Your Questions

Q: Dr. Eppley, I would like to know if you actually do silicone drop down jaw angle implants. Where I am from not many people do it here. I am not a big fan of Medpor. Roughly how much would you charge for this procedure as I am saving up. Let’s say if you do have a drop down silicone implant can one get a few mm width as well? Iwould like a bit of a square look from front but not too extreme as I  have a skinny skeletonized face? On the picture I have uploaded my right side jaw as without the beard I do not like the shape of it. I would like the jaw angle to go back towards my ear and possibly a small drop down so my face does not look too long. Personally I think my chin is fine and my jaw isn’t too bad as some peoples but I’d like it to be more square from the front and from the side. I have also took a picture of my front face and as you can see it is a bit more chiseled. I am hoping I can achieve this look like in my after picture since my face is skinny. I’d preferably like silicone.

A: The concept of vertical lengthening jaw angle implants made of silicone is one of which I am quite familiar. Historically silicone jaw angle implants could only add width and not vertical length, a flaw in their basic design. Snce most patients that want jaw angle augmentation have a high jaw angle position, vertical lengthening is one of their most important dimenions. I am working with a major silicone facial implant manufacturer on these new jaw angle implant designs which will have various length and width dimensions to them. With a silicone material these implants will be easier to insert as well as revise/remove should that be necessary.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 1.  Am interested in an overall approach to address my weak jawline/chin and nasolabial folds. I had a smaller chin implant over 20 years ago, but I am certain that advances since that time could provide me with a better overall result.

A: I have received your pictures and done some initial imaging predictions. Knowing that you have a chin implant in place with your high jaw angles indicates how short your lower jaw really is. Substantial improvement can come by changing all dimensions of the jawline, not just the horizontal position of the chin. There are two fundamental approaches. A sliding genioplasty combined with an extended chin-jawline implant overlay with vertical lengthening jaw angle implants is one option. The second choice would be a custom total wrap around jawline implant made from a computer-generated design off of a 3D CT scan. There are advantage and disadvantages with either method. Either approach takes it way beyond what the simplistic approach of ‘chin augmentation’ would achieve by looking at a complete jawline enhancement. As you know, your lower jaw issue is not just a simple isolated chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering if a jaw surgery can correct my facial features. My jaw appears to start almost directly from my ears and angle downwards instead of forwards like you see in pretty people. My face is long and narrows towards a tiny recessed chin.  Actually, the lower third of my face angles backwards. My chin is slightly bumpy with my mouth closed, and very bumpy when I stick my bottom lips out. I have no bite problems since I’ve had braces when I was a teen (spacers for crowded teeth and a hyrax to expand my upper palete, but no headgear or tooth removal) I’ve heard that orthodontics can lengthen the face and lead to a recessed chin and humped nose over time. I’m not sure if my braces caused my facial problems or if it is genetic because my dad also has similar facial features and also had braces when he was younger. Is there a jaw surgery, or perhaps multiple surgeries that can fix the angle of my jaw and also my recessed features?

A: Your pictures show a classic case of a short lower jaw with a small chin and a high jaw angle. Your chin also shows a mentalis muscle strain which is why it is bumpy. (muscle fasciculations) Since you have no occlusal disharmony (bite problems), jaw surgery (moving the entire jaw forward) can not be done. Even if your jaw was moved forward the high jaw angles would not be changed. (the chin would be corrected however) The proper treatment for you now is a combined sliding genioplasty (moving the chin bone forward) combined with vertical lengthening jaw angle implants. This combination puts the shape of the lower jaw in better balance. (chin comes forward, jaw angles drop down)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have recently had a medium Terino style 1 chin implant and medium lateral jaw angle implants, with another surgeon. I wasn’t happy, and I had the jaw implants removed a week later. For some reason the 2 implants didn’t seem to go together, the jaw implants made my chin look like it was recessed again, and the sides of my jowls looked very narrow, even though they improved the back of my jaw. I now wonder if it was the chin implant I should have removed and replaced instead. I wonder if it was the combination of sizing that was the problem, I want to have a strong jaw that flows all the way to the back. I have a thin face and the sides of my chin, near the corners of my mouth, still look very  narrow. What could be done to solve this problem? Thanks

A: Standard chin and jaw angle implants rarely overlap and, even if they do, will rarely ever make for a straight jawline from chin to jaw angle. That is beyond what they capable of doing. When a patient agrees to have off the shelf stock implants they should know that is the look they can not achieve. Only a custom-designed one-piece jawline implant will provide a straightline effect from front to back because it is made to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to have jaw angle implants in the next few weeks. I had a couple of questions for you for after the procedures.  I was wondering what my limitations will be in terms of food. I’m assuming chewing will be difficult so I wanted to prepare things to eat in advance for the first week or so after surgery. I don’t know if I will be on an all liquid diet for a while or if Iwill be able to eat soft foods (mashed potatoes, soup, jello, etc). I also have 2 big boxes of Boost just in case. Please let me know.

