Your Questions

Q: Dr. Eppley, I have had two sets of hip implants and both were plagued by bulging on the lower end of the implants. How can this be fixed?

A: I have pulled and looked at both your 1st and current hip implant designs. I would suspect that the first lower bulge occurred because the bottom of the implant developed a bend or fold in it. (thin lower edge) The second hip implant design is much thicker (and also heavier) and this probably occurred for the same reason. My thoughts are as follows:

1) This is not an easy problem to solve mainly because there is no assured outcome based on anything that may be done. Good fixes are those where high confidence is in the knowing the exact problem and having a treatment that is known to work for it.

2) I am not sure a change in implant design/shape is the solution. The profile shape of the bottom half of the implant does not match the shape you see in you externally. (see attached side by side comparison) This still suggests a bending problem at the bottom of the implant.

3) If we knew that the implant shape was the issue I would then just hand modify the bottom of the implant to make it have a lower better taper to it. (this is tempting to do and probably has little downside to doing it…probably can’t make it worse but would it work??)

That being said there are only three options:

1)  hand modify the current implants as described above

2) Make new implants of higher durometer (stiffer with with better lower half profile shape)

3) Injection fat grafting around the lower half of the implant to make a more gradual transition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, On Real Self I saw a few answers of yours to questions with regards to vertical augmentation of the chin. You were saying that using chin implants the chin can be vertically augmented up to about 7 mm (but no more) whereas with a vertical bony genioplasty the chin can be vertically augmented up to even 15 mm. The question I had was: from your experiences, what’s about the limit with regards to how much the chin can be vertically augmented with fillers? I’ve heard fillers are usually only good for horizontal augmentation of the chin (but not vertical) but I’d imagine that they could also vertically augment the chin to at least some degree. How much mm would that limit generally be?

Thank you for your time.

A: Injectable fillers can probable increase the vertical length of the chin by 2 to 3mms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always been curious to know if it is possible to increase the pupillary distance between the eyes? I feel it gives a more feminine look and I just wanted to know if this surgery is possible? If not, is it possible in the near future with new technological advancements? Thank you for your time.

A: The eyes can be made wider if one is willing to undergo orbital box osteotomies as an adult. That is a major commitment that requires a full bicoronal scalp incision and a frontal craniotomy to perform. I do not see this surgical approach changing any time in the near or far future.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can temple implants and tear trough implants make my face more symmetrical? I had BSSO advancement which made the jaw angles more obtuse and desire jaw angle implants too. Would like to know your views via a possible consultation.

A:Thank you for your inquiry and sending your picture. The aesthetic benefits of temporal and infraorbital augmentation are fairly clear when imaging your front view picture. (see attached) The jaw angles are harder to properly visualize from just a front view picture. BSSO surgery is well known to adversely alter the shape of the jaw angle bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Am I a good candidate for reverse abdominoplasty and what’s the approximate cost of this procedure that only addresses the upper abdomen?

A: A reverse or superior-based tummy tuck is indicated in the following:

1) Loose abdominal skin is located above the umbilicus while there is no excess/loose abdominal skin below the belly button. In essence the loose upper abdominal skin ‘hangs around the fixed central umbilical area.

2) The patient does not prefer to undergo a traditional lower tummy tuck with umbilical repositioning or has been through a previous tummy tuck and does not wany to undergo that procedure again.

3) A well defined inframammary breast crease exists that is hidden by some degree of breast ptosis. (sagging)

4) The patient is not opposed to a scar line across their inframammary creases that may cross the midline between their breasts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a trauma to the scrotum and testicles secondary to an assault where an effort to “pop” the testicles through the scrotum occurred. This eventually resulted in the loss of one testicle and caused the posterior skin behind the scrotum to become very stretched out and thinned. Now the remaining testicle hangs low and slides out of the muscular part of the scrotum into the stretched out skin below the scrotum. This feels uncomfortable while sitting and especially while exercising even though I use supportive underwear. The discomfort and appearance reminds me of the assault and restoring things as much as possible would be a great help from this devastating and humiliating injury. In cold conditions when the muscular part of the scrotum contracts, the testicle is pushed into the stretched out area of skin towards my leg and feels uncomfortable. My hope is that if the stretched areas were tightened to keep the testicle in the muscular part of the scrotum, I would be much more comfortable. While I did not have a prosthetic testicle implanted when the more severely injured testicle could not be saved, I am not interested in a prosthetic testicle being added because comfort is a great concern and I feel with one testicle my prospects for comfort is greater since a certain amount of chronic discomfort exists; nevertheless, I would like some of the extra scrotum cleaned up and made to look more tidy. I am not concerned about having large and impressive looking scrotum and testicles, but really want to be comfortable and would prefer to have a smaller, higher positioning of the remaining testicle.

