Your Questions

Q: Dr. Eppley, I know after shoulder narrowing surgery patients are released for full activity after 12 weeks but what is your recommendation for returning back to work? (more range of motion at weeks 5 and 6). 

A:That is probably not unreasonable. Given the type of work a dental assistant does the range of shoulder motion at one month after the surgery should be adequate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, So as you can see i have a certain eye area that looks nothing like my desired result (below), and i would like to know the best and most efficient surgeries and augmentations that would take me from what i have to something with the same characteristics as the model below. (a Fair amount of Hooding, 0 sclera exposure and positive canthal tilt). Also it might not be visible in the photo, but i also have a negative orbital vector that is especially striking whenever i squint or lift my eye. 

A:I would say the major difference between you and the model eye look  is that you need a lateral canthoplasty, spacer grafts to the lower eyelids and infraorbital-malar implant augmentation for the lower orbital area. The upper orbital area needs filling of the supratarsal area with some form of a fat graft. (fat injections or an en bloc fat graft) Your brows seem to be sufficiently low.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty done 5 years ago to correct the contour of the sides of my nose. While the surgery made a very significant improvement, the left side is still a little curved from front view, while the right side is straight. I met with a different surgeon recently about whether or not a non-surgical liquid filler could correct this issue, and they said they wouldn’t recommend injecting a filler after a previous surgical rhinoplasty, as it’s “a little dangerous”. 

I’m not sure what the danger is they’re alluding to, but if it’s the vision loss I’ve read about, and the risk is high enough, it might not be worth it. If the risk is very low, though, maybe it would be worth it.

A: If the goal is to augment the flatter side of the nose to better match the curved side, then the use of injectable fillers is a reasonable non-surgical approach.

When it comes to the use of injectable fillers in the nose the risk to which is being referred is that of an ischemic event. This means the pressure of the filler causes a compression of the blood supply to the overlying skin resulting in an area of necrosis or eventual skin loss. In the scarred nose (prior rhinoplasty) this risk is higher due to this scar tissue. How significant that risk is can be debated but I can’t fault the surgeon from passing on doing it as for him/her the reward:risk ratio is just not worth it. Its occurrence may be uncommon but it would create a deformity worse than the original aesthetic problem.

Dr. Barry Eppley

Indianapolis, Indianapolis

Dr. Eppley, Do you perform mouth widening surgery and do you feel it can be done with acceptable scarring. Conversely is there an alternative surgery that can achieve this. My goal is to widen my mouth and smile.

A: Mouth widening is a procedure that I essentially developed from an aesthetic standpoint. Whether the scarring is acceptable is a matter of individual interpretation. What is an issue not open to interpretation is that the need for scar revision in mouth widening surgery is 50% or greater.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope you are well. I have a few questions regarding the clavicle lengthening procedure I have scheduled with you in June and was hoping you’d be able to help.

The first thing is regarding a potential complication. It appears I may have either a Type 1 or Type 2 acromioclavicular joint injury (I’ll attach pictures). I don’t recall any particular trauma, and it may have just been caused from weightlifting over time, or by something that I didn’t think was painful enough to seek out medical attention or suspect an injury. Either way, this was taken a few months ago and it appears to be the same (no further healing). From what I’ve read (but I may be incorrect of course), it seems that if a few months has passed and the injury persists, it likely will not heal on it’s own. I’m curious if you think this is any reason to be concerned when planning lengthening of the clavicles. 

Although it is not causing me trouble now, I’m not sure if it may need to be corrected by surgery if it gets worse (or possibly now to prevent it from getting worse). If you think clavicle lengthening is still feasible, would you think it may cause any complications to a potential A/C joint repair in the future? I ask because I wonder if this is something best corrected now, or if it can probably wait until later (if needed at all) after a recovery from clavicle lengthening. I just wanted to make you aware of this before my X-rays the day before surgery, and to get your opinion.

The second question is regarding exercises and preparation for surgery. Since the lengthening procedure will stretch some muscles, I would imagine it would be beneficial to stretch affected muscles as much as possible beforehand. Would you think this is a good idea, and if so, would you be able to provide a list of muscles that I should be stretching?

Thank you for your time and insight.

