Your Questions

Q: Dr. Eppley, Hello. I want to reshape my head with bone cement. The first image is before and the 2nd is what I would like (used photoshop). Is this possible?

A: You are not going to get that skull augmentation result (or even close) with bone cements for the following reasons:

1) The most common bone cement (PMMA) used in the skull is a plastic material and does not turn into bone. It is in fact a plastic implant so don’t let the name mislead you. It is the same material that is used to cement in orthopedic joint replacements. When used in the skull the manufacturer simply puts it in a different package and calls it Cranioplast. 

2) The other type of bone cement (HA or hydroxyapatite) is a synthetic phosphate (ceramic) that does not turn into bone either. It may be a distant cousin to bone but is still an implant. It was developed for the use in cranial defects (inlay) not onlay (on top of the bone) augmentation. While it can be used for small skull augmentations, it is too brittle to do large ones. Of equal importance its cost precludes its use for most aesthetic patients. At over $100 per gram the cost of the material alone (large skull augmentations are in the range of 150 to 200 grams or greater) would be in the range of $20,000.

3) Even if #1 and #2 were not issues with bone cements for skull augmentation, they require wide open exposure for placement which means a full coronal (ear to ear) scalp incision is needed.

4) Bone cements can only be placed on bone and can not be applied over soft tissues areas. (side of the head) The larger a skull augmentation is (more projection) the more its base needs to be wider and cover more surface area so the result does not look like an unnatural bump on the head. This means the augmentation has to wrap around onto the sides of the head which are soft tissue covered (temporalis muscle and fascia) onto which bone cements can not be applied. (will not stick to it)

In summary bone cements have a very limited role in aesthetic skull augmentations and only have merit in small skull augmentations that are usually in the 50 to 60 gram volume….a result that is a far cry from the one shown in your own skull augmentation imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, At the moment I am undecided as to whether I want bone burring to be done due to the bi-coronal incision (incision that travels over the scalp) so I just want you to assist me in weighing up the risk to benefits by answering some enquiries. I also say this based off a recent Instagram post of yours demonstrating this surgery which is shown in the image attached image. It is to my satisfaction that these incisions in the image look quite simple and much less invasive compared to the approach we have planned for myself hence why I have these enquiries: 

-Based off my CT scan, if you were to bone bur the temporal line, what is the most in millimetres that you could reduce and would this reduction be noticeable? 

-Would I still achieve forehead narrowing if I just had anterior & posterior temporalis muscle reduction without any bone burring? 

-Have you ever had patients encounter shock loss with hair from this large incision ? 

-If the large scalp incision was done, how long would it take for stitches to close up and heal? 

-Is there an alternative incision in achieving bone burring? 

Your answers to these enquiries would influence me in deciding if an incision that large is worthwhile doing as I’m starting to feel that I’ll be the most comfortable with the approach shown in the image below. 

A: You can’t do the type of bony temporal line and anterior temporal muscle reduction that you seek through the anterior temporal incision shown in that picture. That does not apply to your case.

Bony temporal line reduction is always at least 5mms, which when done bilaterally (or even unilaterally) makes a visible external difference. Your case is no different in that regard.

Temporal muscle reduction of any type will not change forehead width. Foreheasd width reduction is controlled by the bony temporal line.

The only hair shock loss I have ever seen in larger scalp incisions is when it is used for large skull implants or tissue expanders (which is very uncommon)….not with any form of skull reduction which is what I would expect with a total lack of tension on the incisional closure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i have consulted with a surgeon about the procedure modified lefort 3. My question is why is the implant route the way to go instead of surgery?

A: The midface implant route is the superior aesthetic approach to midface augmentation IF there is no compelling need to change the occlusion. (one’s bite) It is superior to a LeFort IIII in an adult because:

1) Every midface dimension/thickness can be precisely controlled by the preoperative design.

2) It provides a complete midface augmentation effect particularly in and around the orbit rim and malar region.

3) It provides an assured smooth contour.

4) It is less invasive with a quicker recovery.

