomatic fractures, but I suspect the lower eye bone and cheek complex did not grow forward enough.  Do you perform zygomatic osteotomies electively? I have seen your work in patients with old orbital fractures which really brings forward the cheekbones. Can such a zygomatic osteotomy technique be done for someone with a negative orbital vector.

A: The treatment of a negative orbital vector would not be done using zygomatic osteotomies. They will not being the cheek and orbital rims forward. Zygomatic osteotomies increase cheek width but not anterior projection. Only onlay bone augmentation will do so and that is best done by custom made implants. The creation of infraorbital rim-malar implants placed through a lower eyelid incision is the best way that I know to effectively treat a negative orbital vector. It is commonly believed that these bones can be moved forward, like the jaw bones below them, but such bone osteotomies are unduly complicated and associated with bony irregularities. It is far easier and more effective to create custom infraorbital-malar implants from the patient’s 3D CT scan to treat a negative orbital vector.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Six months ago I had a small dent on the top of my head repaired using an injectible cranioplasty technique. Since then, I have noticed a small piece has broken off and the implant is a bit more raised then I expected. The doctor that performed the procedure said that it may feel raised for up to a year and we should readdress it at that point. I’ve read a lot of your articles and in hindsight I should have come to you for the procedure. However, I must deal with the issues as they are. My questions to you are: is it normal for a piece to chip off? Should the area be slightly swollen up to 6 months? What are my repair options? 

A: Thank you for your inquiry. Can you tell me more about this injectable cranioplasty technique. What material was used and how was it injected? While this is a complication that I have not seen, I could envision it occurring depending upon the material. It could only really occur with a hydroxyapatite cement material not with PMMA bone cement. But more likely than not it is not a broken off piece of material. It likely is an edge or surface irregularity that has become apparent as the swelling subsided and the scalp tissues adhered back down. Since this takes months to occur, the visible edge may not have been seen for awhile. What you see now is not going to go away. If it is just only one area, a small incision directly over it to remove it would seem the logical approach. Also a small incision can be used to introduce a rasp to smooth the material down if it is an hydroxyapatite

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just recently read an article that said that you did a rib removal surgery on a woman. This is something that I have been interested in for a very long time. I was born with a disfigured ribcage and there’s nothing I hate more. The left rib protrudes more then my left side! I used to have pectus excavatum, I had a surgery where the doctor inserted a metal bar in my chest which was removed! Please let me know if you can help me. I feel like this is something that I need to actually be happy with my body.

A: Thank you for sending your pictures for consideration for rib removal surgery. Your subcostal protrusion is due to the prominence or bowing out primarily of ribs #7 and #8. (and a little bit from #9) This is not uncommon in pectus excavatum which you obviously had having undergone the Nuss procedure. (placement of the pectus bar and its subsequent removal) It would be necessary to remove ribs #8 and #9 and either do a shave or beveling of #7. (subtotal removal) The only aesthetic issue with this rib removal surgery is that you need a direct subcostal incision to do so. You would need a 6 to 8cm along the subcostal margin on each side. One has to decide whether a fine line scar is a better aesthetic concern than that of the rib protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about facial implants. I want to improve the narrowness of my face. You have posted many articles on face widening, but it seems there are so many options. I am hesitant to simply stuff my face with implants to solve this problem. Particularly, I feel my temple area and zygomatic arch should go more laterally than they do, which may contribute to the narrowness. Would fat injections be a viable option here? Does the fat just reabsorb like many people say? I looked into submalar implants, but, again, I would hate to go down that road unless I had do. It also worries me that they are placed through the mouth when I’ve had issues with the chin already. Are they at least screwed in? Because my chin implant is not.

A: The options for facial widening are only facial implants, fat injections and injectable fillers. While fat injections can be done to create a facial widening effect, and there is certainly no harm in doing so, one has to be prepared to accept the unpredictability of both its survival and persistence.

Even compared to fat, temporal facial implants are so simple and effective that I would not even consider fat in that area as a first option.

