Your Questions

Q: Dr. Eppley, I wanted to ask a question regarding iliac crest reduction. I have a wide bony iliac crest (photo attached) and as a man, it kinda bothers me. You are the only surgeon I could find online that does iliac crest reduction. I was wondering do you have any before and after photos to see how much of an iliac crest actually gets removed? From my understanding, just a little, and I’m not sure if it’s worth it to go through a procedure.

A: Thank you for your inquiry and sending your picture. I believe you are referring to the two anterior points of the iliac crest known as the anterior superior iliac crest points. (see attached) They could be reduced by a small 3 cm incision over them. Ironically those who have the least prominences benefit the most. (meaning get complete reduction)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, These are the two procedures I was hoping to discuss: 

1) Buccal fat pad removal with perioral liposuction to get a more defined jaw line and decrease my chubby cheeks. I’ve had chubby cheeks my entire life and I was hoping as I got older they’d get smaller. They have a bit – but not to the extent that everyone was telling me they would. At complete rest it doesn’t look as chubby anymore but the moment I smile even a little or talk – they return. 

I’m not worried about the potential effects of buccal lipectomy that can happen when 20-25 years down the line. I feel like when I’m 60 I’ll address the issue then and I’d rather not be so self conscious and have the jaw line I want now rather than worrying about what’s gonna happen when I’m 60. 

I’ve attached pics below showing me at rest and laughing. 

2) Upper lip lift. I don’t want the size of my lips to change because I do think they’re proportional to my face. But, I’m to achieve two things: 

1) to show more of my upper teeth (I think this will also ensure I don’t smile “so big” therefore reducing the chubby cheek effect when I’m laughing 🙂 

2) since birth I’ve had an extra layer of skin located under my nose (I’ve attached a pic below). At rest it’s not overly noticeable, when I talk, you can somewhat see it. The pic I’ve attached is me prominently protruding it. As a child a surgeon suggested I have it removed but my parents were worried it would leave a mark/scar and that’s really been the only thing that’s stopped me from getting it taken off. I happen to come across your work on a message board and would like to discuss whether he thinks a bullhorn lip lift would ensure that this layer of skin is taken off. 

Thanks so much, 

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

1) The buccal lipectomy/perioral liposuction procedure is straightforward so I don’t have any new insights into them.

2) By definition it is not possible to do a subnasal lip lift and not change the size of the upper lip…unless that subnasal lip lift is 3mms or less. If one only wants to show more upper teeth a smile line reduction (mucosal excision along the lower border of the lip) is the procedure to do so. This will, however, make the upper lip look a bit smaller.

3) If there is a roll of extra skin right under the nose of the upper lip, a subnasal excision would be effective. I did not see an attached picture showing this roll so I don’t know exactly where it is or how big it is.

4) The combination of a subnasal excision and a smile line reduction would cancel each other out in terms of lip size….but would improve tooth show and reduce/eliminate the subnasal roll.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Back in 2017, a surgeon convinced me to get a chin implant alongside a rhinoplasty to give me a better profile and to relax my strained mentalis muscle.
The implant felt tight and worsened my strain, giving me a pebble chin so I had it removed in 2019.

 
My chin sagged in the worst way and I couldn’t close my mouth naturally without forcing and making my chin ball up.

 
Another surgeon told me that it was scar tissue and advised me not to touch just massage and let it heal by its own, but I didn’t listen to him and went to another surgeon who performed a sliding genioplasty on my chins months ago (9mm horizontal advancement and 2mm vertical) to stretch the tissues.

 
It semi worked as it reduced the ptosis and I’m now able to close my mouth more naturally, but as you can see on the pictures, the ptosis is still there and not totally fixed.
I still feel like I have to force my lips together a bit and I sleep with my mouth open. I also get spasms and random contraction around my mouth. It’s like the muscles are trying to move by their own.

Do you think that you can help me? I’m very depressed.

A: Thank you for the additional information. Your case is a tough one as having had two prior surgeries you really don’t want to have a third…unless there is great assurance that it will actually make you better. With your still very short chin and having gotten some improvement from the prior sliding genioplasty (not sure why any vertical was ever added as you need to drive the chin forward as much as possible) it is certainly tempting to think that doubling your forward chin projection (out to 16 to18mms) would help even further. But to know if that is even possible would require either a lateral cephalometric x-ray (maybe your surgeon did it after surgery) or a cone beam scan of your chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if I am a good candidate for frontal bossing shaving and hairline lowering. I understand you may not be able to make my forehead flat but I was hoping that shaving it down a little and pairing that with hairline lowering could make a difference for me. 

