Your Questions

Q: Dr. Eppley, I had orthognathic surgery to improve my bite and make my jaw more symmetrical. Even though my bite is better, I now realize that my jaw is too small and narrow. I have been researching to find an implant which is able to make my jaw both longer and wider from the chin all the way back to the angles, but can’t find any.  Are there any off-the-shelf implants that can achieve my goal of back to a substantial and robust jawline? Can Medpor or silicone implants be custom made? I am more favourable towards Medpor because of its ability to form on to the bone and become incorporated in it, rather than silicone or any other materials.  I really hope you will be able to help me with this jaw problem.
A: It is hard for me to know how much change you really need based on your description alone. But in cases that I have worked in the past who have had similar concerns they almost always have needed custom rather than stock or off-the-shelf implants. Custom made jawline implants off of a 3-D model which can be designed and manufactured in virtually any dimension so their versatility makes them always the most ideal choice for total jawline enhancement. They can only be made in silicone, custom made implants from Medpor is not an option because it is not offered by the manufacturer and they would be virtually impossible to place anyway. It is also a misconception that bone grows in Medpor which it does not really do. Rather fibrous or scar tissue is what grows into the material…which is why they can be very hard to remove later.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I hope you can help me. I had lipouction for a witches chin with jowls removed; jowls on advice of plastic surgeon. Chin is uneven with a “fat pad” remaining. Plastic surgeon said he would “fill it in” and used Belotero. I look 10 yrs. older; I am 61. Could you look me up on Facebook and you will see the before and after photos. Plastic surgeon said he will not redo.  Have been to two other plastic surgeons for their advice; both said they would never have lipo’d the chin. What can you advise?  I can’t afford to keep getting filler and feel foolish and depressed over this.  Thank you for your valuable time and advice.
A: I will need to see some current pictures of your chin for my assessment, a front and side picture will suffice. (I don’t do Facebook) As a general statement, liposuction of the chin is not a good technique, will not correct and witch’s chin and usually will leave it uneven or bumpy…often worse than where the patient started. The preferred treatment of a witch’s chin deformity is a submental tuck-up where the overhang is removed and tucked under the chin. A witch’s chin problem is the full thickness of tissues that do not have bony support. It is not an isolated fat problem which is amenable to liposuction.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am curious about having liposuction on my abdomen and thighs what is the average cost, I want to remove about 15lbs.
A: Thank you for your inquiry. While it would be helpful to see some pictures of your abdomen and thighs, let me ask you a few questions in regards both areas:

1) Is this your full abdomen?

2) Do you need the flanks or muffin tops t.reated as well as your abdomen?

3) Do the thighs include both sides, inner and outer? Knees?

When considering cost, knowing exactly what areas needs to be treated as this allows the time to do the procedure to be properly determined. Fundamentally, liposuction like all cosmetic surgery and its cost revolves around the timer to do it.

While 15 lbs of aspirate (1 liter of liposuction aspirate roughly equals 8 lbs) may be removed in surgery, this does not necessarily mean that will translate into 15 lbs of actual body weight lost.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am seriously contemplating having chin revision surgery done by you due to a persistent unilateral numbness on the right side of my chin and lower lip area. This has been causing me a lot of distress for almost 2 years. On top of this, my right mentalis muscle doesn’t contract properly which causes a very noticable crooked smile and asymmetries in other facial expressions.
Here is a short history of what was done on my chin. About 3 years ago a plastic surgeon placed a Medpor chin implant with a 5mm projection via intraoral incision. It was the implant shown in this photo, but with a fair amount of custom reshaping. There were several issues after the first surgery though. While the left side seemed to be alright, the right side wasn’t. The implant was shaped assymmetrically (less prominent on the right angle. The right wing protruded about 2mm from the chin bone, i.e. it didn’t touch the bone which resulted in a bad transition as well as serious irritation and pain that wouldn’t resolve. The implant appeared to protrude slightly more on the right frontal part than on the left. Therefore my surgeon injected hyaluronic acid on the left frontal part to temporarily ameliorate this assymmetry until revision surgery. There was also numbness and lack of motor control of the chin and lower lip. The numbness and lack of motor control eventually fully resolved, but it took a whole year! However, the other problems made a revision surgery necessary. In this surgery the following was done. An intraoral incision merely on the right side (only the right muscle was cut through!), taking away the back part of the right wing to ease the irritation and pain, placing additional MedPor material on the right angle of the chin implant to make it more prominent and placing additional MedPor material on the left frontal part of the chin implant. The revision surgery took care of the irritation and ameliorated the assymmetries, meaning the chin now looked more symmetrically although still not perfect.
Unfortunately, the revision surgery brought more bad than good things. Now the major issue is that even after almost 2 years since revision surgery I still have unilateral numbness in my right chin and lower lip area and serious lack of motor control of my right mentalis muscle. This all became gradually better, but the progress has long halted and I am pretty certain that the remaining numbness and lack of motor control won’t improve any further with time. My surgeon said the odd behaviour of my right mentalis is caused by scar tissue located on the left frontal part pulling on the right side. I have no idea if this is possible. I rather think that the problem is not the scar tissue, but the mentalis muscle itself. Maybe it was not properly resuspended. This is were I need your opinion the most. I attached some images and a video so you can get a better idea of my problems. Among the images is an xray scan that faintly shows the chin implant. Maybe this helps you determine if the implant impinges on some nerve. Also, would you say that my chin is sagging somewhat? Can this be fixed? As a side note I should mention that I have a tendency for scarring and fairly bad wound healing.
Based on my description I have several question that you can hopefully answer:
– What would be your general advise in a situation like this?
– How would you approach another revision surgery? Does the mentalis muscle have to be resuspended? Is there hope it will return to normal functioning?
– Was it a sound approach to only make an incision through the right mentalis muscle? Wasn’t this screaming for a muscle dysbalance later on?
– Would it make sense to make an incision under the chin and not inside the mouth should a revision surgery be necessary again? It seems like cutting through my muscles is causing a lot of complications. But I guess the intraoral approach is necessary if the mentalis muscle has to be resuspended, right?
– Do you think the implant is aesthetically OK?
– Is it a good idea to take out the old implant and place a new and maybe smaller one? I suspect the current one might be slightly too large.
I’d like to thank you very much in advance for taking the time to read and respond to my email. Hopefully you have some encouraging news for me.