A: In answer to your questions:

1) I am not an AC joint authority but I don’t see the correlation between a lengthening osteotomy done on the inner third of the clavicle to whatever injury exists at the distant outer joint. The clavicle bone is of good bone stock so I see no reason why it would have any trouble healing. 

2) The reverse question seems more pertinent….how does a lengthened clavicle affect an injury at the AC joint? That is a question outside my field of knowledge but I would think important to know. This would have to be answered by an Orthopedic Shoulder Surgery specialist.

3) I would certainly see no harm in any shoulder strengthening or stretching exercises before surgery…although I can say they are absolutely essential. The amount of clavicle lengthening achieved in the surgery is not going to be limited by the natural flexibility of the tissues. But I think it is always a good idea to ‘train’ for body surgery almost regardless of what that surgery is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orbital floor surgery on my right side for a fracture. I do some acting but feel I lose parts because my eyes are no where symmetrical. I think the surgery was rushed leaving my replacement floor on my right higher than my left. Thoughts?

A: While I don’t know what you looked like before the injury and before the surgery, and your face is a bit tilted in this picture, the eye asymmetry is obvious. (see attached) It is clear the right orbital floor reconstruction is higher then the left unaffected side. That can be remedied but a 3D CT scan should be done first to have a precise measurement of the different orbital floor heights. That would then be matched with the differences in the external horizontal pupillary levels. (which presumably is 1:1 with the differences in the level of the orbital floors. Do you know what material was used to reconstruct the orbital floor?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I workout 6 days a week and it seems that no matter what I do it’s hard for me to get any real definition in my pecs. I have a very broad chest. I’m 6ft 3 and weight approx 208 lbs. I would be curious if I could get the results I’m wanting for my build with a standard implant or if we would need to go custom to get an idea of $. I have attached a few pictures for reference. Please let me know if you have any other questions.

A: The decision between standard vs custom pectoral implants comes down to what your augmentation goals are in the amount of projection as well as your muscle measurements. (height and width, see attached image) If I could see some examples of your pec augmentation looks as as well as these measurements I could answer what type of pectoral implant would work best for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had facial feminization surgery with very bad results. My chin was amputated instead of contoured or a genioplasty. My mandibular angles were totally obliterated too. This has left my face looking unnatural and with a U shaped. My chin pad hangs below my chin bone now. 

I’m interested in Rib reduction too as i have a rather straight waist, very short torso, 5’7″ tall, ~30″ waist inspite of being thin due to being born a man (I transitioned 3 years ago) 

Question: 

My question is can my ribs be reduced by a couple of inches? 

Can the rib bone be grafted to make my chin better and give me some mandibular angles. (Even if only a slight augmentation is desired) 

Even if rib reduction is not possible can I still get a rib bone or other graft to make my facial harmony better? Im also scared of losing more bone as I age and having danger to my teeth. 

Attachments: 

I have enclosed CT scan images post op and can provide complete ct scan zip folder too. 

Please do help, if possible. After all this I still look male in person. 

My main concern is my face shape, and I’m terrified of choosing implants as I barely have a few mms of bone left in my chin.

A: Thank you for your inquiry and sending your 3D CT scans. Like all 3D facial CT scans they speak for themselves about the state of your chin (an amputation chin reduction is a very unusual procedure given the objective) and the not atypical amputation of the jaw angles in V line surgery. (albeit with a very high starting point to begin the bone cut)

While custom implant designs are the far superior method of subtotal chin and jaw angle reconstruction after any form of V line surgery, and there are no long-term bone loss issues with such implants, your question of whether bone from rib removals can be used for the chin and jaw angle reconstructions is a logical and reasonable one. 

The length of ribs removed varies depending upon which rib is being taken. Rib #12 is usually in 5 – 6 cm range, and ribs #11 and #10 are in the 10 to 12 cms range. Such ribs are usually 1.5 to 2 cms wide. Given these bone lengths their additive amount should suffice for the chin and jaw angle reconstructions.

The issue with using rib bone for the chin and jaw angles, and this applies to any bone graft on the jawline whose objective is to expand the existing contours, is how much of it will survive. Onlay bone grafting can have different volumetric fates than inlay bone grafting in the face.

