Your Questions
Your Questions
Q: Dr. Eppley,I underwent an 8mm sliding genioplasty three years ago. Overall I consider it a big improvement for my face, but now instead of lacking a chin, I have a step-off deformity on the right jawline. It is quite visible (you have to look straight to it thought). I could live with it but I’d also be much free from concern if I could get rid of it. Is there any way to fix and unify my jawline, preferably without major surgery? Thank you very much. Kind regards.
A: Step-offs along the jawline after a sliding genioplasty are common particularly the greater the horizontal movement and the more steep the osteotomy cut is. The simplest method to treat these jawline irregularities after a sliding geniplasty is to fill in the defect from an intraoral approach. There are a variety of material options but hydroxyapatite granules or the layering of porous mesh over it is the most common way I do it. It is a surgery but I would not consider it major surgery compared to a sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about chin implant surgery. I recently had a small central chin implant put in and I am about 3 1/2 weeks post-op. I really dislike the shape and am wondering if an extended chin implant would have been a better option. I have shadows/dents on either side of my chin.
A: There are numerous styles to choose from for chin implant surgery. Obviously selection of chin implant style and size are critical in getting the optimal desired aesthetic chin augmentation effect. While a central chin implant is often a good choice for some women, it does not provide any augmentation effects to the side of the chin since it does not extend past a vertical line dropped down from the corners of the mouth on the bone. Since you are seeing shadows/indents on the side of the chin, this would strongly suggest that this indeed a chin shape or chin style issue. The question is at just under four weeks after surgery whether this is too early to make a final judgment about the outcome of your chin augmentation procedure. I would give it a full three months after the initial surgery date before making a final judgment about the decision to change your chin implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of forehead augmentation. I have a slight depression in the middle of my forehead which in certain lighting becomes obvious. I know it is not big but it still bothers me. I have attached a video of it so you can see what I mean. What is the best method of forehead augmentation for it?
A:Thank you for sending the video which shows a circular dip/depression in the middle forehead. I have seen this before and it does represent a bit of forehead bone depression. While there are a variety of ways to do forehead augmentation, the most important consideration is to avoid any scar in doing so. This leaves us with an injection method of fat which is scarless, simple and can be reasonable effective if not overdone. The most important issue in your case is to make sure the downside of any procedure never makes the problem worse or trades off one aesthetic problem for another. The biggest downside of fat injections is the unpredictability of how well they will survive (although they usually do well in the forehead actually) and this a very ‘safe’ risk since it does not worsen the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about possible chin implant erosion. I’m a female patient in my thirties. A few years ago I had a medpor chin implant inserted. I was wondering whether I could ask for your input since I understand you are one of the most prominent surgeons when it comes to both craniofacial as well as plastic surgery.
I had a cone beam scan performed a while ago because of some concerns about my teeth. There appears to be (what looks like) a ‘step off’ in the bone at the lower frontal teeth roots, but I’m not sure if I’m seeing this/interpreting this well – I might misinterpret the scan. Could this step off be caused by the chin implant? (It concerns a medpor chin implant). I drew a red arrow in the scan where I appear to see some kind of step off/change in the bone level. I appreciate your opinion. Thank you very much.
A: That stepoff you see is a classic example of chin implant settling (many refer to it as chin implant erosion which is an inaccurate term) This illustrates that despite the biologic nature of an integrated implant material like Medpor, implant settling can and does occur just like occurs in silicone.
By bone resorption I assume you mean periodontal (gum recession) and radiographic evidence of lower alveolar bone levels. Whether that is a function of the implant I would initially doubt it as the implant sits much lower than the root level. The usual symptoms would be more pain and tooth sensitivity not alveolar bone resorption. But to qualify that answer I would need to see a front view picture of the cone beam to assess the implant’s location under/over the tooth root levels.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I would like to get deltoid implants, I’m a fairly tall at 6’1 but my shoulders are lacking. I have a narrow frame and would like silicone implants to widen my shoulders by 6 cm all together. I saw where a doctor from South Korea does deltoid implants by placing an incision under the armpit and uses silicone implants over the shoulders to reshape them and widen them. I would like to do 3 cm on each side like that surgeon does. I want to maximize my shoulders as much as possible while not over doing it. I would like to see if my clavicle growth plates have fused though before I get the implants to make sure I still have some growing room, thank you and hopefully you get back to me.
