Your Questions

Q: Dr. Eppley, I’m a 32 year old man. I want a customized implant to provide forward projection to my infraorbital rims. Uniquely, I want this implant to move the frontal process of the maxilla forward. Here, I am referring to the point at which the infraorbital rim meets the frontal process. This would typically be a portion of the face moved by the Le Fort 2 osteotomy. I want to raise my infraorbital margin too. I want this implant to extend onto the zygomatic arch to provide a small amount of lateral projection there. I want no lateral movement of the zygomatic body, because I dislike cheekbone mass. 

The key objective for me however, is to widen the perceived appearance of my orbital complex. I’ve noticed that this is an under appreciated and core aspect of beauty that most male models possess. I believe that this is possible by widening the brow bone, the lateral orbital rim and the zygomatic arch. 

I have so many questions on the theory of this, but I will limit them to 4 questions for your blog, and for now I will ignore the brow bone aspect. And then maybe send another email for a further round of questions. I hope this is ok with you. 

1) Is it possible to widen the bones that surround the side of the eye, to achieve this ‘broad eye area’ look? I believe that the answer is yes, but I’m unclear how to preserve harmony with the anterior temporal area. My concern is that making the lateral orbital rim project laterally, will create an unnatural ratio between the width of the lateral orbital rim and the width of the anterior temporal zone. 

In your experience, is this easily resolvable by extending a lateral orbital rim implant into the anterior temporal area to widen it to the same degree? And most importantly, does this look completely natural and not too ‘egg’ shaped? 

2) Regarding raising the infraorbital margin – my concern is that if I’m simultaneously raising and pushing forward the infraorbital rim – would this not create an unnatural appearance by making the infraorbital margin sit well above the lower border of the obicularus oculi? Obviously in its natural form, the infraorbital margin and the obicularis oculi have a high degree of correlation in their vertical positions. I am concerned about pushing the rim forward, too high above the natural position of these muscles. Might we do a SOOF lift with lower eyelid retraction surgery to resolve this problem? 

3) I’m also aiming to get a few other eye procedures: cosmetic orbital decompression for bulging eyeballs, a canthoplasty to raise my lateral canthus, surgery to raise my lower eyelid, and eyelid fat grafting to resolve soft tissue hollowness. I’d like your opinion on which order I should do these surgeries in? Would it be sensible to do decompression first, or the midface implant first? I also had the idea that doing the eyelid fat grafting may mitigate my concern in question 2, by obscuring the boundary of the implant edge – does you agree that it makes sense to do the fat grafting first? 

I’m looking forward to your answers, and thanks so much for your time.

A: In answer to your custom midface implant question:

1) You are correct in that you must be vigilant about how much lateral orbital rim augmentation is done to not create the appearance of unaesthetic temporal hollowing.

2)) You can extend the lateral orbital rim augmentation onto the deep temporal fascia of the temporal region…but there are limits in doing so.

3) I have not seen the vertical elevation of the infraorbital rim cause the problems to which you refer. Even up to 8mms of elevation this has not occurred with the caveat in the presence of someone with abnormally low infrraorbital rim levels.

4) It would most appropriate to do orbital decompression and any procedure that may change the position of the eyeball and eyelids first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in shoulder reduction surgery with you. I have suffered from my wide shoulders since I can think of, can’t feel fully feminine cause of them. 

I am pleased to find out his surgery exists, however not much info and before after pictures are present hence I have no idea what it will look like on me. Also I’m curiosa why no deltoid reduction surgery was being offered so far, as it seems sensible for this issue perhaps even more?

A: Thank you for your inquiry and sending your pictures. I have done some imaging of them to show what I think can be accomplished with shoulder reduction by clavicle shortening. You can not reduce the thickness of the deltoid muscle for functional reasons and, even if you could, you can not approximate the 2.5 to 3cms reduction per side that is achieved with clavicle bone shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am aware that your office performs rib removal for body contouring purposes. After doing some research into rib removal and other methods of waistline reduction I have come across the Kudzaev method of waist narrowing[1]. This procedure is currently only popular and performed in eastern Europe and involves performing a partial osteotomy on the floating ribs and then using a corset tightened with a belt on top for 3 months during the healing process where the modified ribs heal and get affixed into their new position. Reading the patent of this method it seems like the incisions that are performed are also smaller (2-3cm) than what is normally done for removal. Additionally, it is claimed that this procedure has little pain compared to removal and can be done under local anesthesia.