5) It is reversible or capable of being modified (addition/reduction) should one want to fine tine the result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding facial outline and skull shape. I have looked through your question archives but couldn’t find anything on the exact topic. Is it possible to change the facial outline of your face to make it less round and more straight. I am including a picture as an example. My facial outline is round. The model has a straight facial outline which is well defined. I understand that buccal fat can be removed for less round face but I am asking about the outline of the face and not the cheeks. Thank you

A: Without having a reference point (your picture) I can not say whether your face and what could be done to change to make it more straight is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello! I believe my jaw is not symmetrical and feel one side is longer.. if I sent a variety of photos that it is very visible could you possibly tel if it can be solved/ corrected my by just a custom jawline implant or chin implant or if I would have to go down the path of jaw surgery and jaw reconstruction!

A: I would be happy to review your pictures of your jaw asymmetry but, even without pictures, there is certain known principles treating it based on my experience:

1) A 3D CT scan is the definitive method to fully understand the exact bony anatomy of the jaw asymmetry.

2) A chin implant can never adequately treat jaw asymmetry and often when done alone makes it more apparent as the asymmetry increases as it moves from the chin back to the jaw angles.

3) In some cases a unilateral custom jaw implant on one side may correct the asymmetry if it has a modest amount of bony asymmetry.

4) A total wrap around jaw implant is usually the definitive treatment for jaw asymmetry as the discrepancy between the two sides usually merits it and many men decide to provide some overall lower facia enhancement as well.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I wanted to ask for your thoughts on what you believe would be the best treatment option for me. I have always had a very ‘flat’ face with lack of forward projection. I am 26 now and previously had braces aged 16 to correct a slight crossbite, and also my upper and lower teeth ‘met’ instead of the upper coming over the lower. I now notice mid-face concavity, deep nasolabial lines and I feel my chin juts too far forward. my cheekbones are flat and there is no projection at all in the apple cheek region. There is also a lack of bone support in the infra-orbital area which I feel pulls my eyes down at the outer corners/ gives me a negative tilt. After much reading online I think I have a recessed upper jaw but I don’t feel its significant enough to undergo orthognathic surgery as I imagine that’s quite a traumatic procedure! I was thinking facial implants may be a good option, but I am unsure which type, or where would be most effective. Ideally id love to achieve a more sculpted, ‘forward-grown’ face, with more defined cheek ‘bones’, forward projection, more apex in the nasolabial area and get rid of the bottom jaw ‘jutting’ out appearance. A stronger overall facial structure with more light and shade/ definition. I will add some pics for your reference! 

I greatly appreciate you taking the time to read my message and I look forward to hearing back from you at your earliest convenience.

A: With an overall midfacial hypoplasia and I assume a reasonable occlusion (bite) the most effective treatment to ‘pull’ your midface forward is a custom midface implant. (see attached) Augmenting the infraorbital rim and downward across the face of the maxilla, it will add total midface fullness without adding any facial width. The custom midface mask implant has the advantage of being a single piece. There are standard implant options to consider (infraorbital, cheek and premaxillary-paranasal implants) which can be put together to try and create a similar effect but i would only consider placing unconnected implants in the midface only of that were the patient’s preference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dent in my nose and I find it extremely hard to breathe out of my nose over the years I’ve tried multiple different nasal sprays, home remedies, I’m sure I’ve tried every single suggestion on the internet not only is it extremely difficult for me to breathe I absolutely hate the dent in my nose it’s my biggest insecurity. 

A: By your own description you probably have an internal nasal deformity (septal deviation, turbinate hypertrophy or both) which is the primary source of your airway obstruction. The dent in your nose that you refer to is what is known as a bifid nose, meaning the lower alar cartilages are wide and spread far apart creating a valley or groove down through the tip of the nose. Both can be corrected by open rhinoplasty surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have large posterior PEEK jaw angle implants (~12mm width; no vertical augmentation). My presentation is complicated by significant bilateral masseter dehiscence, as I have history of prior jaw surgeries. The appearance is the classic skeletonized angles + the muscle bulge superiorly. 