A: Deltoid implants are indeed placed through a posterior axillary incision. The implants are placed under the fascia up over the central region of the deltoid muscle. As you may know there are no off-the-shelf preformed deltoid implants that are commercially available in the U.S. due to low patient demand. What I use are Implantech’s silicone contoured carving blocks Style 3. Their greatest thickness are 2.1 cms. While a 3 cms deltoid implant can be made by them that is going to raise the cost of the implants by a significant amount. You will have to decide if the extra 9mms is worth the additional cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested, I think, in a custom jawline implant.The attached photo includes a Photoshop direction I would like to take with a custom jawline implant. Is this achievable or just very wishful thinking? Also, would you suggest a neck lift or would such an implant eliminate the loose muscle/fat under my chin. I’m looking forward to making a decision on this very soon and moving forward. Thank you very much!
A: What you are demonstrating by your Photoshop effort is pretty much what is possible with a custom jawline implant. It is not wishful thinking. Such a custom implant will pick up all the loose skin in the neck particularly back along the jawline and jaw angle area. It will also do so under the chin as well. How effective it is at ‘eliminating’ this loose skin has a lot to do with the size and dimensions of the implant. It does so because the increased surface area of the implant requires greater soft tissue coverage and it pulls it up from below not downward from the face. A bigger bone surface requires more tissue coverage and it has to come from somewhere. Fortunately for the jawline it comes from the neck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to surgically contour my facial bones, specifically from the zygoma and below. Unfortunately, where I am going they do not do temporal reduction bone surgery. So in order to achieve the look I am going for, long and thin, I was wondering, to what extent may the sides of my head be reduced without removing a lot of muscle, mainly temporal bone?
A: Contrary to popular perception, temporal reduction is done by removal of muscle not bone. The fullness of convexity of the head above the ears is a combnation of bone and muscle but the ratio is weighted more towards the muscle and not bone. The thickness of the posterior temporal muscle in men can be anywhere from 7 to 1 mm thick. In contrast the thickness of the bone may be only 3 to 5mm thick. You can demonstrate this by getting a CT scan to see the tissue makeup on the side of your head.
To really make a difference in temporal reduction surgery, you remove the entirety of the posterior temporal muscle not burring the bone. Bone reduction will make little if any difference in its width, muscle removal can make it completely flat. Interestingly, removal of the posterior muscle has no long-term effects on mouth opening as the much larger anterior portion of the temporal muscle remains.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Exploring options as part of the decision making process, I understand an alternative to the custom jawline implant would be a sliding genioplasty along with Gore-tex posterior mandibular angles and a mandibular body piece to go between the angle implant and the chin. The advantage, I believe, would be a somewhat more natural looking ‘mentolabial sulcus’ (more of an ’S’ than ‘V’ shape) and chin.
Do you think a sliding genioplasty could give me the chin width shown in my Photoshop image? I believe the chin can be split vertically and a piece of bone inserted between the halves to increase width.
Do you think the custom wrap-around implant would give me the length, width, and projection I am after, as good as a sliding genioplasty with Gore-tex angles?
As much as I want to avoid adding complexity to the surgery, I do want the best looking and most natural looking end product/result.
Your thoughts would be greatly appreciated.
A: While there are different approaches to a total jawline enhancement effect, using any form of a three piece approach (chin and two angles… or in your description a five piece approach) is, just frankly, an historic and problematic approach to achieving the jawline effect you seek. I have done over the past twenty-five years every conceivable method for chin, jaw angle and total jawline augmentation surgery. In almost every case, the custom jawline implant method is far superior to any other method or combination of jawline surgery methods for the following reasons:
- An important aspect of the total jawline enhancement look that you are going for is smoothness of the jawline from one angle to the other. A one piece implant can do that. A hodge podge of bone cuts and implants will leave a jawline irregular and asymmetric with absolute certainty.