A: Thank you for your inquiry and sending your pictures. What you appear to have is disruption of the enveloping Dartos fascia/cremasteric muscle which allows the remaining testicle to prolapse into the enlarged and thinned skin sac under certain conditions. In essence you have a scrotal hernia. You are correct is that excision of the stretched out skin/tissues with a reinforced closure (aka scrotoplasty) will very likely help with the discomfort as well as its appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know if you’re able to do a tummy tuck on a kidney transplant patient? 

A:Yes I have done it before. (twice) You just have to know that the transplanted kidney is in the abdominal area so it may not involve rectus muscle plication depending upon where the transplanted kidney lies. It also requires clearance from your nephrologist for this elective body contouring surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born with a congenital mishaped head. Do you do craniotomy’s? Do you work on adults? I had a forehead implant in 2009, it held up for nearly 3 yrs then started sliding. I let it go, saw a surgeon and he was going to take out implant & in 6 months do the craniotomy. As we thought I’d torn my dura mater, it was just a very, very severe infection and now he doesn’t want to do it! I was heart sick. I then saw a colleague of his & she wants to do bone paste. I’m just checking out all my options.

A: As I understand your skull situation, you had some type of forehead implant which became infected and had to be removed. I am assuming there is a remaining frontal bone albeit misshapen and recessed. I assume they have done an updated 3D CT scan of your forehead/skull so that the residual bony anatomy is known. I could not give a qualified opinion as to what your options are now without seeing that scan. Whether any form of synthetic material should be now used is the question. I assume the original implant material was PMMA. Certainly that material should not be used again and HA bone cement would be a better option.

Dr Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a skull implant surgery which was performed using 50CC of PMMA bone cement at the back of my head. There is now also a sizeable dent at the top of my head at the site of the incision ( its very hard to see in these photos due to my hair). This dent is palpable and visible to me after i shower and my hair is wet. I assume it’s because of how the PMMA was molded and where it was placed. How can this be fixed?

A: Thank you for sending your pictures. Nothing went ‘wrong’ with your skull augmentation. It is just that the use of PMMA bone cement is a very limiting technique for skull augmentation because of the low volume of cement that can be used and the frequent irregularities of it due to having to insert it and mold it ‘blind’ as it sets. I abandoned this antiquated skull augmentation technique ten years ago due to such inferior results.

By comparison today’s custom skull implants average about 150cc of volume (3X what you have now) with an assured smooth outer surface and good non-palpable edging into the surrounding bone. You would have to have this bone cement removed and replaced with such a custom skull implant for a much improved result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could the crease in the back of my head be removed?

A: You have a common horizontal deep scalp crease at the bottom of the occipital bone on the back of your head which is not rare in thicker scalps. Because of its v-shaped indentation it must be treated just as if it was an indented scar. The indentation needs to be excised (cut out) and the scalp edges closed with a more level surface contour

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am emailing you to ask a very particular question. In the times you have performed the Temporal Artery Ligation Surgery, have you ever witnessed hair loss occurring in any of your patients? In fact, have you ever witnessed hair loss occurring in ANY procedure that relates to any procedure or ligation of the head and neck. I am asking because there are wild theories about blood flow being the cause of hair loss. Please get back to me! 

A: The answer to your question is no nor would I expect that to ever occur. The scalp is simply too vascular with such an extensive anastomotic network that no single artery ligation effects an overall inflow at all.

I will tell you of a not so wild scalp blood flow fact known as homestasis flow. To maintain a vascular flow input to which it is accustomed if one or multiple inflow vessels are ligated the remaining arterial vessels dilate to increase their inflow, thus maintaining the amount of inflow which originally existed.

