Your Questions

Q: Dr. Eppley, I am a 25 y/o cisgender male with a very prominent brow ridge and I am interested in brow bone reduction as a solution. I want to retain a masculine appearance and keep my eyebrows where they are currently at. I was also wondering if a brow lift would be required to stabilize the brows or get rid of excess skin?

A:Thank you for your inquiry and sending your pictures. In answer to your two brow bone reduction questions:

1) Male brow bone reduction is quite different than transgender ale to female brow bone reduction in terms of their aesthetic goals.  A cisgender male wants to take a hyper normal/overprojected brow bone and reduce it to normal (meaning still have some brow bone proejction) whereas the transgender patient wants it to be completely flattened. This I understand well as about 50% of my brow bone reduction procedures performed are in cisgender males.

2) In my brow bone reduction experience in males a brow lift is not necessary with their brow bone reduction.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My head shape dips and then peaks upward again, most notably visible on a profile view seen in the included image. I’m not happy with the resulting contours and was wondering if a bone burring could have any success at reducing the severity of the slope, and I would rather avoid any kind of silicone or insert as much as possible. I’ve lost a lot of confidence and peace over the years I’m hoping could be somewhat regained.

A:Thank you for your inquiry and sending your picture. I would agree with you that the indentation across the top of your head is more reflective of an excessive growth of the crown of the skull than it is an actual coronal dip deformity. While it is true that the easiest strategy to changing the shape is to fill in the indentation that would be contrary to your goal of avoiding any form implant augmentation. Therefore we have to focus on crown reduction which I believe it is possible but we will need to know the actual thickness of the bone to see how much of the crown of the skull reduction can be safely achieved. This is done by a 3-D CT scan of the skull which is then analyzed by color thickness bone mapping.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am reaching out with a serious enquiry around temporal removal and skull reshaping. I have been dissatisfied my entire lifetime with the size of my head (width, depth and height). Circumference at its widest is 62cm and its appearance is completely out of proportion with the rest of my body. Of particular concern is the width/ convex above the ears. Apart from the aesthetic and self-esteem concerns there are also the practicalities that I am unable to wear hats, helmets and any glasses that don’t pinch or hurt.

I am wondering what (if anything) might be able to be done to improve this? I have no expectation of a result as I would see any reduction as an improvement but am open to any and all viable options.

Looking forward to hearing back. Kindest regards.

A: Thank you for your inquiry and sending your picture. When it comes to reduction of head you have two options with different aesthetic outcomes. The first option would be posterior temporal reduction by muscle removal done through a hidden incision behind the ear. As you can see in the attached imaging it does provide some benefit although it is not an optimal correction of the problem. But it does so by being virtually scarless. The second option is a more extensive reduction of the bony temporal lines of the skull as well as the posterior temple muscle removal. This produces a more significant head narrowing I can only really be done through a semi coronal scalp incision. Well more effective it does so at the expense of a fine line scar across the top of your head.

I have seen patients choose either route and in the end that is determined by how much effort do they want to put into improving the problem and for what trade-offs (scar).

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello! I suffer from the common east-asian recessed upper maxilla. The bone under my nose sinks in, creating a flat look and protruding appearing mouth. My occlusion is normal and this is mainly an aesthetic concern. I’ve attached photos for angles & measurement.

I am also planning a Korean rhinoplasty a few months later, where the surgeon will be increasing the height of the bridge and tip. I want to ensure that I can create a proper foundation for that procedure, and I also want to ensure that the implant is balanced to avoid an overly projected midface with the rhinoplasty.

A:Thank you for your inquiry and sending your pictures to which I can answer the following questions:

1) You are a good candidate for paranasal– maxillary augmentation but not for the premaxillary area. Opening up your nasolabial angle would be counterproductive for your second stage rhinoplasty.

2) I would wait three months after such midface augmentation before undergoing an open rhinoplasty.

3) The most contemporary form of paranasal implants are comprised of ePTFE.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in getting temporal augmentation and brow ridge augmentation implants. I’m also planning to get hair transplant surgery after the implants surgery. When can I get the hair transplant surgery done after the first surgery?