A recent academic paper Aesthetic Contouring of the Chest wall with Rib Resection claims that the Kudzaev method doesn’t have clinical trials: “On the other hand, Kudzaev patented a method of narrowing the waist, in 2017, in which the author performs osteotomies on the 11th and 12th ribs by small skin incisions. Thus, he promotes costal fracture, and complements the narrowing of the waist by the use of a corset. In this way, costal resection and its complications are avoided and waist narrowing occurs. However, there is no publication of clinical trials with this approach.”

However, this method seems to have been used frequently in the past with little side effects pertaining to rib contouring when performing extrapleural thoracoplasty for tuberculosis so this technique doesn’t seem particularly new or experimental. It’s only novelty is being used for aesthetic purposes.

Despite the patent saying that only the floating 11-12 ribs can be reshaped, I have talked with a couple Russian plastic surgeons and they claim that the 10th ribs are also able to be narrowed with this method after analyzing a CT scan. Looking at results on Instagram for the surgeons that are performing this, it seems like they are reshaping the 10th rib many other examples I can provide.

Some additional information can be found at as well.

I am wondering if you are aware of this method and what your thoughts of it are. Many of the plastic surgeons that perform this operation claim it’s a much safer operation than removal long term as you retain your ribs. I am also interested if you would be able to perform this operation since I have considered flying to Russia but I would very much prefer to stay in the US for something like this.

A: Thank you for your inquiry and detailing the osteotomy method for waistline narrowing of which I am well aware. Having removed hundreds of ribs for waistline narrowing, and never yet see a single complication or any negative byproduct of removing the outer half of ribs #10,11 and 12, I can not speak for whether rib osteotomies vs rib removal is safer, has a quicker recovery or produces comparative results. What I can say is the following:

1) The skin incisions needed to perform either technique would be similar. I use a 4.5cm single incision per side which can not be made smaller no matter method is used.

2) No form of multiple rib manipulations should be attempted to be performed under local anesthesia. There is no benefit for the patient or the outcome in doing so and may well make the whole experience far less pleasant and even less successful.

3) The key to the technique is obviously the patient’s compliance with the corseting.

4) One of the key components of waistline narrowing is the reduction of the thickness of the lateral border of the latissimus dorsi muscle. This soft tissue reduction provides as much waistline narrowing as that of the rib bone changes.

5) Rb removal has surprisingly less pain afterwards than one would think because there is no bone to heal, it is just a muscle recovery. Whether leaving the ‘fractured’ ribs in place will lead to more postoperative or even long-term rib pain I can not say.

That being said I believe rib osteotomies are a valid method for waistline narrowing….which is probably better called ‘rib osteotomy-assisted corseting’. In the properly motivated patient it is a useful technique  But whether it produces similar results to rib removal surgery no one can yet say. They are both similarly safe but one is not safer than the other.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to undergo skull augmentation surgery. 

My problem is that my forehead is convex and seen from the front it looks very narrow. The areas to increase are shown in the Figure 1 

To hope for a “global” increase it will be necessary to increase the projection of the eyebrow arches.

As the modification would be in the visible part of the skull, the forehead, I was wondering what strategy, materials would you consider minimizing the visibility of the edges of the implants. 

Is it possible to use custom implants ( PMMA or HA or silicone) coupled with PMMA or HA in liquid powder form on site to fill the holes? 

In the link below it is explained that it is possible to use PMMA as a filler for the holes, can you use this technique? 

A: In answer to your implant edge transitional question, there is no need with silicone forehead implants to use bone cements as they have a feather edge to them by design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Lefort 1 and genioplasty in the past and it greatly improved my breathing and lip competence. However a small amount of lower lip incompetence persists. Fixing that lip incompetence is my main objective, though aesthetics are very important to me as well. Based on my pictures, what option do you reckon is ideal? 

1. Sliding genioplasty with horizontal advancement and no vertical changes 

2. Sliding genioplasty with horizontal advancement and 2-3mm vertical reduction via bending of the plate 

3. Jumping genioplasty 

A: Option #2 is the most viable one. A jumping genioplasty is rarely used because of the major bony stepoffs that it creates.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I totally understand in any form of a facelift nothing is permanent and you return to baseline. My questions are:

1.  Does a procedure like the jowl tuck up change how fast or slow you will continue to age?  

2.  In other words, its purpose is to set back the clock some years: not as much as a deep plane facelift but more than facetite.  Is this correct?