This is the vascular basis of pedicled skin flaps which have been used in plastic surgery for over 100 years.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I appreciate if you can provide feedback to my inquiry for ear surgery. Basically I have large size ear which requires upper pole and earlobe surgery and at the same time I am concern that if I do ear reduction surgery (upper pole + ear lobe) my ears might look lower from their position sort of become low set and I am wondering if you can perform AUROPEXY surgery ( lift & rotate) after ear reduction surgery. The purpose is to have smaller size ear but not low set. If this is possible then I would like to book for both surgeries and it is understood that they had to be done with some time distances and can not be done together. I appreciate if you can provide your feedback if this is possible. Thank you and regards

A:While ear reduction surgery can be performed with a very visible alteration in its vertical height, changing the position/orientation of the ear on the side of the ear is more limited. The ear is basically pinned to the side of the ear by the cartilaginous external auditory canal. The position of this canal is fixed as it passes through the skull into the inner ear. The ear canal can be partially released to allow for some ear rotation and the stretch of the ear can allow for some very modest elevation but these changes are less substantial in appearance than that of the ear reduction surgery.

The one question I would ask is how do you know the ear will look too low on the side of the head after ear reduction surgery? The best way to determine if this would even be an issue is to have some computer imaging of the ear reduction done and then see how it looks to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m a young trans person who has extremely bad dysphoria, especially around the shoulder and hips area. I have searched online and even asked on forums to no avail, I even called surgeons in my country but no one is doing anything that can help. Then I found you. 

I have some questions regarding the shoulder width reduction surgery, does the surgery actually reduce shoulder width? I saw on some forums that apparently it just gives the illusion of being reduced and gives bad posture, is this true? 

I’ve also looked into any surgeries that can possibly reduce my frame, when asking about it I was met with hostile responses that I’d end up dying 24 hours later because it would put pressure on the heart. 

My last question is regarding the pelvis and hips, are there any surgeries or even experimental surgeries that are being developed to bring the hips closer to that of a female? I’ve been looking up anything relating to this and all I’ve found are resources that may aid in helping to change bone structure like https://online.boneandjoint.org.uk/doi/full/10.1302/2046-3758.610.BJR-2017-0094.R1 and https://www.ypo.education/orthopaedics/hip/pelvic-osteotomy-t12/video/ . I’m not a surgeon so I don’t know a whole ton about this, all I can do is look at a skeleton and ask questions, like if the clavicle is reduced, wouldn’t the upper rib cage bones also need to be slightly reduced in order to achieve more width reduction? Looking at pictures of a skeleton it looks like the shoulders are connected to a few of the rib cage bones specifically the sockets for the shoulders. I have heard stem cells have been used to help in surgeries, are there any stem cell therapy that’s being developed to help in changing body shape? 

Thank you so much for taking the time to read my message, I’m so grateful.

A: In answer to your questions:

1) Shoulder narrowing surgery effectively reduces external shoulder width by removing a segment of the clavicle, the horizontally oriented bone that keeps the shoulder outward. It also does not adversely affect posture. Whomever would say otherwise on these two aspects has no working knowledge of the actual surgery.

2) You can not reduce the ribcage that lies above rib #10 for a variety of medical and surgical execution reasons.

3) Iliac crest implants exist for giving narrow pelvic patients more of a feminine curve.

4) While stem cells have a role in wound healing and the treatment of certain diseases, they have no role in structural body reshaping surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a silicone testicle implant for many many years I had it implanted when I was 25. I’m now 50.. I have been told that they should be replaced after a time. Is this true ? Also the implant is rock hard and  I’d prefer something more natural is that available now?

Thanks

A: In answer to your testicle implant questions:

1) There is no recommended time deadline by which testicle implants should be replaced. As long as one has no concerns/problems with them there is no need to replace them.

2) Today’s testicle implants are superior to those of 20 years ago in terms of being much softer and with many larger sizes available.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I would like to undergo the surgery for brow bone implant augmentation, and I am wondering what the sequence of steps will be. I live in Southern Washington, so I assume that I would need to travel to Indiana for the consultation, CT scan, and the surgery itself. I recently learned that there is another type of implant material, porous polypropylene, in addition to the standard silicone material. Do you use this type of alternative material?

A: In answer to your brow bone augmentation questions:

1) the needed 3D CT scan is one you get where you live. We help you find a place to get it and then place the order so you can have it done. Then you mail the disc to us.

2) All consultations, discussions and implant design sessions are done online. You only come here once for the surgery.