But the recycling of bone from rib removal instead of merely being discarded is not completely novel. Its most common recycled use in my experience is in augmentative rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just want to clarify that after the surgery, once the clavicle is healed and strength restored, the procedure can be done again, this time lengthening both clavicles. It is my understanding that a clavicle lengthening procedure can be done more than once as long as adequate healing time is given in between. My end goal is to have the right clavicle lengthened twice, and the left lengthened once.

A: That is a correct concept. The clavicle is a very robust healing bone and as long as it is fully healed and has a normal cross-sectional diameter, the lengthening osteotomy can be repeated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The left side of my face appears entirely flattened and hollow. My forehead is hollow on the left, my left cheek bone is pushed in, my left jaw is flattened, and my lip is also misaligned. My eyes are also uneven (one smaller than the other) due to plagiocephaly, and my nose tilts and sinks in towards the left side of my face

Therefore, what surgical procedures could improve the deformities mentioned above?

A: Based on this description alone the possibilities include:

Left Custom Forehead/Cheek and Jawline Implants

Left Paranasal Implant

Rhinoplasty ??

Upper Lateral Lip/Mouth Corner Advancement/Lift

Hard to say about the smaller eye without seeing pictures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implant removed a year ago along with chin implant, wondering how long it takes for the implant capsule to fully go away or if it will fully go away, it was a silicon implant that was only in for 8 months. 

A: Facial implant capsules take 6 to 12 months to be completely absorbed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer with chronic infections at the corners of my mouth, due to saliva tracking there, I wanted to ask my dermatologist if surgery was a option, as summer approaches when I suffer the most. I`m concerned my insurance will consider it cosmetic. At this point, I`m just asking questions. (I`m 71 and live in California, I realize you`re in Indiana)

A: It is fair to say that with your very downturned mouth corners which causes an overhang, this is a frequent cause of angular cheilitis. The mouth corners need to be lifted to remove the overhang and not allow the moutb corners to be chronically wet.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would it be unwise to undergo total periorbital augmentation, potentially including the zygomatic arch, PRIOR to orthognathic surgery in both jaws? I suppose this is an issue mainly for the infra orbital rim part of the implant design process. The aesthetic concern is, for the most part,vertical deficiency that results in round, saggy – retracted lower eyelids as shown in attached photos. However, since some degree of horizontal augmentation may be necessary, wouldn’t that impact either the implant design process with you or the surgical planning with the maxillofacial surgeon? 

Thank you in advance.

A: The level of a LeFort I osteotomy is below the infraorbital rim (technically below even the infraorital nerve) As a result, periorbital augmentation and orthognathic surgery are done at two different facial bone levels. Thus their order of execution is more of an aesthetic choice. While it may seem that one area affects the other from a treatment planning standpoint, it does not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I noticed that your clavicle lengthening results usually add about two inches overall. Since the pectoral muscle attaches to the clavicle does this usually result in a broader chest?

A: Your supposition would be correct. As the clavicle is lengthened it pushes the shoulder out. Since the insertion of the pectoralis muscle is attached to the humerus (upper arm) it will also get pushed out laterally. This will move the lateral pectoral muscle border, which is what defines the width of the chest, outward. Thus the chest does get wider as the clavicle gets longer.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, Hello, I have dynamic/ hyperdynamic chin ptosis. I‘ve planned to get a V-line Surgery in Seoul in some months, where the blunt and wide tip of the chin is cut off by osteotomy, and unnecessary bone parts are cut out, which are reassembled at the bottom center. My question is can I have the surgical treatment for dynamic/hyperdynamic chin ptosis afterwards? I would like to get both surgeries done. 

Have a nice day!

A: I am very familiar with that form of mini V line surgery since I frequently perform it myself. There is no question that hyperdynamic chin ptosis correction should be done AFTER this surgery since the loss of supportive bone structure will make the hyperdynamic chin ptosis worse. Or if done before would eradicate any positive benefit from the hyperdynamic chin ptosis correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Question about how to correct a sloping forehead with a very strong low brow bone with temporal hollowing. 

A: This is a not uncommon forehead shape seen since it is reflective of an overall more narrow skull shape in an anteroposterior direction. Because you are a male your brow bones developed normally but what has developed around them is less developed. This would be effectively treated with a custom forehead implant (minus the brow bones) that has temporal extensions. (see attached)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am contacting with regards to my request for a virtual consultation.With this message I want to outline my concerns/expectations in detail since that wasn’t possible with the other form. 