A:You only need to wait about three months after the implant surgery before having hair transplantation.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had a custom jawline implant placed four years ago in Beverly Hills. Besides implant malpositioning I also got ripped masseter muscles. The surgeon stated he could do revision and fix the issues with the implant as well as decrease visibility of ripped masseter muscles so I had the revision two years later. Revision did not fix the issues with implant or reduce visibility of issue. During revision, masseter muscle on left side tore completely, masseter muscle on right side ripped further. What do I do now?

A:Thank you for sending your pictures and detailing your surgical history. Once the masseter muscle has retraction and fibrosis it can never be put back to its original length (over the implant). Thus the concept that it was going to be fixed in any type of implant revision surgery was, to be kind, overly optimistic. The question now is how to manage it (the left side is the most affected) and what remaining problems do you have with your implants…. Issues which will require further in-depth discussion.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Regarding head width reduction, would Botox be capable of achieving the specific results I’m looking for?

A:I would try Botox first and see what happens as you have nothing to lose by doing so. While it is not a permanent solution in most patients you will find out if muscle reduction alone would be effective. Undertaking Botox to determine its effects is, of course, predicated on that the right muscle area is injected with the right dose. There are many patients I see that have ineffective Botox injections to the temporal muscles because they have an inexperienced injector. I make this statement not because I am interested in doing it, as I am not, but because in all drugs delivery and dosing  is the key to optimizing their benefits.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had a Deso face (deoxycholic acid) fat dissolving injection, how long should I wait before deep plane midface and neck lift to same areas?

A:The effects of any lipolytic agent are largely complete by six weeks after injection. But most by three months the entire degradatory reaction is finalized.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,  I am reaching out because I have been researching options to address significant under-eye hollowness and dark circles, and I was very encouraged to find your work with infraorbital (lower orbital rim) implants. Seeing the results you have achieved for other patients has given me hope that there may finally be a solution for my concerns.

Over the years, I have pursued several non-surgical treatments without achieving the improvement I was hoping for. I initially had under-eye fillers placed, which were later dissolved. After that, I underwent mid-face filler treatment in an attempt to provide additional support to the under-eye area. More recently, I tried PRF with EasyGel. In addition, I have undergone microneedling treatments.

Unfortunately, despite these efforts, I continue to have significant under-eye hollowness. None of the treatments have meaningfully improved the volume deficiency, and they have also had little to no effect on the dark appearance beneath my eyes. I have been told that much of the discoloration may be related to the underlying anatomy and the visibility of the muscle beneath thin skin, which limits the effectiveness of many non-surgical options.

Because of this, I became very interested in the possibility of infraorbital rim implants. Based on the information available on your website and the patient results I have seen, I would love to learn whether I might be a candidate for this procedure and what kind of improvement could realistically be expected in my case.

A:Thank you for your inquiry and sending your pictures. You have the classic problem but I see all the time with the combination of undereye hollowing and dark circles of the lower eyelid and cheek– groove skin.. Which is not uncommon in your ethnicity and intermediate skin pigment. The key question is what is the association of your undereye hollowing and the dark circles or, to put it another way, if you structurally correct your undereye hollowing will you get any reduction in the appearance of the dark circles?

The answer to that question is whether the dark circles are due to shadowing from the lack of structural support or is that actually hyperpigmentation of the skin which may not get any significant improvement with increased structural support. My concern in your case that it is more likely the latter rather than the former. Generally dark circles that have a major contribution for lack of structural support have an actual shelf where the shadowing can occur. You however do not have that as your lid profile is very straight and flat which would indicate to me this is largely hyperpigmentation not shadowiing effect.

That being said I decided to test out what would happen if structural support was added which I have done in the attached Image. In that image all I did was add structural support and did not change any color of the skin. Surprisingly I do see improvement in your undereye condition. Whether actual surgery can the same effect as a simple Photoshop change is an interesting question but this is the best method we have to try and approximate what a surgical change may create.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had a facelift performed in Korea last year that I have been unsatisfied with, particularly around the ear and tragus area. I am seeking your expertise because I believe I have loss of the natural tragus–cheek border / pretragal hollow, with the cheek skin appearing to blend into the tragus rather than having a clean anatomical break. I am not looking for a more aggressive lift; I am looking for precise revision work to restore a natural male ear-cheek transition, improve the preauricular/tragal contour, and correct the operated-on appearance in that area.