A: Your questions about eating are good ones as the jaw angle implants will cause some initial limitation in mouth opening due to masseter muscle trismus. That will take about 2 to 3 weeks before returning to normal. You can really eat anything you want as I don’t place any patient on restrictions, but realistically it will not be a normal diet initially. Soft foods and protein supplements like Boost are good suggestions.  You will find out quickly that cutting up solid foods into smaller bites will bypass the need for any substantial amount of chewing. Fortunately this phase is fairly short and the worst is over in 7 to 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I find that my jaw slants downwards and my chin appears too long for my face. My chin is also weak as it does not protrude as far as my lower lip. If possible, I have attached photos and some crude imaging to get your opinion on what you would recommend for me. Thank you.

A: Thank you for sending your pictures. What you are describing and have is the classic steep mandibular plane angle problem. With a short chin many times the jaw angles are high, all which reflect some degree of underdevelopment of the mandible.  I can see from your attempts at imaging that you need a sliding genioplasty to move the chin forward but to vertically shorten it (an implant will keep it just as long if not longer) and vertical lengthening jaw angle implants that adds zero width. You are correct by that imaging in that the best way to change a steep mandibular plane angle is to lower the jaw angle and shorten the chin as it comes forward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking at augmentation the jaw angles to the side of my chin to make it more horizontal and masculine looking. Would it at all be possible to get a Medpor square chin implant, and angle the wings down a little to achieve that effect, or will I require a customized chin implant for this kind of augmentation?

A: Your question has me a bit confused. A square chin implant does not reach the whole way back to the jaw angles. There are specific jaw angle implants to achieve that area of mandibular augmentation that are different from  chin implants. They are two completely different mandibular (jaw) implant styles. In some cases, a custom jawline implant can be made  that wraps around the jawline and goes from angle to angle including the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent mandible angle and cheekbone reduction surgery over a year ago.  I am disappointed with the changes as it has feminized my previously masculine face. I find that the angle reduction from my jaw is unnaturally high and much too straight to be considered normal.  What options could I consider to replace the previous bony structure?  Another issue that I am faced with is substantial mid to low face sagging.  Several areas seem to be affected such as the infra-orbital muscle (clearly visible, elevated on cheekbone), nasolabial folds, and soft tissue isolation (sides of mouth, fat cheek look).  Could you explain the causes of these irregularities and possible procedures that I could undertake? 

A: I have seen a few cases just like yours where the jaw angles have been completely amputated. The angular shape and the vertical height of the ramus of the mandible can be restored by jaw implant augmentation.  But the implant shape can not be a standard jaw angle implant. it needs to be shaped to just have a vertical augmentation only that has an oblique superior shape to match the oblique cut. That can be done by either using one of the custom jaw angle implant shapes that I have previously used or have one made off of a 3D CT scan.

As for the other facial changes those are obviously a result of the cheekbone reduction. I am going to assume that this procedure was done intramurally with n obliquely oriented osteotomy of the zygomatic body and a posterior osteotomy of the zygomatic arch. That has caused loss of support of the surrounding cheek tissues which not sag creating an orbicular is muscle edge show, deepening of the nasolabial folds and sagging in the submalar area. Like the jaw angle issue, adding back some skeletal support would seem like a logical approach. That effectiveness, however, is not as clear as it would be in the jaw angle area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting jaw angle implants placed from the outside as opposed from inside the mouth. What is the size and length of incision if we went through outside? Are the scars predominately visible or dark? If I choose to go with the external incisions, would they be near the facial nerves and would the nerves be subject to damage?  Can you direct me to before and after photos of your work with jaw angle implants please? And even better, any example photos that show what the external incision scar would look like.