I have read your various posts on masseter muscle reattachment via external approach both on your blog and on forums. I discussed this with my prior surgeon. However, he/she does not think it’s a good idea to do an external surgical reattachment of the muscle to the inferior border of the implants out of fear this may cause masseter tearing, as, given my history of surgeries, there is likely fibrosis within the muscles. In addition, my implants are large. 

Instead, the surgeon has recommended 3-4 Botox regimens over the course of a couple years, which he/she said would help the muscle “fall back down” over the inferior border. He/she said repeated treatments would eventually cause some degree of permanent atrophy and could help eliminate the appearance of the superior bulge. 

I don’t like the idea of using Botox. In addition, I prefer more permanent solutions. 

My questions are: 

1) Is the risk of masseter tearing a reasonable concern when considering masseter reattachment for the treatment of dehiscence. 

2) Would you ever recommend Botox as an effective non-surgical treatment for masseter dehiscence, or is this truthfully just a fairly ineffective alternative. 

A: In answer to your masseteric muscle dehiscence issues:

1) Botox injections are a reasonable treatment option with the understanding of the following:

   a) Their effects are usually temporary and have to be repeated.

   b)  Even with repeated injections any sustained permanent muscle reduction effect may or may not occur. (I have never seen it happen yet) 

   c) The appearance of the muscle bulge will definitely become less but the muscle will not fall back down. This is biologically impossible as it is a contracted muscle mass now. It will not unfortunately just ‘relax’ and go back into place. This is known as magical thinking.

   d) At best Botox will produce a lessening of the muscle dehiscence appearance but it will not make it go away completely.

2) The risk of masseter muscle repositioning is not whether the muscle will tear but whether it is so fibrotic that it simply won’t move much. (unsuccessful repositioning) The other thing you have to consider is how to fix it the muscle to the PEEK material if you are fortunate enough that it is capable of being mobilized.

3) Any effort at masseteric muscle repositioning must be preceded by Botox injections to get the muscle to relax/soften a bit. One or two rounds of Botox, preferably two, before such surgery improves the chances of success.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My little boy is soon to be 6 years old. He has a wide head with flattening mainly to one side and his ear is slightly pushed forward on that side.

I would like to try and get this sorted for him before at this age. Is this something you can help him with?

I think you can use a skull cement that can be used at his age? Is this very costly? And is it effective? Does it leave much of a scar? How long does it take? 

We are based in the uk but I don’t think this can be done in the uk? 

I am really keen to sort and how do we progress with this?

A: When it comes to treating occipital plagiocephaly in children the only good option, in my opinion, is hydroxyapatite cement. While such HA cements don’t really turn into bone, the body does view them as more ‘natural’ and develops osseous integration with the surface of the skull. While such HA bone cements are the ideal material they are not perfect and have several notable downsides which include the following:

1) Placement of them requires direct visual access to properly place and shape the cement. This means that a longer scalp incision is needed to do so.

2) Any bone cements have to be placed exclusively on the bone or otherwise they will fracture. Since plagiocephaly skull deformities wraparound the side of the head into the posterior temporal muscle region, such corrections are imcomplete.

3) HA cements in the U.S. are very expensive compared PMMA acrylic bone cements. But PMMA is a material that should not be used in children due to the growing skull.

For the reasons so stated above I advice parents to wait until the teenage years when a more effective method in treating plagiocephaly exists (custom skull implant) and the use of these other more effective materials are placed in a skull that has undergone much of its development.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I would like to ask about the customized skull, how hard is it and is it safe and almost as hard as the original bone?

A: A custom skull implant will feel just like bone and when implanted you can not tell the difference between it and your natural skull….even though outside the skull it has some flexibility and is not as rigid/stiff as bone. It is a common misconception that an onlay (on top of bone) skull implant should be as hard as bone…that is wrong. It is an inlay skull implant replacement for full thickness defects which should have a stout rigidity to it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, in terms of the occipital procedure, what kind of swelling can I expect and will any hair be shaved to make the incision? Or in other words, will I be able to go back to work pretty soon afterward without worry about the scar being seen as it’s healing and any swelling being noticeable?