3.  In my case do you think I need any facial lipo with the jowl tuck up to meet my aesthetic goal or would the jowl tuck up nail it?

4.  In my case what would be the second runner up procedure to the jowl tuck up that would impact the appearance and have a slimming effect on my lower face?  Examples: Facetite, Agnes RF, Threads, Kybella. (off label in lower face)

Thank you so much for your time!

A: Certainly a jowl tuck procedure has a longer duration of effect than any injectable or energy based therapies by a magnitide of years.

In answer to your specific questions:

1) No. Surgery changes the outward effects of genetic and environmental influences of aging but not its speed.

2) Correct.

3) Small cannula liposction of the submental/jawline and perioral areas is a good adjunctive approach.

4) I would find any of those listed to be very distant runnerups but Threads would be at at the head of the class of these minimally invasive options.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested on total midface augmentation due to very assymmetric and retruded face. I am very interested to use PEEK custom implant. However many surgeons recommend me to avoid implant because according to them such implants will erode or resorb my facial bone over time.

Is there any risk of bone resorption due to implant on the face or does such implant changes my facial bone structure over time?

BY THE WAY, ON YOUR OPINION IS IT POSSIBLE TO AUGMENT TOTAL MIDFACE BY OSTEOTOMY STARTING FROM FRONT ZYGOMA , MALAR, INFRAORBITAL SO TOTAL FACE AND POSSIBLY BONE GRAFTS USING AND IS IT POSSIBLE TO HAVE A GOOD SYMMETRY THIS WAY.

Thank you on your efforts for an answer.

A: In answer to your questions:

1) The potential issue of facial implants and bone resorption has been around for a long time and carries with it numerous misconceptions. While all facial implants, regardless of the material composition, induce some expected imprinting on the bone this should not be construed as active resorption or an issue of any clinical relevance.

2) No form of an osteotomy/bone grafting can replicate the assured smooth preplanned shape of a custom midface implant. The only role for osteotomies in aesthetic midface augmentation is in the patient who does not want an implant AND can accept the irregularities/stepoffs and other aesthetic contour issues that will arise from the much more imprecise nature of osteotomies in this facial area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had custom midface implant surgery performed by another surgeon about 2 years ago, and I am interested in undergoing revision of the implants for a more defined look. However, I do have one concern. The first surgeon performed a subperiosteal midface lift during the surgery to place the implants. I was told that if I have the implants revised by a surgeon who does not perform another subperiosteal midface lift, it could cause the soft tissues to become unsuspended and sag. Having said that, does Dr. Eppley perform a subperiosteal midface lift when he places implants? If not, does he implement any other measures to prevent sagging/collapse of the midface soft tissues? 

Thanks

A: By definition every midface implant incorporates a subperiosteal midface lift. You have to resuspend the cheek soft tissues during closure since they have been disinfested and raised to place the midface implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I hope this email meets you well. I had an in-person appointment with you in 2016. I haven’t done any surgery concerning my head augmentation and would like to come in and move forward. i wanted to ask if you do the PEEK implant for head augmentation? 

A: The PEEK material can be used for skull augmentation with the understanding of the two major differences from solid silicone custom skull implants:

1) The manufacture of PEEK implants is 4X  as expensive that of solid silicone.

2) To place the ultra-rigid PEEK skull implant either a near complete or complete coronal scalp incision will be needed to implant it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I had a BBL 3 years ago in Turkey. After my surgery I realized my stomach became uneven because I had seromas. Can you a needle a seroma after 3 years passed?

A: The abdominal unevenness at this point is not from seromas, that is a reflection of the evenness of the fat layer under the skin from the prior liposuction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to give my face a little bit more definition and therefore lengthen the lower third of my face, while achieving a more harmonic chin – / jawline in profile view. 

Thus I would like to know your opinion on, if a standard anatomical style chin implant placed very low at the border of the mandible, could create to a certain extend such an effect? 

Additionally I have pinned a photo of a girl that achieved exactly the kind of transformation in profile I`m looking for, with as far as I know some kind of chin augmentation and rhinoplasty. 

Thank you very much in advance. 

A: As a general rule you should not use a standard implant in the way it was not designed or intended to be used. That is a setup for positioning/placement/shape issues. Thus taking any standard anatomic chin implant and trying to increase vertical chin height by hanging it off the end of the bone is not a good idea in my opinion. Unique dimensional needs for facial augmentation are why the custom implant design process exists.