A:Unfortunately your facelift was done as if you were a female trying to use a retrotragal  incisional placement, resulting in beard containing skin being placed on the tragus which accounts related issues that you have. This is a relatively poor facelift technique to do in a male for the exact reasons that you have. This is a difficult problem to correct of which there are only two approaches. First you can remove the beard containing skin from the tragus and place a skin graft. This would be the most effective approach of separating lateral cheek skin from the ear but how well will the color match of a skin graft be to of the rest of the ear and the risk is that this may create a patch look which would in essence be trading off one problem for another. Or the beard skin that has been pulled up onto the tragus can be thinned out and the hair follicles removed which may offer some improvement… with the operative word being may. It has the least aesthetic risk but also offers the least chance of any real aesthetic improvement.

What we have here is a lack of understanding of the delicate nature of the difference in ear vs cheek skin in a male. Pulling the cheek skin onto the tragus of the ear works very well in females because they don’t have beard skin and the differences i  the two skin areas are not minimal.  However that changes dramatically in the male because having hair in facial skin doubles or triples the natural skin thickness which makes it quite different from the skin characteristics on the ear.

I would be cautious about using the term restoring the natural cheek ear transition ss that cannot be fully achieved. The better concept to use is what level of improvement can be obtained.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m wondering if I would benefit from paranasal implants with an additional nasal spine implant and if I should combine it with a rhinoplasty. I have some hollowing in my midface and a very small columella I understand paranasal implants would only push the nasal base forward and not the tip and I’m not sure if getting these implants without nasal tip augmentation would look unnatural and cause a very squat looking nose

A:I don’t find your columella or tip projection to be that short given the ethnic nature of your nose compared to many others. The value of having a premaxillary extension (2 – 3 mm) as part of the paranasal augmentation is that it provides a overall better overall nasal base projection with more complete pyriform aperture coverage. The goal is not to significantly open up the nasolabial angle or increase tip projection. In your rhinoplasty you will require some tip grafting for refinement and a modest amount of tip lengthening which will be synergistic with your hump reduction.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello. I am very happy with my nose when completely static. However, it spreads laterally when speaking or with even the slightest smile. It is very dynamic, more so on the right side. I had upper and lower jaw advancement 25 years ago, at a time before an alar base cinch was considered as a last step in the surgery. I have had in-person consultations with 2 surgeons. Both have said there is really nothing I can do except try neuromodulators. When asked about the technique presented in Dr. Eppley’s writing Intraoral Fixation for Nasal Flaring During Smiling, both seemed unfamiliar and said that is not something that would be good to do. As a last effort, I would trust Dr. Eppley’s honest opinion before I give up on the hopes of having this problem resolved. It has preoccupied my mind for decades and causes social anxiety especially around being photographed. I would love to be free to smile and laugh with my family and friends without self-consciousness overshadowing the moment. Thank you for any guidance you can provide.

A:Dynamic lateral nostril flaring is a difficult problem to correct. No matter of the technique used, nostril cinch suturing or actual fixation to the bone (the former is preferred), it has the potential to create some tightness when smiling. So one has to be careful about trading off one problem for another. Thus I would reserve the use of nasal cinch suturing only in the most motivated patient who understands the trade-off and the possibility that if it occurs the suture may need to be released.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in head widening procedure. My head is very narrow compare to my zygomatic area. Temples are also narrow and this create oval look. I can show you my photo.

I want this to make zygomatic area little bit narrow and straight vertical lines and head make wider.

A:The key question in head widening is whether the implant can be positioned below the muscle or whether it must sit on top of it. Based on your own drawings of your results the question is does the augmentation need to extend up to or passed the bony temporal line of the skull. That is a very pertinent question because in sub muscular temporal widening the implant goes up to just the bony temporal line but does not cross it as the attachment of the muscle is at the bony temporal line and stops. If the augmentation needs to extend past the bony temporal line onto the top of the skull it will need to be on top of the muscle to do so.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am a trans women interested In clavicle reduction. My shoulder width is 17.5 is it possible to drop to 15?