A: Thank you for your inquiry and sending your pictures. You are correct is that te frontal bossing can not be completely reduced and that a hairline advancement will help reduce some of the frontal bossing appearance. Both procedures are synergestic to each other…particularly the hairline advancement to the frontal bossing.

The key question now is what amount of hairline advancement do you need and would that amount be realistic. To help answer that question you would need to draw on your forehead or on the actual picture where you would want the hairline advanced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had the tricep implants in the attached photos 3 years ago (subfascial) and I have not had a chance to change them yet- unfortunately the margins can be seen. 

I’ve been reading one of your articles on tricep implants- https://exploreplasticsurgery.com/technical-strategies-triceps-implants/?doing_wp_cron=1619401676.5458180904388427734375

As it says in the article, the implants are placed sub-fascial (underneath the fascia, but above the muscle).

1) Which implant from implantech- does Dr Eppley use/recommend for tricep muscle implants?

One of the calf implants? 

Or one of the contouring blocks- style 1, or do you adapt style 3 which is a bicep implant for the tricep (like the attached photo)

2) Is it possible to place tricep implants sub-muscular instead of sub-fascia without nerve damage to better hide the margin of the implants

Many thanks,

A: To provide any improvement in the tricep implant edge visibility, you have two options:

1) Keep it in the subfascial space with an implant with the identical footprint by with a more feathered edge. (whether that is the same implant modified or a new one doesn’t matter…the key is an implant with an identical implant footprint)

or 

2) A new implant in the submuscular space on the humerus bone. 

The problem with option #2 is that the external aesthetic effect would not be the same (it would be less because a smaller implant is needed) and there is always the potential albeit low risk of motor nerve injury.

Thus option #1 seems the best due to the least risk.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw wraparound done in Europe but very unsatisfied as it has lost me all my angularity even before the surgery, me cheeks now bulge out like there’s air in them especially when I talk, I feel like I have to bite them in to look good. Is this an implant issue or could it be another issue, if I get them removed and new ones placed in, will the soft tissue return back to normal after removal?

A: I can not comment on the cheek issue as that area should not be affected by a jawline implant.

From a jawline result standpoint this is a classic example of an implant design issue. While it looks like it would be good on the skeletal model you now know what that implant shape and dimensions creates externally. From my experience that design looks like on the outside exactly what I would think it would. It is not a sharp angular design but more rounded at the corners. (chin and jaw angles) You learn by considerable experience that in patients with naturally thicker tissues (like you) the implant must be exaggerated in shape at the corners and with the connection between them to get a more angular result. It takes a lot of experience to come that implant design realization.

I would also ask did your surgeon do preoperative computer imaging on your pictures to determine your exact jawline shape goals on which to base the design? If that was not done then there was never a good chance that the desired aesthetic outcome could be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am biologically male, and have been undergoing hormone replacement therapy (HRT) for about a 18 months now. I am more comfortable with most of my body now, except for my shoulders, which seem out of proportion to me. From at-home measurements, my bideltoid width is about 47cm. I would like to bring it down a few centimeters, to get a shoulder-hip ratio that falls within typical female range. I am however quite concerned about the risks of long-term pain and reduced movement, and would like to discuss them.

A: Thank you for your inquiry and sending your picture. With a typical reduction of 2.5cms per side, you cold reduce your bideltoid width down to 43cms. To date no patient that has had shoulder narrowing surgery by clavicular reduction osteotomies has developed any postoperative issues with chronic pain or any restriction of shoulder or arm range of motion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi! I’m contacting you regarding the article here https://exploreplasticsurgery.com/case-study-transgender-rib-removal-surgery-body-contouring/?doing_wp_cron=1619818519.8208200931549072265625 , I’m also transgender and am interested in rib removal to reduce my waist circumference, but I didn’t know that ribs could also be reshaped to change the way they protrude. Would it be possible to alter the size or shape of the upper part of my ribcage? I don’t like how big my chest appears, and if there is a way to make it slimmer I’d be very interested in that. thanks

A: While the lower rib cage can be laterally modified (ribs 10, 11 12), the same can be safely done for any ribs north of #10. (9 and above) which is what you are referring to in changing the shape of the upper ribcage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if an operation is possible. As you can see from my attached photos (+ MRI), I have a lump in the vault of my skull. It makes me very self-conscious. I would like to know if it is possible to reduce it very slightly simply at the point. 

