Your Questions
Your Questions
Q: Dr. Eppley, I was hoping I could be a candidate for upper jaw surgery to correct an overbite caused by over the years involuntary tongue thrusting while sleeping. Hopefully a procedure to pull back the upper jaw? I’m not sure if it would be possible as I’m 65 years old but am in excellent health and very active. Thank you for any help or advice you may have!!
A: Thank you for your inquiry. While it would be unusual to have maxillary surgery at 65 years of age, that age does not necessarily preclude one from doing it. What is more relevant is the current state of your bite (occlusion) and how much maxillary setback is needed. (as judged by the amount of overbite) Almost all cases of such jaw surgery require orthodontic correction so when the upper jaw is moved back the upper and lower teeth will fit together properly. There are also aesthetic issues of your upper lip position and your facial profile to consider.
Please send me some pictures of your face and your bite and I may be able to give you some further guidance as to its advisability for your face and bite relationship.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope you remember me, I came in for a consultation with you awhile back. At any rate, the procedure I was discussing with you was a custom chin/jaw implant. You are and are still my surgeon of choice/my top pick for this procedure and I wanted to move forward with you yet you was out of my price range. So I found a surgeon locally that was more within my budget and who had done one custom chin/jaw procedure and several pre-fab procedures. But, I think despite our best efforts to ‘play it safe’, and size the implant to appropriate proportions to my face/head, it appears as if we’ve inadvertently gone overboard in at least one dimension/direction of the implant. I’ve just had the surgery in early January so it’s only been less than three weeks. (and of course I realize I’m looking at a good amount of swelling right now). Are you available to consult with me via phone and/or Skype? I’m thinking I may need to redesign another implant, and I’m interested in having you help me in redesigning it. It would be greatly appreciated and I could really use your help.
A: It is extremely common that a patient (if they so insist) or a doctor (who has little to no experience with custom facial implants) unintentionally makes a custom implant too big. While a certain implant design and size make look good on the 3D CT scan model, it can not factor in what it will really look like on the outside when the overlying soft tissues ar covering it. I have made this implant design mistake myself in my earliest days of custom facial implant use. It takes experience to know how certain implant thicknesses impact the final augmentation result. This is why it is so dangerous to take measurements straight from the face and believe that is what the implant thickness should be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, It is said that the Terino extended anatomical chin implant produces a wide appearance to the chin. I want to know whether the wideness would be round and wide (like a half-oval) or flat and wide like a skateboard ramp. I’ve heard that the chin will be similar to Dick Tracy cartoon version, but a Real Self review got me thinking otherwise.
A: Every chin implant merely adapts to the shape of the underlying front end of the jaw. So if the implant is oval shape and the bone shape is oval (which almost all chins are) the resultant chin shape will be both wider but round or oval. Only if the chin implant has a different shape on the outside as opposed to a rounder or oval inner surface (like a square chin implant) will the resultant shape be wider and more square. Certainly no standard preformed chin implant available today is going to make any chin similar to a Dick Tracy cartoon version if that is what one’s final shape objective is. Only a custom made chin implant can achieve that very square look. The Terino extended anatomic chin implant does look more square in its picture but it will not create a square outer look in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reshaping. I am wondering whether it is possible to make the inner corner of my brow ridge-glabellar more sloped. I would attach my photos in order to better address my requests to see if they are achievable. I am also attaching an example of the brow shape I am after as I think his brow ridge shape is very elegant. I found out that the formation of the triangular contour that I desire is formed by the downward slope of brow bone in the inner eye corner. Is it possible to, besides make the ridge-line more prominent, also make it more sloped?
Also, I had a previous glabellar implant (not fixed) which has an undesired shape and bad connectivity with my forehead and brow-ridge. I’m 100% sure that I’ll remove this graft sometimes (if not now, it has to be during my revision rhino), but I’m wondering whether it possible to remove this portion with the same incision of brow implant? I have consulted some doctors and they said the position of this graft is relatively high so it’s easier to remove this from upper incision instead of the incision of open rhino. How do you think?
A: When it comes to brow bone reshaping, the ability for remove bone along the medial supraorbital rim depends on two factors. First, the thickness of the rim bone in that area. you have to remember that the frontal sinus lies immediately beneath it. The bone is undoubtably a few millimeters thick so some change is possible, it is just a question of how much. Secondly, it requires good incisional access to reach down that low. No endoscopic or other more limited incisional technique will work.