I can not speak for what exact chin procedure the female to which you refer underwent. It may have been an implant but,, more likely, could have been a sliding genioplasty which is commonly used to create increased vertical chin height.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a T genioplasty in my chin recently and I am left with an extremely pointy and asymmetrical chin. I used to have a beautiful chin that was just a little too long and wide and I am so unhappy with what he did. Would it be possible to have an implant that gave me a slight bit more vertical length and also created more of a round shape as opposed to a pointy v shape? 

A: Thank you for your inquiry and describing your current chin concerns. A t-shaped genioplasty is an aggressive procedure for a chin that was just a little too long and wide. I have done numerous custom chin implants for that exact female postoperative problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Please see the pictures attached. What can be done to reduce or remove the fat roll from the back of my scalp? 

A: Thank you for your inquiry and sending your pictures. What you have is excessive scalp tissue (not just fat) which creates a roll above the horizontal skin crease which exists. This can only be improved by a horizontal excisional procedure of the redundant scalp. Fortunately a very pronounced skin crease exists in which the fine line scar can lie. (which is actually common in such occipital scalp skin rolls)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Very unhappy with my double chin which has been an issue side since I was 20 . Looking at a procedure with liposuction and tightening the little bit of lose skin I have. 

A: Thank you for your inquiry and sending your pictures. In improving your double chin the debate is between liposuction alone vs a submentoplasty. (liposuction, deep subplatysmal fat removal and midline platysmal muscle tightening) Given the thicker tissue of your neck I would favor the latter since it more completely treats the fuller neck. I don’t think you have enough loose skin to justify a jowl tuck procedure

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Ive wanted my hips and buttock enlarged for a really long time now. Is it possible to do so on my body with implants.

A: Thank you for your inquiry and sending your pictures. You are correct in that the only way for you to have buttock and hip enlargement is with implants given that you have little fat to harvest. The question in regards to implants is whether the size limitations imposed by the intramuscular placement of buttock implants (under 400ccs) and small hip implants is adequate for your aesthetic needs. I will not do the subfascial placement of buttock implants or place large hip implants because the complication rates are too high.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an overbite. I hate the way it looks. To compensate, I’ve been walking around with my jaw unhinged and chin thrust forward all day for years. The deception is effective, but it’s started to cause me TMJ pain. I’ve included both front and profile photos of what I look like when I’m thrusting my jaw as usual, and what I look like at rest. Is there a solution for this?

A: Thank you for your inquiry and sending your pictures. The very jaw maneuver you are demonstrating is a 45 degree change of the chin projection. (mainly vertical but with a little horizontal) This jaw thrusting maneuver can be replicated by an opening wedge bony chin genioplasty. While this will leave your overbite as is at least you will not have to do the artificial jaw maneuver to achieve the desired aesthetic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After under eye implant removal, is it possible for there to be soft tissue/fat loss under the eye? After mine were removed I noticed extreme hollowing where I can feel the bone right below my eyelid. There is little to no soft tissue there. 

Also, when operation on patients who have previously had implants, is the soft tissue reattached to the bone, or after implants will it float over the bone and never reattach? 

Lastly, is there any minor procedure to tighten the soft tissue after implant removal, such as skin pinch? A subperiostial dissection scares me after my negative experience. 

Thank you 

A: By definition any facial implant placement requires soft tissue detachment which then floats on top of the implant. When the implant is removed, unless the tissues are elevated and resecured from whence they came, they will ‘fall downward’ over the orbital rim making the tissue over the rim thinner. Short of resuspending those fallen soft tissue, there are no other effective procedures. No form of a lower eyelid skin removal is going to create that lifting/tissue thickening effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My daughter is 18 and so self conscious of her chin. It appears normal when she’s not smiling but gets large when she smiles. Also when she makes a “duck face” it seems small like the bone structure isn’t big. Is this ptosis? How can this be treated? What is the recovery time?

A: Thank you for your inquiry and sending the pictures. At rest in profile she has a borderline protrusive bony chin in which the soft tissue chin pad becomes protrusive when smiling as a result. This common female chin excess is treated by a submental chin reshaping/reduction technique in which both bone and soft tissue excesses are removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible for the occipital knob to continue to increase in mass or grow?  I ask because more recently I’ve experienced a pressure or pain while lying on back on my head and it is sort of alleviated if I lift up on the area or back of my head.  I can feel the pressure in that area & my neck…is this normal or a situation that you have heard of before?