3) Porous polyethylene, also known as Medpor, is another facial implant material option, But it offers no advantages, has numerous disadvantages and adds considerable cost to the surgery. i only use it when that is what a patient wants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After my sliding genioplasty my bottom lip is stuck down and can’t move up all the way.  What can I do to fix it?

A: While one side view picture provides limited information, a likely cause is that the vestibule on the inside of the lower lip is contracted down into the bony stepoff that has been created by the bony genioplasty. A side view x-ray and a lip pull test would conform that diagnosis. If so the vestibule needs to be released and the bony stepoff grafted, usually with a dermal-fat graft, to provide improved lower lip mobility.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will I be able to take hard hits to the head and will my hair grow back again after skull reduction?

A: Skull reduction surgery does not affect hair growth. It also still allows adequate brain protection against traumatic injury.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift 3 years ago which left my right tragus blunted. I am self conscious about it’s appearance and never wear my hair up in public.I see that you have experience with this type of deformity. 

A: The blunting of the tragus from a retrotragal facelift is due to scar contracture on the tragal cartilage pulling it forward. Technically the problem is a skin shortage and a cartilage deformity. What usually effectively treats it is a release (raising a skin flap over it), rebending and suturing the cartilage back and then advancing the skin flap back over it. (ideally a small full thickness skin graft is most ideal but you don’t want to create a skin color mismatch over it)

Dr Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question that I wanted to see if you could address. I previously had a alar base reduction and am devastated with the results. The surgeon removed 2.5mm but even that little amount made a big difference as it changed my nostril curvature.

I have been suggested by another doctor that an option is to take a small piece of skin from my nasal floor (where the alar base reduction should have been done originally to avoid losing the curvature) and place that piece of skin into the curve. The skin is the exact same color and contour so irregularities will not be a problem. The second option is taking a small piece from the bottom of my nasal rim (my nostrils have been brought down so I need to have my alar rim raised anyways). My only question is regarding stitching. Since skin is being placed back, I’ll have another marking of scar. Do scars easily fade away and are they noticeable?

A: The best advice I can give you is to be very careful when embarking on a corrective procedure that is also going to leave a scar of some sort. What you don’t want to do is in the goal of correcting one problem you merely create another new problem. In other words every procedure has tradeoffs. If you fix the nostril narrowing but end up with visible scarring, even if it is slight, is that a worthy tradeoff? I can not answer that question for you, only you can. But what I do know is there is no corrective procedure which will not have a tradeoff.

Be very careful about ending up merely going down the ‘rabbit hole’. Plastic surgery is littered with many rabbit hole patients…I see them all the time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I desired a change for awhile but was too young. Have uploaded 3 images of me and 1 with a crude iPhone edit of what the end goal might be. Was mostly wanting to know how plausible it would be or if the desired results in my case are probably too much or too drastic. Essentially my main concerns are about the forehead. One being how it slants back starting right above the eyebrows, whereas I would like it to be more straight up and down. The second concern being that the top of the forehead is too low. The back of my head is at a higher peak than the front, I believe a more level top of the head front to back would look better for me in my case. The photo I crudely drew on just imitates what that might look like if the forehead was different in these two magnitudes. I know you are the best and would be using y’all if I did anything like this. If there are limitations that would prevent that much volume being added it’s just something I’ll have to accept lol! Thanks so much for taking the time!

A: Thank you for your inquiry, detailing your concerns and sending your pictures. Your pictures are taken from fairly far away so I enlarged them and laid them out side by side to see your imaged changes. You are correct in that the near vertical inclination of the forehead is a bit much…for a reason that is not apparent in a side view picture. When you add that much volume in the forehead in profile you have to consider the effects in the front view as well. Since the forehead like the rest of the skull is a large convex surface you can’t just add volume in one dimension without doing so in all other surface dimensions. In other words as the forehead inclination becomes less (more vertical) it must also become wider or the forehead will just look like a porpoise. As a result there are some aesthetic limitations and also some volume limitations based on the stretch of the scalp. Thus the best way to visualize what could be done is to assume that the achievable aesthetic outcome is probably halfway between your ideal and the shape of the forehead you have now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Maxillofacial Surgery, specifically jaw repositioning (jaw advancement). I have an underbite. I clench my jaw and have TMJ. I want to advance my jaw so that the top and bottom set of teeth are aligned evenly. I like the aesthetic look of an aligned top and bottom jaw. I also like the ease of tension from constantly biting down. I would like to know if its possible to insert and orthopedic plate somewhere on my face bones to prevent my jaw from moving back and to encourage it to rest in the new, forward position. I want my jaw to still be able to move up and down and forward, but not back. Moving back serves no purpose & I don’t like a weak jaw profile at all. I have inserted a photo to explain what I mean by ‘new jaw position’. Please let me know if this is possible. If not, is there another way to achieve this look? Or is this purely dental work? I appreciate your time. Thanks.