Wherever the glabellar implant is located, it most certainly can not be removed through an open rhinoplasty incision. It must come out the way it was put in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implants to give my jaw a more flared and more square look. I would like my jawline to look like the attached picture. Would that be possible?
A: The ability to achieve a look very similar to your ideal jawline/jaw angles depends on two specific factors. First, you have to have a very thin face over the posterior jawline. Your model picture has virtually no fat which is why the jaw angle is so prominent and it is concave in front of it. You do not have that same anatomy. Your face is fuller so you could never achieve that exact look. Secondly, you have to have the exact implant design to create that degree of jaw angle flare. No off the shelf pair of jaw angle implants does that so a custom design set would be needed.
Based on your attached picture, you would definitely benefit by jaw angle implants. But you would not get that exact ideal result. The very picture you have shown i have seen dozens of times by different male patients who want that exact jawline look. But fir the vast majority of men who seek it, it is not possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I did the chin advancement at your clinic about three years ago and attached is the current result. The vertical length of the chin is good and my face is now long enough. But I still feel the chin needs to be horizontally moved forward a little bit. You did a very good chin job at that time but my chin was quite short and the advancement was put to the possible limit. My question now is: Is it possible to do another chin advancement?
A: Good to hear from you and thanks for the long-term follow-up. I remember your case well. I do agree that the vertical length is good but it still remains horizontally short. One of the sacrifices for vertical lengthening is that there is a limit as to how much horizontal movement can be obtained. The question now is whether a secondary sliding genioplasty can be done to move it further forward. (or whether only an implant can now be used) Given that it has been three years, good bony fill of the osteotomy gap should have occurred. If there is good bone stock the answer would be yes. But the only way to know that for certain would be to check any x-ray. The best x-ray would be a 3D CT scan. That will definitely answer the question of adequate bone thickness. There is also the question of the indwelling metal plate which could be completely overgrown with bone. It may not be easy to remove to do the osteotomy and that is another factor to consider.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, recently I had jaw augmentation and lipectomy. Its uneven and asymmetrical. Obviously nothing is perfect but I expected better. I am interested in your chin augmentations for a better jaw line as well as possible wrap around full custom augmentation. I look forward to speaking with you about these revisions. The liposuction isnt aggressive enough and the implants are sligtly off as I said before. I should have traveled to you first. I am interested in a face time consult with you. As you can see the left jaw angle is different that the right and the liposuction needs to more even and closer around the bone. Hopefully a chin implant and small revisions can accomplish a strong even jawline where the bone line is visible. I don’t know how the doctor I went to has the credentials he has as he is satisfied with this procedure. I wish I came to see you first. I just wanted a defined jawline and facial definition not an asymmetrical nightmare.
A: Thank you for sending your pictures and telling your surgical story. I don’t have the advantage of knowing what you looked like before surgery or exactly what implants were placed. You mentioned that you had ‘jaw augmentation’ but that can mean different things. My assumption was that you had chin and jaw angle implants placed separately (three separate implants)?? If this is so one has to realize that a smooth even jawline that connects the front and the back (chin to jaw angles) is never going to be possible as, even if the implant wings overlap, these are the thinnest sections of the implants. Thus there will always be a ‘dip’ in the middle of the jawline. Only a custom wrap around jawline implant which is made to augment the entire jawline can accomplish that effect. That is the one trade-off for having three separate implants.
However, your description of jaw augmentation may also only be that you had jaw angle implants only. Again they only come so far forward so there is going to be a drop off in the jawline as it approaches the chin. The main complication with jaw angle implants is asymmetry. It is very hard to get perfectly symmetric jaw angles with implants. Symmetric placement is difficult and most people do not have symmetric jaw angles initially. That combination leads to a high rate of jaw angle implant asymmetry.
I would need more information as to exactly what implants you have in place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m from South America but I’m planning to travel to the US. Because one year ago I had liposuction on my banana rolls and now my butts looks larger and the gluteal fold is very prominent. I have attached pictures. Can you tell me if there’s anything that can be done to correct this? (maybe a lower butt tuck?)
