Your Questions

Q: Dr. Eppley, I’m considering getting a temporal skull reshaping. I have a narrow skull, and i want to know if i can make a widening along the sides of my head. I’m thinking like 2-3 mm on each side, I want it to look as natural as possible and not something you would notice so much. I live in Europe and would like to ask some questions before planning a trip to the US. 

I know there are different methods, depending on how much needs to be made. 

– Will a temporal skull widening with only 2-3 mm require an implant or can it be done with injection using fat or PMMA/bone cement? I’m trying to avoid a heavy surgery. 

– Is injection permanent? 

– Will it affect my hair growth? 

– How many cuts will there be and where do you place them? 

– How much will it cost for a temporal augmentation like the one i described? 

A: In answer to your temporal (side of the head) augmentation questions:

1) There is only one effective way to achieve a smooth augmentation over a large surface area like the side of the head regardless of its thickness…a custom temporal implant. Bone cements can only be used on bone not soft tissue like fascia or muscle. And even if they could they would have many irregularities.

2) No method of skull augmentation at any location affects hair growth.

3) A custom head widening implant is placed through an incision in the crease of the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 30 year old male, I got an intraoral chin implant about 3 months ago to have a square shape and elongate my face a little. Unfortunately, It gave me more of a V shape to my face and I am not happy with the result. I was looking for a square masculine chin look. 

Also I believe the implant was either misplaced or inserted too high as it made my lower lip thin and the area became very tight and uncomfortable. 

I am looking to see if you can help me achieve this square look and also replace my existing implant. 

A: While I don’t know what type of chin implant was used but if it achieved a V shape then it clearly was not a square style chin implant and had no chance to create that desired effect.  Secondly the intraoral placement method would be exactly what you would not do if one of the chin augmentation goals was also to elongate the chin. This is very difficult to do intraorally unless one is very experienced at doing so, requires a specific type to do it and always needs screw fixation.

What you appear to have is an incorrect chin implant shape, was not positioned low enough and was never screwed in. This accounts for all of the symptoms that you describe.

What you know now is the following: 1) a submental implant placement method is needed for both removal of the existing implant as well as replacement with a new one and 2) a different style of chin implant is needed. Whether this should be a standard or custom chin implant design is open for discussion.

The two pieces of information that would be critical moving forward is some current non-smiling pictures of your face and 3D cone beam scan of your chin so we know exactly the shape and position of your current chin implant for my assessment. That information allows the following statement to then apply….’When you know precisely what doesn’t work well you then you know how to change it to be better.’

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My chest look amazing after getting pectoral implants, thank you. In thinking about my next surgery I have two questions: 1) can you do the biceps, triceps, and traps in one operation so I don’t have to go under twice? 2) During the operation can you also give me a cleft chin? Thanks!

A: Thank you for the followup on your pectoral implants and that is good news. In answer to your questions:

1) Bicep, tricep and deltoid implants can be done at the same time. One could argue that is probably not the best combination from a recovery standpoint. (it makes it tough with the entire upper arm has been traumatized) But understandably it is the most efficient way to do it.

2) Making a chin cleft, which are vertical in orientation and located on the lower half of the chin, are done by a soft tissue reduction method. That can be done through either a submental approach or a direct excisional technique. Which one is best depends on how deep one wants the chin cleft to be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would getting an implant on the back off the head, to correct flatness cause my hair to look really thin or weird, since the scalp would be stretched out?

A: That is a very good question and the answer is no. The scalp is not stretched enough to visibly increase the infrafollicular distances. It is important to differentiate the more limited scalp stretch that occurs from skull implants from that of what happens in scalp tissue expanders.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 3 years ago I had an endoscopic brow lift. I didn’t like my hairline to be elevated so 2 years later I had a reversal done, with the same method. The surgeon released the forehead by making 2 incisions hidden in the hairline. But the surgery failed as my hairline is in the same position. 

Would a second surgery help to bring my hairline and brows back down ? And why can’t it be entirely successful ? If it is possible to bring the hairline up, it should be possible to bring it back down? 

Thank you for your time

A:What is not obvious in an endoscopic browlift is the extent of subperiosteal tissue release that is done underneath those two incisions. An endoscopic browlift reversal is possible but the key is that the entire scalp must be mobilized and then secured in a more forward position. It is very similar to that of a frontal hairline advancement…minus the frontal hairline incision. In short you had inadequate scalp mobilization and lack of any means of   soft tissue fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve lost around 40-50 lbs in the last year and a half and I have a lot of loose skin around my abdomen. Friends of mine who have helped me with my workout and nutrition routines recommended that I consult with you.