A: What you are referring to is the common operation known as a sagittal split mandibular advancement. (SSRO) This requires preoperatve orthodontics in preparation for the surgery. The place to start is with a local orthodontist whom you can work with and they will coordinate that with a local surgeon who can do the actual surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering about artery ligation, I have an artery that pulsates and is bulging, I don’t believe this is from the temporal area ,it is above my left eye and goes into my scalp. (pictures attached) Over the last 2 years it has become more prominent, I’m wondering if it’s possible to ligate this artery safely to reduce or eliminate the appearance, I have been checked for temporal arthritis prior with negative results. 

Thank you very much 

A: The central forehead is a very unusual place for a prominent artery to appear. The vast majority of prominent facial arteries comes from a branch of the superficial temporal artery at the side of the temples/forehead. Most central prominent vessels are larger and are veins. in rare instances it may be the branch of the supraorbital artery (which appears to the case in you) which comes out of a foramen in the brow bone and courses upward across the forehead into the scalp.

To ligate the supraorbital artery this requires a small incision inside the eyebrow to ligate the proximal point (forward flow) and then another small incision behind the frontal hairline to llgate the distal point. (backflow)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need your opinion on what would help me best (even if you won’t perform it) on a rib procedure I am looking to get done. I’ve read so much about you and am just really amazed at the unique work you do and the number of lives you’ve changed. anyway here is my issue. I was born an identical quadruplet, and as a result I was given some congential problems that has destroyed my confidence in my body. So I have assymetrical ribs. And by this I mean there is a thinner side (the right) and a thicker, protruding side which is the left (this is also reflected in my chest wall, my left pec easily grows thick while my right does not). My problem is, not only is it very unappealing, but as I work my abdominals, the thicker side gets all the work and those abs get overdeveloped. What am I wondering is what would be the best way to get the thicker side rib cage in the subcostal region (where the upper abdominals are shaped) to match the thinner, flat side, so my abs can be at a symmetrical level and my stomach be more symmetrical and thinner. I’ve attached a few photos as an example. I am a very motivated patient, and would do anything to get the left ribs to be flatter and as thin as the right. What would you suggest I tell a qualified surgeon to do? I really really appreciate you and all the knowledge i’ve gotten from you and read on your site. You give me hope that my body won’t always be a point of such deep frustration. Thank you. 

A; Thank you for your inquiry and sending your pictures. What you have is an ipsilateral protrusion of the right subcostal cartilaginous ribcage. It is probably not that the subcostal ribs are ‘thicker’ but the arc or curve of the ribs is greater than that of the opposite side. A 3D CT scan of your ribcage would confirm the exact anatomic anomaly.

The question is not whether this subcostal rib protusion can be reduced, as it can, but how to do so with the least amount of scarring as possible. Such subcostal rib protrusions are reduced, usually by shaving, through direct incisional access with an incisional length of 3 to 4 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had dermal fillers to the tear troughs and cheeks three months after having brow bone implants. How likely is it for the implants to get infected because of the injections? Will the capsule around the implant prevent the infection or the capsule hasn’t formed yet?

A: Injectable fillers placed into the cheeks and tear troughs are not going to migrate superiorly up to the brow bone area. Thus I would say the chances of getting brow bone implants infected from cheek injections would not be very likely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an inquiry regarding forehead asymmetry. My right frontal eminence is larger than the left, I am unsure if it is due to natural asymmetry or perhaps from mild unicoronal crainiosynotosis. The left side has less projection and is generally flatter, which continues to the coronal ridge. I had a CT scan done a few years ago, which I unfortunately have had trouble locating recently. I am curious to the extent a unilateral custom implant could improve the symmetry of such a case. I recognize an issue in such an implant would be visible implant borders along the forehead.

Any feedback would be appreciated, and thank you for your time today. 