To give you an idea, when I press hard on this bump and the skin comes in for a few seconds, the shape suits me at that time. Is it a malformation of the skull? If this operation is possible, is there no danger to the skull? What would be the price approximately for this operation? 

I thank you in advance. 

A: Thank you for your inquiry and sending your pictures and CT scan. What you have is a classic posterior sagittal crest/ridge. This skull ridge can be safely reduced and it is an operation I do all the time. You have demonstrated how much reduction you need by your skin compression test which is very achievable. Typically the sagittal crest can be reduced 5 to 6mms as illustrated on a drawing on one of your pictures. This is very safe to do as your CT scan shows that there is ample bone to do so.(see attached)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, As you may know, I’m currently deciding between a custom chin implant and a “standard” implant. I have a question for you, if you wouldn’t mind. It is: If we discount the superior aesthetic flexibility from the equation, does it still make sense to choose custom over a standard chin implant for minimizing the risks of malposition and micro-movements that could potentially cause erosion? Particularly in my case, since I have had previous bony chin augmentation.

Thanks so much for the help!

A: The only reason to use a custom chin implant is if there is an aesthetic effect that can not be created by a standard chin implant. There would be no differences between them when it comes to their potential imprinting effect on the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the side by side custom testicle implant? It is hidden when cold and hangs down when it is warm. So I am not sure if you are thinking one or two silicone prosthetics .. wouldn’t it be weird to have 4 balls to touch .. 🤔 I probably did not understand.

A: The side by side technique is where the much larger testicle implant displaces the smaller natural testicles up and out of the way. In most patients because of their naturally small testicles they are not usually felt. This approach avoids the 10% to 20% risk of testicle displacement out of the wraparound or clamshell style testicle implant.

All testicle implants are ultimately just going to hang regardless of the temperature. Natural testicles contract because of the muscles in the attached cord. Testicle implants have no attached muscular cord.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the beginning stages of planning a facelift. I’m a 32 year old male who lost 100 lbs when I was 17. I went from 285 to 175 – and with that weight loss, came some loose skin around my body. My face is my biggest concern as it’s hard to cover up and has not shown any signs of tightening up. 

I know 32 is young for a facelift but I’m open to other suggestions/options. My biggest concerns are my skin sagging around my cheek and mouth area, jaw line and neck area are not defined very well, some brow area is sagging a bit, and my whole face drops when face down (there’s an awful photo I included). My face is also not symmetric – not sure if that is solvable. I’ve attached some photos for reference. 

Looking forward to hearing more

A:Thanks you for your inquiry, sending your pictures and congratulations on the weight loss. With that amount of weight loss there is going to be some expected loose skin in the face. At your young age the skin has a great ability to shrink but at a 100lb weight loss even young skin can not shrink down completely. Given that the vast majority of your concerns are around the neck, jawline and lower facial area, a lower facelift would be the appropriate treatment for it. The question is not whether you can have a lower facelift but whether the scar locations can be adequately hidden (which is always challenging in a male patient) and still get enough of a result to justify the effort. While most of the time I can just look at a picture of a patient and know the answer to these questions, yours is a unique challenge in that regard. This is the one time that I think seeing you in person will help me evaluate whether this is a good procedure for you and will help you best understand the incisional/scar locations for a lower facelift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I notice a lot of wraparound jaw implant cases from your practice. I myself am looking into jaw and chin augmentation and was wondering what justifies recommending jaw implants over orthognathic surgery besides the respective recovery periods? Are the transformations in appearance generally not as drastic with orthognathic surgery alone? Are implants primarily to place patients within normal cephalometric discrepancies or are they more to do with patient esthetics? Does an objective improvement in the jaw always positively correlate with being in normal ranges based on ceph tracings? 

A: There are major differences in aesthetic outcomes and indications for surgery between orthognathic surgery and facial implant augmentations which primarily include the following:

1) Orthognathic surgery is first and foremost a functional operation whose primary goal in most patients is occlusal correction. Any aesthetic benefits are byproducts of that effort.