A: In answer to your occipital skull reduction questions:

1) No hair is shaved for the procedure.

2) Most of the swelling that occurs is on the back of the head and does not affect the face. So it is really not that noticeable to others. So you should be able to go back to work fairly quickly.

As for the forehead one treatment option that we did not discuss was fat injections, a minimally invasive procedure with virtually no recovery. While it is not what I would consider for medium or larger types of skull augmentation but for small contour concerns it is an option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m curious are there any surgeries to make the eyes look further apart? I know an orbital box osteotomy actually moves the eyes further apart but that’s a obviously a very invasive surgery for a couple of mms.

A: Whether it is 2mm or 10mms the only way to physically move the eyes further apart is with the orbital box osteotomies. Admittedly the lesser the amount of separation needed the more the orbital box osteotomies is a solution that is much bigger than the problem merits.

Dr. Barry Eppley

Indianapolis, Indianapolis

Q: Dr. Eppley, Hey I’m a transgender female patient who is interested in getting hip implants cause I have hip dips and they make me feel like I look boyish.

A: Of all body contouring procedures, hip implants have the highest rate of postoperative problems. I have learned to choose patients carefully for this procedure to lower these complications risks. My preoperative assessment includes pictures of the patient’s hip areas with imaging predictions of what I consider realistic outcomes. The patient’s soft tissue thickness is also a key consideration. Thin tissue patients with little subcutaneous fat have a high risk of implant show/edging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an endoscopic brow lift 3 years ago and I am left with 4 vertical lumps on my forehead (pictures). The surgeon who did the brow lift believes it is scar tissue. 

Do you think you could treat those scars by any means ? Would it require surgery or maybe just steroid injection ? 

Thank you 

A: This is a most unusual sequelae from an endoscopic browllift that I have never seen or heard of before. While you can certainly try steroid injections I would not expect that to provide any improvement. I don’t think this is scar tissue nor could I biologically explain why such scar tissue would occur along these very specific vertical ‘lines’ since in an endoscopic brow lift there are no periosteal/galeal tissue releases done along these lines. There are only vertically ‘pull points’ located at the scalp incision locations. My speculation would be that this is more likely related to the vertical pull of the browlift which has created tension lines in the forehead.  I don’t think it is a coincidence that the tissue lumps are vertical in orientation and that the browlift is based on a vertical tissue pull.

If that is a correct theory then the only solution may be a horizontal release of the galea of the forehead as is more commonly done in open forehead procedures. What is clear that at 3 years postop this is not an issue that time and tissue relaxation will solve.

But I make these comments based on only seeing two pictures and having no specific knowledge of the endoscopic browlift technique

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheekbone reduction surgery via osteotomy 2 weeks ago. The bones were reached and fractured intraorally and with exterior incisions. On my sideburns where the exterior incisions were made there are really hard lumps which are a concern to me because I don’t know if it’s swelling that will eventually dissipate and flatten out or the zygoma arch is sticking out. What is it? 

A: All I can say is that it is either swelling or the back ends of the zygomatic arch sticking out. It is either one or the other. But that would be impossible for me to say based on just your description alone. A x-ray of course would provide the definitive answer if you must know immediately.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What are your thoughts on Vermillion Advancement and why is this better or worse than the bullhorn/gullwing? I have very thin upper lift and downturned mouth. 

Thank you!!

A: FYI bullhorn = subnasal lip lift, gullwing = vermilion advancement

While you can have a subnasal lip lift you should not have it by itself as this will result in an A frame deformity. With the sides of your upper lip absent/folded in and the mouth corners turned down the subnasal lip lift by itself will make the upper lip look even more disproportionate. The subnasal lip lift only changes the central upper lip and not the sides. Thus a subnasal lip lift in you must be combined with a lateral vermilion advancement/corner of mouth lift to look right.