A: Thank you for your inquiry. I have reviewed your history, pictures and video and can make the following comments:

1)      Your case illustrates why placing a firm and inflexible Medpor chin implant through the mouth is generally a bad idea, it is associated with a significant risk of all the complications that you have experienced. But that is water over the dam now.

2)      I find the aesthetics of your chin result very acceptable and certainly don’t think it is too big.

3)      I would NEVER think at this point of trying to remove and replace your chin implant. That is a disaster waiting to happen. Given what has transpired up to the present and the difficult with removing Medpor implants, the risk of worse nerve and muscle problems is very likely. It may not be perfect but a perfect chin result for you is no longer a reasonable goal. I would advise that you accept a reasonable aesthetic outcome. Revisional surgery for you, as you have learned, has a lot more risk of problems than it does in making things better.

4)      It would be highly unlikely at this point that, even if the implant was impinging on the nerve (which I doubt) that relieving it is going to cause return of feeling. The nerve fibers have atrophied and the damage is irreversible at this point.

5)      I do not think you have chin ptosis or sagging.

6)      As for mentalis muscle dysfunction, I would have a very low level of confidence that any efforts at trying to resuspend the muscle would end up in the long run giving you a better result than you have now.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am planning on having a scar revision for a vertical scar on the bridge of my nose. At the same time I want to correct sinus problems: turbinoplasty, septoplasty as well as rhinoplasty for some minor aesthetic improvements. I’m hoping the minor nose humps can be grinded so they won’t exaggerate the contours of the scar. How can I minimize the new scar on the bridge from becoming widened over time, developing little arterioles, or the skin getting too thin? What laser should I plan for post-surgery?

A: Based on your question, I would need to have a better idea as to the type of external rhinoplasty you would be having. Will this involve rasping of the bridge or will it require osteotomies as well? Either way, however, I would not perform a scar revision directly over the nasal skin that is being raised during the rhinoplasty. This is not a blood supply concern but one of scar healing. The swelling of the nasal tissues after a rhinoplasty will work directly against having a good scar result. You would be much better to delay the scar revision to after the rhinoplasty, preferably 3 to 6 months later. Scar revision on raised rhinoplasty skin is not a good simultaneous idea if you want the best scar result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a depressed cheek scar above my nasolabial fold from a previous skin cancer removal using a Moh’s technique. If you inject fat do you utilize the Coleman technique with micro droplets to ensure the tissue becomes a graft and not just a temporary filler? Anyhow, I do not like the dynamic feature when I move the facial muscle as well as when the sight catches  the groove of the scar. I have attached some pictures showing the scar. Thank you for your time.

A:  Thank you for sending your pictures. I did not realize how young you were given that you have had Moh’s. It is actually a reasonable result in a difficult aesthetic area. The only modification I would make to my previous statement is that I would perform a geometric scar revision at the same time as microdroplet fat injections underneath. Even though the scar is well placed and has about as much narrowness as could be hoped for, there is always going to be a ‘groove effect’. That is just an unavoidable phenomenon in linear scar in that area. The scar line may need to changed from a pure straight line to get a better scar effect. Options include either fat injections with concurrent laser resurfacing (#1) or fat injections with a concurrent geometric broken line scar revision. (GBLSR) The conservative approach would be # 1 as GBLSR can always be done later based on the scar outcome. The more aggressive approach would be #2.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I went to see a maxillofacial surgeon to get jaw reduction (my jaw is too square and X rays show that my angles do stick out). He told me that he needed to do a small resection of the angles (osteotomy) because my angles were too square to burr them. and with the burring technique, only 2 or 3mm could be burred which would barely show. Is it possible to round off the angles with the osteotomy technique? or will it be a straight cut leaving the angles straight looking cut and unnatural? is it possible to preserve some angles with that technique? Also, what really surprised me is that he said that since the bone is so far and hard to get to due to the muscles, he might need to put some screws; I did not understand why. I thought that screws were used to put bones back into a new position; which would not be the case with angles osteotomy? I am confused. Thank you for your answers.