2) Equally important is that orthognathic surgery mainly affects the sagittal plane, it can not create width or specific definition to the face/jawline beyond that of chin projection.

3) Custom facial implants of the facial thirds produces far more dramatic aesthetic changes than orthognathic surgery that are highly controllable.

4) In custom facial implants cephalometric evaluation/norms are irrelevant. While it is a bone-based procedure the whole intent is what effect it has on the external soft tissues. Thus patient aesthetics rule.

In short, orthognathic surgery and custom facial implants are not comparative operations nor are they interchangeable. Both are done for different reasons with non-comparable aesthetic outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is hairline lowering + forehead augmentation possible during one procedure and for a male patient? I have a slight asymmetry in my frontal bone where one side bulges out and is more prominent while the other side is flat and has a slight dip. This can be seen in pictures. The result I would like to achieve is seen in pictures 5, 6, and 7. I’d like top of the frontal bone more rounded with the side profiles raised, so that the hairline drops down and wraps around the curve and sits straight relative to my face as seen in picture 5. 

From what I’ve read online, a scalp advancement/hairline lowering is not typically recommended for men due to problems resulting from male pattern baldness/receding hairline and the eventual visibility of the incision scar. If this procedure is done, could minoxidil/Rogaine be an effective measure to prevent the hairline receding and hide the scar? 

If the scalp advancement/hairline lowering is not done, what other ways could we achieve the result in pictures 5, 6, and 7?

A: Thank you for your inquiry and sending all of your pictures to which I can say the following:

1) A frontal hairline advancement and upper forehead augmentation can done during the same surgery.

2) Like any hairline advancement the first question is always whether the patient’s new hairline position is achievable. Based on your own simulation, by pushing your hairline forward, and the natural scalp flexibility that comes with darker skin pigments, I would say the 10 to 15mm advancement you are simulating appears to be possible. (see attached)

3) There are two significant considerations to make in a male hairline advancement, particularly with darker skin pigments….1) how well will the hairline scar do in such a visible area and 2) as you have mentioned what is the permanency in a male of their frontal hairline position? These are two very relevant aesthetic questions of which the answers can never really be completely known…until you do it. I certainly have done darker skin pigmented males for combination hairline advancements and forehead work and have yet to see these potential adverse issues. But not having yet seen them does not mean they can not occur in the next patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I have hyperdynamic chin ptosis as my chin appears normal at rest, however it is very prominent when I smile. I have never had any surgery done, so I believe this might be genetic. I would like to have this issue adressed so that I look the same when at rest and when smiling (my chin no longer looks so prominent/witch-like). What procedure would be best suited for this? Ideally I would like to have the surgery this summer.

A: Like many hyperdynamic chin ptosis patients you have a borderline larger chin at result due to a larger soft tissue chin pad. This larger soft tissue chin pad then pulls down over the edge of the chin bone when you smile. This can only be improved by a submental chin reduction technique in which the soft tissue chin pad is reduced and tightened around the lower edge of the chin bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had upper forehead contouring surgery. (attempted forehead horn reduction). The discussed outcome however wasn’t met, as my forehead had been made flat on one side with the other side still having a horn/bump on it, to the point where my forehead is sloped and uneven. The side where my forehead bone has been shaved down too much has also caused my skull to flatten on this side, and I fear that this is dangerous as my brain has essentially had to become squashed into a smaller and flatter skull area. This has definitely affected my concentration. I wasn’t informed that my skull/head would be made flatter prior to the forehead contouring surgery.

As an expert craniofacial surgeon and someone’s work I’ve seen and admire with regards to forehead shaping, I wanted to ask what corrective work can be done as a result of this? I’m looking to potentially fly out in the future and also wanted to ask for your advice on whether the surgeon’s prior work is considered to be medical negligence?

A: In answer to your after surgery forehead contouring questions:

1) I do not comment on other surgeon’s work or abilities, I can only comment on the anatomical problem that I see and what may done about its improvement.

2) There is no medical or harmful issues with your current forehead/skull shape. External bony reduction does not affect the intracranial space or the brain as they are on the other side of the skull. The inner cortical layer of the skull remains intact.

3) Based on your current forehead shape and concerns the indicated correction would be a small right upper forehead augmentation and further left upper forehead reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in aesthetic forehead/skull reshaping, in addition to anterior temporalis muscle reduction for head width reduction, however I previously had a coronal brow lift done. 

