Q: Dr. Eppley, my chin soft tissue is really just sitting on top of the bone and does not feel super attached. I just would like to know if you believe that a vertical lengthening bony genioplasty will cause it to move down as well.

Thank you so much for your time. 

A:Whether the soft tissue is super-attached or not it it still going to be dragged down to some degree as the chin bone is vertically lengthened. (vertical lengthening genioplasty)

Dr. Barry Eppley

Indianapolis, Indiana

The post Will The Soft Tissue Follow The Bone Down In A Vertical Lengthening Genioplasty? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I want to shorten my midface to bring it into better facial balance. I think a LeFort I impaction osteotomy will work, what do you think? I have attached another surgeon’s result from a similar procedure which is why I ask.

A: Thank you for your inquiry and sending your picture. In answer to your midface shortening question:

No matter what you do to the midface bone in terms of bone shortening or rotation the external midface is not going to get look shorter which I assume is your goal. Everyone forgets about the soft tissue part of the midface which can not be removed or tightened unlike the upper and lower facial thirds. Midface augmentation techniques that improve its projection will help with the illusion that it is shorter..which is done by different forms of maxillary-infraorbital-cheek implants. Otherwise I would ignore that before and after LeFort1 osteotomy example as that is a very misleading result because it is early postop, is deliberately tilted downward and the patient has had a rhinoplasty that has rotated the tip upward. All of this makes it looks like the LeFort osteotomy has shortened the midface when in fact it has not.

Dr. Barry Eppley

Indianapolis, Indiana

The post Can Midface Shortening Be Achieved By A LeFort I Impaction Surgery? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, Over the years I have lost fat above my left eyebrow that is causing a very noticeable shadow in different lights. The shadow/dent makes it seem I am angry all the time even when my face is at rest. It is causing me to be very insecure with my appearance. I have heard that fillers can be used to fill this area, however, have heard that it is a very high risk area to treat due to the arteries around. Can you provide any recommendations on potential treatments that may work to lessen the appearance? I have provided a picture to this message as well.

I appreciate your time so much.

A:Injectable fillers would be an appropriate place to initially treat this left eyebrow subcutaneous fat atrophy problem. The key is to use a cannula injection technique rather than a needle approach as this reduces the risk of any inadvertent arterial injection. There are obviously bone augmentation implants/techniques to use as well but the use of injectable fillers and fat would seem to be the best initial approach to it.

Dr. Barry Eppley

Indianapolis, Indiana

The post Are Injectable Fillers Safe To Be Used To Fill In My Eyebrow Dent? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I had a punch to my face almost 4 years ago and now have a dimple in my cheek. It is not painful but I do not like how it looks. If I smile to much, to hard, or to long it does feel somewhat odd and looks like a big ball on my cheek. I’m wondering what I would need to have done to correct this and get it back to normal? 

A: That soft tissue indentation (dimple) is undoubtably caused by far atrophy/contracture secondary to the original trauma and subsequent subcutaneous tissue loss due to hematoma/bruising resolution. The best way treat it is a release/fat injection method. Whether you can ever get back to the pre-injury cheek shape is unknown but this approach will offer some improvement in the indentation.

Dr. Barry Eppley

Indianapolis, Indiana

The post What Is The Best Way To Fix Cheek Dimple After Being Punched In The Face Years Ago? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I’m a 33 year old female. As a teenager 4 of my premolars were extracted for braces, and later 4 wisdom teeth. My facial profile is very flat with no frontal projection of the cheekbones as a result (I lost several mm of volume in my face). I tried to have my upper and lower palette expanded with removable appliances with a dentist at age 32 but my mandible was left retruded. 

I have UARS and struggle with choking, asthma chronic fatigue syndrome, and flimsy nostrils. Both both my nose and throat are obstructed. I’m suppose to get surgery on my nostrils to breathe better, but I know real problem is that the entire nose lacks support both from the loss of cheekbone fullness to support the nostrils and a retruded maxilla. 