A: Thank you for your inquiry and sending your picture. Congratulations in your successful weight loss. You have the classic near circumferential waistline skin excess that typically develops after such weight loss. This is treated by a near circumferential tummy tuck also known as a belt lipectomy in older terms. Whether this needs to completely wrap around your waistline or only partially so remains to be determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wanting to get more information on shoulder reduction surgery. I want reduction on both shoulders however I have a previous injury on my left shoulder and still have a plate with screws there. Is this procedure still possible for me? Are there any complications my earlier injury will cause?

A: Thank you for your thoughtful question. It would depend where on the clavicle the plate lies, whether it would be in the zone of the osteotomy or not. Do you have an x-ray of that shoulder which shows the plate position? If the plate is in the zone of the osteotomy it can be removed and the clavicle reduction osteotomy done at the same time.

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 have the following questions about custom brow bone implants, to make my forehead more masculine: 

1. How soon after the surgery can I fly back home? 

2. How soon can I return to work in a office-setting? 

Thanks in advance.

A: In answer to your brow bone implant questions:

1) You could fly home the next day.

2) Returning to work would depend on how you feel about any swelling that persists in the recovery phase. Your restrictions after surgery are not physical but appearance related.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am male that has suffered from undescended testicles in the past. When I was a child, a surgery was performed. The result were very suboptimal. As a result of the surgery, my right ball is on the smallish side. My left testicle is less than 1cc in size and is stuck in scar tissue. The right testicle is between 3 and 4 cm in size.I had varicoceles reduction surgery years ago that did not help at all in terms of size. Adding insult to injury, my testicles have further shrunk since I started my HRT. 

Several years ago I had a cosmetic surgeon inject my scrotum with 250 cc of a solution that has 1/3 of its volume in silicone oil. My body has produced close to 200cc in collagen (in addition to the 80cc of silicone). While I am happy with the size of my scrotum, I am very unhappy with my shape. I would like to research and consider the use of the testicular implants. 

My questions: 

1- I anticipate that I would need to remove a good portion of the silicone/collagen I have prior to the implantation of new testicles – can you do this? 

2- I suspect that that I will need one side-by-side and one wrap around implant (what do you think?) and 

3- How big do the implants get? (dimensions and volume) – I definitely like the idea of a testicle size in excess of 80cc – maybe significantly more.

A: Thank you for your inquiry and sending your pictures. This is obviously a novel situation when it comes to testicle implants. (at least I have not seen it before) In answer to your questions:

1) I do not see that trying to excise the silicone/scar tissue conglomerate would be recommended. That will create a host of new problems including scarring, tissue contraction, decreased vascularity and potential loss of scrotal skin. What was probably not mentioned to you at the time of the injections was that it was a one way street. Once you get that mass of silicone and surrounding scar into the scrotum, you are not going to get it out without creating its own set of potential complications . In short while that theoretically will create more intrascrotal space, it will not improve the success of testicle implant placement or decrease their potential risk of complications. In fact trying to remove this scarred mass probably increases implant-related risks.

2) The real question is then can testicle implants be successfully placed into the scrotal tissues that now exist.That is a question that is hard to answer and would depend in my opinion on how soft or hard the scrotum now feels.

3) But what I am certain of is if testicle implants can be placed into the tissues, careful consideration needs to be given to their size. This is no longer a situation where putting in the maximum size now exists. This is a compromise situation now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently consulting for bimax surgery (le fort I + BSSO with CCW rotation). I have mild OSA so there is some health justification, but if I am being honest my concern is primarily aesthetic and I do not think I would go through the cost and risk if there were an easier/better option. I have been told by some that jaw surgery is the only way to address my retrognathic mandible satisfactorily, and that genioplasty would produce subpar result (the chin would be jutting out, and would mess up my labiomental groove, etc) 

I am trying to figure out what other options there might be from a purely cosmetic angle and have heard good things about your clinic in terms of chin augmentation that is more sophisticated than common genioplasty you would get from the local plastic surgeon.