I understand that certain procedures, such as hairline lowering in particular, are contraindicated if one has previously undergone a coronal brow lift due to potential of compromising blood supply to the scalp. Are there any other procedures that are contraindicated if one has previously undergone a coronal brow lift? Are skull reshaping and/or anterior muscle reduction for head width reduction feasible? I suppose I’m concerned because they all involve the scalp. 

Thank you for reading.

A:While a prior coronal browlift means one can not a frontal hairline advancement in the future, it does not preclude any other bony forehead or temporal muscle procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had manly broad shoulders my whole life it’s made me quite self conscious wondering if there’s anyway we couldn’t shorten them I’m not sure if this is a thing please let me know I look forward to a response! 

A: Shoulder reduction surgery is a real and effective surgery for narrowing one’s shoulders whether it is in a transgender male to female or cis-female patient. I would refer you one of my websites, www.exploreplasticsurgery.com, where you can place in the search box the terms, Shoulder Reduction, Shoulder Narrowing or Clavicle Reduction, where you can read in detail how the surgery is performed as well as the recovery from it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking for a solution to my hollowed out eyes. Or perhaps you would consider them deep-set. In any case, it seems that ocular surgeons are afraid or unwilling to fill the hollows under my eyes, and I can’t understand why. Perhaps you have a different opinion or solution.

A: I fill undereye hollows all the time. If the surgeon is not familiar with the use of custom infraorbital and infraorbital-malar implants then they do not have adequate tools to ideally treat the problem for certain patients…which would explain their hesitancy/inability to do so.

It is not that it can’t be done but you have to have all of the tools/techniques to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an online  consultation with you three years ago and you provided me with predictive imaging of the procedures I would be getting. (custom Infraorbital, midface and jawline implants). I had originally planned on getting these procedures done this year but after getting a sleep study and CBCT scan of my airway done, I have come to learn that I will have to undergo double jaw surgery to address these issues. I have also attached updated pictures and a CBCT scan of my skull if it is of any help. Please let me know if I can provide any further information.

1. While double jaw surgery will address my maxilla , lower jaw and chin, I have read that it often will exacerbate an “upper midface” deficiency around my eye area (which I already have). I would like to address this area with custom implants. Is it possible to come up with a surgical plan for this after my orthognathic surgery?

2. What is the approximate cost for custom midface and custom infraorbital implants ? I realize this is a very broad question but was wondering if it would be possible to get a rough range.

3. What is the maximum vertical augmentation possible to get in custom orbital rim/zygomatic implants.

A: In answer to your questions:

1) Bimaxillary advancement surgery will definitely exacerbate an infraorbital-malar skeletal deficiency as it is left behind from what moves forward below it. It is not uncommon to design custom midface implants to treat that issue secondarily.

2) My assistant Camille will provide that cost information.

3) There is no absolute vertical maximum for raising the height of the infraorbital rim, short of staying below the level of the orbicularis muscle below the lashline. I have never seen anyone that needs more than 7 to 8mms. Most patients are in the 3 to 5mm range

 Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I want to look tall with a head implant. Is that possible? And how many cm will I grow? Minimum how many cm?

A: With a 1st stage scalp tissue expansion one can have a skull implant that adds 3cms…but you have to careful in just adding height as the head may look too ‘skinny’…so it needs to come down over the sides into the temporal region as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my situation is I had a zygomatic sandwich surgery done and now look like a woman. It gave me way to much projection in the lower part of the cheekbones, I have a revision surgery booked for later this month and I will either reverse 100% the zygomatic sandwich surgery and get a implant at a later date, or I will reverse just 50% of my zygomatic surgery… but I still don’t think it will achieve what I want as I am looking for a very high look with projection on the zygomatic arch back to the ear, 

This is why I need to talk to you as soon as possible so you can help me decide if I should reverse 100% and get a implant or reverse the surgery just 50%

I have attached three photos, two photos is where the zygomatic arch was done with filler and had the high cheekbone look and the second is with the zygomatic sandwhich surgery. It gave me a chipmunk look. I want permanent projection like I had with the filler. 