Any cheek facial implants placed through the mouth are always secured into place with small microscrews so they will never be dislocated from their optimal placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My forehead is very noticeably high. And it makes my long narrow face even worse. I only style my hair certain ways to cover it (or try to). I’ve been wanting a forehead reduction for years and I certainly do not want to go to just anyone. I know you are very experienced in this procedure. Is it possible to still preserve the roundness of the hairline? I’m a little frightened by some results I see where patient’s new hairlines look like they were drawn across their forehead with a ruler! Also, my forehead lacks projection. I realize I am female and I certainly don’t mean I want the big masculine brow bone! But my forehead goes straight down to my eyeball. I feel like the brow should at least come out a little to be aesthetically pleasing. I know foreheads are often shaved down during this, but can ‘bone’ or something else be added?

A: Most hairline advancements that I have seen done have a rounded effect across the hairline. This is almost unavoidable because the greatest amount of hairline advancement is in the center of the forehead and less so as it goes back into the temporal areas. A hairline advancement can not really just create a perfectly straight line across the forehead.

Brow bone augmentation can be done using bone cements or a custom brow bone implants. When done in conjunction with a hairline advancement, the open exposure provided by this procedure allows any of the brow bone augmentation options to be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw implants. My jawline looks basically non-existent from the outside, which I believe only exaggerates the narrowness/gauntness of my face  Given that I am fairly young, aging is not a factor. I was originally thinking about jaw implants in addition to chin implants to give a more polished look to the whole area, but I have read that jaw implants, because of their placement under the masseter muscle, can cause a lot of pain, swelling, stiffness, etc. I feel I went through a lot of uncertainty with my chin implant, and I’m afraid this might be more of the same, Your thoughts? Would fillers or fat grafting give a similar jawline appearance? How about liposuction around the neck? 

A: When patients use the term jaw implants, they almost always mean jaw angle implants. Jaw angle implants are the best and really only way to create visible angularity of the back part of the jaw. Injectable fillers or fat injections will add indistinct volume and fullness which often can be perceived as just being wider but with any distinct definition.  Liposuction can not create a defined jaw angle shape.

While jaw angle implants will cause some temporary masseter muscle discomfort, swelling and stiffness of mouth opening for a few weeks after surgery, these are not permanent effects.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always had a long and narrow face that lacks definition and bothers me. I was also born with a recessed chin. Over the summer I decided to have a chin implant, but after waiting months for the swelling to go down, I don’t feel happy with the results. I feel my chin implant sits too high up (intraoral approach was used) both in looks and in function. I have not been able to close my lips without due strain since the surgery and I could this before the surgery. There’s no swelling or tightness left either. Not to mention they used the smallest implant possible, so it’s not that the implant is simply too large. Because of this I am afraid that the height of the implant and the nature of the oral incision could be to blame? I cannot find any answers online and my surgeon says t hat everything is fine. Thoughts? 

A: Intraoral chin implant placement has a known propensity to place the implant too high. If the chin implant does not sit down at the bottom of the chin bone, its aesthetic effect will not only be diminished but it can interfere with mentalis muscle function and a competent lip closure. Just based on the description of your symptoms, I suspect your conclusion about the location of the chin implant is correct. Chin implant revision would consist of repositioning of the implant to the proper position and repair of the mentalis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom chin implant but have some questions about it. I’d like to add significant height and projection to my chin (while avoiding a deep labiomental fold). I’d also like to add some slight width to the jaw while maintaining my well-defined cheekbones. To what extent could a custom chin  implant achieve this desired look?

A: A custom chin implant (really a modified jawline implant) is the most effective method for creating the chin projection and slight jawline width that you seek. It is best because one controls the dimensions of the implant in the pre surgical design and allows a smooth jawline to be created from the chin on back to the jaw angles. This is not an effect that any off-the-shelf chin implant design can do.