A: Thank you for sending your pictures. What you have is infragluteal fold accentuation due to lower buttock ptosis where the buttock skin hangs over the crease. This is a common problem that develops after liposuction of the lower buttock/banana rolls. My assumption is that you would like the fold to be less distinct and the loose skin on the lower buttocks removed. If these are your goals, these can be accomplished by excision of the skin above the fold, making a new fold that is less deep and a smoother transition between the lower buttocks and the posterior thighs. Some people call this a lower buttock lift or a lower buttock tuck. And that would be the name to call it. But what is really being done is that the loose lower buttock skin and the fold are being removed to create a less deep infragluteal fold and smoother transition between the buttock and the thighs. But so doing it may also make your buttocks look a little less full because its roundness is decreased.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat injections to make my calfs and ankles bigger. My understanding is that fat injection is not a permanent solution. So if it is applicable in my case do I have to do it on regular basis?
A: While it is true that the lower legs (calf augmentation with fat) is not the best place for fat to take (due to the pressure of the overlying skin), the fat that does take can become permanent. So it is no true that fat is not a permanent procedure. It can be if enough fat is initially placed. The concept of lack of permanency in fat injections comes from the not rare scenario where a repeat fat injection treatment is done to finally get the desired result. This is not because it does not work, just that only a fraction of what was injected (maybe only 10% to 25% of the fat) survives and more fat injections are needed to get to a better end point. Think of it as adding layers to get to the desired result. In some patients, it is a one time procedure but in others a second procedure may be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat augmentation around my facial implants. My biggest concern is how much fat will survive as the plastic surgeon I saw mentioned that the presence of the implants will make it less likely the injected fat cells will be able to develop their own blood supply and grow. This gives me pause as I’m not too keen on another procedure that might just be an expensive temporary natural filler. I would appreciate your thoughts on this and how to maximize the survival of any grafted fat. Are there any other options to reduce the noticeability of the implants and fill/round out the cheeks more?
A: Your plastic surgeon did reach out to me and I have discussed your case with him. Fat injections are the only treatment that can be used as the ‘missing’ piece of your face is now not what is on the bone but is where the bone/implants aren’t. It is true that the final take of injected fat is both variable and not completely predictable. But I know of no scientific evidence that supports the supposition that fat grafts take less well over or around facial implants. And where you need the fat is to fill in the areas around and between the implants which is only soft tissue anyway.
One technique that can be done to improve fat graft survival is the use of platelet-rich plasma. (PRP) By mixing PRP with the fat grafts, it optimally enhances fat cell survival through its growth factor effects. It may also have an inducing effect on the stem cells that naturally reside in fat. Given that it is an extract from your own blood, there is no reason not to use this natural fat ‘booster’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was left with a depressed facial scar with dog ears as a result of multiple cyst removals on the left side of my face along the smile line by my nose. I have been told by plastic surgeons that my scar condition can be improved with fat injections for the loss of volume and surgery which will expand the current scar even more to address the dog ears. I found your article on the internet on the aesthetic refinement of the dog ear correction very encouraging. I am hopeful that it would work on her scar. Please advise.
A: Thank you for sending your facial scar pictures. The depressed scar and dog ears are very evident as you have described. Your facial scar revision would initially consist of elevating the depressed scar can be done with either fat injections or an actual dermal-fat graft. Given the need to harvest dermal-fat grafts with a resultant scar, even though they take better, fat injections would be the preferred technique given that its harvest and injection can be done in a relatively scarless fashion. As for the dog ears, the classic teaching is that the scar must be extended to excise them. And given how they look for a small amount of scar length increase that is not necessarily a terrible idea and may be the best solution. An alternative approach is to defat them with limited excision and see how that turns out.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a weak chin making my side profile look really bad. I think its was because of a overbite. I have been wearing braces but I just want to have a good profile. Can I still get a chin implant? I don’t care about my overbite so I’m not thinking of getting jaw surgery. Will a chin implant with wings be a good alternative?