A: The question you may be seeking to answer I can answer right now based on your goals and how the zygomatic sandwich osteotomy (ZSO) procedure works…you need to reverse it 100% and get an implant later. The ZSO procedure does not create a high cheekbone look which is what you are seeking and what your previous filler has created. The ZSO pushes out the main zygomatic body laterally but not the zygomatic arch, creating a wider anterior cheek look. While it is an autologous procedure (avoids an implant) it simply can not create the high cheekbone look and trying to do so with it is a structurally flawed concept.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a mandibular angle implant surgery (on one side only) to correct asymmetry on the lower part of my face. In other words, I am looking to match the side that is flatter to the side that is fuller. I had asymmetry in the mandibular area since birth. It bothered me a bit less since the overall facial volume/baby fat camouflaged the asymmetry somewhat when I was younger. But as I aged and lost facial volume, I started noticing the issue become more apparent to the point where I feel the need to address it. Moreover, the lack of fullness in the mandibular area not only causing visible asymmetry but also does not provide adequate support for the upper face, which exacerbates the sunken/gaunt appearance. I have looked into fillers but I prefer a permanent solution in the form of an implant. 

1. Based on the picture, would you recommend “off the shelf” or a custom implant to address the issue? Or any other type of implant? 

2. It is also important to me that an implant is made out of silicon and NOT porous polyethylene, as I would not want to have anything in my face that can’t be easily removed if there is an issue down the road. Also, from doing my research about this procedure, I think it is important for a surgeon to secure an implant with screws to avoid any type of implant migration. Do you agree? 

3. Also, I would like to know the recovery (how quickly can you return to work, etc.) associated with this type of surgery. 

Thank you very much and I look forward to your response.

A:In answer to your jaw angle asymmetry questions:

1 I would never try and use a standard implant to correct jaw angle asymmetry. All that will do is just create a different type of jaw angle asymmetry. These asymmetries may seem ‘simple’ to correct but they are not. It requires implant design precision to do so and only a custom approach gets the best chance to optimize jaw angle asymmetry.

2) Solid silicone is my custom implant material of choice for the very reason you have mentioned. There is no type of jaw angle implant that should be placed without screw fixation.

3) Swelling is the primary recovery issue which will take 2 to 3 weeks to look non-surgical and up to 3 months after surgery to really judge the final aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi there! I had a question about facial implants.  I had vertical lengthening jaw angle implants about four years ago and I am starting orthodontics for TMJ soon and it will be moving my lower jaw forward just shy of 2mm and moving other teeth etc.  I was hoping that my jaw implant won’t be affected by the orthodontics and jaw bite plate that will move my jaw joints?

Thanks so much

A:If you are not having an open surgical procedure on the jaw angles, which it appears you are not, then your jaw angle implants should be unaffected by these orthodontic treatments.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am slightly concerned about the eye incision for the infraorbital-malar implants:

• • 1) What are the reasons for not inserting them through the mouth?
  • 2) What types of patients are more at risk of developing lower lid retraction?
  • 3) Are patients with darker skin tones more likely to develop lower lid retraction?
  • 4) If lower lid retraction does happen, are there any procedures that can be done in the future to help improve their appearance?

A: In answer to incision questions about the the infraorbital-malar implants:

1) When placing the implants through the mouth the risks of infection, implant malposition and permanent numbnerss of the infraorbital nerve are dramatically increased. Have done that many times and seen all of these issues it is not an approach I will ever use again when the eyelid incision has virtually none of these issues.

2) The risk of lid retraction is very low in this procedure because it is a non-excisional tissue access approach usually done n young people with good lower lid tissues and canthal support…and infraorbital rim support is being added.. This should not be confused (which it often is) with a traditional lower blepharoplasty done in older patients with weaker lid support and where lid tissues are actually removed. The few times I have ever seen any lid retraction is if a postoperative hematoma has occurred or the infraorbital rim is raised excessively high in close proximity to the incision location.

3) Skin pigmentation does not increase the risk of lid retraction or adverse scarring in my experience.

4) The treatment of lid retraction is well established with release, spacer grafts and canthopexy/canthoplasty as effective techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 20 years old and my skull and temples are narrow which makes my face looks bigger is there any other way other than surgery and implants. Can’t you put something on top of the scalp or skin and not inside it. I just want to look normal but I am very scared of surgery especially on my head and temples.