A: I believe what you are asking is whether a sliding bony genioplasty or even a custom chin implant would produce an aesthetic result comparable to that of a BSSO +/- genioplasty. Certainly that is a fair question given the magnitude and process of double jaw surgery. All I can really say just looking at a lateral cephalometric x-ray is that the horizontal projection of the chin needs to be at least 12mms, maybe a bit more. This indicates that a bony genioplasty would be the better procedure as opposed to an implant. But how that would look on you and its effects on the lower lip and labiomental fold requires computer imaging of your facial pictures to determine if you see that change as a desirable aesthetic improvement or that it looks unnatural.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr, Eppley, I’d like to get started on the process of consulting and booking with you. I am very interested in a form of genioplasty (chin shield?) which could improve the chins height, width, and projection. I currently have 2ML of chin filler injected earlier this year. 

I am on the fence about lateral commisuroplasty and submentoplasty, and would love to hear your thoughts on how beneficial they would be for me. My mouth is narrow for my face but the risk of scarring scares me, and I believe I genetically have a low hyoid bone and am prone to storing submental fat.

A: Thank you for your inquiry and sending your pictures. There are numerous bony and implant methods for chin augmentation not all of which can produce identical three dimensional chin augmentation changes. Since you have specifically mentioned all three dimensions (projection, height and width increases), such 3D changes can only be done by an implant, specifically a custom designed implant. But before we get into how your chin augmentation should be done, let’s first begin the discussion about what exact chin shape changes you are seeking. In that regard I have attached some initial computer imaging to begin that discussion. (see attached)

As for the ancillary procedures, combining chin augmentation with submental liposuction has obvious benefits and there would be no reason not to do so. You have said all I need to know about the mouth widening procedure…the best way to avoid the risk of adverse scarring is not to do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am scheduled for Bilateral Anterior and Posterior Temporal Muscle and Bony Temporal Line Reductions. My question is:

“How long would it take after the temporal surgery for all the swelling and wounds to completely heal? I have a hair transplant procedure that I’m going to reschedule to a date after this surgery and I was wondering when’s the earliest date I could postpone it to.” 

A: I would at least two months after this surgery to do a hair transplant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a hip replacement 6 years ago and anticipate the same for my other hip. How might this affect my options for hip augmentation? Thank you,

A:T hat would depend on the scar used for the hip replacement but probably makes it untenable for subsequent aesthetic hip implants. The soft tissues in the hip area is now compromised and hip implants require good quality tissue over and around them to be successful and reduce the risk of complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi there, I’ve actually messaged before concerning my issues with a crest/dip on my head. I am a yoing male and shave my head bald and feel very uncomfortable with its unique shape, especially the fact that the dip in my head really highlights the pointed crest toward the back (I definitely notice it more than others). I have some questions about potential surgery for reshaping these parts of my skull, and like I said, I’ve previously messaged (I think 2 years ago), although would again like to be informed in what kind of procedure I would undertake and the anticipated success of such a procedure. Would I need someone with me if I were to undertake this procedure or would I be okay in traveling alone? Apologies for so many questions, I do hope you can answer them with some confidence though. Any further questions I have I will ask at any possible further consultation. Thanks for your time.

A: Good to hear from you again. As you have correctly pointed out you have a combination of a posterior sagittal crest and an anterior coronal dip. (caused by the transversing coronal suture line) The key question is whether the sagittal crest could be reduced enough to eliminate the appearance of the coronal dip. This would require getting a CT scan to assess the thickness of the sagittal crest and evaluating how much bone could be safely reduced compared to the level of the coronal dip. If enough bone can be safely removed then a posterior sagittal crest skull reduction procedure would suffice. If not then the combination of a sagittal crest reduction with a coronal dip augmentation procedure is needed to get a smooth and confluent contour. Regardless of the skull reshaping procedure, this could be done with you traveling along which is how most of my international patients present.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi doctor I want to have cosmetic skull surgery I am a footballer, I can play football after surgery I can play with a protective cap after surgery 

Thanks 😊🙏

A:You should have no problems playing football after having a skull implant placed. The implant can not be deformed, broken or displaced with any external force.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi there , I’m 50 years old male ,interested in paranasal- premaxillary implant to improve my sunken area under my nose due to lost front teeth long time ago . Would like to hear from you about the process Thank you 

A: Thank you for your inquiry and sending your picture and x-ray. For the majority of nasal base augmentation patients the use of a preformed ePTFE (Goretex) premaxillary-paranasal implant works just fine. While that is still an option for you the anatomic issue that you present with is the loss of the teeth and the resultant alveolar process atrophy that results. This makes the available soft tissue coverage over the implant thinner with a higher risk of implant extrusion/exposure. Ideally an autologous bone graft (rib) is better in these situations as your own tissues are more tolerant of this anatomic situation. But that may not be very appealing but it does offer a procedure of less postoperative. These are issues that merit more in depth discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley ,I am interested in shoulder narrowing surgery. I was wondering about long term recovery and mobility of the shoulder. As I do a lot of social dancing (Latin dancing) it is important for me to maintain flexible shoulder movements. Will this surgery limit flexibility and mobility, or with correct post operative care should I expect good mobility and flexibility to be restored after recovery? Thank you!!