I’m in the early stages of looking for a jaw surgeon to correct my airway issues but I know that no amount of surgery can bring back fullness to my cheekbones and upper alveolar process because of the bone loss from so many dental extractions and retraction from braces. 

I was curious if you ever work closely with a maxillofacial surgeon to address some of these aesthetic concerns while they address functional ones? I’m hoping to find a surgeon who is able to do a counterclockwise rotation. 

Ideally I’d love if these procedures can be completed before 9/17/22 because I’m suppose to be married on that date. 

I’ve included multiple photos to show my face and jawline from the side, front, and at various focal points. (The ones not taken in doctors offices were from this year, and I included several from various doctors to account for any discrepancies in focal point, etc., of the photos) 

I think a lot of these issues have to do with my upper palette growing more narrow as a child and preventing proper tongue posture/jawbone growth resulting in a subtle lengthening of the entire face over time, exacerbated by braces and extractions. This lengthening is best shown in side photos of my gonal angle, and the resulting lack of projection in the lower 1/3rd of the face. This elongating also effects my eyes, which are a few milimeters closer together than they were before braces/extractions at age 16 and my nose, which appears larger as a result of the set back maxilla and mandible.

A:Thank you for your detailed inquiry and sending your pictures. My interpretation of your current facial issues are that you may need bimaxillary orthognathic surgery (double jaw surgery) for opening up your airway but, as you have acknowledged, such surgery will not likely adequately address your aesthetic issues. (and may create some new ones as well) While some form of facial augmentations may eventually be of benefit, such aesthetic facial implant surgeries are never performed at the same time as the orthognathic surgery. This is due to not only an increased risk of infection but also because the true aesthetic needs can not be accurately determined. Thes two surgeries are separated by at least six months and also requires an after orthognathic surgery 3D CT scan for treatment planning and implant design.

Dr. Barry Eppley

Indianapolis, Indiana

The post Can Custom Facial Implants And Orthognathic Surgery Be Done At The Same Time? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I am very very stressed about a situation i am confronted with. I have put medpor jaw angle implants actually and i don’t like the way it looks on my face and i would like to replace them. 

However I read in several web sites that it’s impossible to replace, others say possible but difficult, i m very scared about it, am i obliged to keep them all my Life ? What solution can i havé ? 

Thank you doctor

A: They can be safely removed and/or replaced. I have done it many times.

Dr. Barry Eppley

Indianapolis, Indiana

The post Can Medpor Jaw Angle Implants Be Removed And Replaced? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I am a patient who would like to inquire about reversal otoplasty surgery for over-corrected ears. I have attached some photographs.

I had otoplasty 10 years ago, and I regret it. At the time I was young and insecure about my appearance, but have since come to the opinion that my original ears, although they stuck out a bit, were suited to my face. 

Unfortunately my ears seem to have been operated on badly – they are now harshly shaped and too close to my head, especially the left one. They are also different to each other, one is big and one is small, and the right ear has a sharp ridge of cartilage on the anti helix.

I am not looking for perfection, and know it is not possible after a failed surgery. However, I would like, if possible, to regain a more natural look – with the mid to upper part of my ears to come outwards a bit more – so that there is a more rounded appearance from face on. And for the ear shapes to match each other better.

I hope this is enough information and the photos are suitable, I’d really appreciate your thoughts on my situation. Also an estimate to the cost of this type of surgery would be helpful. 

Many thanks for your time,

A: The reason your ears were over corrected is that you had the wrong otoplasty procedure. You had a well defined antihelical fold originally and the proper technique was a conchal setback rather than antihelical fold sutures. Now the outer helical rim is pulled behind the antihelical fold. For a reverse otoplasty the antihelical folds need to be released  and an interpositional cartilage graft placed. You are correct in that they still won’t be perfect but they will look better.

