Your Questions
Your Questions
Q: Dr. Eppley, I am looking to get some surgeries eventually for gender affirmation and my PCP recommended your office if I had some more specific questions. The surgery I am mainly interested in at this time is FFS. Does Dr. Eppley recommend a certain time being on HRT before he performs this? Also, would it be possible to get an estimate on how much this usually costs?
A: FFS is a collection of over a dozen procedures, most of which are done to change the structure/shape of the face. Not every patient needs all of the available FFS procedures based on the natural shape of their face. The FFS procedures of greatest value must be determined on an individual basis based on a picture assessment and computer imaging of potential changes. Once this is determined then the cost of such surgeries can be provided to you.
In addition I would wait a minimum of six months after being on HRT before proceeding with FFS surgery….not so much because it makes major face changes but more for assurance that this is the correct change in life you desire to do.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, i am interested in getting custom jaw implants and upper maxilla implants with Dr Eppley. i’m a transgender woman and previously have had a few jaw surgery procedures during my transition including double jaw surgery and also mandible shaving (all done in Korea) i’m from the UK. i got these done years ago and i never was so happy with the results as i feel the surgeon shaved off too much of my mandible and as i am aging all the definition is now gone in that area. i want to get more of a western ideal squarer jaw, and also correct the asymmetries i have in my upper mandible as i have had some bone loss in this area due to the jaw surgeries and want more projection using a custom implant in the midface/nasolabial fold/upper maxilla area
A: Thank you for your inquiry and detailing your surgery history and current objectives. Your V line surgery history is not uncommon as such surgery can only be done one way,,,significant bone removal due to the intraoral access used to perform it. A custom jawline is the only way to achieve partial or complete restoration of the jawline. Foe the midface it is yet unclear whether a custom implant approach is needed as opposed to standard ePTFE premaxillary-paranasal implants. For now I will. assume the former.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Quick question, I’m considering to have a skin rejuvenation procedure done with CO 2 laser or something similar, I’m wondering, will these risk damaging my infraorbital implant if used on the tissue that lies above?
A: Thanks for the long term followup. In terms of the IOM Implants they are down at the bone level while any form of skin rejuvenation affects only the skin/dermis. No significant heat or tissue damaging effects can get that deep. In addition the implants are structurally stable up to 190 degrees Celsius before they will melt so I believe they will be OK!
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m interested in discussing a chin implant overlay. I’ve had a previous sliding genioplasty and would like to get a broader chin and smooth out the minor bone irregular from the genioplasty cut.
A: Overlaying a prior sliding genioplasty between getting a specific aesthetic change as well as to adequately cover the posterior bony stepoffs is optimally done with a custom chin implant design.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am an asian male, 29 year old. I recently did a custom jaw implant (just jaw implant, no chin implant) with about 5mm lengthening and 3.7mm widening (each side). I am almost 2 months post op but since 1 month ago, i noticed an obvious lump where the jaw implant ends near the chin. When i run my hand over the jawline from the chin, i can feel that the jawline is not one straight line. Even in photos, i can see the bump. The surgeon said its swelling but i feel that its more likely bad placement or the design of the implant is not good. Can you offer your advice?
A: This is between you and your surgeon to sort out. But always when there is an implant positioning question a 3D CT scan will provide a definitive answer provided that the implant is of a material that can be visualized.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hey I was planning to do boxing in the future and get some implants. I heard something saying that it’s not a good idea to get implants if you’re boxing. I was wondering if there’s anyway you can possibly make them smaller or make in a certain way so that they don’t have a chance of falling off.
A: Skull and facial implants quickly become encapsulated which firmly locks them into their location on the bone, making it extremely difficult for them to ever be displaced by any external force. I would have no concerns with boxing after getting facial implants once they are well healed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Is it possible to make my skull more egg shaped… narrower and taller and more 3D shaped at least from the back? Should this surgery be done before or after a 3 piece lefort1? Thanks
A: Skull reshaping procedures such as increasing height with implants and narrowing the sides by temporal muscle reduction are common independently done procedures. But when combined can create an overall skull shape effect like more of an egg-shape. How effective that would be for your head shape requires pictures so i can some imaging to see what degree of these changes are possible.
Skull reshaping is anatomically separate from that of the face so whether it is done before or after a LeFort Osteotomy is a personal preference.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to know if skull reduction is a possibility cause I will like to reduce mine from circumference 63cm to 58cm. Will that be possible?
A:Such a circumferential measured head reduction change is not surgically achievable.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I recently got jaw angle implants size 8 mm and it has been 4.5 weeks. My left side however seems a bit larger and the jaw angle goes slightly further than the cheekbone while the right side is in line. My first question is: do you think the asymmetry could be due to swelling or that’s just how it is going to be moving forward?
