Your Questions

Q: Dr. Eppley, Is it possible to narrow my chin without implants? Also I had double jaw surgery before so I don’t know if that will complicate things. I can send pictures of myself. How long do I need to take time off from work for this procedure? Also, please let me know the estimated cost of this surgery. Thanks!

A: Thank you for your inquiry. First, implants can only widen a chin and can never make it more narrow since it is an additive procedure. There are two methods for chin narrowing. The first method is an intraoral approach where a sliding genioplasty bone cut is made and then central edge of bone is removed. When put back together this creates a T-shaped pattern, hence the name T-shaped chin reduction. The other approach is done from a skin incisions below where the chin is narrowed by shaving off the sides of the bone known as submental chin reshaping. Each method has its advantages and disadvantages.

I would need to know which method your prefer to adequately answer the cost question. Please send me some pictures of your chin for my assessment and recommendations.

While the swelling takes 4 to 6 weeks to largely resolve, I would not think you would take more than 5 to 7 days off work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Inquiring about en bloc explant of 700cc mentor moderate plus silicone breast implants, implanted April 2014, and fat grafting to reshape breast (either immediately after explant or at a later date). 32 year old female. Experiencing pain/tingling/itchy sensation in left breast.

My commitment to explant waivers greatly with the uncertainty/fear of outcome and the inevitable mental ramifications.  I understand that I have very large implants and it’s virtually impossible for my skin to retract.  The desire for fat grafting would be to restore some volume and “correct” shape, in lieu of a lift (if that would even be possible).  I do want to try to avoid more scars.  The plastic surgeon who performed my initial breast augmentation said that I could easily drop 200ccs without the need for a lift.  I had contemplated staged breast implant revisions with smaller implants until eventual explant, but that seems like unnecessary trauma and certainly expense.  I do have a good amount of native breast tissue.   My implants are subglandular and were implanted via inframammary incisions.

A: While I don’t know what your breasts looked like before the implants or now, I can say as a general statement is that it would be unlikely that fat grafting would the a substitute for a breast lift should that really be needed. Fat grafting is a volume addition procedure but doesn’t have the push that an implant provides, it is too soft to do so.

I would caution you to be very careful about trading off one problem for another. Total explantation of 700cc implants is a drastic decision and should be done for a problem that is equally significant in magnitude to justify the aesthetic sequelae that will occur. Recovery of breast volume is not going to be done by fat grafting as that is not realistic.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m very interested in getting the custom midface implant as advertised on your page. I have a recessed mid face and as a result weak under eye support and a gaunt looking face. I would like to fix that. I’ve already had a nose job and I feel like this is the final step I need. I have a couple of questions in regards to the implant. I’ve done a lot of research but can’t find anything on it since it seems like not many doctors are offering it. 

1. What is the price? 

2. Is the custom mid face implant a better option than getting cheek implants in combination with paranasal and infraorbital implants? Is there even a difference in results? Also infection and complication wise – which of these two options is more safe? 

3. Will the mid face implant have the same effect on the eyes as an infraorbital rim implant would? I have weak under eye support so I’m wondering which would give me the best result. 

Thanks so much for taking your time to read this and answering. Have a blessed day.

A:Thank you for your inquiry. While I have no idea what you face looks like our what your exact aesthetic needs are, I can provide the following general comments:

1) I will have my assistant Camille pass along the cost of the surgery to you later today.

2) All midface implants carry the same safety profile and risk of complications, regardless of their design. Obviously the more midface surface that an implant covers the aesthetic outcome will be different.

3) The infraorbital component of a total midface implant can have the same undereye effect if it is so designed to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I currently have been using filler injections (mostly Voluma) to approximate the amount of augmentation I would want if I was to do a full custom jawline implant and infraorbital-malar implant. 

Is it possible for you to get a very rough idea for the amount (millimeters) of jawline and midface enhancement I would like if I was to give you the volume and location of my filler injections?

For instance, the surgeon I went to for filler injected:

About 0.75 syringes of voluma along each cheekbone (had to get a small amount removed as I thought it was a little too much when he used 1 syringe for each cheekbone). The location he injected was high and over zygomatic arch moving forward all the way to infraorbital area, or there about)

About 4 syringes of voluma to the jawline (included the mandibular angles, body, and chin). 

Knowing the above, does this help approximate the amount of volume for implants that I would be looking for?

A: Knowing the volume of filler injected does not provide a useful approximation of how to design custom infraorbital-malar and jawline implants. While the volume injected is not useful, what does count is the facial appearance that has been created. Knowing by pictures what facial look has been achieved, provided it is satisfactory, does help provide a guideline for such implant designs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, it looks like I’ll be moving forward with the custom infraorbital-malar and jawline implants next year.