A: While some patients complain of discomfort from an occipital knob, they are not known to grow in adults to the best of my knowledge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have very hollow tear troughs and I am pale enough that the darkness is noticeable. I’ve done regular fillers in them in the past but was looking for a more long term option to fat graft to them. I am mostly interested in seeing if it is possible.

A: Thank you for your inquiry and sending your picture. While injection fat grafting to the lower eyelids/undereye hollows is an appropriate treatment for them, it is a procedure in my experience with a high rate of irregularities in the unforgiving thin tissues of the lower eyelids for which revision is very difficult to remove and/or eradicate them. Thus it is not a procedure that I am comfortable doing any longer knowing that most patients will end up with the need for a revision. I only treat under eye hollows today with either standard or ustom undereye implants where the issues of irregularities and asymmetries are minimized.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Has you can see from the photos, the center of my forehead caves in. I seem to be a little confused over the type of surgical procedure I require in order to fix it.

A: You are referring to the suprabrow bone break hollow that exists just above your brow bones. While every male has that to some degree yours is magnified by the upper forehead protrusions often called forehead horns. Your options to get rid of it is to either fill the hollow or reduce the upper forehead protrusions…that is merely a matter of personal aesthetic choice.

Assuming you want to fill in the suprabrow bone indentation/hollow, the forehead augmentationoptions ae either the use of bone cements or a custom suprabrow bone implant. Besides cost the one difference that separates these two options as the length of the scalp incision needed to place them. The custom implant can be put in through a very small 4cm incision while bone cements would require an incisional length closer to 15 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw an ear surgery on your site a while back, it was to do with bringing top of ear closer to head, but not by increasing the fold. It was at the point of the helix root I guess, and it mentioned something about people with a bald head, how moving in ear at this point reducing the look of the ear sticking out. So again it wasn’t increasing the fold, it was pulling the helix root area to the scalp. I have an ear with a weak helix root, fold is fine, but ear lops out a bit at top, and I can see how this surgery would fix this, as it’s clearly visible how it’s so weak at his point. Can you send me a link to this surgery on your website, I recall seeing it but can’t locate it now.

A: You are referring to bringing in the top of the ear at the superior helical root area. You are correct in that no traditional form of ear reshaping, like used in setback otoplasties, will work for this type of ear protrusion. You can’t find or bend the cartilage in this area to create that effect because it is not caused by the lack of a cartilage fold. Te technique that I have found to be effective is to reduce the postauricular space by removing skin from both sides and sewing the cartilage to the temporal fascia

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking for a total face makeover to maximize my look and my pic and morph pic uploaded, is it possible to achieve the look of that morph pic realistically? Or whats the maximum bar i can reach? 

Some of my flaws noted were bad chin/mandible, vertically, horizontally, non forward/widen jaw, malocclusion, long midface, negatively tilt eyes and small but fat lips. 

And these are some surgeries I studied that I think might help me. 

DJS/Bimax/CCW Rotation Jaw Corrective Surgery/Lefort 1,2,3 osteotomy/BSSO/Wraparound Custom Jaw Implant/Sliding Genio/Chin Wing/Chin Implant/SARPE/MSE/Lateral Commusuroplasty/Orbital Decompression/Ptosis/Infrainfraorbital rim implants/Canthoplasty /Fillers/Orthodontic treatment 

A: Thank you for your inquiry and sending your morphed facial picture. From a skeletal standpoint I do not find the morphed changes terribly unrealistic. What is important in these morphed predictions is to see more than just the front view. A side and oblique morphed images would also help validate the realistic nature of these morphed changes.

It is not clear where orthognathic surgery, if indicated, has a role to play in these type of facial makeover. Without seeing x-rays and an occlusal assessment, the potential role of orthognathic surgery can not be determined.