A: If one was to place jaw angle implants through an external approach, the location of the incision would be in the classic Risdon location. This is the incisional approach through the neck to repair fractures of the mandibular angle which has been used for over fifty years. This classic mandibular angle incision is located two finger-breadths or about 3 cms. below the jaw angles in a horizontal neck skin crease. It’s length is also about 3 to 3.5 cms. It is placed in this location because that places it below the path of the marginal mandibular branch of the facial nerve which controls the depressor action of the lower lip. If well placed and executed the scar is very acceptable…although never as scarless as an intraoral approach.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have long been looking to improve my jawline and it seems, based upon my research, that you and your staff are a great fit for what I want to do! I have yet to find another doctor who has a lot of experience with jawline improvements. I am a 30-year-old male with a somewhat feminine/steep jawline. I am looking to improve it from both the front and the profile with a more masculine look. I have read your articles and am looking to get a consultation to get the ball rolling and want to inquire as to what my next step is. I have attached pictures of myself as well as pictures of the jawline I am looking for. As you can see from my profile, my jaw angles are steep and feminine. I am looking to get my jaw angles as square as possible, like the pictures I have attached after my own. Furthermore, my front view could use a bit of width on the mandible to provide a more masculine look; I guess a widening starting from the back of the jaw. In addition, my left-side jaw angle is better than on my right side, so I am sure that would slightly alter what you do with each side. You will be able to clearly see what I am looking for after viewing the pictures that come after my own. I will leave it up to you to determine if this look is possible for me.

A: Thank you for sending your pictures. My comments are as follows:

1) I believe you would get good improvement with off-the-shelf jaw angle implants that add about 10mms of vertical length and 7mms of width.

1. Jaw angle asymmetry is common and it is virtually impossible using standard jaw angle implants to ever get perfect symmetry. There are too many variables involved and modifying one side over the the during surgery is just guessing about what to do and rarely creates much better symmetry. Custom-designed implants are the best option when significant asymmetry exists. But that adds considerable expense to the operation which your degree of asymmetry does not justify in my opinion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I currently have mandibular implants, off the shelf from Implantech.  I am unhappy with the off the shelf size and contours and have decided I need custom implants to reach the desired look. My question is can the implants be placed from and outside incision, rather than intra-orally? My current implants were placed from inside of my mouth and that was the WORSE part of the surgery. Not being able to open my mouth for 3 weeks = not eating for 3 weeks. Plus the pain on the inside was very bad. I believe by placing the custom implants from the outside incision would be much more generous when it comes to pain and downtime. Is this possible, opposed to intra-orally placing the implants? Any feedback would be greatly appreciated.

A: Jaw angle implants can certainly be placed from external skin incisions although in an aesthetic facial operation it is hard to imagine that the resultant neck scars might not be a concern. You should know that any replacement of your existing implants would likely be easier the second time around since the pocket under the muscle has already been partially created. Also, what is done on the side or below the jaw bone is the same whether one comes from inside the mouth or below in the neck (jaw opening restriction), the incisional approach is just a means to get there to do it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, for my chin and jaw angle implant surgery I have couple of questions. I had originally mentioned the idea of some liposuction below the Jaw line/ chin and wanted to see if you thought that was still an option( especially if it could be done through the chin implant incision.) Finally, any ideas of a realistic downtime from work? Would 3 weeks be enough to be off work and able to go back without looking extremely swollen? Also can the surgery be done under IV/ twilight sedation?  Thanks again for your time. Thanks again 

A: In answer to your questions:

1) Submental liposuction can certainly be done at the same time with access through the same incision as that of the chin implant.

2) The vast majority of the swelling from this type of surgery is from the jaw angles and you are correct to assume that 2 to 3 weeks is enough time for you to look normal, even though the final details of the result will take months to fully emerge.

3) This is not a procedure that is done under sedation anesthesia. Lifting the large masseter muscles off of the mandible is less than a pleasant experience to place the jaw angle implants. This is a procedure that requires general anesthesia to be done correctly.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in jaw implants for my weak chin. I would like to know what the implants are made from and how durable they are. I do martial arts and blows to the face are quite common, so I wonder how well the implants will endure against physical trauma? Also do you believe there might be a possibility that corrective orthognathic surgery might help me, both cosmetically and in terms of snoring/breathing issues? Thank you. 

A: The chin and jaw angle implants are made from silicone of a firmness slightly less than bone. I screw the implants into the bone that they will never move from their implanted position. It will require a force great enough to break the bone to ever dislodge them. And they might actually be a buffer against traumatic forces, ultimately protecting the bone to some degree. Whether you would benefit by orthognathic surgery instead of jawline implants is not a question I can answer based on the information you have provided the best way to answer that important question would be to get and orthodontic evaluation and see if the process of pre- and postsurgical orthodontics and orthognathic surgery would be a more appealing alternative that at least partially address the underlying bone problem of your weak jawline. You owe it to yourself for the sake of educational completeness to get such an evaluation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had the Mandibular Matrix system implanted in 2010 including the two 7cm jaw implants and a 7cm chin implant. However after three years, the two jaw implants have shrunken/settled into my bone so that my jaw corners are around the same size as they were before the surgery. I plan to have my jaw revised. From looking around, I can tell that you are one of the top-experts on male jaw enhancement. Do you recommend replacing the jaw implants or stacking a new implant on top? What are the risks of bone settling and how can I reduce them. Also, how can I schedule a consultation and surgery date? I can send you pictures. Thanks.