A: I can only speak for what I do, I can not explain what your surgeon said or their technique.  When you cut off the angles, no matter how small, there will be a rounding effect created. Burring in the jaw angle area can be difficult because of the surgical  access. Therefore, I choose to use a reciprocating saw and perform an outer table ostectomy, which thins the bone but preserves most of the angle’s shape. I have never used screws for this technique nor can I envision why they would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Moh’s surgery on my right cheek Dec. 27th 2012. I am unhappy about the indentation on the mid to lower half of the scar especially when I speak. I have photos I can send. Would like to know if you think I would need a revision, subcision, or laser, or this will subside in the months.  Also, if revised, do you agree with the theory of lasering 4 to 8wks after sutures are removed to reconfigure the modeling of the tissues resulting in superior results, rather than waiting the full year of the old theory. I am not interested in temporary fillers.

A: I am assuming that you had a primary closure of your original Moh’s defect. The reason you have an indentation is that there is tissue missing over a dynamic area. As such, no amount of release or scar revision is going to improve its appearance. This is a tissue loss problem and releasing underneath or cutting out the scar/indentation from above does not address the biology of why it is there. I would take a reverse approach to conventional wisdom by doing fat injections under the indented area. This will provide both a release and adds volume at the same time. While fat may be unpredictable in survival, this natural form of tissue volume expansion better addresses the cause of the problem. This would be more effective done early in the healing process (months) rather than later. (year or longer) The overlying scar in the face of underlying tissue expansion should wait for further healing.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, three weeks ago I underwent surgery for brachioplasty on my arms. As the tape was coming off the incision looked great. There was no redness, it was perfect. As more of the tape started falling of I noticed that on the surface of a section of my incision, an opening, or blister, was forming. I was told to gently remove the rest of the tape down my arms. Now instead of seeing my original clean incision, I have a few blisters with a bit of pus along the incision line, and it is now read and bleeding slightly in some areas. Is this normal? I stopped wearing my compression shirt as were my doctors orders, but he said if it were to start swelling again to put it back on so I did. Does all of this sound normal?

A: There is a natural evolution of incisional healing that understandably confuses most patients as it relates to body contouring surgery. All incisions look fantastic the first 10 days or so after surgery because the wounds have not started to really heal yet and the normal inflammatory process has not set in. Then the incision line begins to look worse…gets red and inflamed in some areas and make even have a few sutures that work their way through the skin. This process will continue for up to about 8 weeks after surgery when the incision line is finally healed and the inflammatory process has subsided. What you are observing is perfectly normal and armlifts are one body area where this process can often be more exaggerated due to the thinness of the arm skin.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have some questions about jaw angle implant surgery.

1) If I have a jaw implant surgery, do you custom make the jaw implant for my specific jaw? Is custom making an abnormal activity for jaw augmentation practitioners or something that is done with regularity at most clinics?

2. Which material do you normally use as implant and from which brand? Why do you do this type or these types of implants?

3. What are  the best/worst properties with these type of implants?

4. Approx. how many jaw implants have you done in 2012 and 2013 and what are the total number of jaw implants you have done?

5. If you were to say a number of the total people that have underwent jaw implant surgery, how many have come back of the total number and been displeased with the result?

6. What were they not happy about? and what do you do in such an situation?

A: In answer to your questions:

1) I would need to see photos of your face to make an assessment of whether you need standard or custom jaw angle implants. It has been awhile since I have seen your pictures. Regardless, using custom jaw angle implants is done by a very few surgeons in the world.

2) Depending upon what dimensional changes need to be done, the implants could be made from either silicone (widening the jaw angle only) or Medpor if vertical lengthening of the jaw angle is needed.

3) I do dozens of cases of standard and custom jaw angle implants every year.

4) To you on the outside, the different materials of the implants are irrelevant. Your current choices of jaw angle implants is based on what dimensional changes you need so you really don’t have much choice when it comes to vertical lengthening jaw angle implants because only one manufacturer (Medpor) makes them.

5) The revision rate of jaw angle implants is not insignificant and averages around 20%. This is the hardest facial implant to surgically place.

6) Asymmetry is the biggest reason for revision of jaw angle implants. In some cases, the result may be too much or too little for their aesthetic liking.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have further questions in regards to Temporalis reduction please. The area I want reduced is around squama temporal and the parietal area near the temporal line. In anatomical images, the temporalis muscle shows up white in that region, so is there very little muscle mass there? Will Temporalis muscle show up on CT scans? Also, would the surgery involve having to sever my temporal arteries? If so, will there be side-effects later in life? As temporal concavity is dependent on muscle mass, is that why elderly people appear to have narrower temples due to muscle degeneration? If so, will temporalis reduction increase wrinkles around that area and make me look older? I know you said it won’t affect mastication processes, but would it impede speech and pronunciation, since it involves jaw movement too? Will temporal muscle reduction make me unable to play soccer or tennis for the rest of my life?

A: To answer your further questions on temporalis muscle reduction:

1) The muscle is thinner near the anterior temporal line.

2) The muscle will show up on a CT scan.

3) The superficial temporal artery is not cut during muscle reduction.

4) The fullness of the temporal region is prinicpally controlled by muscle mass and an underlying extension of the buccal fat pad. As people age the fat resorbs and the area becomes more concave. The temporalis muscle does not really atrophy with age.

5) Temporal muscle reduction will not affect chewing or speech.

6) I see no physical restriction after such surgeries for either tennis or soccer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had multiple jaw implants that have left me with an unsatisfactory result. My jaw is naturally asymmetrical so it was hard for the surgeon to match left side to right side I suppose. He tried to fix the asymmetry by shaving down the implants, then another surgery to add implant on the right side which just made it bumpy and stuff. I think I just need to start over with newly designed implants. In addition I also want a reverse sliding genioplasty, my chin sticks out too far and looks unnatural. I can get a 3D print of my skull and a physical 3D exact model from a computer, so that new implants can be made to make my face sides perfectly symmetrical. I have attached a video which described in detail exactly what I don’t like about my jaw result.

A: I have seen your video and your problem is one I have seen many times. I can make the following comments:

1) Jaw angle implant asymmetry is not uncommon and is a result, most of the time, from different placements on the jaw angle rather than some inherent bony asymmetry. Bony asymmetry does not help but it is actually very difficult to get perfect symmetry (alignment of flare) between two jaw angle implants.

2) The problem you have on our left side is that the two implants (chin and jaw angle) do not meet, thus leaving a depression or lack of smoothness between the two. That, again, is reflective of the asymmetrical placement of the jaw angle implant on the left which is further back and higher than the right one. Note that your right side is smooth probably due to the better position of the right jaw angle implant.

3) Correcting jaw angle asymmetry, in my experience, rarely works by just shaving down the implants while they are in place. The implant almost always has to be removed, modified if necessary and then reinserted in a better position. Modifying it while in the patient is treating implant malposition by adjusting the shape or thickness of the implant, potentially worsening the problem or at the least ending up no better for the efforts.

4) You are correct in now assuming that the best approach to the problem is to get a 3D model of your jaw, see exactly where the implants are and make new implants if needed.

5) As for your chin, I do not have the advantage of knowing what you looked like before. But your chin result is not particularly abnormal or unexpected. It may be more projection than you want but many chin implants when placed on a smaller chin will end up with that result. It may look like it is sticking out and the labiomental sulcus will deepen. Medpor chin implants are thicker and more bulky than other materials and this may also be part of the aesthetic problem. You may simply benefit from a smaller projecting chin implant design.

In conclusion, making a completely symmetric 3-piece chin and angle jawline enhancement is not as easy as it looks on a skeletal model and you, unfortunately, are reflective of some of the problems which can occur. But your next step of getting a 3D analysis of what you have and why it looks that way is the only effective way to move forward.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was wondering if when I got a breast lift plus augmentation if I can get the scar around only the areola. Who is the best candidate for it? I have doubleDD breast size and a lot if sagging since having my son who is almost a year. And I am 19. Thanks so much!!!

A: Having DD size breasts suggests that you definitely do not need an implant but a significant breast lift. A periareolar type breast lift only provides a very limited lifting effect and is almost used exclusively in the small sagging breast when the effect of the implants helps considerably in filling out the loose breast skin and providing a lifting effect of its own. As a stand alone procedure a periareolar breast lift, also known as a donut mastopexy, does not create a significant breast lift. By your description you are in need of a full breast lift that involves a horizontal and vertical tightening and creates the classic anchor scar pattern. While every woman would like a breast lift with limited scarring, that does not appear to be an option in your case.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a serious head injury in 1994 that left me with a skull indentation on the right side of my upper forehead and it looks like I still have swelling in the temporal area. Would it be possible to flatten that temporal area and fill in the dent in my forehead to make my face symmetrical?

A: At this point nearly 20 years after your injury, I can assure you that the bulge or fullness in the temporal area is not swelling. It is either a perception of a bulge due to the forehead indentation or an alteration (uprising) of the temporal bone as the forehead area became indented. Regardless, I am certain both areas are improveable at the same time. I would need to see some pictures to get an idea of the magnitude of the problem and see exactly what needs to be done. The forehead indentation can be filled in with bone cement (frontal cranioplasty) to match the other side as best as possible and the temporal bone or muscle can also be reduced if needed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am having a facelift two weeks from today and want things to go as well as they can. I have read about taking arnica and bromelain supplements to speed healing and make my recovery quicker. Would these be good to take before surgery?

A: These are common non-pharmaceutical supplements for healing that some plastic surgeons endorse and prescribe for surgery including facelift surgery. Arnica is a well-known extract of the mountain lily flower that has been used for decades to prevent or clear bruising related to any form of trauma. Taken one week before and one week after surgery, it helps prevent some of the bruising that will occur as well as speeds its resolution after surgery. Arnica is most commonly used as an oral tablet but can also be applied directly to the bruised site as a topical ointment. Bromelain is an extract in oral or liquid form from the pineapple fruit that has anti-inflammatory properties. It is commonly used for sports injury, trauma and surgery to decrease swelling. Contrary to popular belief, eating pineapple will not increase your levels of bromelain as it exists mainly in the stem of the fruit. My feeling on both supplements is that they do no harm, are relatively inexpensive, and may provide some recovery benefit so I do advise my patients to take them particularly for any facial surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 32 Chinese female who is interested in cheekbone reduction. More specifically, I find that my left zygomatic arch sticks out more than my right, so I want to reduce by a little bit to balance out my face. Can I you send you pictures to see if I am a good candidate for this procedure?
Also I have a couple of questions:
 1) I am very worried of sagging of the soft cheek tissue, what is the risk of this and what type of procedure is done to avoid this.
2)  Is this surgery common at your office? How much experience do you have doing cheekbone reduction?
3) Will is be possible to see pictures of your previous patients that have undergone cheekbone reduction at your office?
4) Since I am an out of town patient, how long will I have to stay in town for this procedure?

I have been contemplating this surgery for a very long time and I am very keen to do it.
Thank you for taking the time to answer my questions.

A: Thank you for your inquiry. Please send me some pictures of your face for my assessment. Cheek osteotomy reduction, specifically that of the zygomatic arch, is done by a combined anterior zygomatic osteotomy (from inside the mouth) and a posterior zygomatic arch osteotomy where it attaches to the temporal bone. (from a small temporal scalp incision) In answer to your questions:

1)      Soft tissue sagging is not a concern with this type of cheek osteotomy because the soft tissues are not detached from the arc bone during the procedure. They simply move inward with the medial movement of the zygomatic arch.

2)      This is a common aesthetic craniofacial procedure in my practice. It is done almost exclusively for Asian patients.

3)      Out of respect for patient privacy and their confidentiality, we do not send  out patient photographs to prospective patients.

4)      This is a type of facial osteotomy procedure in which you could return home within 48 hours after surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a facial scar below my left cheek that I want revised by a geometric broken closure. One question I have is that I had Silikon 1000 injected under the scar to try and raise it several years ago. The material has migrated around the scar making the scar look even more indented as the surrounded tissue is raised. So I know the scar I have is around 2.2cm but I’m not sure how wide it is including the surrounding skin. Would you be able to remove the Silikon 1000 filler or at least the raised skin around the scar? If so could you still do geometric broken line excision or would you have to do a straight line scar.  I REALLY want to get rid of this Silikon 1000 but not if it leaves me looking like one side of my face is way thinner or not symmetrical to the other side. What would be your advice with this? Warm regards.

A: Once silicone oil droplets are in the tissues there is no way to get it out unless it is part of the actual scar revision. I would treat the fact that there is silicone in the tissues as irrelevant. It would not change how I would do the scar revision or the amount of tissue removed. Trying to go beyond the actual scar borders in an effort to achieve the ancillary goal of silicone material excision is fraught with causing additional scar problems. It is best to treat the scar as if it was not there.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, You suggested 10mm of vertical projection for both my jaw and chin. However, when I measured my face with a ruler, I determined that in order to achieve the 1/3 1/3 1/3 ratio, I would need between 15-20mm vertical lengthening. I am hoping we can design a chin implant that has close to 15mm of vertical length. In my experience am more worried about undershooting than overshooting. Is a 15mm vertical chin possible? If so, does it carry increased risk?

2) Can we use computer imaging to figure out the ideal dimensions? My left jaw projects significantly more than my right jaw.

3) With a custom 3-piece chin + jaw set that includes both vertical and horizontal projection, will there be a smooth transition in the space between the chin and jaw(body) 

4) In terms of safety, what is the difference between my current Medpor implants and silicone? I heard that silicone breast implants may rupture.

5) Can silicone be flexibly shaped to my jaw contour using hot sterile saline the way Medpor can? And if so, would that mean that the easiest approach is to use a previous patient’s custom implants, and skip the CT scan? 

6) How much vertical lengthening do my 7mm Mandibular Matrix jaw and chin implants already have? I can’t find the vertical jaw dimension online.

7) Since my current Medpor implants have been screwed in, how will you remove them? Do you “unscrew” them? I believe there are two screws anchoring each one of the pieces. 

8) How many custom combined jaw+chin procedures have you done in the past? Are you the only one who does this?

A: In answer to your questions:

1)      The vertical length of the jaw angles can be lengthened in the range of 15 to 20mms. The chin can not be done as much because of the lack of adequate soft tissue to recruit for coverage. A more realistic lengthening in 8 to 10 mms.

2)      2) Computer imaging is great to provide a general concept or trend but it would not be an accurate way to determine the desired millimeters of change. Unless the picture is taken so that the computer recognizes its size, it can not be used for estimating exact changes.

3)      One of the main purposes of a custom 3-piece jawline implant system is to have a smooth transition between the chin and the jaw angles.

4)      There is no danger is using silicone as a
facial implant material. It is a solid material unlike silicone breast implants. I ma not sure where you would get the concept that a silicone facial implant would rupture.

5)      Silicone always adapts better to the bone than medpor. Medpor is a very stiff material that is minimally adaptable using ‘hot water’. This is not necessary with a silicone material.

6)      It is impossible for me to say how much vertical lengthening your current implants provide since that is highly influenced by how they were placed in addition to their design.

7)      Your current implants have to be unscrewed…that is the easy part in trying to remove them.

8)      I have been making custom facial implants for 20 years. I can’t speak for who else may use this approach around the world.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have wide temporal areas between the sides of my eyes and my hairline that I want reduced. Is the temporalis muscle the reason why some people have bulged temples that are wider than their cheekbones, and some with troughed temples as wide as, or narrower than their cheekbones? Or has it also got something to do with the cranium itself? Is this feature genetic at all? My mother has troughed temples that are slightly narrower than her cheekbones, and my dad has bulged temples wider than his cheekbones. So have I carried my father’s genes for that particular feature? Thank you.

A: The shape of the temporal region, whether it is a convexity or a concavity, is largely controlled by the thickness of the temporalis muscle mass, not bone. Only very rarely, in cases of a temporal bone tumor, is a temporal convexity driven by the size of the bone. This feature appears to be completely genetically derived.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am asking you to ask about your experience with midface Medpor implants. How often do you use them, especially in men and is this your preferred material to work with? Do you have much experience in customizing the standard implants offered by the company that produces them?

I was wondering if you could take a minute or two and look at the pictures I’ve attached.

The first picture is of someone else that shows the area I’m trying to augment. This is not the malar or submalar area as such, but rather the cheekbone area high and laterally – my goal is augmenting laterally as much as possible along the zygomatic arch. The cheeks in attractive men are almost always perfectly flat or even hollow, as is the case with most/all fashion models.

The second picture is of me – I apologize for the low quality. I saw a plastic surgeon locally who said that I’m exactly the opposite of the man in the first picture. The area I marked in green is my main problem. This area (please notice the same at the opposite cheek) is very, very prominent, bulging, and very not-masculine, worsening the problem with my under-eye hollows and nasolabial folds. Someone recommended buccal fat removal, however, I don’t think this is at all right for me, as buccal fat will remove the area I marked in red, and that has little if any overlap with the problematic area on my face. Am I right in this? Or is there a way to remove the fat from the marked green area? I thought the best solution for me, instead of removing anything, would be building the upper-mid face, as I discussed above using the example of the man in the picture I’ve attached. I marked that area in black in my picture. This particular area looks depressed on my face (as you can see on the opposite, unmarked cheek), and the prominence of that diagonal strip on the cheeks (the green area) makes it much worse. Most people think i’m older than I actually am and I look tired all the time. Another surgeon suggested some sort of mid-face vertical lift, but I don’t think there is any effective way to do this. Most techniques result in short-term results and awfully lot of swelling for months. 

So, I concluded my best option is building that area marked in black with medpor implants. This would balance the prominent bulging cheeks. I attach here their catalogue (please see pdf file). On page 6, I noticed the “extended malar shape” type that the company says extends laterally along the zygomatic arch. I think it also captures the infraorbital rim area, if I’m not mistaken, and I could really benefit from it, as the existing hollows under my eyes are also a problem.

If I could please ask you: Having seen my picture, would you say this implant is the right for me, or would there be a better type? As it is extremely important for me that the implant does not add to the problematic, already prominent diagonal stripe in the submalar area of my face (marked in green), can this part be cut off from the standard implant? Or will there be no need for that? I can’t judge at all how much vertically the implant drops, but the part below the infraorbital rim is where the bulk of it is. The more vertically it drops, the worse would the outcome be for me, because it will make the cheeks even more bulging. 

I find it hard to believe that there aren’t any standard mid-face implants on the market that would cater to the needs of men. Even in this “extended” type, the extended part looks thin and stops prematurely, while the remaining malar part is quite bulky. I would probably have to go for the largest size and cut off much of the unwanted part to benefit the best. For illustration, I’ve attached here some pictures of models – in any beautiful male face the cheeks are always perfectly flat (most of malar and definitely submalar parts) and even hollow (the exact opposite of what 90% of the malar and submalar implant do!!!), but the cheekbones are high and the whole area is always built naturally well laterally along the zygomatic arch, all the way to the temporal process. 