- Every aesthetic surgery has risks of of revision which are cumulative based on the number of procedures done. While a custom jawline implant does have a risk of revision for aesthetic reasons, it is a single risk of around 15% because it is a single implant/procedure. When you combone five procedures together, as you have described, the cumulative risk from that approach will approach 100%.
- Gore-tex implants, even if they were available in the right size and thickness (which they are not) are soft and compressible. To vertically lengthen the jaw angles as you desire you need something that not only has the right shape but can push the overlying muscle and skin downward and then maintain it. Gore-tex is not the material for that job.
- While a sliding genioplasty can be split in the middle and bone grafted, the inferior edge transitions back along the jawline will not be smooth. Besides that issue you will need a bone graft harvested which must come from either your skull, rib or hip.
- The impact of a sliding genioplasty or a custom jawline implant on the labiomental sulcus are perfectly similar. The labiomental sulcus is a fixed anatomic structure whose effects from any procedure below it will remain the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead scar revision. I was on Dr Eppley’s website and noticed a few pictures of a scar revisions he had performed with great results. Seeing that he has successfully treated similar scars in the forehead region I would like to see if Dr Eppley can help me with my indented forehead scar. My scar is a result of a scar revision done one year ago for an indented chicken pox scar. The scar is approx 1/2″ in length and it sits directly on my natural wrinkle line in the center of my forehead. Unfortunately the incision line is indented which results in an aweful shadow effect. Also at the one end of the incision there is small indented hole possibly caused by the corner of the incision opening up a bit early on.The plastic surgeon who did the revision used 3 buried dermal sutures and 6 exterior sutures however he said he did not evert the wound edges as he felt it was not necessary. No eversion plus possibly too much forehead movement during the healing phase resulted in what my scar looks like today. I have also had 1 dermabrasion procedure done to grind down the indentation appearance with very minimal results. If Dr Eppley can help minimize my scar it would be greatly appreciated. Thanks very much for your time.
A: In looking at your pictures I do believe your forehead scar could be improved by forehead scar revision. But I don’t think it is as simple as just cutting out the scar and closing it in a linear fashion…with or without wound edge eversion. While the scar needs to be re-excised and closed, the key element for sustained improvement is providing some structural support underneath the wound edges to prevent a recurrent indentation. This can be a small piece of fat, dermal graft from an old scar or even a piece of allogeneic dermis. (e.g., alloderm) This will create a mild temporary elevation of the scar which will settle into a flatter profile. But without adding anything to it the wound edges are likely develop recurrent indentation given the high muscle activity in the area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what can be done about my eye asymmetry? My whole left eye is about 5mms lower than that of my right eye. What is the best way to amend this problem?
A: To correct your orbital box eye asymmetry, multiple adjustments need to be made to the orbital floor (augmentation), brow bone (inferior reduction) as well as upper eyelid (ptosis repair) and lower eyelid (fat injections and lateral canthoplasty) The issue is that the bone changes will cause problems with the current eyelid positions and then these will need to be adjusted. I have treated many cases like yours and sometimes you open ‘pandora’s box’ by trying to make these changes. The position of the eyelids is perfectly aligned to the bony orbital skeleton now albeit lower and asymmetric that it is. Once changes get made to the orbital bony box, the eyelids will be off alignment to the globe (eyeball) and these realignments often take multiple surgeries to get the optimal result.
Once the horizontal level of the pupils differs by 5mms or more in eye asymmetry, attempts at surgical improvement are often met with mixed results and lead to multiple revisional procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had this horrible deep line between my brows that drives me insane. I recently tried Botox which I knew would not be a fix and I have contemplated fillers but I know fillers are not permanent. Words cannot express how I feel everyday about having this deep crease on my face. I have had side swept bangs for years and I’m tired of hiding behind my hair and wearing hats all the time. This is border line ruining my everyday life and has completely crushed my confidence. I took a few pictures for you to see my problem.
A: Thank you for sending your pictures. What you actually have are three distinct vertical glabellar lines, the central one is just the most deep. It is important to know that the ‘standard’ treatment would be a combination of Botox and injectable fillers. Botox to stop the cause (muscle movement) and injectable fillers to fill the defects. While this would definitely provide improvement it is probably not going to be a lifelong treatment strategy.On the opposite end of that approach is a surgical one with endoscopic muscle release and fat injections. In between the two lies the placement of a dermal fat graft or allogeneic dermis graft threaded into each one of the glabellar grooves.