Since the implant also added slight vertical length, I feel that when I smile my face looks slightly bulkier than before in the lower half due to my cheeks extending. My second question is do you think that could change with swelling decreasing or that’s a permanent issue I will have to get used too?
A:I don’t comment on cases that are currently under active care by another surgeon…which at one month after the surgery would clearly be the case.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I want to get some implants in the lower part of my face to improve it without changing the features, just enlarging the size. Also, implants in the forehead and brow bones to make the eyelids less visible. I want to inquire about the extent of the change in my appearance and whether people will notice a big difference. I am 18 years old. When will the face bones stops growing ، and are implants affected if the face grows?
A: In answer to your facial augmentation questions:
1) The extent of change in facial appearance from custom facial implants is a direct reflection of their design…which is based on a predesign understanding of what the patient does and does not want to achieve.
2) Implants do not affect facial bone growth nor are they affected by facial bone growth.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My nose on the right sight is tilted and sits further into my right cheek than my left cheek. I thought it was my nose itself that was crooked but I noticed it’s not the nose itself, it’s my cheek bone and premaxillary bone. It is more recessed on on the right right which pulls the right side of my nose over and also pulls the right side of my lips up.
I was wondering if a paranasal/ midface implant could help this?
A: I think some form of a midface implant on the right be helpful for sure and will do about as much correction as possible. A 3D CT scan will provide the definitive proof of the extent of the midface asymmetry as well as serve as the platform for the implant design.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in the following procedure: Harline lowering/ Facial feminization surgery – but has the following question: I’ve had a previous (coronal) incision from a different surgery and am now unsure if i’m able to be possible to go ahead with this procedure with Dr Eppley. Do you know if this is a possibility?
A: Unless the location of the coronal incision is at the frontal hairline then a frontal hairline advancement can not be safely done. It can technically be done but there is increased risk of hair loss between the two incisions.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, “I just want to confirm that the “forehead-brow bone reduction/reshaping” includes the hairline advancement component? From what I understand it is always performed with a type III brow reduction because without it the skin would be loose since there is less bone volume.”
A: That is not an accurate statement. Forehead/brow bone reduction does not cause loose skin. Thus many forehead-brow bone reductions are done using a variety of incisions in which no hairline advancement is done. That being said forehead browbone reductions can be done in conjunction with a hairline advancement in which case by necessity a frontal hairline incision is used.
You are undoubtably confusing or making references to transgender forehead-brow bone reductions in which many such patients need a frontal hairline advancement for its feminizing effect and thus they are quite commonly done together…but it is not for fear of loose skin.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I read all the plagiocephaly page but my answer was not there, I am really concerned about the facial assymetery and protuding / the bulging face, I really love my left side, but my right side concerns me and is making me feel low and low all the time, can the custom implants for the back of head to fix plagiocephaly fix the facial assymeteries and make the right side face look same as left side or do I have to get specific surgeries such as rhinoplasty/fillers to even them out like the left side? And is it possible to fix assymeteries first using fillers and afterwards do rhinoplasty (nose reduction) etc?
A: Custom back of the head implants address the back of the head asymmetry but any anterior facial asymmetries must be addressed separately.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, regarding rib removal I have a concern, since I am breastfeeding, how can we ensure or know that my body has enough nutrients to recover from the surgery and for the bone to heal?
A: Don’t do the surgery until you are finished with breastfeeding…that is the only assured way to know.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Looking to have jaw implants done. I’ve had TMJ replacement, so my ramus on one side is titanium as my joint is a prosthetic. I would think I can still have jaw implants, but I would like clarification. This will explain if your unsure what this is.
A: I am very familiar with the Total TMJ Joint Replacement system since I served as one of the clinical investigator sites in the late 1990s for its FDA approval. An implant can be placed over the the titanium ramus component but should be done through the external incisions to lower the higher risk of infection that exists from an intraoral approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had jawline implant removal in South Korea which caused masseter muscle dehiscence and I would like to have it corrected. I attached some pictures and would like to know if this can be done and how much it costs. Additionally, I might replace my implants and want to know if I should do this before or after the muscle correction procedure.
Please let me know.
A:The first concept to grasp about masseter muscle dehiscence is that you can not move the muscle back down over the bone. The muscle fibers have become shortened and fibrotic and basically are not going to move. However, the appearance of masseter muscle dehiscence can be improved by viewing and treating as a soft tissue contour problem through various augmentation methods. But this should not be attempted/done until you have made the decision to place a new implant or not. If a new implant is to inserted the jaw angle soft tissue problem can be treated thereafter.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I have a pronounced sagittal keel and an osteoma an inch lateral of it. Due to MPB I would like to shave my head, unfortunately they are preventing an aesthetic appearance. I’m looking to get them removed/reduced. How can I go about determining if the sagittal keel is a thickened region or a raised intracranial region. Can you use an old CT scan?(5 years ago). I’m hoping an operation is possible. Thank you.