I am seeking temporary improvement before I see you. I find that when I pull my skin in an upwards/diagonal vector, I see large improvements in the nasolabial area and my overall appearance. Would a PDO threadlift (I know its effectiveness is debated, but the nurse I’d be seeing uses a newer thread and had compelling before and afters) be contraindicated given implants with you in May? My understanding is that most of the effects of the threadlift would likely dissipate by May, but there is a chance some of the sutures won’t have completely dissolved.

A: Pulling your skin upward by fingers is not representative of what a thread lift can really do. It will have a much less significant effect than that simulation and will never make the nasolabial folds appear less deep. Such digital manipulations way over estimate what is possible with any thread lifting procedure. 

Otherwise any threadlift done now will not impact any custom facial implants planned for next year.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In a previous email you said you wouldn’t drop the jaw angles any further down than 7mms for fear any muscle coverage problems which I understand– purely out of curiosity, is 7mm the maximum you can lower the jaw angles or does it depend on each individual patient?

A: The risk of masseteric muscle dehiscence exists any time you use an implant to extend the existing shape of the jaw angles vertically downward. There is no absolute number which has been determined to be ‘safe or not safe’ to do so. In my experience I have dropped it down 25mms and not seen any muscle problems and have dropped it down 7mms and have seen it. It is not a completely predictable effect. What I can say for sure is that the more it is vertically elongated the more the risk increases What I have also learned over the years is that the amount of vertical jaw angle lengthening that is really needed is often over predicted preoperatively. In essence a little bit goes a long way particularly when there is some width added also. Lastly, like all aesthetic surgery it is a balance between benefit vs risk. One must always be careful in the goal of the ideal result to not incur other aesthetic complications that are hard to fix. (and masseter muscle dehiscence is very hard to fix) It is always better to have 80% of the ideal result with no complications that it is to have 100% of the ideal result with complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am strongly considering a temporal reduction in the near future due to my wide head, but i have a few questions. 

1. Is this procedure dangerous in any way? 

2. Will the temporalis muscle grow back once it is reduced? 

3. With my age being only 19, am i too young for this operation? 

4. How often do you perform these procedures? 

5. Roughly, what is the cost for this procedure? 

I hope I am not asking for too much, but a response would be greatly appreciated. Thank you. 

A: In answer to your temporal reduction questions:

1) This is a very safe procedure.

2) The muscle will not grow back.

3) Age 19 is not too young for the surgery.

4) I perform Temporal Reduction surgery on a regular basis.

5) My assistant will pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a cartilage chin implant for 13 years and it was ok. A Dr. convinced me to replace it for a silicone implant which I had for 15 years and caused bone loss and chin ptosis. I didn’t want a replacement but no Plastic Surgeon would remove it without a replacement. I had a plastic surgeon replace it with a Medpor which was AWFUL so 3 months later it was replaced with another Medpor chin implant with 4 screws. I have had 2 chin pad resuspensions as well. Now 7 years later I am seeing my chin get pointy and believe it is due to bone loss. My body is not liking this implant. Would you be able to remove this Medpor chin implant without another synthetic chin implant. Do you do cartilage chin implants or is there something else I can do as my chin might look deformed? Thank you.

A: While I don’t know what you look like or the size of your existing chin implant, a synthetic chin implant can be replaced with either autologous (your own tissue) or allogeneic (cadaveric) cartilage or bone grafts if avoiding another synthetic chin implant is the goal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have asked you questions before and I read your boards here and you seem very knowledgable in implants. I had a right cheek implant replaced from silicone to medpor 2 weeks ago. Have medpor in the left side as well. My Dr is well known and well versed in implants but not a good communicator and I really don’t want surgery with him again. My question is about pain. I have some swelling but not significant and some redness but not much, no fever and no heat at the site. However, I have a significant amount of pain. I will do an MRI to look for possible low grade infection. I think this is unlikely but possible. My question is, could things down the road be okay possibly? I mean, could things settle down and this pain be from swelling and tissue/nerve disruption of the infraorbital nerve? It is placed mid cheek (slightly higher) It is very bothersome (obviously). I don’t want to remove it, but also could not live like this the rest of my life either…Thank you for your input.