Yet another surgeon recommended the use of hydroxyappatite instead of implants to build the area of the face I’m interested in augmenting. However, I don’t think HA can achieve that much as implants can and I wonder if it does give so much flexibility and is safe, why more surgeon are not using it?

A: To answer your questions succinctly:

1)      I use both silicone and Medpor facial extensively and have a lot of experience with both of them. I have no preferred fondness for either material as the body does not care what is implanted…it treats them all the same from a biologic response standpoint. I choose the implant material based on which one offers the best shape and size for what I am trying to achieve for the patient. In many cases the implants have to be modified during surgery to create the desired shape. In other cases, I make the implants before surgery (true custom designed implants) based on modifying existing implant styles or design my own shapes for a specific patient.

2)      You are correct in that there is no current facial implant style, regardless of the manufacturer, that is designed to create the effect you are after. This will require a modified malar implant design to achieve.

3)      The Medpor extended malar implant is the closest preformed shape but there is way too much material in the submalar area.

4)      Hydroxyapatite granules are never going to create the look you are after as they will be flattened by the pressure of the overlying cheek tissues.

5)      The cost of your malar implant surgery would be influenced by the material you want it composed (Medpor vs silicone) and how you want it prepared (intraoperative modification or custom premade).

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Many months ago, you responded via Real Self regarding my botched gull wing lip advancement. The plastic surgeon also did a v-y advancement under the cupid’s bow.  It has ruined my cupid’s bow and my lips have taken on a very flat appearance. I’ve been to 3 plastic surgeons for consults and each one has told me that there is nothing that can be done to correct my problems.  You had mentioned on Real Self that you could remove tissue (not skin) to give me a cupid’s bow which would also help with the flat look that I now have.  Would you be so kind as to explain exactly what this tissue removal involves.  I am somewhat concerned about more scarring.  As of now I have scars (small) where the current cupid’s bow is.  If you change the cupid’s bow to a more pleasant look, wouldn’t I have additional scars. I just hope that you can explain the procedure a bit more and inform me about any additional scarring.  I have attached recent photos which are 6 months after the initial gull wing lip advancement. Thank you so much, and I look forward to hearing from you.

A: What you have, as you know, is a flat or absent cupid’s bow of the upper lip. This is due to a lack of an indentation or greater vertical skin between the normal peaks of the cupid’s bow. To create this normal feature of the cupid’s bow, a few millimeters of vermilion in a curved fashion needs to be removed between the height of the cupid’s bow. You already have a scar line at the skin-vermilion junction so the risk of more visible scarring is very low. How much the prolabial skin will stretch down is uncertain but this is the only lip revision treatment option.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 37 yrs old and I have some wrinkles under and around my eyes I would like to get rid of and not sure if I should just do Botox or try and have surgery to remove them. I have attached some pictures for your review.

A: There are basically three treatments for aging eye issues, Botox, blepharoplasty surgery and skin resurfacing. (chemical peels vs. lasers)  Botox is the only treatment for wrinkles that occur OUTSIDE of the eyelid area. (e.g. crow’s feet area) Blepharoplasty (eyelid) surgery is the only treatment that can remove excess skin and fat of or ON the eyelids. Skin resurfacing using either chemical peels or fractional laser resurfacing can be used for fine wrinkles ON and OUTSIDE of the eyelids. Given the nature of aging around the eyes, many people need a combination of these approaches to get the best result…not to mention the need for maintenance therapies such as Botox injections, topical skin creams and the avoidance of smoking and extreme sun exposure.

What I see in your pictures is hooding of upper eyelid skin and a roll of skin underneath the lashline of the lower eyelid. These are definitely surgical (blepharoplasty) issues. I suspect there is wrinkling beyond these areas but the quality of the pictures does not permit that assessment. These pictures are also only smiling which creates animated rolls of skin on the lower eyelid which may or may not be present when not smiling.

The short story is that you are likely in need of surgery for major improvement but I would not use the term ‘remove’ when it comes to eyelid aging changes as that is not realistic. You need to think improvement of them that is not going to be a permanent cure to them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a flat back of the head that I think makes me look odd and I want to build it out. I have attached pictures from the side of my back of the head profile. How can this head change be done?

A: Thank you for sending your pictures and illustrating your desired back of the head change. Based on your goals and drawings, the first thing I would point out is that the skull bone actually stops at just about the level of the top of the ear, an area much higher than most people realize. Therefore, no type of skull bone augmentation can go that low. The lower half of your desired expanded area are the soft tissue of the neck not bone. Secondly, as a man who shaves his head any incision to do skull augmentation  is a very treacherous aesthetic trade-off and I would not recommend it for most men. The only option I would consider would be fat injections to build up the back of the head. But the problem with fat injections is whether you nave enough fat to harvest to do the procedure and the unpredictability of how much would survive and how smooth it would be. But this is the safest aesthetic option with very little downside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can the silicone implants be inserted through an armpit incision? I’m looking into getting implants. Im 30 years old and have had 3 kids. I use to be a full C now I’m barely a B. I know by research that knowing what one to go with or how big to get the look I want is impossible via email but could you send me as much information as you could. Maybe a price range I would be looking at before I get my hopes up on finally getting it done. Thanks in advance.