A: My first question is whether the jaw implants have really sunken into the bone. That would be very unlikely given how the Medpor material is treated by the underlying bone. The first thing I would do is have a 3D CT scan done and a model made to really look at the current relationship of your existing implants and the jaw bone. It would be impossible to give good advice/recommendations without knowing the answer to this very important question. It may also be likely that any new implants may have to be custom made whether they would be placed on top of or in replacement of your existing implants. Be aware that it would be very difficult to remove your existing implants…not impossible but very difficult.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My goals are increased horizontal projection of my chin( no vertical lengthening)and a more square chin. Jaw angles flared out with augmentation of the angle itself and of the ramus but not the body? ( not necessarily a drop down of the angle itself as I think the angle is low enough currently). Rhinoplasty to decrease the hump in the nose possibly decreasing the width of the bony part of the nose when viewed from the front and the tip refined somewhat( picture with red hat)( My morph( lateral view of my nose in the blue shirt) I admittedly got a bit crazy/unrealistic with the tip of the nose. Finally, liposuction below the lower jaw/chin area to get rid of the adipose tissue that has always been there no matter my weight( a good 10-15 mm in various spots under the jaw/chin when I do a pinch test.) Also, wondering if the chin implant can be placed through an existing scar on my chin from my childhood.( picture added of scar 20 mm long and 10 mm long in the 2nd aspect and around 3 mm of width to the actual scar line( the scar is basically a T shape) Attached are some before and after pictures that I’ve done in photoshop as what I’m kind of looking for in general terms. I don’t know if this is even possible / what would be proportional for my face, but thought I would include them as a rough reference since I’m not there in person currently. My overall goals are increased balance in my face as I think the upper 1/3 of my face/ head is much larger then the lower 1/3. Also, I’m looking to do this with IV/ twilight sedation and not general. I’ve had septoplasty (2004) and a hernia operation in the past with just iv sedation(+ spinal for the hernia sx) and prefer this option. Thanks a lot.

A: Thank you for sending your pictures and doing the array of imaging. My review of the imaging matches fairly well with your goal descriptions and I would agree with much of it with the exception of a few minor variations.

For your chin you seek more horizontal projection, a more square shape in the frontal view and no change in its vertical length That would be possible using a square silicone chin implant, probably of at least 7mm to 9mms in thickness placed through a submental incision. It would not be wise to use your existing scar as it is too small, would become more prominent as the chin is pushed forward and would dive through the mentalis muscle in the process. A scar revision can be done on it but it would not be used to place the implant.

Your jaw angles show width expansion, a sharpening of the angles and no vertical lengthening. That could be accomplised by a 9mms silicone lateral augmentation implant placed directly over the existing angles.

The only comments about potential results with these implants is that the angularity of them (point of the angles and sharpness of the chin corner) may or may not be as sharp/pronounced as you have shown. The other issue is the continuity or smoothness of the jawline from the chin back to the angle. While the ends of a square chin and jaw angle implants will overlap, these overlapping areas are not as thick as the other parts of the implants. This it is not clear that the jawline will be as perfectly smooth from front to back as you have imaged.

The nose can be changed through an open rhinoplasty with a hump reduction and tip narrowing and some mild lift. I think those results are very achieveable.

Lastly, this collection of combined facial structura procedures can be done very well under just IV sedation. These are operations that are best performed under general anesthetic to get the best result.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in having the following procedures done:

* Ear surgery – ear pinning + fix right ear that sits lower than left ear or fix left ear that sits higher than right ear + improve general appearance of ear cartilage
* Blepharoplasty – lower eyelid of my left eye (when I smile, it creates a prominent bag under the eye – not the case with my right eye though)
* Septoplasty – nose veers a little bit to right (possibly due to deviated septum)
* Rhinoplasty – remove slight bump & also looking to have a thinner nose
* Lip augmentation – improve general appearance
* Liposuction under chin – just to get rid of dreaded dubble chin
* Other possible procedures (if doctor recommend them): cheek implants, jaw implants and chin implant – I would like to have more masculine facial structure
Other possible procedures, if you offer them: tear trough implants, cheek lift
PICTURES:
First pic: how I actually look
Second pic: alterations I made to my face on your website (not perfect, just played around).

A: In answer to the facial procedures:

1)      It is possible to raise an ear .5 to .75 cms but it is not possible to lower an ear. Ear pinning or antihelical fold setback can effectively reshape the outer ear cartilage.

2)      The ‘bag’ of the left lower eyelid is hard to appreciate in your non-smiling views so I am not sure if it is a skin issue or a fat issue.

3 and 4) A septorhinoplasty is needed to straighten the nose, reduce the bump and have a thinner tip.