Dr. Barry Eppley

Indianapolis, Indiana

The post How Can My Over Corrected Ears Be Fixed? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I have egg shaped eyes and I would like a more almond shaped kind of look sorta like Megan Fox’s eyes. I would just like for my eyes to be smaller instead of big and I was wondering if that was a thing or not. Also do you guys do the cat eye/fox eye lift ? My last and final question is am I eligible for a lip reduction I have big lips and I would like them super small. 

A:The main reason you have ‘big’ eyes is that the bone around the eyes is not well developed, thus the eyeballs stick out more. (known as pseudoexophthalmos) No form of eye corner or eyelid reshaping will work in this situation because of the lack of adequate periorbital bone structures. As for the lips, while they can be made smaller they can not be made ‘super small.

Dr. Barry Eppley

Indianapolis, Indiana

The post How Can My Big Eyes Be Made Smaller? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley,Thank you for getting back to me. I truly appreciate your team’s time, as I know that Dr. Eppley is renowned in his field and ahead of the curve. I have one last question for him, so that I can consider my options and then decide which one I want to schedule a consultation for. My question is: Is it possible to do a bone reduction by itself, without doing a temporal reduction, or is it necessary to do the temporal reduction first, to get to the bone?

A: When it comes to temporal reduction, if the intent is to reduce the width or convexity of the side of the head, the most significant effect come from muscle removal and also can be done in a scarless manner from an incision placed behind the ear. If one wants to do temporal bone reduction this requires an incision up on the side of the head. That more visible scar tradeoff and the negligible effect that temporal bone reduction has due to its thinness (1 to 2mms only) is why temporal bone reduction by itself has little benefit and is not usually done as a standalone procedure or before muscle removal is done. This doesn’t mean it can’t be done but is not an effective head width reduction technique in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

The post Will Temporal Bone Reduction Be Effective? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, Hi my 14 year old son has a great complex. 

He has uncorrected brachiocephaly. The pediatricians told us that it would correct itself but it did not. 

At what age could I place the 3D implant?

A: Once past puberty I think it could be done anytime that the patient feels that it is aesthetically bothersome.

Dr. Barry Eppley

Indianapolis, Indiana

The post Can A Teenager Get A Custom Skull Implant? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, Are there any risks to a genioplasty revision not present in the original procedure (or risks that rise when you do a revision, versus the original)? I.e.: mentalis sag, infection, step off

• About how many secondary genioplasties have you done? (can be in the last few years, or whichever time period, but let me know which one you are using). When was the most recent secondary genioplasty you did?
• In your patients who undergo secondary genioplasty: has anyone ever experienced complications, and if so what kind? Have you ever had issues removing the original hardware?
• Does secondary genioplasty become more difficult to perform/get good outcomes from the further along post-op you are from the original procedure? (maybe because bone grows around the hardware, for ex.). How far along post-op are secondary genioplasty patients, usually?
• is it riskier/less risky to do a submental incision, versus intraoral?

Thank you!

A: In answer to your secondary genioplasty questions:

1) The risks are identical to the first genioplasty.

2) I so bout 10 to 12 secondary genioplasties a year.

3) Unless bicortical screws are used for fixation removal of existing plates and screws is not a problem.

4) Secondary genioplasties are done weeks to years after the original procedure. It is obviously easier to at weeks after surgery rather years but they can be successfully done in the short or long-term.

5) You can not do a sliding genioplasty through a submental skin incision….unless the goal was a reduction and not additional forward bone movement.

Dr. Barry Eppley

Indianapolis, Indiana

The post Are The Risks Greater With A Secondary Genioplasty As Opposed To The First Time? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I hope this email finds you well. I am interested in a non-custom chin implant of about 7.5mm, or whichever size you would recommend for my face. I also have a bit of asymmetry where my chin skews toward the left and is especially visible from the front, which I’m also hoping to correct. Based on these details and the photos attached what do you recommend?