A:Such sagittal crests are reducible, the only question is by what amount. That is the role of the CT scan to make that determination. A previous head/skull CT scan should suffice for that assessment, regardless of its age, since your skull structure is stable.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m planning to get a head widening implant. Does a implant on the side of the head above the ears cause any complications to the muscles that moves the ears up and down? Especially the top auricularis muscles?
A:Since a postauricular incision is used for placing most head widening implants I make the assumption that the auricular muscles will be adversely affected. Thus one will probably not be able to wiggle one’s ears after the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in deltoid implants do to atrophy caused by spinal stenosis. I have been a body builder for most of my life and wish to address the shoulder asymmetry. Thank you.
A:Thank you for sending your pictures in which the atrophy of the deltoid muscles is very apparent and disproportionate to the rest of the well developed body musculature. There are two submuscular approaches to implant augmentation of the deltoids, anatomic and non-anatomic implant placements. The anatomic approach is to place implants that paralllel the natural orientation of the three muscle bellies of the deltoid. (two or three implants placed longitudinally through combined posterior and axillary incisions. (see attached diagram) While this is anatomically correct it is more technically challenging to perform and involves multiple implants…with a loss of muscle mass and a tighter fascial sleeve due to the atrophy. The non-anatomic approach places a single implant perpendicular to the muscle bellies in a front to back direction. (see attached diagram) Each approach has their distinct advantages and disadvantages.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in having plastic surgery to remove the temporal muscle. I would like to know if there is pain, visible scars, hair loss in the postoperative period, or any side effects.
A:I am not yet certain which part of the temporal muscle to which you refer. But assuming it is the posterior portion above the ears that is a procedure from the sulcus in the back of the ears so there is not visible. Within a day after the surgeyr most people have minimal discomfort. There is no hair loss in the overlying temporal scalp nor is there any negative effects on jaw opening and closing.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I just wanted to reach out as I’m looking for more information regarding plagiocephaly. I think I suffer from it as one side of my head is misshaped quite noticeably on one side, my ear is also lower and my jaw is misaligned too. My left eye is much more stuck out than the right and altogether It’s really effecting my mental health as when I am out on a day to day basis people stare or laugh and it’s damaging my confidence massively. I would like to see if theirs any way I can I can help fix this asymmetry? And if so what sort of price would something like that be? Hopefully you see this message I would love to hear back. Thank you.
My skull is basically twisted to the right including my facial features, my left ear is lower than the right one, my left eye protrudes out more than the right one, my lower jaw shifts to the right and my forehead sticks out more on the right side of my head.
A:Every skull and facial abnormality that you describe is consistent with plagiocephaly. In treating plagiocephaly you have to make a list of all abnormal features that you see and then PRIORITIZE them from the most important to improve to the least important to try and change. Working off of that list then establishes the surgical plan and how to proceed. Some of these feature changes have high success rates of improvement (e.g., skull flattening) while others may not be changeable at all. (ear position) Generally most plagiocephaly patients rate the flattening on the back of the head as the #1 priority.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I was hoping after seeing the videos we would have some modifications to my jawline implant designs. I agree with less is more. Still very uneasy over the unknown. I understand that every patients anatomy is different but would you guys be able to share any before and after photos with me with specification on implant design measurements just so I can see what that looks like, because at this point I really have no idea. Either way I will trust your recommendations and expertise.
A:Your dilemma is a common one in custom facial implant designs. You are trying to understand/determine the external soft tissue effects from an implant design on the bone. But that is impossible to do with any accuracy since everyone’s soft tissue thicknesses are different with varying responses to underlying pressure displacement. This is why there remains as of yet no scientific formula for making that correlation. Thus custom implant designing is a best guess estimate of what implant dimensions have the greatest chance of getting close to the desired patient results. It also explains why there is a 40% revision/replacement rate in custom facial implants…as the true effects of an implant design are only known after it has been put in. Then the patient now knows the exact implant dimensions that are needed to achieve their ideal result.
In my experience the more the patient tries to figure out what the best implant dimensions are the worse the design usually ends up. Or to put on another way…the patient who exerts the greatest effort in trying to perfect an implant design have the highest revision rates. The main advantage I have over patients is that, after over 1,000 implant designs and surgeries, I have a better feel for the cause and effect relationship between the implant design and aesthetic outcome. That doesn’t make what I choose perfect, just that I am in a better position to do the guessing.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I managed to take a very symmetrical picture of my face and it shows that I definitely have vertical orbital dystopia, and not just facial asymmetry like I used to think. I have for a long while been conscious about my eye asymmetry so I’m wondering what the treatment could be? Thank you for answering.