A: Silicone implants can be placed through the armpit up to a certain size, usually in the maximum range of 400cc to 500ccs based on my experience. Beyond that size they need to be placed through an inframammary fold incision. Having had three children a very important consideration is if you have any significant breast sagging. If you do you may not be able to get by with just implants alone. I would have to see pictures of your breasts to better answer that question. One can anticipate the total cost of silicone breast implants to be in the $5,000 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I incurred a closed depressed skull fracture from a head-butt when I was 22. I am now 28. The depression in my skull has bothered me emotionally since it happened and I have some physical pain too (I feel like there is constant pressure on the area). When I participate in rigorous physical activity (such as running) I get severe head aches. I hope to get surgery to elevate the depression and was interested to know more about possible procedures.

A: If you are having symptoms of headaches and pain from your depressed skull fracture, the first thing you need to do is to consult a neurosurgeon to be certain that there is no undue pressure on the brain. While I would doubt that is the case after this many years, it would be an important first step to do. That is the only reason that the skull fracture would be elevated and that will require an open craniotomy to accomplish. If your neurosurgical work-up is negative then the depressed skull area can be treated for its cosmetic appearance by an onlay cranioplasty to build up the outside of the bone. A skull fracture is not elevated by craniotomy for a cosmetic change only.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like my chin made shorter, smaller, more even and to have fat removed from the chin where a plastic surgeon mistakenly added fat in my chin. I have outlined the fat I want removed in one picture. I also have sort of a balled chin and I believe it is weird and uneven in many ways including a minor balling problem. I want a normal, nondescript chin, as much as possible without putting in another chin implant.  You can see that my chin is too long, uneven and overly prominent. In one picture I outlined in brown pencil where another plastic surgeon mistakenly injected fat. I would like to have this fat removed if possible. In another picture you can see my overly long chin in profile. In the last picture you can see me pinching the extra skin that resulted from 3 chin implants that were placed and later removed.

A: Thank you for sending your pictures. You will need a significant reduction of some bone and soft tissue to effect a visible chin change. You do not need an implant but a reduction in tissue volume that is best done from a submental chin reduction approach. The chin bone needs to vertically reduced, transversely reshaped and a large wedge of overlying soft tissue removed as well. The fat that was injected was placed in the labiomental fold area, a difficult if not impossible area to remove. Small cannula liposuction can be done but its effectiveness is uncertain.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had liposuction done to my calfs out of state.  My calves look great and I am happy with results but I’m not happy with the indented scars that are left. Three of the eight incisions are indented.  The incisions were left open to drain and were not stitched up.  I understand some docs do this and some don’t.  I guess it’s a preference thing.  They are very small incisions but I still do not like that they are indented.  Because of the location on my calves, they show a lot.  I feel like everyone will now know what I had done.  I can’t enjoy the results because of this.  I feel like I would have been better off if they were stitched up and became keloid scars this way I could flatten them with scar strips like I have done in the past.  Even with scar revision, I know they will not go away completely.  I am realistic about this but as indented as they are, they will attract more attention.  I have had liposuction in the past on other body parts and the incisions were sutured up and now you cannot even see the scars.  So I do have experience with this.  That is what I was hoping for these too.  Now there is nothing I can do to pull them out.  I have included pictures.  I would like to discuss what method you would use to pull them out or even cut out the scar and resuture.  I heard some doctors make another incision and then loosen the connective tissue (with a needle) that is pulling it down and then suture it up.  This is what I would be interested in.  What would you charge per indentation?   If this is something that you are comfortable doing or have experience with, please have your assistant contact me.

A: Indented scars from liposuction are common on the calfs if they are not sutured closed because the skin is so naturally tight and thick. This is particularly true on the back of the calfs. The best approach would be to a simple scar revision by excision, release the indentations by needle (subcision) and then reclose them. This would be a fairly simple procedure done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My forehead it’s very high and it also sticks out, I feel it takes the beauty away from my face. Is there a surgery to fix it and if there is I would like to know if it is too risky?

A:  The high protruding forehead is usually due to a combination of a hairline that is set back too far and the forehead bone having some degree of protrusion to it as well. It can be treated through a combination hairline lowering (scalp advancement) and burring bone reduction of the upper forehead bone. This procedure is very safe and has no significant risks to it…other than a fine line scar along the frontal hairline. Whether you would be a good candidate for this procedure would depend on how much laxity is in your scalp and the pattern and hair density of your frontal hairline. A review of any pictures of your face/forehead from the front and side view would be very helpful in determining if you are a good candidate for this forehead reduction procedure.

Dr. Barry Eppley

Indianapolis,Indiana