A: Thank you for your inquiry and sending your pictures. I would probably use a Mandibular Glove style chin implant of which the size options are either 6.0 or 8.0mm. When it comes to the asymmetry all that can be done with a standard chin implant is to deliberately shift it more to the right…which may lessen the asymmetry. How much to shift it to the right would depend on assessing a panorex x-ray and determining preop how much the central point of the chin is deviated to the left.

Dr. Barry Eppley

Indianapolis, Indiana

The post What Type Of Chin Implant Do You Recommend? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, I do have a couple of follow up questions for you in regards to the total jawline augmentation that we discussed

• 1) Are you able to combine a sliding genioplasty with a single piece custom jaw wrap around implant or can it only be combined with 2 lateral custom jaw angle implants?
• 2) If the first instance is possible, how will the design process of the implant happen given that a CT scan of what my chin will be like wouldn’t exist yet?
• 3) I am also considering hd liposuction (not facial or neck related) with another doctor, and I am wondering how far apart should the surgeries be. If I were to do the lipo first, how long would I need to wait before you would want to operate on me?

A :In answer to his jawline augmentation questions:

1) A sliding genioplasty can be combined with a single piece custom jawline implant.

2) You make the exact movements of the chin on the scan and then design a jawline implant around it. It is a not uncommon combination.

3) I would separate them by at least 6 weeks.

Dr. Barry Eppley

Indianapolis, Indiana

The post Can You Combine A Sliding Genioplasty With A Custom Jawline Implant? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, How accurate is computer imaging of the face in regards to the final outcomes achieved?

A: The role of computer imaging in facial surgery is frequently misunderstood by patients. Computer imaging is done to help determine what the patient’s aesthetic goals are. It is a method of interactive visual communication to help your surgeon understand what your specific facial reshaping goals are. It is not necessarily a completely accurate predictor of the final outcome nor is it intended to be. In facial structural (bone) surgery it is a critical part of the preoperative workup because the patient is going to a look that they have never had and I have to know what exact look they are trying to achieve. Conversely In facial rejuvenative (soft tissue) surgery, computer imaging is less frequently done or of great value because the patient’s goals are well known as they are just trying to go back to achieve a look they are already know. (look younger) In addition such soft tissue facial imaging is prone to shape and shadowing distortions that introduce limitations to any visual value that it has.

Dr. Barry Eppley

Indianapolis, Indiana

The post How Accurate Is Computer Imaging Of The Face With Actual Surgical Outcomes? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

Q: Dr. Eppley, Will intraoral chin resuspension work for the loose chin tissue that I now have after mini V line surgery?

A: You suffer now from chin pad ptosis/’extra’ tissue from the loss of bone support and the wide stripping off of tissues to perform the chin osteotomy. Simply put you have too much soft tissue for the bone volume underneath it.  Intraoral chin suspension is not going to be effective alone and one is certainly not going to perform an external wedge excision of redundant soft tissue chin pad tissues due to the scar. Unless you are prepared to put back the lost bone support, which would be the antithesis of what your original aesthetic goals were, I do not believe anything is going to be effective.

Dr. Barry Eppley

Indianapolis, Indiana

The post Is Intraoral Mentalis Muscle Resuspension Effective for Fallen Chin Tissues After Mini V Line Surgery? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

The post Why Did My Wraparound Jawline Implant Make My Face Look Round And Not Angular? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

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

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

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

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

One of the calf implants? 

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

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

Many thanks,

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

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

or 

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

The post What Is The Best Way To Eliminate The Visible Margins Of My Tricep Implants? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

The post Can Frontal Bossing Reduction Be Done At The Same Time As A Hairline Advancement? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

The post Will A Second Sliding Genioplasty Help Me? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.

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

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

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

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

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

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

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

Thanks so much, 

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

The post Will A Subnasal Excision Get Rid Of My Horizontal Upper Lip Line? appeared first on Plastic Surgeon | Dr. Barry L. Eppley, MD.