As you can see the treatment of your glabellar lines is not an easy problem to solve. But at least there are a variety of different options to treat it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant replacement surgery or a double chin implant surgery. Hi I had read some of your articles and believe that you have much experience with chin implants. Would be grateful if you could respond my simple question, for which I can´t find any answer anywhere else. I have a Medpor chin implant (2 years ago) that isn´t big enough, and need a larger implant. If my surgeon don´t dare to remove the porex implant, is it possible to insert a new silicone chin implant over the Medpor implant? Would be so grateful for your answer!
A: While it is technically possible to place a silicone chin implant over your existing Medpor one, that would not be a good choice. There is a high risk of implant displacement and symmetry, not to mention the probably appearance of a ‘stacked’ look of two chin implants placed on top of each other. It would be far better to do a chin implant replacement approach, removing the Medpor implant and placing a new silicone chin implant that has all of the desired dimensions. (this may or may not require a custom chin implant given what have in and what the dimensions of your ultimate chin augmentation goals) Like all face and body implants the concept of stacking one implant on top of the other often leads to future problems. If your surgeon is unwilling or uncomfortable in removing a Medpor chin implant, you need to find a surgeon who has the experience in doing so. A one piece chin implant replacement is always going to be superior to trying to put two different chin implants together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty for functional purposes. I am a 40 year old female with moderate obstructive sleep apnea with an AHI of 24 and 90% oxygen saturation at night while sleeping. I also have a very recessed chin and need a sliding genioplasty to both improve my obstructive sleep apnea and my cosmetic appearance. Maxillomandibular advancement osteotomies is not feasible for me. What type of sliding genioplasty is best, a mortisized genioplasty or a straight horizontal osteotomy? A craniofacial surgeon told me I need the mortisized type with a 4mm advancement.
A: I think what you are referring to is the difference between a straightforward sliding genioplasty and a ‘jumping’ genioplasty. I am not completely sure what you mean by a ‘mortisized genioplasty’ as that would refer to a bony genioglossus advancement only which would have no cosmetic benefit. That choice depends on which will give the greatest amount of chin advancement (which you need for your OSA) and what impact that would have on our appearance. With plate fixation the concept of a jumping sliding genioplasty has less significance than it did when only wire fixation was used. I would need to see pictures of your face and x-rays to best answer your question as to the optimal method of a sliding genioplasty for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction surgery. I am a 26 year old male and I am quite self conscious about my cheekbone width. They span almost 16cm and I am wandering if it would be possible to take about half a centimeter off on each side to make my eyes (pupilliary distance of about 65mm) more proportional to my face.
A: Your fundamental premise is that if the width of the face was less wide, your eyes would not look too close together. Since you can’t move your eyes this leaves only the cheekbone width to be changed. Cheekbone reduction surgery works by moving in the zygomatic arches of the zygomatic complex. These arches are what makes up the width of the middle part of the face. The inward movement of the cheeks usually is no greater than 5 to 7mms per side due to the location of the temporals muscle which lies underneath it. The bone should not ‘pinch’ the temporals muscle as this could interfere with the workings of it which is to help open and close the mouth. Usually it is a good idea to get a 3D CT scan before cheekbone reduction surgery to look at the anatomy of the zygomatic arches and see how much reduction is possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about midface implants. A maxillofacial surgeon recommended to me maxillary advancement to correct midface hypoplasia. Can you produce similar results through midface implants?
A: The aesthetic benefits of onlay midface implants can rival if not be superior to maxillary advancement surgery. The only area in which the deficiency will remain is at the tooth or occlusal level as one’s bite will remain the same. Not changing the position of the anterior maxillary teeth does effect upper lip support and this is one aesthetic component of the midface which will not be improved by skeletal augmentation above it. Midface implants come in a wide variety of styles and sizes from the cheeks, infraorbital rims and tear trough, premaxillary-paranasal as well as maxillary implants. With the exception of the lower orbital rim implants, all midface implants are placed from incisions inside the mouth. Because of the location of midface implants on the side of the face, they are usually best secured with small titanium microscrews. When covering larger areas of the midface, it is often best to have custom midface implants made so that maximal midface augmentation in a smooth manner is achieved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I see you prefer to secure your chin implants with screws. I’ve searched all over my area for a doctor who does this and can’t find a single one. Do you know why this is? Is it inexperience? Is there some added risk of using screws of which I’m unaware? Do you ever do them without screw fixation? What about those who secure with sutures… what does that even mean? Thanks for your time.
A: Fixation of chin implants is done by various methods by different surgeons. By far the most common technique is the use of sutures where it is passed through the implant and done to the lining on or around the bone. One can have a debate about how secure this makes chin implants but this method highly depends on the size of the implant pocket to control asymmetry caused by a tilt in the left-to-right axis of the implant’s placement. Suture fixation can not control the potential for tilt from a single central point. Screw fixation is the most secure method and is really simple and quick to do…if one is familiar with doing it. Having done craniomaxillofacial surgery for decades this makes the use of screws for chin implants as familiar as using suture to close the wound.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, For midface augmentation, should I choose paranasal filler (my maxilla is quite forward, my midface is flat and doesn’t point forward as you see in my picture) and cheek filler, or should I get an implant? The second question: how do I change my eye shape? As you see, I got strong dark circles and they are round if you look from the front, do I need infraorbital rim implants to get rid of the circles and more almond eyes (this male model squint look) or can I use filler (upper eye lid for hood look and under the eye for the circles and almond look). Thanks and kind regards.
A: The use of injectable fillers, injectable fat or implants for midface augmentation are all possible treatment options, each with their own well known advantages and disadvantages. But as a young person the best long-term approach is to have custom facial implants made for a permanent and more controlled facial shape change. Fillers and fat do not produce the same type of augmented facial look and are only going to be temporary. Eye shape change will require a lateral canthoplasty to deround the eye.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in removal surgery. I was born with pectus excavatum and significant rib protrusion. I have been advised by a thoracic surgeon that the worst ribs are 7-9. The deformities seem to be limiting my lung expansion. My insurance will cover cosmetic procedures to correct congenital deformities, as well as, medically necessary procedures for respiratory issues. I have seen you write about providing a rib resection procedure for narrowing the appearance of one’s waistline. The thoracic surgeon indicated that there is a procedure for removing the ribs while leaving the lining intact so that new ribs can form hopefully more normally (sometimes requiring bracing). I would prefer to have a plastic surgeon do such a procedure to increase the likelihood of having a more aesthetically pleasing result. Therefore, my question is: Do you have experience with any rib removal procedures that would allow for rib regeneration, and if not, do you know of any other plastic surgeon that may?
A: Rib removal in an adult is a permament procedure. As an adult, ribs that are removed whether they be the bone or cartilaginous portion, will not regenerate. That ability is lost when one is older than one year of age. So your thoracic surgeon is either misinformed or you may not have understood fully what he/she was saying. More likely the thoracic surgeon was referring to rib reshaping. The proper treatment for a pectus excavatum deformity in an adult is known as a Nuss procedure. This is where a rigid bar is placed under the ribcage to push it outward and allow for expansion and some rib recontouring. For rib protrusions of the anterior subcostal margin (ribs 7 through 9) the cartilaginous portions of the ribs can be removed to lessen the visible portion. This will improve their appearance but will not provide any improvement in pulmonary function. Only a Nuss procedure can do that. Rib removal is a cosmetic procedure not a functional one. Loss of thoracic support from rib removal can not contribute to improved pulmonary function.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about faclal implants. Can cheek implants be done with local or non general anesthesia? Also I have a short face and need to add lateral width and height but I worry about the big wrap around jaw implants involving the masseter muscle. So can we do a custom chin implant with wide wings extending laterally and vertically as far back posteriorly as possible but not hitting the masseter muscle. I realize there would be a major step off somewhere further down the jaw and the rest all the way around the ramus I would fill in with fat or radiesse. Also could that be done without general anesthesia too?
A: In regards to facial implants, certainly cheek and an extended chin implant can be done under IV sedation or MAC. (monitored anesthesia care) The use of local anesthesia for most facial implants alone would likely be inadequate and that would be doubly true if both cheek and chin implants are done at the same time. Be aware that the use of local or IV sedation does not save any money as the intraoperative time to do facial implants takes twice as long as when done under general anesthesia. So your motivation for the selection of anesthesia for these facial implant surgeries should not be one of saving money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I am a 29 year old female who has not had any children yet (would like to eventually), but has always wanted larger breasts. I am more than ready (financially and otherwise) to pursue surgery now, but am wondering if you recommend waiting until after pregnancy to have breast implants. Dies it matter having breast implants before or after pregnancy?
A: Your question about the timing of breast implants is a very good one for which there is no right or wrong answer. Unless one has a pregnancy planned in the near future, the placement of breast implants could be done at anytime. Unlike a tummy tuck, for example, pregnancy does not usually have a dramatic effect on the results of breast implants. Breast implants is also a self-image surgery so the timing of having that type of surgery is controlled by many personal factors, not a physical one per se. if you are psychologically and financially ready now, with no pressing plans for pregnancy in the foreseeable future, then placement of breast implants now is probably as good as anytime you may have for the rest of your life.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in making my chin vertically longer. I consulted a Oral and Maxillofacial Surgeon where he took x-rays and he said that I should probably do jaw surgery because he cannot do a sliding genioplasty of more than 3 mm without any hip bone grafts. Is this true? I definitely do not want to do a corrective jaw surgery because of the high risks. I would be okay with doing a sliding genioplasty but I am concerned with the involved hip procedure. Do you have pictures of patients who have had custom implants for the jaw and chin so i can see the results? Will they be similar results to someone doing a sliding genioplasty? Also how long is each of these procedures and recovery time?
A: It is absolutely not true that a vertical lengthening sliding genioplasty requires a bone graft. While a gap will be created between the two bony chin segments, the use of a synthetic hydroxyapatite block works quite well as the interpositional graft. There is even some debate as to whether this bone gap needs to be treated at all. But certainly a bone graft is not needed in my experience. I have never placed a bone graft in the many vertical sliding genioplasties that I have done.
The vertically opening sliding genioplasty and a custom implant can have very similar effects. The only potential difference is at the jawline behind the chin and how well the bony genioplasty cut blends into it. But from the front view there would be no difference in the chin lengthening effect.
Both procedures requires several weeks for most of the swelling to go down. Recovery will also involve some temporary chin and lower lip numbness. (bony genioplasty only)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. I have a weak jawline. I have had braces in the past so I do not think it is related to an overbite. My face is vary narrow and I am hoping that I can add some lower jaw width. I really like that you are trained in maxillofacial surgery and your results are beautiful. I have attached some pictures and am open to suggestions and would like to get a quote. I have also attached photos of my aspired look. I look forward to hearing back from you!
A: Your face is narrow and your jawline or lower third of your face is your weakest skeletal feature. It is short in both jawline width and chin projection. The best method to achieve the ideal pictures you are demonstrating is through a custom jawline implant. That is the only method to get the desired facial width and have a smooth shape and transition from the chin back to the jaw angles. Standard chin and jaw angle implants are another option but are suboptimal as their effects will be a bit unconnected and not smooth…which is really crucial to the jawline look you desire. A custom jawline implant is the proven ideal method to improve the balance of the lower third of your face to what lies above it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have developed a neuroma after a facelift three years ago.I first noticed it when driving and my shirt collar rubbed against it and it felt as though there was something tickling my right ear. The surgeon treated the neuroma with a steroid shot. Although the numbness and sensitivity went down it was still there. The doctor treated the neuroma two more times without improvement. The numbness extends along my lower right jaw line, upper right neck, right cheek in front of the right ear and the right ear. My surgeon told me he never had a patient with a neuroma that was not treated successfully by injecting a steroid.
I visited another facial surgeon earlier this year. He told me if he did the facial surgery he would recommend treating the neuroma at that time as another facelift. He said he would cut the neuroma off/away from the nerve. He said it might not correct the problem completely and that I might have complete numbness in some of the areas where I now I have this strange feeling in my face.
I am reluctant to have either surgeon cut me since neither has treated a neuroma before. I would appreciate your recommendation concerning my neuroma at this time.
A: Thank you for the detailed descriptions of your after facelift issues. I can make the following comments.
1) While steroids is not an unreasonable approach to an initial treatment of a neuroma, when refractory, others more definitive approaches need to be considered.
2) I have not had a patient develop a neuroma of the greater auricular nerve after a facelift but I have treated several that have.
3) The traditional treatment of a neuroma would be excision and burying the ends of the nerve into the muscle. It is possible, although less likely, that the entrapped portion of the nerve could be identified, excised and the nerve repaired by putting the two ends back together. This would be dependent on being able to find the actual location of the neuroma amidst scar tissue which is usually possible because it is so superficial and its location can be identified externally before the surgery.
4) What will happen to the sensory innervation after any of these possible neuroma treatments is unpredictable…meaning it may get better worse or there be no change. Bring three years out of the procedure makes it a different situation than when done much earlier. Similarly the impact of the neuroma repair plus or minus facelift in your tinnitus is similarly a wild card. Getting it or its exacerbation from a facelift was not a predictable event so what happens with further surgery should not be assumed.
5) Whether you treat the neuroma independent on a facelift or at the same time is personal decision and depends on your motivation for a secondary facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you have performed this type of skull reduction surgery before. I have a very pronounced bump on the top of my head near the back as you can see. I would like to have the spot reduced down to make my head shape a little rounder. I am also wondering what kind of scarring I will have afterwards? I am bald so minimal scarring procedures would be the best option for me. If you could also give me a rough estimate of the cost that would be great.
A: Sagittal crest skull reduction is a procedure that I have done numerous times. Your situation is exactly the type of patient in which this type of skull reduction is done….male, shaved head, and a posterior raised end of the sagittal crest. This is done through a small curved 4.5 cm incision. From this limited incision as much bone is reduced as possible. I have always been impressed with how well this incision heals and how imperceptible it can be later. On average the total cost of the surgery is around $ 6,500. Most patients can achieve a near complete flattening of the raised area with sagittal crest skull reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read one of your posts about reversing cheek dimple surgery and I would like to set up a consultation with you. I had cheek dimple surgery on my left smile groove about 2 years ago. The day after the surgery I knew it was a mistake and asked the surgeon to undo the dimple. He loosened the suture but since then the dimple is still there. It was suggested that I do a subcision and I have had a total of 3 subcisions in the same area but now I have a donut-like shape to it whenever I smile. I also have a hard bump underneath the dimple that may be contributing to the donut-shape (I’m thinking this may be scar tissue from the subcision). I would like to fix the donut shape and to get my natural face back. Would this be something you would do in your office?
A: Most cheek simple surgery procedures have the problem of being unable to sustain their effect and the result is less than some patients want. Your problem is unusual in my experience in that a cheek dimple surgery undone the next day has resulted in a permanent indentation. Subcision early after the procedure was certainly a reasonable approach. But now at two years after the procedure, it is going to take more than that to create improvement in the cheek indentation. Your cheek dimple reversal surgery is going to require a fat graft either through injection or placement of a dermal-fat graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you did the ‘chin wing osteotomy’ surgery which is different from a genioplasty where they move the jaw forward ? I saw your response to someone else asking the same question on Real Self and you said you’ve done it before and I was interested. Not a genioplasty or a chin implant which I can get done where I live. I’m not sure if there’s other names for it but that’s what it’s called on other surgeons websites who do it. I’m assuming it’s called a chin wing osteotomy.
A: I am very familiar with the chin wing osteotomy, having performed it numerous times. Quite frankly I think it is not a very good procedure for the problem that it is designed to treat. It is technically difficult to perform and is prone to a high rate of complications. Iy requires a long bony cut back from the chin to the jaw angles underneath the mental nerve foramen and the path of the inferior alveolar bone as it courses through the bone.