5) To make that amount of lip augmentation change, you would have to think about fat injections even though their survival in the lips is anything but assured.

6) Submental liposuction can be done but, more importantly, significant chin augmentation will eliminate that concern on its own. Cheek and jaw angle implants would be complementary to the chin and, in your thin face, would make it very sculpted and angular.

7) Cheek implants will obviate the need for a cheek lift. Tear trough implants can be done to fill out the under eye hollows.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had submitted this question via the website, but never received a response so not sure you received it. I had a sliding genioplasty with you probably close to 2 years ago now. I am interested in further enhancing my jaw and chin. I know the sliding genioplasty was brought forward as much as possible, but I am looking at the possibility of a custom jaw/chin wraparound implant as I a.) want to move it even more forward and b.) want it to appear that the entire jaw has been augmented rather than just the chin. I also want to widen things as I think the sliding genioplasty makes me lower face appear much narrower. I wanted to find out how closely this could resemble my having jaw surgery (I do have a class II malocclusion, but jaw surgery would be more complicated in my case). By this approach, how much further forward could the chin/jaw be brought by an implant? I know it is a much more expensive approach than off the shelf implants, but they are not going to help me I don’t think due to my unique problems. If I sent you a current picture, could you demonstrate to me what this would look like from the front and side?

A: This is the first I have seen your question. To create a wider and more prominent entire jawline, you are correct in that some type of wrap around implant approach is needed. The question then becomes whether it is done best by off-the shelf-implants (square chin and lateral augmentation style jaw angle implants) would suffice or whether a custom chin and jaw angle implant approach is needed. I would need to see some pictures of you currently, do some imaging, and see exactly what type of changes would be satisfactory. Please send me a few pictures at your convenience.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,I am a 27 year-old man currently looking for the best surgeon to carry out jawline and perhaps chin augmentation. I would love to get rod of this beard which I sue to camouflage my weak lower jaw. I have added you on Skype for a consult and have attached some pictures for your review.

A: I have done some imaging on your pictures. Yo do have a very short chin and high jaw angles. I don’t think a chin implant alone would suffice for the change that I have imaged. The concept of a sliding genioplasty with an overlay small square chin implant can create a 12 to 13mms of horizontal increase and add more squareness to your chin from the front view. Your jaw angles need vertical lengthening only with a minimal horizontal increase. All put together this should create a dramatic change in the jawline that will make you be able to dispense with the beard if you so desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I like what I see, much more “chiseled” appearing. Would it be unnecessary to or insensible to increase the length of my chin to make it sort of protruding? I’ve always found that to be appealing/masculine. I know people get chin reductions to avoid that, but I’ve always liked that. If not, I feel that I see some flaw in my chin/jaw line that stands out to me. I’ve always wanted a stronger jaw/chin, maybe overly strong, beyond typical. Maybe it is my jaw? Would you recommend a possible jaw implant along with the rhinoplasty and chin implant? Do you think this would match my desired traits? I desire an angular sort of jaw, with a square appearing and strong chin, and my nose looks great after, but is there a way that it could be made that you couldn’t see the bottom of my nose? Its always made me self conscious that the bottom of my nose has been visible when i am looking at someone. I am sorry I’m asking so much, I just want to make sure that I am 100% pleased with the procedure and I want to get as much done at once as possible by the same person and you seem to know exactly what I want.

A: When it comes to vertical lengthening of the chin, that can not be done with an implant by more than few millilmeters. It would require a chin osteotomy or a custom chin implant to do that which, although can be done, adds to the cost of the procedure. I would just use a square chin implant of 9mms augmentation and position low on the chin bone so that is some degree of vertical lengthening. I believe that will more than suffice.

The trifecta of jaw angle implants and a chin augmentation are the best way to create a chiseled jawline. The key question in jaw angle implants is whether they should just be of the lateral augmentation type (just adds with to the jaw angle) or whether they should be of the vertical lengthening type with variable amounts of width addition. What most men who seek the chiseled jawline look need is the latter, some vertical lengthening and width addition to create a sharper and more defined jaw angle at the back of the jaw.

Your nose is slightly over rotated (tip up too high). The tip could be rotated downard to some degree using septal extension and tip only grafts during your rhinoplasty.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 25 year old male and I am interested in facial cosmetic surgery. My previous history of cosmetic surgery is otoplasty, rhinoplasty and a chin implant. I would like a more balanced face and more of an oval/square shape. 

Frontal/anterior view:

-Is it possible to augment more on the weaker side (jaw and cheeks) to balance asymmetry?