A:In clavicle reduction surgery 1 inch or 2.5 cm of bone is reduced from each side. It it’s hard to go past that amount given the curvature of the bone and the plates use to fix it together once the reduction is done.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I was wondering if Dr. Eppley believes I would be a good candidate for a custom wrap-around jaw and chin implant. I currently have a silicone chin implant that was placed two years ago.

My primary goal is to achieve greater jawline definition and improve overall facial balance. I feel that my upper face and cheekbones are relatively wide, which makes my lower face appear narrow by comparison. I am interested in whether a custom wrap-around implant could help create a stronger, more proportionate jawline.

Thank you for your time, and I look forward to hearing Dr. Eppley’s thoughts.

A:Like all aesthetic surgeries one is a good candidate if their aesthetic objectives could be achieved by surgery. In that regard, while your chin implant has undoubtably added good horizontal projection, you remain with a round shaped chin that is vertically short, you have a flat mandibular planeangle, and you have jaw angles that remain too narrow for the width of the rest of your face. Does a wraparound shoreline implant that adds vertical length to the chin and squares it out with widening of the jaw angles are the effects that it could produce. If you see this type of change as shown in the attached imaging is favorable then you are a good candidate for the surgery.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am looking for a clinic to carry out a custom, patient-specific mandibular/facial implant (PSI) — a personalized prosthesis in titanium or PEEK, designed by CAD-CAM from a CT scan — in order to correct a facial asymmetry. I am not looking for dental implants.

I would like to ask:

1. Do you design and place custom (patient-specific) mandibular/facial implants for asymmetry? In which materials (titanium, PEEK or others)?

2. Is the design and manufacturing carried out in-house or through an external provider? Where are they manufactured, and with what certification?

3. Can you work from an existing CT scan (DICOM), or would a new one be required?

4. Which surgeon would perform the procedure, and how many cases of this type have you carried out? Do you have clinical cases or before/after photos?

5. What would be the surgical approach (intraoral or external), the duration, the type of anesthesia and the length of hospital stay?

6. Could you provide an itemized estimate (consultation, 3D planning, design, manufacturing, surgery, hospital, anesthesia and follow-up) and the expected timeline?

7. For a patient travelling from abroad: do you offer an initial remote assessment (based on photos and a CT scan)? How many trips and days would be needed, and how is the follow-up handled afterwards?

8. What are the main risks?

A:Much of these questions seem to be based on a lack of knowledge of the tremendous amount of online information that I have on numerous websites. I would advise that you visit www.eppleycustom facial implants.com as well as look at the Photo Gallery on www.eppleyplastic surgery.com under Custom Facial Implants in which most of your questions would be answered.

That being said I will provide some abbreviated answers to your questions:

1) Yes, I have done over 1,500 custom  jawline implant surgeries alone.

2) The design and manufacturing of any custom facial implant is done through various companies that provide those medical devices at their facilities. There is no surgein in the United States that would legally be allowed to provide any in-house design and implant fabrications for placement in humans.

3) Whether an existing scan can be used depends on whether it is a 3-D scan and what its quality is. I can only make that determination by seeing it.

4) I perform all of the surgeries myself and I will refer you back to the websites previously listed to provide the information that you request.

5) All custom implant surgeries are performed under general anesthesia and jawline implants are no exception. All jawline implants are placed through three incisions, one submental and the other two intraoral. Some patients prefer all three incisions to be external but that would be the exception.

6) From the time of acquiring the 3-D CT scan and going through the design and manufacturing process that is a 2 to 3 month timeline. But that can vary based upon the material selected. For example titanium vs PEEK.

7) All preoperative evaluations are done virtually as well as the implant design process. A patient only comes here for the actual surgery and would likely return home within 2 to 3 days after the surgery. All follow-ups are also done virtually.

8) Like all implant related surgery the three main risks remain the same; infection, implant placement asymmetry, and over/under sizing.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello doctor! I had hairline surgery 6 months ago and I feel my hairline is too low and doesn’t match my facial proportions. I’ve read your answers about using tissue expanders to reverse a hairline that’s been lowered too much. However, I’ve also read some studies that say that after the tissue expanders are removed, the loose skin on the forehead will sag, wrinkle, and droop down towards the eyes and eyebrows, and won’t be able to retract or lift the hairline on its own. There’s also a risk of scarring, permanent facial paralysis, and disfigurement. Could you please clarify this for me? I really want to know where the tissue expanders would be placed in this case: the scalp with hair, the forehead area, or between the previous surgical scars?