A:To determine if and what surgery may be effective for VOD the workup includes a true straight on facial picture (not with the head bent slightly down) and a 3D CT scan of the face. Until then only the general concepts of VOD surgery can be discussed but not if it would be effective for you.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have large conchal bowl on both ears and this is something I don’t see many surgeons can correct, I believe it is because that scar it will leave due to the wedge resection. I don’t know how else the conceal bowl can be reduced but I wanted to see if the doctor could help as this is a concern that I’ve had for many years. I’m not sure if the photos show it but in person my conchal bowl is very large compared to the rest of my ear.
A:You have correctly surmised that only a mid-ear wedge resection can reduce the size of the concha and that the resultant scar to do so may not be a good aesthetic tradeoff. And should one find the scar undesired there is no going back as it is irreversible…so it is a big aesthetic gamble.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had 2 questions regarding the CMA and WMA implants. I was wondering what your thoughts on the CMA vs the WMA mandible angle implants were; I see they were both designed by you, however I saw previously you say you favor the WMA, and was curious as to why?
Secondly, when comparing both these implant types, which do you think offers more vertical projection? I know that these implants focus on the lateral projection, but that a small amount of vertical projection comes with horizontal focused implants. As such, would be curious as to which would help the vertical projection as well.
A:The two fundamental jaw angle implant styles are for different aesthetic effects, one for widening and one for vertical elongation. So it is not an issue of surgeon preference, it is an issue of what fundamental jaw angle shape change does the patient need/desire.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am from the UK you are the only surgeon I have found that thoroughly explains the different types of chin surgery and have so many amazing testimonials.
I am looking to horizontally reduce my chin protrusion. I especially don’t like how long it gets when I smile and gives me some chin ptosis.
Would I need: Submental technique for combined excision of horizontal bony excess and redundant soft tissue chin pad. With chin ptosis tuck
I worry that it will make the chin ptosis when I smile worse as I saw you mention that the chin ptosis tucks don’t always give long lasting results, so can it come back?
I also of course want a rhinoplasty, but don’t want this before I can get the chin reduction as my side profile would be off balance and it’s much harder to find a credible chin surgeon as it is less practised.
I have attached lots of photos. On the ones with before and afters I have edited the after images to give an idea of the desired result I would be looking for.
A:You have correctly surmised that most chin reductions, and particularly a significant horizontal reduction requires management of both the excessive bone and soft tissue chin pad. Thus only the submental chin reduction approach be effective.
I am not familiar with the statement ‘you mention that the chin ptosis tucks don’t always give long lasting results, so can it come back?’ as I am sure I have never said that. What I undoubtably said was when doing the soft tissue reduction it is impossible to know whether one is taking enough soft tissue off. Thus in 50% of the cases a secondary chin tuck and/or scar revision is needed to maximize the result.
I have attached your imaging that I think is reasonable and the other image which is not realistically obtainable.
It is also true that the nose and chin are linked. It would be aesthetically hard to just reduce one since the reduction of one makes the others prominence even more so. Whether they are staged or done together is a matter of personal preference.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Will implants give me a more defined look than the fillers I have used for jaw augmentation?
A:Fillers create soft non-defined soft tissue augmentations. Implants augment the bone, are deeper and are firm creating more defined external results. The effects of any facial augmentation depends on the materials used and their anatomic location of placement.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m wondering what kind of surgery I should get regarding the “dent” in my forehead? A surgery that can totally remove it or reduce the “dent”
A:The dent in your forehead is caused by your very large brow bones, making the forehead above it appear deficient or indented. The question then becomes do you augment the forehead above the large brow bones or do you reduce the size of the brow bones. That would be up to our aesthetic preference and it requires side view picture imaging of both types of forehead changes so you can see what looks better to you
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have several lip and nose surgery questions.
Lips:
I want a lip lift upper and lower ones so they can look bigger because in real life they are so dry and they look small and the most important thing i want my mouth a bit wider than that because my mouth look so small in real life And please i want it to look natural just a bit of lifting so they can be a bit bigger and the most important thing wide lips and natural look
Nose:
My goal is i want to fix my nose but i want it to look masculine and natural . I want to remove Droopy tip and remove this one but pls i want an natural and masculine transformation
A:The key to any facial procedure in looking natural is to not overdo it. In regards to surgical lip lifts and advancements a few millimeters of skin removal creates improved vermilion show (fullness) without looking overdone or unnatural. With tip ptosis and a less than 90 degree nasolabial angle your nasal tip needs to be lifted to the 90 degree angle range, correcting the sagging tip but still looking like a male nose.
Dr. Barry Eppley
World-Renowned Plastic Surgeon