In short, more information is needed to provide an assessment of what is and is not possible and how to accomplish such changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a genioplasty along with double jaw surgery 2 months ago, the chin was cut in a way so as to make it narrower (although my chin wasn’t wide at all it was already narrow and feminine) and was increased 10mm horizontally and 15mm vertically. The chin looks very very pointy now, as there is almost no width left and it further sticks out because of the intentional 15mm increase which in my opinion was a bit too much. The surgeon at first only said that I will take it back after a few months and now has denied and is insisting on plate removal. I’ve talked to another surgeon who hasn’t told me his plan yet, I’ll have to physically go to his place and ask, but he said to come as soon as possible. My requirement is to get my lower third to be more angular again. The width of the chin can not be increased now, but I’m hoping that reducing it vertically about 8 to 10mm should make it look much better. I know the measurement 10mm in vertical reduction is quite huge but I’m afraid that without that much reduction the chin will not look good at all. My chin is sticking out from the rest of the jaw and has very very less width, almost none. I also plan to take it back slightly by 3mm or so. I’d be really grateful if you could tell me if it’s possible and advisable to reduce 10mm vertically, and also, when it should be done. I’m 2 months out of my surgery and I am sure that even if the other issues, like the pain in chin and the rolled-in lip, might get resolved in coming months, despite that I will be going for a vertical reduction of the chin as my face looks too long and the chin looks very very pointy and is not going with my wide face. I’m worried about getting saggy skin after the reduction and also any other complications that may arise with a revision genioplasty. Please suggest me the best option and also when to go for the revision.

A: Certainly a 10mm horizonal advancement and 15mm vertical lengthening is going to make any chin more pointy…which would be even more emphasized if narrowing was done as well. In my opinion you do a revision when you are certain that the desired changes is not the desired result AND you have a clear plan as to what type of revision would be beneficial. Without seeing before and after pictures and x-rays I can not make any further constructive and informed commentary about how to improve your current chin situation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Questions for Dr. Eppley regarding PMMA bone cement for skull augmentation: is it safe and permanent? Are there long term complications associated with its use? Why isn’t this procedure not commonly performed? 

A: While PMMA bone cement for skull augmentation is both safe and permanent, it is an aesthetically inferior technique because of its limitations in volume addition, the need for a long scalp incision for placement and a higher risk of contour irregularities. Custom skull implants are aesthetically superior due to more controlled aesthetic outcomes, less risk of contour irregularities and they are placed through smaller scalp incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had infraorbital implants and lower eyelid spacer grafts with canthopexy of which I am very satisfied as they have made a great improvement. I wonder now of custom infraorbitalmalar implants might provide even further facial improvement. I really don’t want to one up my lower eyelid incisions again since I have had such a good result. What are your thoughts on this potential procedure? I know it create a more compact orbit bit what are the other benefits?

A: As a general statement what I would tell any patient who has undergone an aesthetic procedure which has made a good improvement…be very cautious in trying to take a good result and make it a great one. The reward:risk ratio changes and just because you have had a uncomplicated experience the first time is no assurance it will be so the next time.

That being said it would be fair to say beyond a somewhat more compact orbit it provides an extended high cheek look as well. Based on your one limited side view picture I would not be an advocate of this procedure in your case because of the risk vs reward benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a review of my case and photos. Your practice is very appealing to me because you offer a wide array of treatments and surgeries. I want the procedure(s) that give me the BEST chances of reaching my aesthetic goals. I am open to all suggestions. I am specifically interested in learning if I could benefit from facial lipo, kybella, threads and/or facetite OR should I just go straight to a facelift or other surgery. I have attached 5 photos: current frontal, side, 45 degree and smiling pics with areas that bother me marked. I also attached a frontal version photoshopped to show how I’d like my lower face to look. I am not adverse to surgery or down time if the procedure gets me what I want preferably permanently. My only restriction is I want as minimal scars as possible and no silicone facial implants. I am 40 yrs old, 5’2, 123 lbs and have had the following aesthetic procedures done several to many years ago: buccal fat removal of entire pad, open rhinoplasty, upper eyelids, ultherapy of lower face and neck, chin implant and then removal of implant years later. Please let me know if any additional info is needed. Thanks

A: Thank you for your inquiry and sending your pictures. The lower facial slimming effect you are trying to achieve is best obtained by a surgical jowl tuckup procedure. (aka limited lower facelift, mini-facelift etc) All other less invasive procedures you have mentioned are for those that are not ready to jump to a surgical procedure. They do not create the same result but serve as methods to delay a surgical approach until more significant signs of facial aging are present or that their results have proven they are inadequate for the patient’s aesthetic goals.

I have attached an example of such a younger type of limited facelift with a close up of the scars around the ears. (6 weeks postop)

FYI no facial rejuvenation procedure, surgical or otherwise, is permanent. They all degrade over time…it is only a question of how much and over what time does one eventually return to baseline. That would be particularly applicable at a young 40 years old.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am concerned about the asymmetry on my face. My jaw slopes to my right and my right eye, lip, and nostril area are dragged downwards. My right eye is lower than my left, I don’t consider it to be too severe but it is quite noticeable and I would really like to fix it. My right brow, nostril, and lip corner are lower as well. I think an orbital floor augmentation/ implant and any procedures accompanying it would solve my VOD, however I’m not sure if I’m the right candidate. My desire would be for the affected areas on the right to be symmetrical to the left accept for my jaw which I would like address in the future. I am very curious to know your informed opinion and ballpark prices for each of the procedures that would be needed to fix the asymmetries on my right being my lip, nostril, and eye + (brow). A response and price estimation would be greatly appreciated, thank you so much!

A:Thank you for your inquiry and sending your pictures. In the assessment and treatment planning of facial asymmetry it requires a good quality frontal picture (yours does not include the full face, is not current and are very grainy in clarity) and a 3D CT scan of your face to have full knowledge of the underlying facial bone structure. 

But those issues aside, what is equally important is for the patient to make a list of their specific facial asymmetry concerns AND to prioritize them in order of importance. This allows the patient to focus their resources on the procedures that have the greatest value to improvement of their facial asymmetry concerns. 

In short a better picture and knowing your priority concerns would allow some more useful information to be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin implant which is a medical grade silicone implant by Implantech. Over the last couple years my chin has changed. I think the implant shifted. Recently in the last few months I felt a tearing sensation on the left side, along with pain and itching. Now there’s a little divot along the left side and to me it looks like it shifted up closer to my mouth. I’m concerned that it shifted up or scar tissue tore as well as bone erosion. I want it out my face. I’m concerned about my skin not shrinking back after having it for 20+ years and I’d rather not go back to a recessed chin. My mouth is moving normally and I’m not in pain. It does feel weird compared to the left side. I can almost feel it now being closer to my mouth on that left side.

Questions/ideas: 

Can the implant be removed and hydroxyapatite be used to create a chin? 

How about a sliding genioplasty without another implant? 

A: Normally I would get a 3D CT scan of the lower jaw to fully understand the chin position on the bone and what style/size the chin implant is. But since it is clear that you want it removed and not replaced with another implant then the scan will not be useful. The question then is not whether it needs to be removed but what to replace it with and what should those dimensional changes be. 

Hydroxyapatite cement is a theoretical replacement but it is a hard material to control its shape and would only be viable if just a few millimeters of augmentation were needed in the central chin. A more controllable autologous option is a sliding genioplasty. The only question with it is what are the dimensional movements needed. That can be determined by how you feel about current chin look and what contribution the indwelling chin implant is making towards your current chin shape. (which can be accurately determined intraoperatively with its removal) That would then guide the amount of horizontal chin bone advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I was born with a large nose and recessed chin and had rhinoplasty and chin implant twenty years ago.  The rhinoplasty left me with a bump so I had a revision several years later. During the revision he scooped out my slope and took a chunk of my ear cartilage and put it on the tip, and angled the whole thing up. You can now see inside my nostrils. He also narrowed my left nostril at the base and the right nostril now sticks out and up. The tip is kinda pinched-looking and my slope is gone. It does not fit my face and I can’t breathe properly. After the revision he tried to shrink the tip using a steroid injection called Kenalog (0.1 mL).  I think he tried to do the Barbie-style of nose. My left nostril wall is collapsed and I’ve recently found a huge benefit wearing breathe right strips at night. I’m now sleeping through the night and it’s amazing. Several years ago two stitches worked their way out through the tip area on the inside of my nose. That was scary. I feel like the entire nose is unstable. I’ve had a couple consults in my area and they’re not what i need… I need functional and aesthetic rhinoplasty. 

A: By your nose surgery and symptom description you have both functional airway and aesthetic nasal shape concerns. Positive improvement with the Breath Right strips demonstrates that there is internal nasal valve collapse +/- weak lower alar cartilage support. This often happens when the structural support of the nose has been over reduced. This is best approached by the combination of middle vault spreader grafts and batten grafts to the lower alar cartilages using septal cartilage grafts. Septum is the best source and it is unknown to me whether your septum has previously been harvested or not. (I suspect it hasn’t given that ear cartilage has been previously used) This functional surgery can be combined with the needed aesthetic changes which appear to be bridge augmentation, columellar support, tip scar removal and right nostril adjustment.

Dr. Barry Eppley

Indianapolis, Indiana