A: If mandibular advancement (orthognathic) surgery is not going to be done and of that you are certain, then attention can be directed to its aesthetic enhancement or camouflage. Chin augmentation can be done successfully using either a chin implant or a sliding genioplasty. Whether a chin implant is best for you depends on how short your chin is. Off-the-shelf chin implants do not exceed 10 to 11ms in horizontal projection so very short chins in men may be inadequately treated by a standard chin implant alone. I would need to see a front and side view picture of you to determine how successful a chin implant would be in your case. These pictures would be used for computer imaging to determine how much increase in chin projection is needed based on measurements and different changes in chin dimensions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I had cheek, infraorbital rim and paranasal implants placed last year. While they have helped the look of my flat midface significantly, the implants look a bit ‘skeletonized’ and need some additional volume around them to create an overall fuller facial look. I know that injectable fat grafting is the only long-term option available but I am concerned that I will spend a lot of money and it will not work. What are some insights to improving the success of fat grafting to the face?
A The take of injected fat is a multifactorial issue and includes where and how it is harvested, the technique of concentration, the method of injection and what facial area is being injected. (cheek and the midface have the highest average percent of take) Because of all of these variables, most of which are not understood how they influence the process, it is no surprise that fat grafting remains as much an art as a science. It is also fair to say that all surgeons who inject fat are not created equal.
The most important key in properly injecting your facial areas of concerns is to have enough fat volume to do it. The surgeon must harvest at least 60cc and concentrate it down to 15cc to 20cc. (it takes far more fat than one would think to really create the overall volumetric increase that it is needed) I personally prefer to add to facial fat injections a PRP solution to have a ‘booster’ effect. PRP (platelet-rich plasma) is an extract of your own blood that adds numerous growth factors and cytokines which theoretically improves fat cell survival and stem cell conversion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, , I’m interested in a skull reshaping (flat back of head). My estimate is that I would need approximately 25mm to come to a ‘normal’ shape. I understand that this would require a skin expander that needs to be applied for 6 weeks or so. As I would need to travel from Europe is there an alternative? For example, could it be done in two steps by adding 15mm with bone cement and than in a second step add another 10mm or so (couple of month later)?
A: Having performed more of this type of skull reshaping surgery (occipital skull augmentation for a flat back of the head) that just about anyone in the world at this point, I can tell you that adding 25mms (no matter how it could be done) will create another aesthetic problem. Most people do not realize that the lower end of the occipital skull stops at about the level of the top of the ear. So bringing out the back of the head that much will create a very unnatural step-off below the area of augmentation. Having done this I can tell you that it will look and feel ‘strange’.
Thus you need to focus on a small amount of occipital augmentation that does not excess more than about 15 to 18mms of projection at best. This would still ideally require a first stage tissue expansion. Settling for 10 to 12mms of augmentation can easily be done in one stage.
While sequentially adding material in stages for skull augmentation seems to make sense, it does not work. Each surgery makes the scalp stiffer due to scar so the first surgery (short of using a tissue expander) is the best opportunity as the scalp is the most flexible. Either short for the ideal through a two-stage skull augmentation process or settle for a lesser amount of augmentation as a single stage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting jaw angle implants. My main concern is making this non-obvious to the people who know me. I am from out of town and would be flying in to have the procedure. I was thinking of coming in for two weeks (I..e fly in on the day of or night before the surgery and then stay for 2 weeks to let most of the swelling subside). I was thinking if I possibly grew a beard prior to the surgery and then keep the beard on for a few months, that by the time I shave it off, it wouldn’t really be noticeable to my family and friends. What are your thoughts on this ?
A: That is the most common strategy that men do for any jawline procedure. Be clean shaven for the surgery and let it grow for 2 to 3 weeks and then shave it. That does make for non-obvious surgical change. By three weeks 80% of the swelling has subsided. The resulting 20% residual swelling is not that noticeable as it continues to go down almost completely by six weeks after surgery. I do not think you need to leave the beard on for months as the swelling will have gone down long before that. It is also not necessary to stay here for two weeks. If swelling was not an issue, you could go home within twp days. If swelling is a concern, one week should be sufficient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital rim implants. Are they dangerous? I know you do them. I have three questions: 1) Are they effective? Can they diminish hollow eyes and give them a better aesthetic look? 2) Will they cause retraction of lower eyelid? 3) Can you go blind?
A: In answer to your questions about orbital rim implants:
1) With proper design and placement they can be very effective at improving bony recession of the infraorbital rim and tear trough areas. They often, however, need to be supplemented with fat grafts in the lower eyelids to balance out the entire lower eyelid area.