A: Once the bone is fully healed (8 weeks) there should be no restrictions in strenuous physical activity about the shoulder. One can do gradual increases in arm range of motion 4 weeks after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been really uncomfortable with my forehead/ temple appearance for as long as I can remember. I am really tired of having to wear cap to hide my rounded, prominent front. I would love to have a forehead that matches my lower face which I love. Please, find attached a few pictures where you can see my face. 

I look forward to hearing from you. 

A: Thank you for your inquiry and sending your pictures. Based on the description of your concerns and the pictures, it appears that you seek an overall forehead reduction with a less round and prominent forehead. The question is not whether that can be done, as it can, but whether he scar tradeoff to do so is a worthy one. It would really require a near coronal scalp incision for adequate access to do the procedure. While these scalp incisions can heal very well it is a fine line scar nonetheless back behind the hairline. For some male patients that can be a limiting tradeoff, for others it may not be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m fairly thin and my tailbone is very prominent, even more so when I am bent over. It’s an area I’m Insecure about and experience discomfort when I do certain exercises (like crunchers on the floor). I’m addition to the tailbone area I feel like the lower back area has a weird central divot to it. Would a dermal skin graft work for me? Would you also file down the tailbone some? Is this often paired with fat transfer? If so, what does that process look like? Where do you take the fat graft from? 

Thank you! 

A: In very thin females the tailbone (coccygeal bone) is often exposed due to a very thin subcutaneous tissue layer. This is very evident in you by the central divot in the interguteal cleft area, a manifestation of the lack of fat udner the skin. It is not really that the coccygeal bone is so prominent  (due to a bigger size or angulation but the lack of a thicker fat layer makes it appear so. While many thin people have a prominent coccyx they do not usually have discomfort. You have ‘positional coccydynia’ when your body gets in certain positions.

Ideally the best treatment approach is a partial coccygeal reduction (tailbone reduction) and thickening the subcutaneous cover in some fashion. This is a very tough area for injection fat grafting and sitting on it will just make it resorb. A dermal-fat graft is always best but that requires a harvest site which may be substantial given the surface area to be filled. An alternative is to place a 1 to 2mm thick Alloderm (tissue bank dermis) graft between the reduced coccyx and the skin. That is a stouter tissue graft which is less likely to resorb.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i just wanted to mention that I participate in a lot of contact sports especially in wrestling and kickboxing so would getting such a surgery be a good idea due to the constant pressure and blows put on my skull and would the implant be strong enough and hold its place in my skull. Also, are titanium implants an option? Because few other surgeons have that, thanks

A: In answer to your questions:

1) I never seen a solid silicone skull implant be a problem of exposed to external trauma. You can not fracture, fragment or deform a solid silicone skull implant. It is very much like putting a bumper on your skull. These implants are hard enough to get into place. They can be made to move or displace later as they cover too much surface area and their position is locked in by encapsulation.

2) Titanium implants are not used in aesthetic onlay skull surgery due to their tremendous cost as well as the needs to have a full coronal scalp incision for their placement. It is not that they can not be done but they provide no better benefits with their added liabilities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I had a couple of questions regarding the amount of lengthening and the result prediction/estimate. You had previously mentioned that a patient could get close to 2 inches of overall broadening. On a page on your website (https://www.eppleyplasticsurgery.com/does-shoulder-widening-surgery-by-clavicular-lengthening-widen-the-scapula-as-well/) it is stated that there is about an 80% correlation between widening of the bone and of the soft tissue/deltoid to deltoid measurement.

As for the specifics of my surgery, you said that you could do 2 cm lengthening per side. 80% of 4 cm comes out to 3.2 cm, so about 1.26 inches total. In addition, I measured the surgery prediction before and after photos in multiple spots around the shoulder and factored in my current  bideltoid measurements, and it looks like about 1.13 to 1.26 inches total widening, so a similar result to the above estimate but not close to 2 inches total.