-On the cheekbone I would like to augment both the temporal process and the zygomatic bone, augmenting both the sides and front of the cheek bone (particular more augmentation on the right side to balance the weakness)

-On the mandible, i would like the Ramus more laterally augmented (a more square jaw) (also particularly more augmentation to balance the weakness on the right side)

-On the nose, a narrower and more defined tip

Left and right profile views:

-augmentation of the cheekbone (both the temporal process and the zygomatic bone)

-more square mandible angle

-slight de-projection of the nasal tip, lower and upper cartilage*

*Tip projection is more pronounced in the photos of the oblique smiling views. 

I am sending pictures of anterior view and right oblique smiling view. If you could please send me altered photos with your expected results explaining the procedures you have added and why you feel so.

Thank you for your time and consideration

A: Thank you for your inquiry. Unfortunately the images you have sent me are inadequate for imaging. Only the front view is useful. A NON-SMILING oblique and side views are needed to get a more complete analysis.

Other issues:

1) It is not clear if the images are flipped or not. As I see them, the left side of your face is the smaller or weaker side.

2) The concept of oval and a square face are contradictory. As a male I will assume you mean more of a square facial shape is what you desire.

3) While the temporal hollows can be augmented, the bony zygomatic arch and its temporal process  which lies below it can not.

4) Correction of facial asymmetries is difficult even using differently sized implants for each side. Improvement may be obtained but do not expect perfect symmetry as that will not happen.

5) Since you have already have a rhinoplasty, what was done to the tip of the nose initially? What tip changes ere already done and didn’t achieve your goals? It is now a scarred tip and a review of the previous operative note would be helpful to know what now lies underneath and whether cartilage grafts were harvested from your septum. You also have a right middle vault collapse, a step-off at the osteocartilaginous junction, significant nasal deviation and nostril retraction/asymmetry. These and the desire for tip de-projection are going to require cartilage grafts.

All this being said, I have done some imaging based on the one useful frontal view that you have provided with jaw angle, cheek and temporal implants as well as revisional rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year-old male, fairly thin, with concerns about my facial profile. I feel that I have both a weak chin and jawline and have some concerns with mandibular vertical height as well as width. Any advice would be greatly appreciated. I have attached some cell phone pictures for you to see what I look like.

A: I have taken a look at your photos and can offer the following comments.

1) I do agree that your chin does have some moderate horizontal deficiency as well as a touch of a vertical deficiency as well. (short vertical anterior height)

2) Your jaw angles show good vertical length (posterior vertical height) and no deficiency in that regard. I do agree that there is some width deficiency in the jaw angles however.

Taking these two pieces of information would indicate that the correct surgery would be lateral jaw angle implants and a square chin implant that is positioned as low on the inferior border of the chin as possible to gain a few millimeters of vertical height as well.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to achieve a more masculine jaw line. My face is oval and I want a more square cut lower face. I had a chin implant back in 1990 with a rhinoplasty. Would like to know what my options are and also would this implants just be inserted or are they secured with screws. How many days do I have to stay inIndianapolis before flying back to home. Thanks so much for your fast response.

A: Thank you for sending your pictures. I did some preliminary imaging based on what I perceive as your desire for a more masculine jawline. This was done using a combination of chin and jaw angle implants, the most common approach to make a circumferential change to the jawline. One interesting issue with you is that you already have a chin implant and the change to get you to the imaging result is significant. This raises the question of whether an off-the-shelf (stock) chin implant can really achieve that goal of which I have doubt. This leaves the possibility of either making a custom chin implant or doing a combined sliding genioplasty with a small square chin implant placed in front of it for the square width effect.
All facial implants are always secured by screws for stability of position on the desired bone position long-term.
No matter how it is done, you would be returning home 48 hours after surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, thank you for doing the imaging on the predicted changes from chin and jaw angle implants. I am blown away that this can actually be done. This is well beyond my expectations. What size implants would you be using for my jawline enhancement?

A: Quite frankly more extreme changes than those can be done but I kept at the limit of what I see as reasonable and not excessive. (I have attached some results so you can see how extreme it can be made if one wants…although I don’t advise that on you). Your imaged look can be approximated by a combined square chin implant (style II square 9mms) and bilateral jaw angle implants (lateral augmentation style silicone 11mms or Medpor lateral augmentation of 7mm size). If the chin would benefit by vertically lengthening as well, I would do a chin osteotomy for lengthening 5mms and bring it forward 7mm with an overlay of a small square chin implant style II of 3mms.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in the procedures of jaw enhancement, facial fillers, and nosejob. I would like to achieve a more defined and symmetrical jaw line. I want a more filled out face. Perhaps cheek fillers or cheekbone reduction also?  I am not sure which approach would be best to give me a fuller face. I want facial features more similar to Brad Pitt.

A: I can see your concerns in regards to a fuller face. You have a very skeletonized face with virtually no fat between the prominent cheek bones and your jaw line. I have done some imaging based on the procedures of jaw angle implants to widen the lower posterior face, a rhinoplasty and fat injections to the sides of the face below the cheekbones down to the jawline. This combination appears to give you better facial proportions and also demonstrate that the cheekbones are not really so prominent. It is the lack of soft tissue fullness (fat) that is why you have your current facial appearance. While cheek bone reduction is an option, I used fillers just to see how the face would look without changing the width of the cheekbones. This confirms their benefit over cheekbone reduction.

The pictures are not of good enough quality to reveal what a rhinoplasty can really do but I made my best effort.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a question regarding chin and jaw implants. My question is: if a person plans to have both chin and jaw implants, do they have to be done in one procedure? In other words, is it possible to get jaw implants and then in a year get a chin implant? I’ve heard it’s easier when done together, but I just don’t have the resources to get both of them at once right now, so I’m wondering if it is possible to get a jaw implant this year and then next year a chin implant without complications?

A: There is certainly no reason why chin and jaw angle implants they can not be done separately. Economics is a very good reason why some have to ‘stage’ their overall jawline enhancement. Which one you do first is a matter of personal preference and would depend on what you see as your biggest problem. For many patients that would be the chin because it is the most visible part of the jaw and often displays the most obvious deficiency. For others the chin has a more minor deficiency and the high and weak jaw angles is the most deficient part of the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is about jaw angle implants and tissue thickness. In previous blogs regarding questions about very angular jaw implants (medpor) vs standard silicone implants, you wrote that the medpor can indeed achieve a very sharp, angular, V-shaped jaw, but then you cautioned that SOME men will never be able to achieve this look because they have very thick tissues. My question is this: Normally, I have pretty normal jaw angularity. BUT when I clench my teeth together my jaw slightly widens and becomes VERY angular, V-shaped, and chiseled. Does this prove that my tissues are not overly thick, and that the right implant will succeed at achieving a very angular look?

A: What you are demonstrating is masseteric muscle contraction and the outline of the muscle fibers not the bony angle per se. But what that shows is that the overlying subcutaneous fat layer is thin enough so that the muscle outlines can be seen through the skin. That would be a favorable sign for being able to have jaw angle implants placed on the bone whose shape and angularity will be visibly evident through the external skin.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a question about silicone vs medpor jaw angle implants. Forgive me if my question is silly, but I have only recently discovered the existence of jaw angle implants and am very, very interested. I am not only interested in widening the width of my jaw, but also of increasing the sharpness, angularity, and “chiselled” look of my jaw. In some before / after pictures on the internet, the patients' jaws are indeed wider, but they are still the U shape they were before. In other pictures, they are wider AND they are also the V shape–in other words, they have become much more angular, sharper, and more “chiselled” than before, not simply just wider.My question is this: I have read somewhere that only medpor implants can achieve this very sharp and angular jaw, and that silicone cannot achieve this. This is probably false information, but I am still a bit concerned about medpor if this indeed were the case, so my question is: Can silicone implants also achieve this sharp, angular and chiselled look?  Thank you so much, and I look forward to working with you.

A: Your question about jaw angle implants is nether silly or irrelevant. It actually speaks to a very basic difference befween styles of jaw angle implants, those that create width only and those that drop down the angle vertically and make it wider if desired. What you are referring to as increased angularity is the latter. As of now, Medpor makes the only jaw angle implant that adds this vertical dimension and comes in width increases of 3mm (virtually no width increase, 7mms, and 11mms) Silicone jaw angle implants do not come in this shape yet although that will change very shortly. I am designing these jaw angle shapes with a manufacturer in silicone currently.

I would caution you however that, regardless of any jaw angle implant style, the amount of definition seen is highly influenced by the thickness of the overlying soft tissues. Some mem will never be able to have highly defined jaw angles if their tissues are too thick.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have jaw angle implants placed on both sides. Even though I have jaw angle asymmetry, getting custom implants is currently out of my budget.  Do you think I could still get great results with doing a CT scan and having you pick “off the shelf” implants based on my CT scan?  Or would I be better off coming back in a year or two after saving up?  Also, what about the possibility of using this “artefill” permanent filler instead of an implant?  Do you have any experience with that?

A: What you are referring to is using a combination of a your jaw model from a CT scan and using off-the shelf implants to get the best result. That is what I call a 'semi-custom facial implant' approach in which the stock implants are modified before surgery on the model. An advantage with this approach that you do not have in surgery as you can never see the jaw angles in full detail and certainly can't really compare their anatomical differences. A semi-custom approach is reasonable if the anatomical problem is really one of asymmetry and the changes desired do not exceed what off-the shelf implants would normally do. In other words, you can do some adjustments to the shape and size (reduction) of the implants but you can't add to them. If one is looking for changes that go beyond the scope of existing shapes of current implants then only truly custom-fabricated implants will do. My perception is that you probably fit more into the semi-custom jaw angle implant approach.

As for 'permanent' injectable fillers, that does not really exist. No injectable filler, Artefill included, is a permanent filler. (if you do it enough times, some permanency of the result will occur due to its non-resorbable PMMA bead content) But on a practical basis, and I will assume that you can get a similar result to a facial implant (which you really can't), the cost of the filler based on volume needed will have allowed you to have had custom facial implant surgery…for a result that is not equivalent. The real role of injectable fillers as a substitute for facial skeletal augmentation is a temporary trial to see if augmenting any facial skeletal area is worth actually having the real surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 52 year old white male 5'9″, 165 pounds. I have had a hair transplant and ears pinned back in 2002 and nose job way back in the in mid '80s. I have a very strict diet and workout extensively and have developed a very msucular physique, particularly for someone my age. I am concerned with my face as I am interested in male model look. What do you think could be done to make my face more aesthetically pleasing, proportional, etc. more in line with a male model type of look? I am very curious to see a computer projection of your proposed procedures. Thank you.

A: The first thing that I observe is that you have a body physique and msucular definition (to your credit) but the face doesn’t match it. While age never helps any face, your facial proportions and skeletal structure is not as robust/proportioned/chiseled as that of your body. Thus there is a mismatch and I can see why this has become an area of interest to you.

When it comes to the so-called male model look, what that means is defined facial skeletal structures or highlights of the facial triangle, the cheek, jaw angles and chin. Augmenting these three areas is what is usually done to create a more defined masculine facial structure. While your chin has reasonable projection, your jawline and face is narrow. I have done some imaging based on jaw angle augmentation, cheek implants and a square chin implant. None of your pictures are really great for imaging due to their quality, angles, lighting and facial expressions but at least they give a general idea of the effect. Be aware that computer imaging is really just a point of discussion and communication of the desired effects and reflects only one variation of the potential effects. There are magnitudes of potential change and this first set is just a starting point.

When it comes to your eyebrows, you have all of the issues that must be considered for any male browlift patient. Because of the absence of a hairline, none of the traditional browllift approaches can be used. (through the scalp) Thus most men need an upper eyelid approach (transpalpebral) with release of the medial muscle around the nerves to get sosme inner lift and relaxation of the glabellar musculature and a lateral brow lift using an endotine device. The ‘below the brow’ approach, which by necessity must be done in most men, only produces a modest brow elevation. But that usually turns out to be a good thing as one of the most unnatural and peculair looks in a man is an over elevated browlift. (e.g., Kenny Rogers, Bruce Jenner)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, a little over a year ago I had contacted you about possibly doing a jaw implant procedure. I decided to try an injectable filler (Radiesse) first for a year before moving forward with any permanent surgery. I now think I would like to move forward with an actual implant(s). I have some asymmetry between my left and right side, with the right side being the “weaker” side. I could use a slightly stronger jawline overall, but I see my main area where I want improvement being my right side. I am still unsure if I want to do both sides for a wider jawline and symmetry or just the right side. Can you comment on the swelling time frame and when I can expect to look 100% again?  And if I do decide to do surgery will a CT scan be part of the process?  Thank you very much

A: When it comes to fixing slight asymmetries on just one side of the face (in a young male patient), I would caution you that it is very hard to achieve using standard off-the-shelf jaw angle implants. There will invariably be improvement but asymmetry will usually persist/develop for other reasons. It is virtually impossible to get a perfect match to the other side by just guessing with stock implants. When it comes to asymmetries like yours and only one side wants to be done, I would urge a patient to get a custom implant made on matching the anatomy from the other side. That is the best way to not develop another 'problem' after the surgery. Doing just one side with a stock implant is fine but you would have to accept that it will not be perfectly symmetric so such an approach is only good for the patient who is willing to accept the imperfections of the procedure.

To put it bluntly, the recovery from jaw angle implant surgery is significant. It is not that it is so terrible it is just that it will be much longer that you envision it and most men are not really prepared for the duration until they look more normal. (socially acceptable) If you are using the criteria of 100%, meaning the final result then that is 3 months. If you are looking at when do I look reasonably normal (50% to 75% of the swelling is gone) then I would look at three weeks. Other than some early jaw stiffness and decreased oral opening, the recovery is largely social. (how do I look?)

Lastly, a CT scan is only part of the process if custom implants are being made.

Dr. Barry Eppley

Indianapolis, Indiana