1) My primary wish is to improve the lower third of my face (chin, jaw). By that I mean: 

a. Making it more massive, increase it’s overall size. My lower face should take up a bigger portion of my face. I have gained a lot of muscle mass these past years (and some fat mass as well). Also I am about 6’2. That means I am a really big guy and my face doesn’t quite match that (it’s not narrow or rescinded, it is about average and that’s no longer enough). My jaw needs to be much wider and have a wider angle. Also my chin needs some more projection. That way my lower face would fit in better with my overall physique. It is very important to me that the surgery does not end up being barely visible, it should be clearly noticeable, ie the implants have to be massive enough. I found several great before-after improvements in your photo gallery “Custom Facial Implants” that we should perhaps lean on for my own implants. Those are the transformations of patients “1”, “2”, “48”, “54” and “56”. 

b. Making it more defined, more “chiseled”. A big part of this could be simply decreasing my overall body fat percentage though. Perhaps neck liposuction could be helpful as well since I definitely have a certain fat pad below my chin. 

c. Add either a cleft or dimple to my chin. This is purely a preference of mine and I believe the facial implants are a great opportunity to check that off my list too. 

2) Another goal of mine is to improve on my facial (a)symmetry. I don’t know exactly how to achieve more symmetry, I guess the facial implants are one way, maybe they are other procedures to improve symmetry as well that you could inform me on. 

A: Thank you for your inquiry and detailing your objectives to which I can say the following:

1) How large any facial implant can be is a function of the soft tissue tolerances to which is placed underneath them. Thus there are limits which must be made on an individual basis.

2) Chin clefts and dimples do not come from indentations in the bone. Therefore putting those features into an implant design will not necessarily make it appear on the outside. These are soft tissue muscle defects which, in large chin/jaw implants, may not be wise to do since this requires thinning out the soft tissue over them.

3) Whether midface (cheek) implants may be necessary for facial balance/proportion with a larger lower third jawline implant augmentation will require computer imaging to assess.

4) At age 20/21  99% of your lower jaw growth is over so there are no concerns with implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do the temporal shell implant last forever and how much does it cost? Thank you for answering in advance.

A:The temporal implant is made of an ultrasoft solid silicone material that does not degrade or break down. It can only changes its chemical structure at 375 degrees F. Thus it will last forever.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,Hi, I understand your practice specializes in custom facial implants. I have a cosmetic bony deformity from trauma and I would like to learn about your experience with the outcomes of those specific implants and complications, planning procedure, choice of material, etc. Thanks

A: Thank you for your inquiry and sending your 3D  CT scans. What you had is a classic ZMC fracture with downward and inward rotation. Unfortunately the ORIF surgery failed to adequately derotate the ZMC complex so there is undoubtably some flatness of cheek projection extending out onto the zygomatic arch. Your two options secondary reconstructive options at this postop time period is a ZMC osteotomy with replating into a better anatomic position or a camouflage technique overlay technique using a custom implant design. Each option as its advantages and disadvantages. The custom inmplant overlay technique oiffers a less invasive surgery with a more assured anatomic restoration. Custom implant designing works just as well in secondary facial trauma patients as it does in aesthetic facial surgery. From a design standpoint it is ‘easier’ than aesthetic facial enhancement use because there is a well defined target. (the opposite normal side)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there any way to reduce the width of the forehead?

A:Yes there is. It is known as temporal line reduction….the bony anatomic lateral birder of the forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is about the possibility of ribcage expansion + pelvic narrowing + clavicle lengthening to create a bone structure for the optimal “V-taper look”, that is desired by many bodybuilders. I notice you already answered a similar question (https://www.eppleyplasticsurgery.com/ribcage-expansion) But i am asking again in the case of any new technological developments. 

Compare the image provided. Would it be possible for the left’s clavicle to transform into the right? Or, do you think rather the right’s picture has more of a camera angle illusion, perhaps flexing his lats to create more of a V-taper compared to the unfortunate shoulders of the left. 

Do you think it would be possible to undergro ribcage expansion + claviacle lengthening + pelvic reduction with smaller, mini Distraction osteogenesis devices getting released?  

Have you ever completed any pelvic narrowing/waist narrowing procedure on men who desired the small waist, V-tape look? If so, what methods were needed to achieve their desired look?