A: Unfortunately the very thing you fear is the only way to make any difference for a narrow head shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just over 3 weeks out from having double jaw surgery (3 piece lefort 1 w/BSSO).  I also had cheek implants added because of deficient mid face growth. Lastly I had a mandibular jaw angle implant on one side only… reason was that  the other side has a little bump that jetted out and the implant was to make both sides symmetrical. However, swelling/ that side of my face where the angle implant was placed is way bigger than the other side. I got steroid shots but no improvement. My doctor said the swelling is preventing the jaw to set properly in the joint on that one side which makes it look worse. Two other things he noted: location for that implant requires much more than just reposition the jaw like the other side…he said it requires positioning it under the back muscle which requires work that induces note swelling. 

I noticed the structure itself compared to the other side was not symmetrical when putting my finger to both and using my ears to gauge. He said not to use that because the tissue on one said was thicker than the other so he accounted for that so you can go off bone because it will even out when settled in which could be 7-9 months.

Would like to get someone else to look at it to be sure it’s not the implant size that’s incorrect and too big. Pretty sure it was a Medpor implant…. 12 months from now could make it hard to replace.

However, if this is all normal and you’ve seen similar instances turn out well given time to heal, I wouldn’t mind that and happy to wait… just want a good outcome.

Thank you for your time!! 

A:I do not comment on any surgical result while under the active care of their primary surgeon. That is both inappropriate and a disservice to both the patient and the surgeon. What I can say as a general statement is that when the positioning of any facial implant is in question, whether it is 3 weeks, 3 months or 3 years, you don’t guess by external look or feel. You get a 3D CT scan which can show the exact position of where the implant is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I have a few additional questions about the secondary t-shaped genioplasty procedure.

I would be interested in a small amount (2-3mm) of additional narrowing at the same time as my projection is restored. Would this be possible given that I had a t-cut osteotomy as part of my original genioplasty in November, or would the risks of shattering/unwanted fracturing be too high? How much time passage between my original surgery and the revision would allow this cut to be done safely (or would it never be possible)?

Additionally, part of the reason I’m interested in restoring my projection is to address soft tissue laxity in the submental region and ptosis of the chin pad that has come from the horizontal reduction. If I were to have a few millimeters of narrowing, would that fully or partially negate the benefits of restoring the projection horizontally? What are the risks of ptosis from narrowing genioplasty vs from horizontal reduction?

A: In answer to your secondary bony genioplasty questions:

1) I would not advise doing a secondary narrowing of a t-shaped sliding genioplasty for a few extra millimeters of narrowing. That bony union is often incomplete and it never heals in a completely normal shape. Doing it a second time may risk further incomplete healing. Point being is that it is not worth it for that small amount of difference.

2) Any loss of bone support, regardless of the dimension, is another factor that either creates more or risks optimal improvement in the chin ptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In 2017 I had double jaw surgery, bottom was moved backwards and top moved forward. After time has passed my cheeks have gotten really saggy and my midface is unbalanced. I am wondering if maybe cheek inplants can sort of give me more fullness in the mid face and also add structure, to kind of lift my saggy cheeks.

A: One of the well known adverse effects of a LeFort osteotomy can be loss of cheek fullness and/or the development of excessive persistent fullness in the lower cheek area. (due to the wide subperiosteal tissue release needed to perform the procedure) Such effects can become more apparent also based on the type of upper jaw movement, particularly in larger forward advancements. Increasing the bony support of the cheekbones can help but the key to doing so is to get the right style and size of cheek implants in place. What you really lack is a combination of undereye and high cheekbone structural defieciency. This is where a custom infraorbital-malar cheek implant style works best. Standard cheek implants do not have the ability to provide this type of bony footprint coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent a buccal lipectomy about a year and a half ago and I was very dissatisfied with the result. Searching for a solution to my problem, I recently read your article on buccal lipectomy reversal with dermal-fat grafts and was interested. I would like to know if you did more cases similar to the one reported in the article and if you had good results. In addition, I would like to know the chances of graft necrosis in the procedure. 

A: As you may know the most common treatment for any form of facial fat loss/atrophy would be fat injections. But in the handful of cases where patients have specifically requested non-injectable dermal-fat graft for buccal fat restoration have done well and have not suffered fat loss/necrosis. That is not a surprise to me as the typical size of the buccal fat pad is in the 3ccs range, which translates into a small dermal-fat graft, which usually does well anywhere on the face when implanted.

Dr. Barry Eppley

Indianapolis, Indiana