2) With good surgical technique and resuspension of the lower eyelid, no. In some cases they are placed through an intraoral approach where there is no risk of lower eyelid problems at all.
3) Blindness is NOT a risk of orbital rim implants. This is a surgery that is not done on the inside of the orbital rim and would not cause any increase in intraocular pressure or injury to the optic nerve. Other than lower eyelid retraction, the biggest risk to the eye is that of a corneal abrasion if corneal protectors are not used. Or in some cases could even occur if they were used as a result of placing and removing the corneal protectors.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw a topic on premaxillary implants on your website and I am really interested in it. I am wondering whether this can be done separately with & before my revision rhinoplasty? In fact, the result I’m trying to achieve as a before-after is in the first attachment (not the second one, that is just an over exaggerated example). I have consulted one plastic surgeron but he seems to be working primarily on the “nose” itself instead of the surrounding area(s). I am trying to get a bigger nose, and more precisely speaking, I think the reason my last rhinoplasty was failed was because the doctor doesn’t know this internal area; he was trying to achieve the result just by pulling the nose itself outward which is laborious to the skin itself.
A: Premaxillary implants have been around for years and were initially developed to open up an obtuse or recessed nasolabial angle. (as your first illustration image demonstrates albeit extremely so…this must be a photoshopped image not an actual surgical result) There were developed to be used in conjunction with rhinoplasty surgery and were inserted into the subcutaneous space through an intranasal incision.
As the technique of premaxillary augmentation has evolved, it is clear it needs to be placed on the bone in a subperiosteal location. This is well below the lip muscles and soft tissue so as to not interfere with lip and mouth movement. (otherwise it can cause a blocking effect to the lip when one smiles) This also gives the opportunity to create more of a ‘LeFort I’ or maxillary advancement effect to the base of the nose if the implant design and size is sufficient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tracheostomy scar revision. I have already consulted some local plastic surgeons, but they are not expert with this kind of procedure. One of them told me I would have to go there twice or three times to have a reasonable repair conclusion. Actually, I am kind of afraid of it. I would like to receive an advice from you. Please, show me if it is possible to be removed! Would you perform a lipofilling procedure? Thank you!
A: Thank you for your inquiry and sending your pictures. You have a very deep tracheostomy scar deformity that goes well into the sternal notch area. This represents a severe loss of fat between the skin and trachea. I imagine that there is also a skin retraction deformity which occurs when you swallow. In my hands, I believe you can get a very good result in a single procedure using a dermal fat graft to fill the defect and excising and closing the horizontal skin scar over it. Dermal-fat grafts survive very well in small defects like a depressed tracheostomy scar.This is a very straightforward and uncomplicated procedure that has a very minimal recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Im very interesed in the temporal implant/augmentation for a more youthful look.I have atrophy from weight loss and aging over the years.I also feel that there is some geneic predisposition for me to have this,as well.I no longer wear my hair pulled back because it accentuates the problem. I have a very busy business and am curious how much downtime this procedure requires? Also, how effective are they and can they be removed in the future?
A: Thank you for your inquiry. In answer to your questions about temporal implants
:
1) There is very minimal downtown from temporal implants. You could return to your work within 48 hours with only minimal temporal swelling.
2) Temporal implants are the most effective treatment that I know for temporal hollowing. The surgery is short, down time minimal and the volume results stable and permanent.
3) Temporal implants can be reversed just as easy as they are to put in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to ask you a few things about skull reshaping.1) Can you reshape a skull that its parietal bone is not curved but straight down towards my forehead? 2) Can you implant a flat back head to be curvy? 3) Can you narrow the side head? My side head is over widened till its not a straight, smooth to the back. 4) Are there risks for death if this surgery is done (with jaw angle enhancement)? 5) How much will all of the surgery cost? I wish you could reply my questions to my email. Please reply, thanks.
A: In answer to your skull reshaping questions:
- You can reshape the parietal bone so that it is straighter and not so curved.
- An implant can be placed on the back of the head to add projection.
- The side of the head can be narrowed by a combination of temporal muscle reduction and bone thinning.
- There is no risk of death by combining skull reshaping with jaw angle augmentation. Skull reshaping is a perfectly safe aesthetic surgery that should not be confused with its very distant cousin in Neurosurgery of craniotomies.