A:In answer to your questions:

1) Clavicle lengthening osteotomies is a real and effective procedure. For now it is done by a sagittal split technique. Distraction osteogenesis with acceptable devices and limited scarring does not yet exist.

2) Ribcage expansion is not a real or even safe procedure.

3) Iliac crest reduction is an actual procedure which may be combined with rib removal of the goal is a very tapered waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to consult about the treatment of my protruding forehead. I think my forehead is too prominent for Asian people, and it doesn’t match my facial features or my aesthetics.

The pictures below are my original picture and my desired look (with photoshopped forehead area) addition, my own hairline is not high, it is still appropriate, and I think it should not be a situation that requires a hairline shift down.

The situation I would like to ask is.

1. What kind of surgical option am I suitable for? Do I need to get staples or implants for this procedure (I am very concerned about this)?

2. What level of results can I expect to achieve? (compared to the picture I photoshopped)

3. What is the success rate of the surgery so far? Will there be subsequent growths? What are the after-effects?

A: In answer to your forehead reduction questions:

1) This is a bony reduction procedure so an implant is not needed.

2) I use small dissolvable sutures for incisional scalp closure NOT staples.

3) I believe your own imaging is 90% to 100% achievable.

4) Boney regrowth of the forehead convexity is not known to recur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am mainly looking to fix my lower lip – it looks like I have a wad of chewing tobacco under it.

A: A major contributor to the ‘compressed’ look of the lower lip-chin area is that the chin is vertically short. This makes the enveloping soft tissues become compressed up against the lower lip. (mismatch between the bone and soft tissue. This is also why the labiomental fold is so deep. The most effective treatment would be to vertically lengthen the chin bone which will stretch out the soft tissue to help improve that appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can your buccinator myectomy procedure, the one where you excise muscle to create a more concave effect, incorporate the same principles into the upper parts of the cheek to create a more concave appearance in those higher cheek areas? 

A:That is a good question but that can’t be done higher because of the location of the exit of the parotid duct (Stenson’s duct) at the inner cheek level. You can easily feel where that duct is located opposite the first maxillary molar) with your tongue. (that is the small bump that you feel)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if filler or fat transfer could be safely applied slightly below and above the zygomatic arch to conceal vertical asymmetry between the left and right arches? I was born with one zygomatic arch noticeably lower than the other (see attached CT scan image). 

I’m assuming the zygomatic arches cannot be safely moved up or down via osteotomy to correct the asymmetry, is this correct? 

If so I’m thinking the best bet would be to add some type of filler below the higher arch and above the lower arch to make them kind of match one another more. 

Unless this could be done with implants? 

Thank you for reading.

A:In answer to the management of your asymmetric zygomatic arches:

1) Injectable fillers or fat can be used as you have drawn on your 3D CT scan. Certainly this is the simplest approach albeit the most unreliable and/or non-permanent effect.

2) You have incorrectly assumed that zygomatic arch osteotomies can not be done to change their horizontal position. Whether this would be an effective approach depends on how much up or down movement of them is needed.

3) Zygomatic arch implants may also be an option depending upon what exact dimensional movements are needed.

In most cases of facial asymmetries of any kind there is often a good (preferred) side and a non-good side. Usually the higher side is the preferred side and this is almost always the case with cheek/zygomatic arches. If so, then the goal is to make the lower side match better with the higher side in which all three mentioned options are possible each with their own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty four weeks ago. It involved a +3mm lengthening, +3mm projection, and +4mm widening. As my swelling has gone down, I realize that from a side profile view I like the lengthening and projection achieved, BUT, from the front view I see that my chin is asymmetric. I like how the left side of the chin looks, but on the right side the chin looks ‘sunken in’ – as if the bone segment were angled more inwards (and maybe upwards) in comparison to the left. The right looks ‘slimmer’ and left looks ‘fuller’ in comparison. It’s subtle, yet obvious. I can also feel this difference when gently running my fingers down/along the chin. Could you please advise regarding the appropriate solution, and the associated timeline? I would like to take this forward with you at the soonest. 