Don’t get me wrong, the after prediction is an improvement. But I wouldn’t want to have an inaccurate idea of what to expect. My questions are: 

1. Am I perhaps missing a factor in play when looking at this, or is that loosely1.26 inch total bideltoid increase a good estimate? I certainly realize each patient can experience different results, but I did have concerns when the numbers didn’t seem to add up to begin with, especially coupled with the fact that they came out to be very close to my own measurements of the picture, which was closer to one inch than two inches

2. Is more than 2 cm lengthening possible or do you think it would significantly increase chances of complications to the point of not being feasible? Perhaps 2.5 cm to 3.0 cm. I read a post on your website (https://www.eppleyplasticsurgery.com/can-clavicle-lengthening-be-done-as-much-as-3-5cms-per-side/) stating that 2.5 was the upper limit to what you believe would be reasonable. I noticed some minor discrepancies on surgery details on different pages of the website (I imagine due to new data becoming available or your own experience), so I wondered if that 2.5 limit is still your current limit at this time.

A: Understandably you are probably misinterpreting the role of computer imaging. While it is interesting to calculate how much shoulder widening was actually done on the image vs what amount of bone is actually lengthened, which turns out to be a pretty good correlation, that is not the actual purpose of the imaging.

Its role is really to determine what is the minimum threshold for the patient to consider the surgery worthwhile. If what was imaged was the ‘maximum’ amount of lengthening possible, would the surgery be worth it? That is its real role in helping the patient determine whether they would be satisfied. What I want to obviously avoid is to do this surgery and the patient say later that he thought it would be more.

As to what more could be, or what is the maximum lengthening possible. that is really a question of geometry as well as one unknown factor….how much sagittal split lengthening can be done until the bone won’t heal. For example, if a sagittal split bone cut is made 3 cms in length, almost 10mm of bone contact in the middle can be maintained for 2 cm of lengthening of the clavicle. (see attached) This we know is safe/bone will heal. But if the split was made 4 cms in length, for example, the bone lengthening would be 3 cms per side. Would that heal as well as 2 cms lengthening per side….maybe.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Last year I had a skull reshaping surgery (plagiocephaly is my problem), but i had an infection and they took out the skull implant. I treated infection for six months and now I ma cured I would like to try it again .

Can I have the information of how you treat the patient who has had this type of skull implant problem.

Thank you

A: Thank you for your inquiry. To determine if you are a good candidate for a second attempt at skull augmentation for plagiocephaly I would need some more information:

1) What type of skull implant was used? (what material and how was it made?)

2) What type of scalp incision was used for placement of the skull implant?

3) What was the identified bacteria? (cause of the infection)

Dr Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What’s the biggest oval size buttock in plant that can be placed intramuscular? 

A: The general volume ranges of intramuscular implants is in the range of 300cc to 400ccs dependent on the size of the patient. Larger patients would be closer to 400ccs while smaller patients would be closer to 300ccs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know what the cost of doing an extensive skull shaping surgery would be. I basically want some projection of my glabella tapering down the eyebrows and also I would like to add thickness to the forehead both below and above the hairline if possible. 

I would also want to increase the sides of my head from the temporal region back. I have seen your custom implant designs and my overall goal is to basically get a thicker skull all around maybe 1 cm of thickness on the sides less on the forehead I would think due to managing the hairline proportions. 

I am fine with scars, I believe I have the hair to cover it up well enough. What is a price range for what I would want? Do you preform this kind of thing more often now, once per week? I believe this will be more requested in the coming years (brow and head).

A: Thank you for your inquiry and detailing your skull reshaping goals. In custom skull implants, virtually any surface area coverage and thickness can be designed. That is never the question. Rather the key issue is whether the volume of the skull implant designed can ‘fit’. The concept of fit in skull augmentation means the ability of the scalp to safely tolerate the underlying implant without a significant increased risk of incisional dehiscence and scalp stress. (potentially seen as increased risk of infection and hair shedding/loss) As a general rule the volume of custom skull implants needs to be under 200ccs. Such volumes are always calculated in the design process and such information helps guide the implant design.