- I will have my assistant pass along the costs of the surgery to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery and have been studying face and body proportions. Does the master sculptors of the Middle Ages use a formula in order to determine the length of the face in a statue? Was it one-eighth the height of the statue?
A: The use of numerous face and body proportions, often called the classical canons, comes from figure drawing and sculpture. Such concepts are based on ancient history that goes back as far as over 3,000 years ago. Clearly there are subtle and sometimes not so subtle differences between people and their features, but there is a fairly standard range of human proportions that seem to be most aesthetically pleasing. Artists and sculptors have made numerous attempts to put these to numbers and ratios and this forms the basis of almost accepted human proportions today. More scientific anthropometric studies have been done more recently and these have established some variations amongst ethnicity and gender. Most artistic body proportions are based on how they relate to the length of the head. Using the head as a unit of measurement, the height of the person is ideally at 8 heads tall. Thus your question of whether the length of the face was ‘one-eighth the height of the statue’ is correct by human drawing standards.
But I would be careful about trying to extrapolate any of this to plastic surgery and specifically rhinoplasty. These proportions were really established so that artists and sculptors could create a figure and face that was proportionate…and humans have a very difficult time drawing proportionate anatomical structures as there is nothing innate about doing so. Trying to translate these concepts to surgery is far more difficult and often unrealistic as people do not develop and grow in perfect proportions and there is a limited range of surgical changes that can be done to make them so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about a possible male jawline augmentation procedure and how it might fit into my existing plans. I have been using Radiesse under my eyes regularly since 2010. My last procedure was November 2013 – and I have purposely foregone any additional procedure to pursue something more. As well as building the cheekbone area solidly with filler in the upper portion of my face, my primary objective is to “etch out” a defined masculine jawline. There is also some laxity in the jowls and neck area to be resolved. I consulted with a plastic surgeon where I live and his approach is laser-assisted surgery combined with Acculift to remove and sculpt the excess fatty tissue in the lower face, jowl, and neck areas as well as enhanced with Sculptra in the lower jaw and Radiesse or Voluma to heighten cheekbones. This may still be a viable option. But I question if this will result in the “look” I am speaking of – or if, in your opinion, a jaw implant is a better way to go.
I have attached comparative photos of male models illustrating jawline and facial balance. Obviously, this is a much younger crowd – but the “look” I speak of is clear. Most particularly – and this is important – the “notch” etched diagonally between the ear and chin. I mention this because in the implant photos I have seen online, the jawline itself is improved – but this defined “etch” between cheekbone and jaw is seriously absent. And in all seriousness, it is this etch I am hoping to acquire. I would very much appreciate, Dr. Eppley, your take in this and how this might be achieved.
A: Thanks for sending your pictures and provides specifics as to the jawline changes you desire. The important concept to grasp is the jawline changes you seek can only be obtained through skeletal enhancement. They are not ‘missing’ because of soft tissues excesses and loose skin. Nor will they be obtained through the diffuse effects of filler augmentation. Only a bone-based augmentation method (implants) is going to create that degree of change and create more distinct and angular features. The other benefit of jawline implant augmentation is that it will pick up any loose or sagging skin from the neck which is of one of its side benefits. This is particularly so if a custom wrap around jawline implant is used as it has an overall lifting effect through its volume. This is ideally what you need and is the most assured method of achieving the type of jawline change that you seek.
As a commentary on the ‘etched’ facial look you hope to acquire, that is a soft tissue issue as it lies in the so called trampoline area between the skeletal highlights of the cheek, chin and jaw angle. Only fat removal has any hope of making that area more of an indentation or notch. The debate can be had about where and how the fat can be removed. A stronger and more defined jawline will help in that regard but ultimately even it needs to be combined with fat removal to have any hope of achieving that look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello! I had a breast augmentation done almost 4 years ago. I had beautiful results overall but the doctor went on a very conservative size (230 cc) due to me being naturally quite thin. I feel like throughout the years after the swelling went down and after I stopped taking birth control and gained 10 lbs, they’ve looked smaller and smaller. In addition my left breast is visibly larger than my right. What are my options for breast implant replacement now? Thanks!