You will not, however, avoid deepening the labiomental fold (technically the labiomental sulcus) with a custom chin implant. The depth of the fold is a fixed point so any substantial increase in the horizontal projection of the chin, and yours would be considered substantial, will deepen the fold. This can not be avoided short of leaving your chin where it is.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I am interested in facial asymmetry surgery. I have an an asymmetrical face due to irregular growth of the jaw bone. Will the chin reduction on the right side correct it? I also notice that the right side of my face has less soft tissue so will the jaw angle implant balance out my face? Thank you.

A: Your facial asymmetry correction surgery approach certainly appears to be the correct one. Based on your pictures, the right side of the chin is longer and the width of the right jaw angle is more narrow than those two jawline areas on the left side of your face. So a right vertical chin reduction and right lateral width jaw angle implant should create improved facial symmetry. The only question is whether one wants to make the judgments for the amount of vertical chin reduction an the amount of width needed in the jaw angle up to the surgeon’s aesthetic sense or whether to make a more scientific quantitative assessment of them. That may be best done using a 3D CT scan or, at the least, get a panorex and lateral cephalometric x-rays to make some preoperative measurements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a car accident over a year ago and had a portion of my scalp avulsed. I was missing a long swath of my scalp. I had to have surgery where my scalp was undermined and made into a flap and stapled back together. Everything has healed nicely and I have thick hair which covers the scar. However, there is a noticeable dent and asymmetry with my scalp which looks funny and requires me to grow my hair longer on that side to cover the area, kind of like a small comb over which I am not comfortable with. I am interested in having that area filled to improve the symmetry of my scalp and provide a normal look to the shape of my head. I buzzed my head and provided a picture that you will see attached.

A: Since your original injury was a soft tissue one (scalp) and not loss of bone, the indentation along the line of the original scalp avulsion closure is from a soft tissued defect not a bone defect. Building up the skull is not the solution to solving the scalp dent problem. This is a scalp reconstruction issue. The likely solution is either fat injections to release the scalp scar and build up the dent or open the scar and implant a dermal-fat graft or an alogeneic dermal graft. Either way the scalp tissue needs to be built up or thickened to create a smoother scalp contour.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently an A cup and would like to set up a consultation to review my eligibility for breast augmentation. I would like to consider a full B cup. Some information about me – 32 year old female, kidney transplant recipient five years ago and on dialysis for seven years prior to the transplant.I have wanted to have breast augmentation for many years and after a lot of research I have not been able to find anyone locally who has previously done this type of plastic surgery on a kidney transplant recipient. Please let me know your thoughts, I see that you do have previous experience in this specialized procedure.

A: I have done various types of cosmetic surgery in kidney transplant patients from breast augmentation, breast reconstruction, tummy tucks and facelifts. I have not seen any complications from any of these procedures despite the patients having a kidney transplant and being on immunosuppression. I think as long as your transplant doctors so not see a contraindication you should have an uncomplicated postoperative course.

In theory the elective placement of a synthetic device, like in breast augmentation, in a patient on immunosuppression seems one that would be fraught with peril but that has not been my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, As for back of the head surgery (occipital augmentation) I have a few questions? 

1) how much in cm or mm can I expect the head to become rounder using implants? 

2) if the implants get infected how dangerous is it? Can it be prevented or treated?

3) Very important question – So the back of my head is flat but it is not level. The right hand side it is about 1 cm bigger than the left so basically I have Plagiocephaly and brachephly. (I think) Can a good result still be achieved and how? Are you able to shave some bone off the skull to get it to the same level and then insert the implant?

A: Thank you for your inquiry. In answer to your questions about occipital augmentation by an occipital implant:

1) Usually 12 to 15mm is the maximum implant thickness that most scalps will accommodate.

2) I have never seen an occipital augmentation infection. But the implant can be easily removed if needed.

3) With skull asymmetry the implant would only be placed on some side to have the two sides match. In these cases, the best way to make the implant would be from a 3D CT scan to get the best match between the two sides.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I had some questions about cost and procedures for the fat transfer breast augmentation/liposuction. I am 28 year-old Caucasian weighing around 130 lbs and have been doing exercise over the last couple months to reduce my body fat percentage however there are some problem areas that while they decrease I can’t seem to get the results that I want in particular stomach/thighs/triceps areas. Also unfortunately with my overall weight loss I am noticing I am losing volume in my breasts, not a significant amount, but enough to where I am considering the fat transfer from unwanted areas to my chest.

A:Thank you for your inquiry. Fat transfer breast augmentation, while understandably very appealing, is for only a few very well selected patients. First and foremost, one has to have enough fat to be able to do the procedure to make it worthwhile. Being only 130 lbs this already make you a bit suspect in that regard. Then there is the issue of your athleticism and focus on weight loss which bodes very poorly for fat survival and retention. That is why in young athletic fairly lean women fat grafting is often not a viable option. Breast implants offer a more assured outcome and do not prohibit one from any type of physical activity.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I met with a plastic surgery this week for a consultation and asked about the posterior jaw implants. He said no one really does them any more because the implants are known to slip and move a lot. What do you do different to combat this complication? Is this a frequent problem you have dealt with? Thanks.

A: I am afraid that your surgeon is misinformed and not up to date on the most contemporary techniques and use of jaw angle implants. Not only have the styles of jaw angle implants changed but it is now routinue to secure them into place with a single small microscrew. This obviates the entire problem of jaw angle implant slippage after surgery and does a much better job of maintaining intraoperative positioning. There can still be issues with malposition due to intraoperative placement like any other bilateral implant procedure but secure fixation to the bone is the key to obviating the potential movements of jaw angle implants in the submasseteric pocket location.

Along with the understanding that fixation is needed is the development and use of new styles and sizes for jaw angle implants. Vertically lengthening has been an inability to be achieved with older style jaw angle implants.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a plastic surgeon and I did some internet search on options for treating prominent temporal artery and I came across your opinions and website. I have chatted with a few of my colleagues and seniors and nobody seems to have experience with this ! Have you had success in treating the prominence with temporal artery ligation? I have a bald male patient who is very bothered by the prominence and is looking at surgical options. I would totally appreciate it if you would give me your opinion on the temporal artery ligation procedure.

A: This is a procedure that I have done many times and with good success. It is not, however, performed as has been historically done for temporal artery ligation for temporal arteritis or for temporal artery biopsies. It requires careful tracking of the arterial branches with multiple ligation points to prevent back flow and to get any feeders coming into the main anterior branch of the superficial temporal artery. The other key element of the procedure is that the incisions must not exceed 5mms in size and requires loupe magnification and head light to meticulously work through such small incisions and tie off the small arterial branches. One must also be prepared to venture out into the forehead to get the distal branches and do careful dissections to avoid the frontal branch of the facial nerve.

While not every case of multiple point temporal artery ligation will result in complete elimination of the prominent vessel, it always results in significant reduction in their visibility.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom cheek implants. I have sent in a picture of the design I want and where I want it to cover over my cheeks. I appreciate your comments that you think the design is too big and I understahd what you’re saying. But given the cheek implants I currently in place now, and it is a strength that works for a look of health, that is a strength I would hope to keep. Is it that you object to the look of it, the safety of it, or simply that is has not been customary in your practice?

A: I never professionally care what shape or size the custom implant design that a patient wants.  Custom cheek implants would be no different. What I care about with custom facial implants and what I look at carefully in the planning are only two things. First, can I safely make the implants fit into the tissues and close the incisional entrance. Secondly will the implants be too big and the patient will then have a 100% probability of needing a revision to downsize it. Having performed more computer designed custom skull and facial implants that probably any surgeon in the world, of almost every conceivable shape and size, I have a acute awareness of what will work and what will turn into a problem. I am merely trying to guide you in avoiding the latter. The single greatest error when patients provide their design layouts is that they have no understanding of the powerful effect of a custom implant that covers a large surface area over that of what a traditional implant shape does. Custom cheek implants are very powerful in the size you are envisioning and it would be very easy to make them too big, particularly in a more lean face like yours.

Dr. Barry Eppley

Indianapolis, Indiana