 Thank you.

A:None of the complications that you have described for forehead tissue expansion are ones that I have ever seen so I am not sure where you are getting your information.

In forehead tissue expansion for a hairline that has been moved too low the tissue expander must be placed into the forehead and not the scalp as it is the forehead skin that needs to be expanded. You would not use the existing hairline incision s is that is counter productive and all the tissue expansion would do would be to cause postoperative incision separation/widening. The tissue expander is placed through  small incisions in the temporal hairline.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I hope you may help me as I have been trying to find an answer for my situation for months now.

As you can see by my attached photo, at the corner of my eye I had a raisedbump. Over a period of time I had scratched it to try and remove, now it will not heal over. It develops a scab and after several days the scab falls off when washing. It leaves a small hollow where the scab was; the tissue is a yellowish colour and slightly grainy looking. No infection, odor, or bleeding. In a day the area starts to heal over again and develops a new blood clot covering, but no skin covering.

My local doctor wants to take a biopsy which I am worried it make make matters worse. I live in the countryside and to see a specialist it of great trouble to do. You mention the A & D ointment and I wonder if that will help me in developing new skin tissue.

Any help you can give me would be extremely wonderful.

A:This problem requires expert medical attention and the biopsy would be the first place to start. When you have a non-healing wound in the face, which is rare to occur due to the superb blood supply of the face, you have to think about a medical reason for it. Ruling out basal cell carcinoma would be the first important problem to exclude. Either way this requires a surgical solution not a topical ointment to resolve.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have high and wide cheekbones and the zygomatic arch flares out to the side. I am a Caucasian male and noticed this is a very uncommon surgery for my demographic to have done, as this is typically done on Asian patients with a different skull type than what Caucasians have. I would like to leave the part that flares out reduced so that my cheekbones don’t go out to the side, but the front pillar / main cheekbone is left alone and remains high up.

A:Regardless of one’s ethnicity all that matters is what does their facial skeleton look like and how can it be best addressed if it needs to be changed. High and wide cheekbones can occur in anyone. The proper approach is to get a 3-D CT scan to assess the shape and flair of the zygomatic arches from which cheekbone reduction osteotomies can be used to reduce it. The key question is whether posterior zygomatic arch osteotomies alone would be effective or whether it requires some anterior osteotomies as well. That is the type of information that a 3-D CT scan can provide.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My maxillary atrophy was evaluated with an overlay technique using a 3D Ct scans ten years apart. The overlay came back as orbital-malar and midface bone koss. One plastic surgeon recommends fat grafting because I  have thin skin undereyes yet another surgeon said only after implant augmentation if I feel needed and he’s not worried about thin skin.

A:Based on your inquiry I’m not exactly sure what you are trying to accomplish. Are you trying to augment the maxilla where you have the atrophy or are you trying to augment the entire mid face including the infraorbital-malar region as well under the eyes. While I’ve only seen a front view picture you certainly have a negative orbital vector which is pretty common when you have generalized midface recession regardless of its origin.

Knowing what do you want to augment exactly makes the difference between a custom midface mask implant design versus an infraorbital–malar implant or an isolated maxillary implant.

Regardless of the midface area to be augmented it is certainly accurate that fat grafting would not be a good primary choice of treatment. Even if the fat survives you are  just going to end up with a bloated midface with persistent lack of any undereye support. Fat grafting is almost never a good solution for s facial bone problem.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have always had significant hollowing under my eyes. I am so tired of it! I have done some reading about this, and I really want to consider tear trough implants. I want a permanent fix more than a temporary one. I am curious about pricing for this, if you offer it, as well as can a payment plan be used for it, or does it need to be paid all at once? Please tell me anything you can about this procedure, thank you.