You could also have a total vermilion advancement but with some cupid’s bow presence and a long upper lip I would go with the former which will produce a greater upper lip shortening effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to fix dents in my butt cheek that I might have gotten from a steroid shot when I was younger. I’ve had this noticeable set of dents/dimples for as long as I can remember. These dents show more when I’m simply standing or wearing tight clothes. I am always covering it up with shirts and long clothes. I don’t want butt implants. I am okay with my butt size. What are my options to fix this deformation?

A: This is a classic soft tissue indentation from exactly what is known to cause it…previous injection therapy. This is not a problem that would be improved by buttock implants anyway. This requires contouring reconstruction with fat. Given the broad and fairly shallow base of the indentation fat injections would be the appropriate treatment choice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested into getting a few things done in your Clinic. I would like to get Hip Implants, Rib Removal and my Shoulders narrowed. Is it possible to get it done in one surgery? And how long would you recommend to stay in your clinic?

About me: I’m trans (mtf) and have no medical problems. 

I’m looking forward to hearing from you.

A: Thank you for your inquiry. The question about whether all three body contouring procedures you have mentioned could be done at once is a recovery issue not a technical one. Since you would most likely be coming by yourself it would be very tough on you to do all three at once. I would choose which two of them have the highest aesthetic priority for you. Those two alone would make recovery hard enough. From an aesthetic standpoint it would also be important to look at some imaging changes to determine what can realistically be achieved from these procedures on you. That may also help with establishing procedural priorities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering if a submalar cheek implants works effectively on African-American skin for someone with facial lipodystrophy?

A: I am not aware that there are any racial differences when it comes to the aesthetic effects of submalar cheek implants. If someone is a good candidate they can be effective regardless of race, age or gender.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a couple quick questions regarding the posterior temple reduction surgery that I have been very interested in. I’ve been reading up on it and it says that after the surgery, the full results won’t be shown until 6 weeks after. Why is this? Is it because there’s a shrink wrap effect that takes place to where the skin flattens and tightens over where the muscle was removed? Or is it because it takes 6 weeks for swelling to go down and for the muscle to atrophy? I understand you have two methods of either removing the whole muscle or tapering it off towards the back. Is there a significant difference between the two? Thanks in advance

A: To see the operation’s full effect it takes complete resolution of all the swelling. Like any other face or skull surgery this is the expected time for the full aesthetic effect to be seen. Most patients are well into the benefits phase by 2 or 3 weeks after surgery but its 100% result takes the full 6 weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to email you in regards to the cost of a chin augmentation using either an implant or sliding genioplasty. I have a slightly recessed chin I would like to bring forward. I can provide photos. I would like some more information about the custom implant process and how that would work.

A: Thank you for your inquiry and sending your picture. I have done some initial imaging to try and get a feel for what amount of chin augmentation looks sufficient to you. In terms of selecting how to do the chin augmentation:

1) standard chin implants are indicated when the chin deficiency is modest to moderate in size. (like yours)

2) a sliding genioplasty is best done when the amount of chin deficiency is large or the patient very specifically is opposed to an implant.

3) custom chin implants are indicated when the patient’s aesthetic goal can not be achieved by the use of a standard implant. (e.g., very square chin shape)

Based on just this one picture, #1 seems appropriate for you.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, Looking to correct previous gynecomastia surgery. I have bilateral surface irregularities/depressions and scar tethering during flexion. Original surgery completed one year ago with fat grafting completed six months later. Pre and post pictures included.

A: Thank you for your inquiry and sending your pictures. As I understand your history you had an open areolar approach to your gynecomastia reduction complicated by a postoperative crater deformity. This was  followed by a second surgery of fat injections in attempt to release the adhesions and improve the contour.

Fat grafting as a treatment for the crater deformity after gynecomastia reduction is an appropriate approach. One can debate whether that should be by injection or the open placement of a dermal-fat graft. Each has their advantages and disadvantages. Fat injections are a more simplified and convenient approach to the problem but how much survives and their contour effectiveness is very unpredictable and far from assured. Dermal-fat grafting is more effective in terms of a successful release and volume retention but it is an open surgery and involves the need for a donor site harvest. 