It is really an historic procedure for which there are more effective procedures today. It is far easier, has less complications and a better result is obtained using a custom made jawline implant when attempting to obtained total vertical jawline augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like a more elongated lower 3rd of my face with less of a square look. I previously had liposuction done underneath my chin but it has never improved. Will the chin augmentation improve this area? Also, approximately how much length in mm is needed to achieve what I am looking for? Thank you!
A: You have a very distinct chin augmentation need. Your square jawline and distance between the base of the nose and the chin indicates that there is a vertical lower facial deficiency. I would not have expected liposuction under the chin to change what is a skeletal issue. There are twi fundamental approaches to managing a vertical lower third of the face deficiency. If it is just located anteriorly a vertical lengthening sliding genioplasty or a custom vertical lengthening chin implant can be used. If one feels the entire jawline is vertically short from front to back only a custom jawline implant that lengthens the entire jawline can be done. In looking at your face my feeling is that a vertical lengthening sliding genioplasty would probably be the best choice. In my experience at least a 7mm vertical increase is usually needed to make a noticeable vertical chin augmentation change. This is done by an open wedge bony genioplasty where the front edge if the bone rotate down while the back edge of the bony cut keeps the bone in the same position. The exact measurement of vertical chin lengthening needed can also be determined by two other methods. One can open their lower jaw to the vertical chin length that looks good to you and measure the created distance between the front teeth. One can also take measurements of their facial thirds and then see how short in millimeters the lower facial third is. I would do both methods to see how well they correlate so you can select the most effective vertical chin augmentation improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I spoke to you this last summer on Skype regarding forehead augmentation. I favor using bone cement as opposed to a silicone implant. Do you think burring of my supraorbital ridge will be necessary? If so, would the charge me extra? and is there a risk of damage to my sinus cavity?
A: When you have the severely sloped forehead that you have, it would be good to to do some modest burring of the supraorbital ridge. It would be complementary to the forehead augmentation in creating a better overall result. With burring the key is to stay out of the frontal sinus which requires experience in doing so. How much reduction can be obtained is a function of the thickness of your frontal sinus wall. If you need a frontal sinus setback that would be important to know up front because it will take some more surgical time to do and there will be some extra costs in doing so.
The choice of forehead augmentation material is a personal one. I have used both bone cements and custom implants successfully and each has their own advantages and disadvantages. I do not necessarily favor one over the other, I just try and educate the patient on the merits of each material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a corner of mouth lift. I have had fillers and Dysport to lift the corners of my mouth. I don’t believe the doctor who did my filler placed it right. I have a puffy place then it goes flat and it didn’t raise the corners of my mouth at all. I spent a lot of money to get that done. I was wondering if you think a corner of the mouth lift would help and how much does it cost. I am 48 years old. Thank you.
A: While injectable fillers and neuromuscular modulators can have a positive effect on the corner of the mouth, it depends on what the original problem was (how severe is the corner of the mouth droop) and what type of change (corner of mouth lift) one was looking to achieve. Your result may be a function of an incorrect treatment for the problem (mouth corners to severely sagged) or the correct treatment that was not ideally done. I can not say which led to your post-treatment results. I would need to see pictures of your mouth area to determine what is the best approach now.
What I can say is that a corner of mouth lift is the single most effective method for changing the shape of the corners of the mouth that produces a more profound and sustained result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis repair surgery. I am emailing you to see if you are able to correct my chin deformity from a previous surgery five years ago. I had a chin implant removed from twenty five years ago because it made my chin look very wide and bulky. The surgeon performed a sliding genioplasty for a 3mm advancement and a lipectomy which left me with a depression and a bulge. I now have redundant skin hanging and my chin is very flat and wide and misshapen. If there is anything you think you can do to correct this please let me know.
A: Thank you for sending your pictures. What you have is chin ptosis and a residual wide chin. (since I do not know what you looked like before I can only go by your current picture) The best approach for your chin ptosis repair is a submental chin reshaping procedure to taper your bony chin and get rid of the overhanging tissue. This is the most assured way to get a better chin contour by dealing with both the bony and soft tissue components of the problem from the underside of the chin. As your chin problem is primarily that of loose skin this is particularly the best chin ptosis repair approach for you.
Dr. Barry Eppley
Indianapolis, Indiana