A: The good news is that the breast implant replacement or breast implant exchange (secondary breast augmentation) is a lot easier than the first surgery. The implant pocket is already established so minimal tissue dissection is needed for re-entry and implant replacement. Since your desire is to go bigger, the key is not underestimate the size of the new breast implants that are needed. You should go a minimum of 100cc to 150cc bigger to even see a visible change. (maybe 1 cup bigger) Whether the new implants should be even bigger is a matter of further discussion. The chronic problem with some breast implant exchanges is that one thinks they need less volume that they do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had otoplasty performed 5 years ago. While mostly satisfied with my result at that time, I did feel my ears were just a tad too close to my head. Very recently a plastic surgeon removed all the scar tissue and sutures from that otoplasty years ago in hope this would bring the ears out slightly. Along with the scar tissue, this included removal of sutures that were placed to create the antihelical fold since I was born with virtually not one in the bottom 2/3 of my ears & mastoid sutures. It’s only been several days since the removals and my ears did come out some immediately. For example, the antihelical folds are not folded quite as tight as they were. In your experience or opinion, do you think the folds will tighten up again to where it was previously or do you think since they pretty much popped out right away they will stay? Of course there is still some swelling so I’m sure any results will take longer. Even a few millimeters would satisfy me, so I took the chance of this. I still should’ve research more beforehand. Please let me know your thoughts. I may schedule a consultation with you if these results do not work.
A: While it is possible that an otoplasty revision by removing the scar tissue and sutures between the cartilage folds will allow them to spring out a bit more, I would not be optimistic that would work. Besides the fact that the cartilage has not been released and supported outward, scar tissue will soon fill in the fold area and recontract back down. Removing the sutures and scar tissue inly really works if it is done within three to six months after the procedure. ( or sooner)
To successfully create increased ear prominent, the cartilage folds need to be help apart. I used to do this with either pedicled ear cartilage grafts or even a small rib graft, I have evolved to just placing a small ‘spring’ (1.5mm bent metal plate) which serves the same purpose and is much simpler. Since tjhe tiny metal plate is on the back of the ear, it is never a long-term concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Here are some questions I have about head widening surgery with temporal implants. I am very interested in this procedure but just want t make sure I have all of my bases covered being having it.
1) When having the implants in the head, are the visible in airport X-Ray and scanning machines, it would be quite embarrassing to have them visible in the machines?
2) Are they comfortable to have in the head?
3) Is there some other alternatives than having the implants.
I would appreciate your help in answering my questions. I really have a big head shape problem in the width and I want to change this permanently.
A: In answer to your specific questions about head widening surgery through temporal implants:
1) Silicone implants can not be detected by x-rays or airport scanners.
2) Submuscular temporal implants feel very comfortable and natural and patients do not report any abnormal feelings from having them in place.
3) An alternative to implants for head widening surgery would be fat injections with PRP. (platelet rich plasma)
Heading widening surgery done with submuscular temporal implants is a very effective procedure that is accomplished in a scar-fee scalp technique through post auricular incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering what my options are in order to completely reshape my chin. When I smile it wrinkles up and I have as deep crease on my chin with a thick lower chin. I want to smooth it out completely to have no crease or dimple. would this be possible?
A: Let me first separate chin dimpling (which is a stippling through the chin pad with muscle moment) from a chin dimple/cleft. (a permanent indentation or groove in the chin pad which is present when the muscle is not moving.
Chin pad wrinkling/dimpling is a difficult problem for which the options include Botox injections, fat injections or mentalis muscle disinsertion/resuspension. Botox can be temporarily effective because it partially paralyzes the muscle and stops the animation deformities. Fat injections work by adding volume to the chin indentation to help fill them up to a smoother level. Mentalis muscle manipulation works by creating a new attachment level for the muscle which changes its length of contractile excursion and hopefully lessens the dimpling action.
Chin dimples/clefts are treated by adding volume for which fat injections remains the simplest way to accomplish that effect.
As you can see fat injections is the only method that can treat chin dimpling and dimples but does so at the expense of making the chin somewhat bigger. (which may not be desirable)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was born with a good amount of frontal bossing. It got better as I aged but it’s still there and very noticeable, especially when my hair is cut short. This is something that has bothered me every single day for the last 5 years now. I also believe the muscles on the side of my head protrude out and this adds to the awkward appearance. My question is that do you think the mid/upper and sides areas of my forehead can be reduced by burring away some of the bone? Would it be possible to say if I have excess bone or just that my skull was formed with a protruding appearance? If this was done, could I still play sports? What I mean by this is that would the area be much more easier to fracture if I happen to take a blow to the head? How does frontal bossing even occur and what is the average size of the frontal bone in men? .How bad will the scar be and what would something like this cost? My last question is how many of these types of surgeries have you performed and do you think I would benefit from this surgery? I apologize for all the questions but I tried to sum it up as best as I could. Thank you for your time.