Most surgeons and patients when presented with the two options would understandably opt for the fat injection method. The question moving forward is whether another effort should be made at fat injections or whether one feels better about moving on to a ‘Plan B’ correction method. I can make arguments either way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I like the first chin augmentation imaging that you did the best, I believe that is the smallest correct? For some reason though I just think I may Iook too masculine. I mean I know I have a boyish face but sometimes I feel like my recessed chin is the only feminine thing about my face lol. I would like to see what it would look like from the front profile because honestly that’s what bothers me the most. I feel like my lower face does not add up to my mid face and I feel like my lower face is sagging— perhaps what I need is a face lift. I honestly don’t know. Maybe you have other suggestions? I’m so lost. You’re the only surgeon I would feel comfortable getting anything done from so I really appreciate your input. Ultimately I guess I just want a more v shaped jawline and chin to look the most feminine that I could possible look. I just gotta figure out what needs to be done. Thank you so so much

A: In answer to your chin augmentation imaging responses:

1) I think it is wise for a female with a significant chin deficiency to be very careful about doing too much, Such patients often have a hard time recognizing themselves afterwards and can never adjust to a so called normal chin position. So the use of computer imaging has helped flush that concept out in you.

2) Since the chin augmentation would be small I would just go with an implant which is probably no more than 5mm horizontal projection and has no extended wings. (anatomic style chin implant) It also would need to be hand modified so it looks just like a V. With implants you have to exaggerate their design on the bone as the overlying soft tissues will blunt their effects. So to have a more narrow chin the implant must literally look like a V.

3) Not doing frontal imaging was not an oversight. You can’t really pull the chin forward with imaging so It won’t show much of anything. Unless one is interested in increased chin width (which you aren’t) frontal imaging is not useful. For chins and jawline the combination of the side and oblique views is the most informative and accurate.

4) A jowl tuckup procedure always makes the jawline sharper as it pulls the soft tissues back over the jawline bone. So the question is not whether that is beneficial but rather how far does one want to go for how much effect. At the least submental/neck/jawline liposuction is needed with the chin implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Has you ever had patients post-operation suffer from weakness in chewing or keeping the jaw closed after having done the posterior and/or anterior temporalis muscle removal/reduction? 

-What sort of feeling should I expect post-operation and during the healing process when Dr Barry performs bone burring on my enlarged temporal line? 

-Just to confirm, is it the over-developed anterior section of the temporalis muscle that contributes to forehead width ? I say this cause reducing my forehead width is one of my main goals with this operation. 

-Roughly how long would it take for the major swelling to settle down post-operation and for me to comfortably go out in public ??

-Will I lose much sensation on the scalp post-operation from the coronal incision ? 

-What medication would I get prescribed with post op and is this medication available back home in Australia ? If not what’s an alternative ? 

Looking forward to hearing from you. 

A: In answer to your temporal muscle and bony temporal line skull reductions:

1) No patient has ever experienced any lower jaw motion or chewing difficulties after the surgery. When the anterior temporal muscle is manipulated there can be some temporary tenderness with wide mouth opening.

2) Skull bone has no sensroy innervation so no pain/discomfort comes from bone reductions. It is the scalp that has sensory innervation.

3) The width of the forehead is ultimately defined by the prominence of the anterior temporal line.

4) Most patients have a reasonable appearance 10 to 14 days after the surgery.

5) Postoperative pain medication can consist of either narcotics (e.g., Percocet) or potent anti-inflammatory medications. (e.g., Toradol Ketolorac) That is a patient’s choice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How many centimeters can you extend your shoulder reduction surgery? There are many places where triangular muscles, seolsang muscles, and chest are connected. What are the side effects? Please explain this in detail. 

A: The amount of clavicle bone removed in shoulder narrowing surgery is 2.5cms per side. This has consistently shown to be effective and safe and within what is clinically supported by the orthopedic surgery literature for the amount of clavicle shortening that can occur without untoward shoulder function effects. (based on unoperated clavicle fracture repairs)

Other than the small scar in the supraclavicular fossa through which the surgery is performed, there have not been any functional side effects.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What are the chances of getting brain infections or any other risks during the cranioplasty?