A:Thank you for your inquiry and sending your picture. While this is just a front view picture, and a side view would provide more complete assessment, I believe you have a significant negative orbital vector and pseudo proptosis (your eyes appear to be bulging when in fact the eyeball position is normal but the underlying bony support is lacking). This is a skeletal deficiency issue in which a custom infraorbital-malar implants design is necessary to properly treat it. Tear trough implants, which are small standard implants, were made to treat a very small infraorbital rim soft tissue deficiency which your issue is not.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I was also concerned about the premaxillary implant increasing the nasolabial angle. However, would this be able to be fixed if the surgeon performs a septal extension graft to reduce the upturned nose? The full surgery would be: donated fascia in tip & bridge, septal extension, and alar base reduction.

Additionally, do you think performing both the rhinoplasty + paranasal implant in one procedure would lead to a more aesthetic result?

Or would paranasal after yield a better result? Im just concerned that without paranasal first, the surgeon may create a nose that is slightly underprojected after the implant is added.

A:In answer to your questions:

1) A premaxillary augmentation is going to fight against the effects of a septal extension graft. How significant that diametric effect is is hard to say as there is the amount of premaxillary augmentation and how much is the septal extension graph really going to drive down the tip of the nose

2) if one is absolutely certain of the benefits of either procedure, rhinoplasty and paranasal augmentation, then you can make an argument for doing them at the same time. However, given your concern about not having stable pyroform aperture base first then you really have answered your own question… do them as a staged approach.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am a 65 year old male with central loose neck skin. I wear a beard that extends to just above my Adams apple. Can the excision of a direct neck lift stop where the beard hair stops.I would prefer not to have a visible scar on anterior neck below the beard .

thanks

A:Thank you for your inquiry and sending your pictures. In the direct neck lift the excision pattern typically follows down to the inferior end of the midline neck web  which is usually at the  second horizontal neck line. At the minimum the direct necklift needs to go to at least to first horizontal line To be effective. Your beard ends at the halfway point between the submental crease and the first horizontal neckline so keeping it limited to that beard area is not going to producing a very effective result. I can certainly appreciate the scar concerns but I don’t see anyway around trying to carry it down to at least the first horizontal line to get a reasonable result.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have old dermal filler in my face that clogs up my lymphatics and swells sometimes and stays swollen. I also have lymphedema in my body, so altogether, a compromised lymphatic system. The other day, I was stupid and got a manual lymphatic drainage massage whilst sick, and they massaged my face. Two days later my eyes changes dramatically. Now have very small, sunken in appearing eyes and worst of all, they appear really close set now. I don’t know if it’s due to swelling or clogged lymphatics or old filler, but I don’t recognize myself in the mirror and I’m terrified I’ve damaged myself permanently. Is there any way to fix close set eyes? Thank you

A:Injectable fillers, when done enough times and in adequate volumes, can certainly obstruct lymphatic outflow. However it slows it but does not stop it. Therefore I think if you get it a few days to week it should be a self resolving issue. That would be important since there is no surgical solution to chronic lymphedema of the face.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am inquiring about getting a brow bone implant modeled and performed. Attached are two photos of my eyes currently, I am curious if it is possible to get just enough hooding to fully cover my eye lid at rest without having to squint in photos to pull it off like the first shot. Something similar if possible to the third photo I attached so you see what I mean.

I look forward to hearing from you, I have had so many friends recommend you!

A:Thank you for sending all of your well taken pictures. I am assuming the picture that is posed is the goal compared sure your relaxed natural pictures. Based on this information I do believe that a brow bone implant can get you very close to that. The key in brow bone augmentation for men who are seeking this very typical change is what is the natural position of their eyebrows. The medial half of your eyebrows is reasonably low and that makes it very favorable for your desired change. The tail of the eyebrow is higher and that will not come down as low as the inner half of the eyebrows but in your goal photo the tail is still sitting higher so I believe the goal is still reasonably achievable.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, my chin is long and wide, just very prominent.  However, maybe, having more balance, might help without having to have surgery? My face is really thin, a bit of fat transfer maybe and slightly enhanced lips (fat transfer?) may make me feel as though my chin isn’t so prominent?  

Any other feedback or questions, please let me know.

A:I don’t think that adding volume in the face will help very much if at all. The value of those procedures is more supplemental to the chin reduction as a synergistic effect. But standalone volume addition probably won’t do very much.

The proper chin reduction technique in your case is a submental approach through which the bone and soft tissue pad can be reduced.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,I previously underwent orthognathic surgery with mandibular advancement and genioplasty. My primary concern is aesthetic rather than functional. I would like your opinion on whether a revision orthognathic procedure could provide a meaningful aesthetic improvement.