Just by your description (1 cm increase on the sides and coming across the forehead) I can tell you without even an implant design that is going to make a skull implant over 200ccs in volume.That would need an implant design that virtually covers 2/3s of the skull’s surface area. (to have an adequate feathering of the implant to blend into the rest of the skull’s convex surface area and to not look unnatural) As an aside to this observation, most patients way overestimate their skull augmentation needs by thickness and under estimate the expansive effects of large skull surface area coverage.

But for the sake of discussion for now let’s assume that your implant thicknesses/size is correct. That leaves you with two options; 1) do a two stage skull augmentation which requires a first stage scalp expansion or 2) reduce the dimensions of the implant so that it falls under 200ccs volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi! My head is flat and small I want it to be rounder and more asymmetric and  not embarrassing, Specifically the top and back of my head are flat they don’t contain that roundness which some people have it. 

A: Thank you for your inquiry and sending your picture. This is the most common area that women request for skull augmentation. In determining how much skull augmentation can be achieved there are limits to how much the scalp can stretch to accommodate a skull expansion by an implant. Thus the first decision to make is what degree of skull augmentation can one accept vs how much is one willing to undergo to achieve their ideal result. This is where the concept of immediate vs a two stage skull augmentation procedure must be considered. To help make that determination I have attached a drawing of the likely differences in shape between these two choices.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had this x-ray a few days ago, and here it is clear how wide my clavicle is and that my ribs are very close to my hip bone, for this reason you do not see a thinner waist, having this type of ribs so large and united, does it make it impossible to operate and have a lot of risk since several important organs were down?

A: Thank you for sending your picture and x-ray. Rib removal surgery does not pose any risk of organ injury, that is a common myth/misconception about the surgery.  I see nothing in your x-ray that would preclude you from having rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 4o years old, past surgeries include Lefort 1 osteotomy, rhinoplasty, septoplasty, along with braces. I had a class III malocclusion, maxillary deficiency and  crooked nose. I feel very subconscious about the look below my eyes and my hollow cheek and eye area. Like my jaw area is out too far now. I would like to see what you would recommend to make me look better. Thank you

A: Thank you for your inquiry and sending your pictures. What you have is essentially an incompletely treated midface deficiency. While the alveolar level of the midface may have been treated/corrected by the LeFort I osteotomy, every structure north of that was ‘left behind’. To get a more complete midface augmentation effect a custom midface implant is the definitive procedure and far easier to undergo and recover from that the LeFort I osteotomy by comparison.

There are different variations of the total midface implant that are customized to the patient’s specific aesthetic needs but the general footprint of the implant is largely the same. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi. I had calf implant surgery to help correct the imbalance In my lower legs. I tore both inner heads of my calves during spotting activities. I am not happy with the implants that I have. They only look somewhat ok when viewed directly from behind. The projection is all wrong and they are not nearly wide enough. The implants do not resemble a natural calf muscle. I wanted custom made implants shaped to my leg. I called a company name Implantech and they can help with custom implants unless you know and use another. Please let me know if we can speak further. Thank you. 

A: While you can have custom calf implants made that offer better surface coverage by design, I would caution you that your existing calf implant replacements is not quite as simple as just swapping them out. The now etsablished implant pocket will need to be extended which is difficult to do through a remote behind the knee incision. There is also the risk of creating a visible scar line between the old and new calf implant pockets due to the capsular release needed to accommodate the larger implants. This can create an unaesthetic line down over the new larger calf implants.

While this aesthetic issue may not occur one needs to be aware of its possibility since there is limited control over how the overlying soft tissues will respond to the edge of the capsular release.

Dr Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about skull reshaping (or temporal implant). I have already done a back of head augmentation 4 years ago, but it was in South Korea and with bone cement. I initially suffered from back of head asymmetry. The back and one side was flattened. The operation i have done in South Korea helped for the back of the head, but one side is still a bit flattened. The doctor said it coulnd’t go there because of temporal muscle. The flattening begins juste behind the ear. 

My first question is : is it necessary to remove what have be done with the first operation ? 

And if the answer is yes, is the scar big to remove that ? 

A: What you had done was a bone cement augmentation which must stay restricted to bone as it will not stick to muscle. Because most plagiocephalic back of the head flatness wraps around the side you ended up with incomplete correction.

You can simply add what is missing by a custom implant design from a 3D CT scan which can wrap around the side going from the bone cement and as far forward as needed over the temporal fascia for the correction.

For now I assume the existing scalp incision/scar can be used for placement.

Dr. Barry Eppley

Indianapolis, Indiana