A:Thank you for your inquiry and sending your pictures. I believe the answer is clearly seen on your x-ray which shows the more prominent inferior border stepoff on the right side due to exactly what you have described. (see attached) Your visible and palpable symptoms match what your x-ray shows. This is a contour deformity along the right inferolateral border of the chin. There are two approaches to resolve it; 1) immediate intraoral bony adjustment to rotate the segment out and down or 2) delayed implant coverage of the bony defect, probably using ePTFE from a submental approach. Each approach has their advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I’m hoping you could help me here. I had a reduction genioplasty 8mm bone shave. The outcome looks awful but I’m now suffering with tightness in the chin. I feel like I’m unable to move my chin. It feels tight where the muscle has been stitched. My intraoral incision has scarred to high up on my tooth line. My mouth movements look funny and I also can’t retract my lower lip downwards. Not being able to show any of my bottom teeth this also has an effect on my speech and movements. I’m so scared to have another procedure because of the amount of scarring I have. I have attached some pictures for you to see. My chin also looks lumpy.

A:I believe we have had this discussion previously but to review it again. A large shave down intraoral bony reduction genioplasty is never a good idea and is prone to a lot of potential problems…many of which you have. Once such a large amount of bony support is removed where does all the enveloping soft tissues go? Unfortunately it does not just shrink down and adapt around the reduced bony chin. Rather it turns into a ball of contracted muscle and scar tissue which is both stiff and immobile. The contour also become irregular due to the soft tissue contracture. I see no other effective option for improvement but to release the scarred soft tissue chin pad and put back some of the bony support lost. (aka sliding genioplasty) Whether the movement should be a partial or complete restoration of the lost bony projection can be debated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking into deltoid augmentation through fat grafting.  Is this something you have done in males?  Is the result permanent?

A:I have done fat grafting to the deltoids numerous times in men. Like all fat injections the survival is not always 100% predictable but what does survive should be permanent long term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an average jaw and chin. I was wondering if the off the shelf implants would suffice, or if the custom chin wrap would be more fruitful. I would love to consult with you and compare options. I have included pictures for computer imaging.

 Thank you,

A:I have done some initial jawline imaging which should be interpreted as follows:

‘The purpose of computer imaging is frequently misunderstood by patients. Computer imaging is done to help determine what the patient’s aesthetic goals are. It is a method of interactive visual communication between the patient and surgeon to help establish what your specific goals are. Your task is to evaluate this initial imaging and determine what you like and don’t like about it. Then I adjust the imaging to make it the way the patient wants it. This then establishes the aesthetic target from which I design the operation to try and achieve.’

There are significant aesthetic outcomes, risk considerations and cost differences between the use of 3 standard implants and a one piece custom implant approach to jawline augmentation. But when you break it down to the most simplistic level there is one and one reason only that a patient may choose standard implants over a custom designed one….cost. The use of standard implants has inferior aesthetic results and a higher risk of implant placement asymmetries.

Dr. Barry Eppley

Indianapolis, Indian

Q: Dr. Eppley, I am a naturally broad shouldered female with narrow hips. I am interested in a hip augmentation procedure to widen the width of my hips in proportion to my shoulders. I likely do not have enough donor fat to have a fat transfer to the hips, so I am primarily interested in hip implants.

A few questions:

Does you always use custom implants shaped for the hip region?

Do synthetic hip implants need to be replaced after some years?

Can hip implants be felt when touching the hips?

Is there a danger of hip implants migrating, given that the area is above a joint?

A:In answer to your hip implant questions:

1) Since there are no standard hip implants available, all must be made custom.

2) Like all body implants, other than breast implants, they are solid, do not degrade or breakdown, and thus never need replacing due to device failure.

3) How palpable they are depends on how much soft tissue cover you have.

4) Hip implants do not migrate once well healed. There are no joint issues as these implants are placed on of of the TFL fascia which is well away from the hip joint.

5) When considering hip implants I would read the following statement based on my extensive hip implant surgery experience:

   ‘Hip implants have a fairly high rate of complications so patients have to be selected very carefully to try and lower those risks. There are two major risk factors, 1) thin patients with little subcutaneous fat (inadequate

    soft tissue cover) and 2) implants that are too big. (too thick for the tissues to adequately support them) Both of these hip implant considerations are judgment issues with no absolutes. Before a patient should

    consider hip implants they should exhaust every other method of hip augmentation and to be aware that it is a procedure that is in a state of evolution and is far from a perfected surgery’

Dr. Barry Eppley

Indianapolis, Indiana