A: Forehead bossing /protrusion occurs for unknown reasons. Significant size reduction can be obtained by an overall burring reduction of the entire forehead side to side between the temporal lines. Such reduction can accomplish a reduction of 5mm to 6mms throughout which is very significant on the forehead. I have done this type of forehead reduction surgery numerous times and have always been impressed with the difference it makes. Such forehead reduction will not make your skull weaker or more prone to fracture. The procedure is done through a fine line incision in the scalp (no hair is shaved) and that scar can heal remarkably well in my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had fat grafting done 3 months ago and the fat was harvested from my thighs. However, the issue I have is that there is still quite a bit of residual ‘browning’ of the areas where the fat was taken from. I read online that this is known as hemosiderin staining. Based off your experiences, will this ever go away or is it permanent? Are there any treatments I can consider to fix this problem?
A: Ay surgical procedure that has caused bruising always runs the risk of developing hemosiderin staining. These yellow to brownish patches are the result of the breakdown of red blood cells which leave behind a compound that the body uses to store iron. It is still very possible at three months after surgery that the body will eventually break down the compound and recycle it, clearing the stain and leaving the overlying skin unblemished. How long this could take is unpredictable and I would not judge it as permanent until a year after the surgery. There are no treatments that I am aware of that can expedite the resorption process or induce the stain to resorb if it i not going to on its own.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am two months out from my forehead augmentation procedure using hydroxyapatite cement. I believe I am happy with the outcome although I enjoyed it more when it was swollen but it is still big enough at present. I just wanted to know have your patients experienced longevity with the cement? Does it have the staying power of a implant or do cases like these need to be redone because of absorption.
A: Like all forms of bone cement, hydroxyapatite cement is non-resorbable. It will never resorb or change shape over your lifetime. It is just as stable and enduring as a forehead implant. It is very normal to maximally like the result when it is swollen in the first few weeks. But the vast majority of forehead augmentation patients are happy with their final size result even if they wish it were just a touch bigger. The biggest fear in forehead augmentation (at least my biggesty fear) is to make it too big as that will result in a revisional surgery 100% of the time. A forehead augmentation that is a bit too small, as long as it is not way too small, is very well tolerated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw you back in July and was inquiring about Saddlebag removal. We also discussed Fat Grafting my breasts. Definitely, want to remove the saddle bags. I have a couple questions about the Grafting.
I understand it’s not a guarantee that it will stick, but based on your experience:
1. Have you performed this several times?
2. Is there a risk of them being uneven?
3. Is there any discoloration?
4. What would be the major risks of performing this procedure?
5. What’s the recovery time?
A: Good to hear from you again. In answer to your questions about fat injection breast augmentation (FIBA):
1) Fat grafting to the breasts has become more common in the past five years and is a safe method of breast augmentation that is now formally acknowledged by the American Society of Plastic Surgeons in their position paper on the procedure published last year.
2) I do perform FIBA in properly selected patients. A properly selected patient fulfills the following criteria:
a) Absolutely opposed to the use of breast implants
b) Is accepting of a modest 1/2 cup to maybe full cup size breast increase with maximal fat take
c) Has reasonable donor fat areas from which to harvest (enough to make the procedure worthwhile)
d) Is accepting that fat grafting by injection has unpredictable volume retention (outcome can not be assured)
3) It has been my experience that about 50% or less of the fat injectate into the breasts persists. Volume retention is the main risk, not unevenness or lumps.
The real question in your case is whether the amount of fat harvested from your saddle bags alone is sufficient for a FIBA procedure. The answer is probably not. The only reason to do it in your case is because the fat is otherwise going to be thrown away and maybe 1/4 to 1/3 cup size increase may be better than where you are now. But if your goal is one to two cups sizes bigger, then implants are the only options to achieve that goal.
Dr. Barry Eppley
Indianapolis, Indiana