A: Using a 3D CT scan a unilateral custom forehead implant can be designed to improve your forehead symmetry. With the feather edging of the forehead implant having a visible edge of the implant on the forehead, while a potential risk, is not something I have yet seen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about to possibilities surrounding your clavicle lengthening Q: Dr. Eppley, I am inquiring about to possibilities surrounding your clavicle lengthening procedure. I understand that you have two techniques for lengthening the bone, one being an oblique cut into the bone and the other a sagittal split pattern. I was hoping if you could tell me which one is able to extend the bone the longest.

A: The sagittal split osteotomy pattern allows the clavicle to be lengthened the most…but still should not be more than 2.5cms per side to ensure that adequate bone healing takes place.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m looking into shoulder reduction surgery, and also breast reduction and rhinoplasty. I am from the UK, so if I was to travel to your practice to have these surgeries, would it be possible to have them done at the same time?

A: Thank you for your inquiry and detailing your surgical objectives. Shoulder narrowing, breast reduction and rhinoplasty could all be done in the same surgery. The controlling factor in the recovery would be shoulder narrowing…breast reduction and rhinoplasty do not create much discomfort and are less limiting than shoulder narrowing in the recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have mild/moderate plagiocephaly for which I intend to try and surgically correct as much as possible in the near future. 

As you can see from the attached photos, the right side of my skull is prominent by several millimeters / 1/4 inch with a corresponding flat area on the back right of my skull. My jaw (and to an extent my whole face) is skewed to the recessive left side. 

What is your opinion of the success of treatment options.

A: Thank you for your inquiry and sending your pictures. You have the classic plagiocephalic skull and facial changes which only differ in affected patients by their magnitude. I always use a 3D craniofacial CT scan to treatment plan. But in the end you treat what bothers patients by what they see externally. Also as part of the treatment plan the goal is also not to create undue scarring from the surgery.

That being said you have identified one very definitive concern, the flat back of the head on the right side and the ipsilateral protrusion of the parieto-temporal bone to which my treatment approach is a custom skull implant to build out the flat skull area and an ipsilateral temporal reduction to reduce the width through an incision in the crease in the back of the ear. Both are very low scarring procedures that are highly successful in improving the head shape to most patient’s satisfaction.

The facial asymmetries are a bit different in that they are more subtle and I would have to defer until seeing a 3D CT scan to make any treatment recommendations. In addition I need input from the patient as to those concerns, particularly what they see as the most bothersome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just want a harmonization from my lower face. I think my lower cheeks are too fully and my upper and lower jaw are to small. I feel it because i bite on my tongue and you see on the pics my teeth are going forward.

Additionally i bite really often on the inside of my cheeks

Anyway, i thought to solve this all it is important to go to a specialist. He can see what procedure came with the best results…So maybe you have some good ideas for my problem.

You can see on my pics how it is and how i imagine it.

I would very much look forward to a personal interview!

A: Thank you for sending your imaged/wish pictures. What you are demonstrating is a forward and elongation of your jawline with the jaw thrust maneuver. This can be achieved three different ways aesthetically and only one way functionally. (bite improvement) There are:

1) Orthodontics combined with entire lower jaw advancement (aesthetic and functional improvement) with sagittal split ramus osteotomy.

2) Vertical Lengthening Bony Genioplasty (aesthetic improvement of chin area only, no functional improvement)

3) Chin wing osteotomy (aesthetic improvement of chin and anterior 2/3s of jawline, no functional improvement)

4) Custom jawline implant (aesthetic improvement of entire jawline, no functional improvement)

The key decision points are:

1) do you want the bite improved or can it be left alone as long as the aesthetic objectives are improved?

2) If no change in the bite is acceptable then it becomes a question of whether wants to use only their own bone to achieve the effects or is an implant acceptable?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal implants. I have been getting injectable fillers into my temple for some time but am getting tired of the repeated injections and the cost. Do I have to dissolve the injectable fillers before getting temporal implants? What type of temporal implants do I need?

A: In answer to your temporal implant questions:

1) There is no issue with filler in the temporal region for placing an implant provided it does not interfere with the aesthetic assessment of how to design an implant to augment it.

2) Most hyaluronic-based fillers significantly or completely resorb in six months after their placement.

3) I assume you mean a custom temporal implant for one side? What temporal area is being augmented? Seeing a outline of the desired temporal augmentation zone would be helpful to determine the type of implant needed as well as determining the cost of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana