Your Questions
Your Questions
Q: Dr. Eppley, I am interested in forehead reduction. I was wondering if it’s possible to even out my forehead and make it smooth and symmetrical? I am bothered by the sides areas of my forehead which I have marked in the attached pictures.
A: What you have are prominent anterior temporal lines on each side of your forehead. This is not really due to a prominent forehead per se but due to a deficient temporal muscle on the side. This makes your forehead look very square and boxy. Rather than burring down the temporal lines (forehead reduction) I would recommend extended temporal implants to build up the area beside the forehead. This would be simpler and would create a more masculine forehead as opposed to burring down the bone and making your forehead rounder. (although that could be done based on your personal choice)
The aesthetic problem with temporal line reduction is that it will require a scalp incision to be done which is challenging to place in male without some visibility. Conversely the small temporal incisions for placing extended temporal implants are in the temporal hairline and are much less of an aesthetic concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about custom facial implants. Is there a standard “ideal” facial structure dimension the digital system will use? Will you send me an image of the implant and how it will fit my chin? I would have a scan sent to you. Most custom facial implants are ready in 3 weeks? Is this correct? Thank you!
A: Even though custom facial implants are designed on the computer, the computer does not have any innate knowledge as to what looks best for any patient. It is up to the surgeon to create the dimensions of the implant, the computer software does not do that. It merely makes the implant by the dimensions that the surgeon provides. This is a common misconception by many patients. What the computer software will do is make the implant have a perfect fit, be smooth on its outer surface, adjust for any bony asymmetries and make for a smooth edge transition from implant to the bone. But no software yet can create for the patient some ideal design that will produce the best aesthetic change for the patient.
Custom facial implants usually takes about three weeks from getting the 3D CT scan to having the implant sterilized and ready for implantation. We usually arrange for an actual surgery time once we start the implant design so the surgery process runs expeditiously.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin, cheek and jaw augmentation. Like others, I am looking for exceptionally square, strong and masculine jawline to bring my facial aesthetics to the next level. I already have a fairly low body fat percentage (around 7-8%) but have always had slight TMJ on my right side and for as long as I can remember wanted to really strengthen my face.
Would I be a good candidate for a jaw, cheek, chin augmentation, and/or rhinoplasty to strengthen and balance my face? Or should I address the slight TMJ issue first? Which procedure or combination of the aforementioned would lead to the highly coveted male model facial look? I’ve attached a photo with the front and both sides of my face as well as a goal photo for reference.
A: I have done some imaging looking at rhinoplasty, cheek, and total jaw augmentation for your review. You have a good face for these type of changes because your face is already skeletonized, just disproportionate. The jawline change will require a custom wrap around jawline implant. Whether this would achieve the male model look that you desire is open to one’s interpretation
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw augmentation. I want to change my whole jawline to make it like one of the men in my goal photos. Up until this point I was assuming the custom wrap around jawline implants would achieve it, but since I shaved my beard off to see what I had, I am unsure if it will even be enough. Do you think I need any other procedure like lefort, jaw advancement, chin wing etc. Do I have a recessed jaw/chin, or is it just generally underdeveloped? I just don’t know, but I’m willing to get whatever jaw augmentation procedure I need.
I attached the best pictures I could take with my phone, I hope they are good enough. Based on them, can you tell me if any of my goals are possible (and what procedure or combination of procedures I would need). If any of the picture’s quality is good enough, is it possible to have a ‘predict my face’ and get a morph of what is maximally possible with custom implants? I really want to achieve a jawline that of one of my goal pictures.
My ultimate goal is to achieve a front jawline as close to any of those goal pictures as possible. And the side profile to have as much of an L shape as possible (male model look). Currently whenever I am in public I push my jaw out as much as possible and also bite my teeth to flex the jaw, it is a small improvement but is too much effort for me to maintain all day (not to mention I shouldn’t have to resort to that just to look less ‘bad’)
Note: I also plan on having other procedures done (rhinoplasty), but right now I am most concerned about jaw augmentation, as I think that will have the biggest impact, and then get the other procedures.
A: Your pictures do not show an abnormal lower jaw that is significantly underdeveloped or would be in need of major orthognathic surgery. To achieve your aesthetic goals you need jaw augmentation by any of the conventional implant methods. There is nothing more powerful and than a custom jawline implant and that would be the ideal approach for you. But the more economic approach to a more complete jaw augmentation is that of a square chin and jaw angle implants. This could also be effective for you since your jaw shape is not overlying deficient and enhancements at the chin and jaw angle areas would go a long way towards a more defined jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper and lower blepharoplasty surgery about two years ago. My upper eyelids have scars, the left eye is worse than the right. Another surgeon said the right eye just has some extra fat that needed removed. I have very high cheekbones and when I smile or laugh I still have extra skin below my lower eyelids that bunches up and makes me look a lot older than I really am. I didn’t know if that could be fixed by doing a little tuck. The only problem is I do have dry eyes. I also had a neck lift which I was very pleased with but my double chin seems to be coming back. The other surgeon I spoke with said he would do a chin tuck up. I would go ahead and book with you because I have read all the great reviews about you and I’m not really satisfied with my current plastic surgeon.
A: Thank you for sending your pictures. What I see are upper blepharopasty scars that are not in the eyelid crease line and are above it. The actual appearance of the blepharoplasty scars are not atypical but because they are high they are ore noticeable than they otherwise would be. Unless there is more skin to remove (and there is in the right eye) the scars ca not be lowered or made less noticeable. While a pinch lower blepharoplasty can be done, whether there would be any worsening of your dry eyes is unknown. It often is not a good idea to do an operation based on excess skin that appears in facial animation. While that may be effective during smiling, the critical question is what impact that may have in eyelid position when you are not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very interested in having a surgical procedure to make the width of my lips longer. (mouth widening procedure) I am fully aware of the pros and cons of this procedure but the pros do weigh out the cons. I’m just enquiring more information as to the procedure such as how long I would be out of work for and is this a procedure that I would need to have done frequently?
A: The mouth procedure to which you refer is technically known as a lateral commissuroplasty (mouth widening procedure) where the corners of the mouth are opened up at the skin level and the vermilion/mucosa lining is brought out to make the horizontal length of the mouth from corner to corner longer. (wider) When you speak to ‘do I need to have it done frequently’ you are likely referring to the potential for scar contracture which may require secondary release. While this is a risk, it is not an expected outcome and hopefully would not occur. Thus a successful mouth widening procedure would be a one time procedure with permanent effects. As a general rule the horizontal width of the mouth can be increased about 5mms per side for a total of a 1 cm mouth width increase.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had contacted you months ago inquiring about temporal artery ligation. But I had to reconsider that procedure because the artery on my left side now appears when doing physical activities or with heat but not as bad as the right. And even down the middle of my forehead. So now I was wondering if you do fat transfers to the entire forehead and if you thinks this could help with my appearance. It seems that I suddenly have lost fat in my forehead which is making these arteries appear worse.
A: Fat transfer is not known to be an effective treatment to camouflage prominent forehead arteries and veins. While this seems like it would work, it does not in my experience. This is because it is difficult, if not impossible, to put the fat on top of the arteries. Rather it ends up going around them and does not result in decreasing theie visibility. Temporal artery ligation is the best approach for prominent arterial vessels of the temporal and forehead area. It is also far simpler as it directly treats the problem…the vessel themselves.
Temporal artery ligation is usually done under local anesthesia using small 5mm incisions to isolate the arterial branches and tie them off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buttock augmentation. I am a 53 year old athletic woman who had liposuction years ago that left me with misshaped and sagging buttocks. A skin lift four years ago helped just a little, but, as photos show, still a big problem. I am wanting to fill out my buttocks but keep an athletic look, since the rest of my body has good muscle definition. Is there a buttock augmentation procedure that will enable me to continue to do extreme sports?
A: The residual problem with your buttocks is a volume issue not one of a skin sag. The dilemma you have is that of two treatment options, fat grafting and implants, one of the them (fat grafting) is not a viable option due to your very lean body. Buttock implants, while effective, poses both a recovery and potential physical activity limitation (during the long recovery process) for what your physical standards are. (extreme sports) It would probably take three months for a full recovery. Given these issues, I do not see any method of buttock augmentation that will work for your specific physical needs. While full gluteal muscle function will return, the impact of intramuscular buttock implants is suspect in very highly athletic people.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about skull reshaping surgery. In my opinion I’ve got quite a bit to do on my skull as I guess about 60% of my skull needs filler. My head slopes down from the centre of my skull on the top of my head to the back of my head. Also from the back of my head to my ears has flat spots and low spots that need to be filled on both sides. On both sides of my head above my ears is needs to be filled as it slopes abit to the top centre of my head. Hope this makes sense. I can draw pictures If that helps or a Ct scan might be needed. Also I live in the United Kingdom which would mean I would have to fly over. Would that have any effect on having the operation then having to return to the UK?
A: From your pictures, I can clearly see your skull shape concerns which are located onj the back half of your head. I would not think that the skull area involved is as much as 60% surface of your head (probably closer to 1/3) but that is a moto point. Your skull reshaping needs could only be done by a custom skull implant procedure. That is the best way to smoothly and evenly augment your skull contour issues. That requires a 3D CT scan from which the actual implant is made through a computer design process.
I have many patients from the UK for a variety of procedures including various forms of skull reshaping. There are no adverse effects from air travel on this type of aesthetic skull procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I underwent an 8mm sliding genioplasty three years ago. Overall I consider it a big improvement for my face, but now instead of lacking a chin, I have a step-off deformity on the right jawline. It is quite visible (you have to look straight to it thought). I could live with it but I’d also be much free from concern if I could get rid of it. Is there any way to fix and unify my jawline, preferably without major surgery? Thank you very much. Kind regards.
A: Step-offs along the jawline after a sliding genioplasty are common particularly the greater the horizontal movement and the more steep the osteotomy cut is. The simplest method to treat these jawline irregularities after a sliding geniplasty is to fill in the defect from an intraoral approach. There are a variety of material options but hydroxyapatite granules or the layering of porous mesh over it is the most common way I do it. It is a surgery but I would not consider it major surgery compared to a sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about chin implant surgery. I recently had a small central chin implant put in and I am about 3 1/2 weeks post-op. I really dislike the shape and am wondering if an extended chin implant would have been a better option. I have shadows/dents on either side of my chin.
A: There are numerous styles to choose from for chin implant surgery. Obviously selection of chin implant style and size are critical in getting the optimal desired aesthetic chin augmentation effect. While a central chin implant is often a good choice for some women, it does not provide any augmentation effects to the side of the chin since it does not extend past a vertical line dropped down from the corners of the mouth on the bone. Since you are seeing shadows/indents on the side of the chin, this would strongly suggest that this indeed a chin shape or chin style issue. The question is at just under four weeks after surgery whether this is too early to make a final judgment about the outcome of your chin augmentation procedure. I would give it a full three months after the initial surgery date before making a final judgment about the decision to change your chin implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of forehead augmentation. I have a slight depression in the middle of my forehead which in certain lighting becomes obvious. I know it is not big but it still bothers me. I have attached a video of it so you can see what I mean. What is the best method of forehead augmentation for it?
A:Thank you for sending the video which shows a circular dip/depression in the middle forehead. I have seen this before and it does represent a bit of forehead bone depression. While there are a variety of ways to do forehead augmentation, the most important consideration is to avoid any scar in doing so. This leaves us with an injection method of fat which is scarless, simple and can be reasonable effective if not overdone. The most important issue in your case is to make sure the downside of any procedure never makes the problem worse or trades off one aesthetic problem for another. The biggest downside of fat injections is the unpredictability of how well they will survive (although they usually do well in the forehead actually) and this a very ‘safe’ risk since it does not worsen the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about possible chin implant erosion. I’m a female patient in my thirties. A few years ago I had a medpor chin implant inserted. I was wondering whether I could ask for your input since I understand you are one of the most prominent surgeons when it comes to both craniofacial as well as plastic surgery.
I had a cone beam scan performed a while ago because of some concerns about my teeth. There appears to be (what looks like) a ‘step off’ in the bone at the lower frontal teeth roots, but I’m not sure if I’m seeing this/interpreting this well – I might misinterpret the scan. Could this step off be caused by the chin implant? (It concerns a medpor chin implant). I drew a red arrow in the scan where I appear to see some kind of step off/change in the bone level. I appreciate your opinion. Thank you very much.
A: That stepoff you see is a classic example of chin implant settling (many refer to it as chin implant erosion which is an inaccurate term) This illustrates that despite the biologic nature of an integrated implant material like Medpor, implant settling can and does occur just like occurs in silicone.
By bone resorption I assume you mean periodontal (gum recession) and radiographic evidence of lower alveolar bone levels. Whether that is a function of the implant I would initially doubt it as the implant sits much lower than the root level. The usual symptoms would be more pain and tooth sensitivity not alveolar bone resorption. But to qualify that answer I would need to see a front view picture of the cone beam to assess the implant’s location under/over the tooth root levels.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I would like to get deltoid implants, I’m a fairly tall at 6’1 but my shoulders are lacking. I have a narrow frame and would like silicone implants to widen my shoulders by 6 cm all together. I saw where a doctor from South Korea does deltoid implants by placing an incision under the armpit and uses silicone implants over the shoulders to reshape them and widen them. I would like to do 3 cm on each side like that surgeon does. I want to maximize my shoulders as much as possible while not over doing it. I would like to see if my clavicle growth plates have fused though before I get the implants to make sure I still have some growing room, thank you and hopefully you get back to me.
A: Deltoid implants are indeed placed through a posterior axillary incision. The implants are placed under the fascia up over the central region of the deltoid muscle. As you may know there are no off-the-shelf preformed deltoid implants that are commercially available in the U.S. due to low patient demand. What I use are Implantech’s silicone contoured carving blocks Style 3. Their greatest thickness are 2.1 cms. While a 3 cms deltoid implant can be made by them that is going to raise the cost of the implants by a significant amount. You will have to decide if the extra 9mms is worth the additional cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested, I think, in a custom jawline implant.The attached photo includes a Photoshop direction I would like to take with a custom jawline implant. Is this achievable or just very wishful thinking? Also, would you suggest a neck lift or would such an implant eliminate the loose muscle/fat under my chin. I’m looking forward to making a decision on this very soon and moving forward. Thank you very much!
A: What you are demonstrating by your Photoshop effort is pretty much what is possible with a custom jawline implant. It is not wishful thinking. Such a custom implant will pick up all the loose skin in the neck particularly back along the jawline and jaw angle area. It will also do so under the chin as well. How effective it is at ‘eliminating’ this loose skin has a lot to do with the size and dimensions of the implant. It does so because the increased surface area of the implant requires greater soft tissue coverage and it pulls it up from below not downward from the face. A bigger bone surface requires more tissue coverage and it has to come from somewhere. Fortunately for the jawline it comes from the neck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to surgically contour my facial bones, specifically from the zygoma and below. Unfortunately, where I am going they do not do temporal reduction bone surgery. So in order to achieve the look I am going for, long and thin, I was wondering, to what extent may the sides of my head be reduced without removing a lot of muscle, mainly temporal bone?
A: Contrary to popular perception, temporal reduction is done by removal of muscle not bone. The fullness of convexity of the head above the ears is a combnation of bone and muscle but the ratio is weighted more towards the muscle and not bone. The thickness of the posterior temporal muscle in men can be anywhere from 7 to 1 mm thick. In contrast the thickness of the bone may be only 3 to 5mm thick. You can demonstrate this by getting a CT scan to see the tissue makeup on the side of your head.
To really make a difference in temporal reduction surgery, you remove the entirety of the posterior temporal muscle not burring the bone. Bone reduction will make little if any difference in its width, muscle removal can make it completely flat. Interestingly, removal of the posterior muscle has no long-term effects on mouth opening as the much larger anterior portion of the temporal muscle remains.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Exploring options as part of the decision making process, I understand an alternative to the custom jawline implant would be a sliding genioplasty along with Gore-tex posterior mandibular angles and a mandibular body piece to go between the angle implant and the chin. The advantage, I believe, would be a somewhat more natural looking ‘mentolabial sulcus’ (more of an ’S’ than ‘V’ shape) and chin.
Do you think a sliding genioplasty could give me the chin width shown in my Photoshop image? I believe the chin can be split vertically and a piece of bone inserted between the halves to increase width.
Do you think the custom wrap-around implant would give me the length, width, and projection I am after, as good as a sliding genioplasty with Gore-tex angles?
As much as I want to avoid adding complexity to the surgery, I do want the best looking and most natural looking end product/result.
Your thoughts would be greatly appreciated.
A: While there are different approaches to a total jawline enhancement effect, using any form of a three piece approach (chin and two angles… or in your description a five piece approach) is, just frankly, an historic and problematic approach to achieving the jawline effect you seek. I have done over the past twenty-five years every conceivable method for chin, jaw angle and total jawline augmentation surgery. In almost every case, the custom jawline implant method is far superior to any other method or combination of jawline surgery methods for the following reasons:
- An important aspect of the total jawline enhancement look that you are going for is smoothness of the jawline from one angle to the other. A one piece implant can do that. A hodge podge of bone cuts and implants will leave a jawline irregular and asymmetric with absolute certainty.
- Every aesthetic surgery has risks of of revision which are cumulative based on the number of procedures done. While a custom jawline implant does have a risk of revision for aesthetic reasons, it is a single risk of around 15% because it is a single implant/procedure. When you combone five procedures together, as you have described, the cumulative risk from that approach will approach 100%.
- Gore-tex implants, even if they were available in the right size and thickness (which they are not) are soft and compressible. To vertically lengthen the jaw angles as you desire you need something that not only has the right shape but can push the overlying muscle and skin downward and then maintain it. Gore-tex is not the material for that job.
- While a sliding genioplasty can be split in the middle and bone grafted, the inferior edge transitions back along the jawline will not be smooth. Besides that issue you will need a bone graft harvested which must come from either your skull, rib or hip.
- The impact of a sliding genioplasty or a custom jawline implant on the labiomental sulcus are perfectly similar. The labiomental sulcus is a fixed anatomic structure whose effects from any procedure below it will remain the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead scar revision. I was on Dr Eppley’s website and noticed a few pictures of a scar revisions he had performed with great results. Seeing that he has successfully treated similar scars in the forehead region I would like to see if Dr Eppley can help me with my indented forehead scar. My scar is a result of a scar revision done one year ago for an indented chicken pox scar. The scar is approx 1/2″ in length and it sits directly on my natural wrinkle line in the center of my forehead. Unfortunately the incision line is indented which results in an aweful shadow effect. Also at the one end of the incision there is small indented hole possibly caused by the corner of the incision opening up a bit early on.The plastic surgeon who did the revision used 3 buried dermal sutures and 6 exterior sutures however he said he did not evert the wound edges as he felt it was not necessary. No eversion plus possibly too much forehead movement during the healing phase resulted in what my scar looks like today. I have also had 1 dermabrasion procedure done to grind down the indentation appearance with very minimal results. If Dr Eppley can help minimize my scar it would be greatly appreciated. Thanks very much for your time.
A: In looking at your pictures I do believe your forehead scar could be improved by forehead scar revision. But I don’t think it is as simple as just cutting out the scar and closing it in a linear fashion…with or without wound edge eversion. While the scar needs to be re-excised and closed, the key element for sustained improvement is providing some structural support underneath the wound edges to prevent a recurrent indentation. This can be a small piece of fat, dermal graft from an old scar or even a piece of allogeneic dermis. (e.g., alloderm) This will create a mild temporary elevation of the scar which will settle into a flatter profile. But without adding anything to it the wound edges are likely develop recurrent indentation given the high muscle activity in the area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what can be done about my eye asymmetry? My whole left eye is about 5mms lower than that of my right eye. What is the best way to amend this problem?
A: To correct your orbital box eye asymmetry, multiple adjustments need to be made to the orbital floor (augmentation), brow bone (inferior reduction) as well as upper eyelid (ptosis repair) and lower eyelid (fat injections and lateral canthoplasty) The issue is that the bone changes will cause problems with the current eyelid positions and then these will need to be adjusted. I have treated many cases like yours and sometimes you open ‘pandora’s box’ by trying to make these changes. The position of the eyelids is perfectly aligned to the bony orbital skeleton now albeit lower and asymmetric that it is. Once changes get made to the orbital bony box, the eyelids will be off alignment to the globe (eyeball) and these realignments often take multiple surgeries to get the optimal result.
Once the horizontal level of the pupils differs by 5mms or more in eye asymmetry, attempts at surgical improvement are often met with mixed results and lead to multiple revisional procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had this horrible deep line between my brows that drives me insane. I recently tried Botox which I knew would not be a fix and I have contemplated fillers but I know fillers are not permanent. Words cannot express how I feel everyday about having this deep crease on my face. I have had side swept bangs for years and I’m tired of hiding behind my hair and wearing hats all the time. This is border line ruining my everyday life and has completely crushed my confidence. I took a few pictures for you to see my problem.
A: Thank you for sending your pictures. What you actually have are three distinct vertical glabellar lines, the central one is just the most deep. It is important to know that the ‘standard’ treatment would be a combination of Botox and injectable fillers. Botox to stop the cause (muscle movement) and injectable fillers to fill the defects. While this would definitely provide improvement it is probably not going to be a lifelong treatment strategy.On the opposite end of that approach is a surgical one with endoscopic muscle release and fat injections. In between the two lies the placement of a dermal fat graft or allogeneic dermis graft threaded into each one of the glabellar grooves.
As you can see the treatment of your glabellar lines is not an easy problem to solve. But at least there are a variety of different options to treat it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant replacement surgery or a double chin implant surgery. Hi I had read some of your articles and believe that you have much experience with chin implants. Would be grateful if you could respond my simple question, for which I can´t find any answer anywhere else. I have a Medpor chin implant (2 years ago) that isn´t big enough, and need a larger implant. If my surgeon don´t dare to remove the porex implant, is it possible to insert a new silicone chin implant over the Medpor implant? Would be so grateful for your answer!
A: While it is technically possible to place a silicone chin implant over your existing Medpor one, that would not be a good choice. There is a high risk of implant displacement and symmetry, not to mention the probably appearance of a ‘stacked’ look of two chin implants placed on top of each other. It would be far better to do a chin implant replacement approach, removing the Medpor implant and placing a new silicone chin implant that has all of the desired dimensions. (this may or may not require a custom chin implant given what have in and what the dimensions of your ultimate chin augmentation goals) Like all face and body implants the concept of stacking one implant on top of the other often leads to future problems. If your surgeon is unwilling or uncomfortable in removing a Medpor chin implant, you need to find a surgeon who has the experience in doing so. A one piece chin implant replacement is always going to be superior to trying to put two different chin implants together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty for functional purposes. I am a 40 year old female with moderate obstructive sleep apnea with an AHI of 24 and 90% oxygen saturation at night while sleeping. I also have a very recessed chin and need a sliding genioplasty to both improve my obstructive sleep apnea and my cosmetic appearance. Maxillomandibular advancement osteotomies is not feasible for me. What type of sliding genioplasty is best, a mortisized genioplasty or a straight horizontal osteotomy? A craniofacial surgeon told me I need the mortisized type with a 4mm advancement.
A: I think what you are referring to is the difference between a straightforward sliding genioplasty and a ‘jumping’ genioplasty. I am not completely sure what you mean by a ‘mortisized genioplasty’ as that would refer to a bony genioglossus advancement only which would have no cosmetic benefit. That choice depends on which will give the greatest amount of chin advancement (which you need for your OSA) and what impact that would have on our appearance. With plate fixation the concept of a jumping sliding genioplasty has less significance than it did when only wire fixation was used. I would need to see pictures of your face and x-rays to best answer your question as to the optimal method of a sliding genioplasty for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction surgery. I am a 26 year old male and I am quite self conscious about my cheekbone width. They span almost 16cm and I am wandering if it would be possible to take about half a centimeter off on each side to make my eyes (pupilliary distance of about 65mm) more proportional to my face.
A: Your fundamental premise is that if the width of the face was less wide, your eyes would not look too close together. Since you can’t move your eyes this leaves only the cheekbone width to be changed. Cheekbone reduction surgery works by moving in the zygomatic arches of the zygomatic complex. These arches are what makes up the width of the middle part of the face. The inward movement of the cheeks usually is no greater than 5 to 7mms per side due to the location of the temporals muscle which lies underneath it. The bone should not ‘pinch’ the temporals muscle as this could interfere with the workings of it which is to help open and close the mouth. Usually it is a good idea to get a 3D CT scan before cheekbone reduction surgery to look at the anatomy of the zygomatic arches and see how much reduction is possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about midface implants. A maxillofacial surgeon recommended to me maxillary advancement to correct midface hypoplasia. Can you produce similar results through midface implants?
A: The aesthetic benefits of onlay midface implants can rival if not be superior to maxillary advancement surgery. The only area in which the deficiency will remain is at the tooth or occlusal level as one’s bite will remain the same. Not changing the position of the anterior maxillary teeth does effect upper lip support and this is one aesthetic component of the midface which will not be improved by skeletal augmentation above it. Midface implants come in a wide variety of styles and sizes from the cheeks, infraorbital rims and tear trough, premaxillary-paranasal as well as maxillary implants. With the exception of the lower orbital rim implants, all midface implants are placed from incisions inside the mouth. Because of the location of midface implants on the side of the face, they are usually best secured with small titanium microscrews. When covering larger areas of the midface, it is often best to have custom midface implants made so that maximal midface augmentation in a smooth manner is achieved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I see you prefer to secure your chin implants with screws. I’ve searched all over my area for a doctor who does this and can’t find a single one. Do you know why this is? Is it inexperience? Is there some added risk of using screws of which I’m unaware? Do you ever do them without screw fixation? What about those who secure with sutures… what does that even mean? Thanks for your time.
A: Fixation of chin implants is done by various methods by different surgeons. By far the most common technique is the use of sutures where it is passed through the implant and done to the lining on or around the bone. One can have a debate about how secure this makes chin implants but this method highly depends on the size of the implant pocket to control asymmetry caused by a tilt in the left-to-right axis of the implant’s placement. Suture fixation can not control the potential for tilt from a single central point. Screw fixation is the most secure method and is really simple and quick to do…if one is familiar with doing it. Having done craniomaxillofacial surgery for decades this makes the use of screws for chin implants as familiar as using suture to close the wound.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, For midface augmentation, should I choose paranasal filler (my maxilla is quite forward, my midface is flat and doesn’t point forward as you see in my picture) and cheek filler, or should I get an implant? The second question: how do I change my eye shape? As you see, I got strong dark circles and they are round if you look from the front, do I need infraorbital rim implants to get rid of the circles and more almond eyes (this male model squint look) or can I use filler (upper eye lid for hood look and under the eye for the circles and almond look). Thanks and kind regards.
A: The use of injectable fillers, injectable fat or implants for midface augmentation are all possible treatment options, each with their own well known advantages and disadvantages. But as a young person the best long-term approach is to have custom facial implants made for a permanent and more controlled facial shape change. Fillers and fat do not produce the same type of augmented facial look and are only going to be temporary. Eye shape change will require a lateral canthoplasty to deround the eye.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in removal surgery. I was born with pectus excavatum and significant rib protrusion. I have been advised by a thoracic surgeon that the worst ribs are 7-9. The deformities seem to be limiting my lung expansion. My insurance will cover cosmetic procedures to correct congenital deformities, as well as, medically necessary procedures for respiratory issues. I have seen you write about providing a rib resection procedure for narrowing the appearance of one’s waistline. The thoracic surgeon indicated that there is a procedure for removing the ribs while leaving the lining intact so that new ribs can form hopefully more normally (sometimes requiring bracing). I would prefer to have a plastic surgeon do such a procedure to increase the likelihood of having a more aesthetically pleasing result. Therefore, my question is: Do you have experience with any rib removal procedures that would allow for rib regeneration, and if not, do you know of any other plastic surgeon that may?
A: Rib removal in an adult is a permament procedure. As an adult, ribs that are removed whether they be the bone or cartilaginous portion, will not regenerate. That ability is lost when one is older than one year of age. So your thoracic surgeon is either misinformed or you may not have understood fully what he/she was saying. More likely the thoracic surgeon was referring to rib reshaping. The proper treatment for a pectus excavatum deformity in an adult is known as a Nuss procedure. This is where a rigid bar is placed under the ribcage to push it outward and allow for expansion and some rib recontouring. For rib protrusions of the anterior subcostal margin (ribs 7 through 9) the cartilaginous portions of the ribs can be removed to lessen the visible portion. This will improve their appearance but will not provide any improvement in pulmonary function. Only a Nuss procedure can do that. Rib removal is a cosmetic procedure not a functional one. Loss of thoracic support from rib removal can not contribute to improved pulmonary function.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about faclal implants. Can cheek implants be done with local or non general anesthesia? Also I have a short face and need to add lateral width and height but I worry about the big wrap around jaw implants involving the masseter muscle. So can we do a custom chin implant with wide wings extending laterally and vertically as far back posteriorly as possible but not hitting the masseter muscle. I realize there would be a major step off somewhere further down the jaw and the rest all the way around the ramus I would fill in with fat or radiesse. Also could that be done without general anesthesia too?
A: In regards to facial implants, certainly cheek and an extended chin implant can be done under IV sedation or MAC. (monitored anesthesia care) The use of local anesthesia for most facial implants alone would likely be inadequate and that would be doubly true if both cheek and chin implants are done at the same time. Be aware that the use of local or IV sedation does not save any money as the intraoperative time to do facial implants takes twice as long as when done under general anesthesia. So your motivation for the selection of anesthesia for these facial implant surgeries should not be one of saving money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in making my chin vertically longer. I consulted a Oral and Maxillofacial Surgeon where he took x-rays and he said that I should probably do jaw surgery because he cannot do a sliding genioplasty of more than 3 mm without any hip bone grafts. Is this true? I definitely do not want to do a corrective jaw surgery because of the high risks. I would be okay with doing a sliding genioplasty but I am concerned with the involved hip procedure. Do you have pictures of patients who have had custom implants for the jaw and chin so i can see the results? Will they be similar results to someone doing a sliding genioplasty? Also how long is each of these procedures and recovery time?
A: It is absolutely not true that a vertical lengthening sliding genioplasty requires a bone graft. While a gap will be created between the two bony chin segments, the use of a synthetic hydroxyapatite block works quite well as the interpositional graft. There is even some debate as to whether this bone gap needs to be treated at all. But certainly a bone graft is not needed in my experience. I have never placed a bone graft in the many vertical sliding genioplasties that I have done.
The vertically opening sliding genioplasty and a custom implant can have very similar effects. The only potential difference is at the jawline behind the chin and how well the bony genioplasty cut blends into it. But from the front view there would be no difference in the chin lengthening effect.
Both procedures requires several weeks for most of the swelling to go down. Recovery will also involve some temporary chin and lower lip numbness. (bony genioplasty only)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. I have a weak jawline. I have had braces in the past so I do not think it is related to an overbite. My face is vary narrow and I am hoping that I can add some lower jaw width. I really like that you are trained in maxillofacial surgery and your results are beautiful. I have attached some pictures and am open to suggestions and would like to get a quote. I have also attached photos of my aspired look. I look forward to hearing back from you!
A: Your face is narrow and your jawline or lower third of your face is your weakest skeletal feature. It is short in both jawline width and chin projection. The best method to achieve the ideal pictures you are demonstrating is through a custom jawline implant. That is the only method to get the desired facial width and have a smooth shape and transition from the chin back to the jaw angles. Standard chin and jaw angle implants are another option but are suboptimal as their effects will be a bit unconnected and not smooth…which is really crucial to the jawline look you desire. A custom jawline implant is the proven ideal method to improve the balance of the lower third of your face to what lies above it.
Dr. Barry Eppley
Indianapolis, Indiana