A: There is a zero chance of brain infections with cranioplasy. All aesthetic skull reshaping procedures are performed on the outside of the skull not the inside. We do not come close to the dura mater let alone violate it into the subdural space.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m thinking about getting a skull reduction surgery sometime in the future. I’m thinking about specifically getting a temporal reduction surgery, mainly because my head appears overly wide. And I’m hoping to have my head appear more narrow after the surgery is done. I just had one question about the procedure. I read online about the temporal reduction surgery and how it will be carried out. I understand that to reduce the width of the head, you can remove the posterior temporal muscles located on the side of the head. But isn’t it also possible to remove some of the outer layer of the bone located on the side of the head if this bone is thick enough? Just like how it is done with the occipital reduction surgery, where the amount of reduction is limited to the thickness of the outer bone located at the back of the head. I’m asking this because when I plan to get this surgery, I’m hoping to make my head not appear as wide as it does now, and I’m hoping to get the most results from this surgery. 

Thank you for answering my questions.

A: In answer to your temporal reduction surgery questions:

1) In every case of temporal reduction I have done removal of the muscle alone has been adequate…even in those that believed that bone reduction was needed as well.

2) Temporal bone reduction can always be done if one is willing to have the incision located on the side of their head. (as opposed to hidden behind the ear when the muscle is removed)

3) The temporal bone is very thin and just a few millimeters can be removed. Thus the minimal benefits gained is usually not worth the scar burden to do it…particularly if one has no hair to hide it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheekbone reduction surgery last week. Upon having my post op CT scan — I noticed my right cheekbone was slightly separated. My doctor said this will heal fine, but I’m still concerned because every time I open my mouth or touch my right cheek—I can feel my cheekbone moving slightly and making tiny cracking sounds. It’s also a little difficult to chew on my right side. I know I’m very early I’m my recovery process, but my main concerns are that this will cause asymmetries in addition to malunion requiring further corrective surgeries and longterm complications such as skin sagging. What are your thoughts based on your experiences, doctor? 

Thank you 

A: You had the classic oblique cut cheekbone reduction surgery with plate fixation at its most inferior part closest to the intraoral incision. While the left side is ideal the appearance on the right side is not uncommon. There is a slight rotation of the right cheekbone segment which can happen as the superior part of the bone is not accessible for direct plate fixation.

Everything you are feeling on the right side is not abnormal and the bone segment should go on to heal. (it will probably heal with a fibrous union rather than a bony union…which does not matter in a non-mandibular facial bone) The sensation of movement should pass in a few weeks. This slight osteotomy line should not cause any asymmetry.

The risk of soft tissue sagging has nothing to do with the osteotomy line as long as the bone is stabilized from falling inferiorly. Soft tissue cheek sagging often occurs because of the way the procedure has to be done. (stripping of the soft tissues off of the cheekbones) and then reducing the projection of the cheekbone)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve looked over the imaging pictures of my sliding genioplasty chin augmentation and I like the medium and large chin projection changes for my side profile. I wouldn’t want any larger than the large so if youhad to go bigger or smaller from that id prefer smaller. In between medium and large would also be perfect.

I forgot to add, how much do the different changes affect the view from the front and 3/4 view? I know you said it’ll look narrower. How much narrower would the large change be compared to the medium change? And how much longer from the front will my chin be in the end?

Thank you so much!

A: What you are really saying from a dimensional standpoint is keep the projection of the chin behind a vertical line drawn down from the lower lip. And to no surprise in females with naturally smaller chins ‘less is more; so to speak.

The larger forward movement the more narrow the chin will become from the front view.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, Last year I had bilateral testicular wrap around implants. Overall I am pleased, the left one is perfect. The right one however has a strange “pointed” shape at the bottom that is bizarre and sometimes causes pain, I was wondering if this could be rounded?

A: I would assume that this is related to the implant and, thus, it could be depointed (rounded off) in place.

Dr. Barry Eppley

Indianapolis, Indiana