More specifically, I would like to know whether additional maxillary advancement could improve facial harmony, midface support and upper lip projection, and how it might affect the appearance of my nose (wider/larger versus more balanced and harmonious).

Based on the records provided, do you believe there is significant aesthetic potential for improvement through revision surgery?

Thank you for your time.

A:The simple answer is no. You have already obtained the most aesthetic benefits in what bimaxillary surgery with a genioplasty can do. Further aesthetic facial enhancement are going to come from adding on with other procedures to what you already have such as secondary chin augmentation, rhinoplasty, and midface implant augmentations.

Bimaxillary surgery rarely achieves all of any patient’s objectives because it is a dimensionally limited procedure with its his primary benefit in increasing facial projection. But there comes a point when more facial projection by  bone movement is not effective or even counterproductive.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,  I developed scoliosis and had a long fusion 6 years ago. I’m interested in rib contouring to address rib asymmetry.

A:Rib asymmetry is the norm in scoliosis which is usually most manifest in the lower rib cage. While the rib asymmetry can never be fully corrected it usually can be improved by identifying the rib(s) that causes the greatest protrusion on the convex spine side. This is done by a 3-D CT rib cage scan and then matching that with what the patient sees on the outside.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, O have been researching deep plane facelifts and am seeking advice on how to combine that with an orbital-malar implant.

A:Thank you for your inquiry and sending your picture and that of the AI generated image. As you have astutely noted an Ai image is an ideal goal that can never be fully achieved. An Ai image makes many other soft tissue changes but either aren’t in the scope of what the patient wants to do or are simply not possible. For example in your AI image it has completely eliminated your nasolabial folds (not possible with any form of the facelift), enlarged your lips, narrowed your nostrils and even changed your eye color.

But that being said it is tremendously useful from a structural standpoint because those are changes that are very possible. Eliminating/reducing your undereye hollowing with higher cheekbones exactly is what an infraorbital – malar implant can do and will produce higher cheekbones and a lifting effect that can never be achieved In any type of facelift surgery.

If the question you are asking is can you combine a deep plane facelift with custom infraorbital-malar implants and that answer is absolutely.  That is not a technical question but a logistical one. The key to that combination, as it is with any type of niche procedure in plastic surgery, is finding a surgeon who is capable of doing both. The facelift part of that equation is easy, it is the custom implant part that becomes more difficult given the rarity of surgeons are actually perform it.

But if you had to stage it, and I’m not saying you should, you would do the custom implant first to establish the skeletal foundation and then do the facelift secondarily.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in learning more about your custom testicular enhancement procedures, specifically the side-by-side displacement implant technique.

My goal is a substantial cosmetic enlargement rather than a subtle or natural-looking enhancement. I have reviewed your website extensively and have seen references to implant sizes ranging from 6 cm to over 10 cm.

One aspect of my history that may be relevant is that, although my resting scrotum is relatively tight, I have performed saline infusions into my scrotum, reaching maximum size of around 17.5″ in circumference. I understand that temporary expansion is not the same as permanently supporting large implants, but I wanted to mention this in case it is relevant to tissue elasticity, implant sizing, or the potential for staged enlargement.

My questions are:

1. Based on my anatomy and expansion history, what implant size range do you think is realistic?

2. Would you recommend a staged approach, or could my desired result potentially be achieved in a single procedure?

3. Do you think I could ultimately be a candidate for very large implants (9–11 cm range)?

4. What is the largest sized implants you have used in a patient?

A:Thank you for your inquiry and detailing your testicular enhancement objectives. Your history of saline scrotal infusions is very relevant as this suggests you would have a large scrotal stretch skin capacity. This along with your height and weight, indicating you are not a small size male, would indicate that very large testicular implants would be appropriate. Just based on that information alone I would think that the size range of 9 to 11 centimeters, as you have noted,  is well within the range of what will likely fit.

The largest testicular implants that I have a placed is 11.5cms. As you might guess at that size this patient also had a history scrotal expansion and it also graduated from an initial 8.5 cm to the 11.5 cm size.

Dr. Barry Eppley

Plastic Surgeon