A: I think the fundamental question you are asking is whether the cheek implant is impinging on the infraorbital nerve…as this would be the only reason to have more than the typical pain associated with cheek augmentation which usually is not very significant. The best way to check cheek implant positioning, or any facial implant positioning, is to get a 3D CT scan. That will answer that question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, a friend of mine has had large prosthetics and augmentation in his entire forehead region and even supraorbital a while back. He doesn’t care for them now however, and in fact, finds that his forehead is too prominent now and wants them removed. He is wondering what will happen to his upper eye area when this happens. Will his eyes become more hooded and his eyebrows descend? He actually prefers this because he feels his upper eyes at the moment are too hollow and eyebrows are too high at the moment 

He is also considering a hairline lowering procedure but was told by a doctor that his scalp was too tough. Would the removal of these implants also make it possible for him to achieve a hairline lowering without the usage if a tissue expansion? 

A:I think it is fair today that removing a large forehead augmentation will result in some potential brow ptosis and even upper eyelid hooding….which sounds like what he prefers anyway.

Whether he could get any significant hairline lowering without tissue expansion I can not say given that I have no idea what he looks like or have felt his scalp. Suffice it to say that hairline lowering is most effective when a first stage scalp expansion is done.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, Does a custom midface implant or any other implant (significantly) reduce naso-labial lines? If not, what is the best procedure? Am I stuck with continuing to use fillers?

A: Thank you for your inquiry. If you are having success with injectable fillers, it is possible that you MAY benefit from some type of midface implant. It would all depend on your facial anatomy and the depth of your nasolabial folds. I would need to see pictures of your face/folds to determine if underlying soft tissue release and midface skeletal augmentation would be of benefit.

But the concept of building up the bone beneath the nasolabial fold makes sense in terms of pushing the overlying soft tissue outward. The best test to determine if this would work is to have the injectable filler placed down at the bone level….which would verify the effect of a ‘bone push’. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a temporal brow lift which I got reversed 3 weeks after the initial surgery as it was VERY aggressive. However though it has been reversed I feel that the surgeon totally messed up the upper third of my face, my forehead/temple and eyebrow shape is no longer feminine and softer. there are dents and bulges in random parts around my temples. gives me an almost masculine look. Can you please suggest what could be done to help regain my old structure back. Thank you.

A: Thank you for sending your pictures. That was an aggressive temporal browlift procedure. Fortunately most of the pleating and tissue irregularities has resolved. Short of further skin release and allogeneic dermal interpositional grafting, I am not sure you can obtain much further improvement other than what more time and healing has to offer. Time and aging will eventually be the most important factor that will reverse most of the effects of an undesired lateral temporal browlift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 24 year old male, and I am interested in getting custom zygomatic implants to augment my cheekbones. Reading through your site, I’ve come to learn that the key to the chiseled, high cheekbone look is to augment the zygomatic arch. So this is what I want to do. I also have a lack of projection in all directions of my zygomatic body and my infraorbital rim, so I want to cover those areas too. 

However there are a few things which I’m not clear about when it comes to cheek implants, and I thought you might be able to help clear them up for me. I’ll number the questions. I hope they aren’t too long. 

1) Angularity. I wanted to ask you how much the shape of the implant contributes to achieving the ‘angular’ look that a lot of models have. The angularity I’m referring to is where the zygomatic body progresses posteriorly into the zygomatic arch. A lot of models have an angular transition here. Would making the implant more sharper (slightly more square shaped) as it wraps around the zygoma help achieve this, or will this look unnatural? 

2) Anterior projection. I wanted to ask for your opinion on giving more anterior projection to the zygomatic body. In your opinion does this an anteriorly protruding zygoma look feminine? Basically I don’t want to divert attention away from the zygomatic arches by making the zygoma too big anteriorly, but at the same time I don’t want to miss out on the benefits of making my face look more anteriorly developed. 

3) Lateral projection of the zygomatic body? I’m confused as to whether it is desirable to laterally project the zygomatic body, or just the zygomatic arch. Would you be able to explain to me the aesthetic effects of projecting the zygomatic body along with the zygomatic arch, compared to just the zygomatic arch alone? 

4) Will it be possible to modify the implant at a later date by burring/shaving if there are some minor imbalances? 

5) The cheekbone ‘pop’ underneath the outside corner of the eye. A lot of models have this definable pop/prominence in this area. I’m trying to figure out how to achieve this. Am I right in saying that we would need to take into account the balance between the infraorbital rim and the zygoma, ensuring that the zygomatic prominence sticks out relative to the infraorbitals? I’m concerned that this will leave me with infraorbital hollowness. 

6) Frontal process of the zygomatic bone (inferior portion of the lateral orbital rim). Is it possible to include this area? I’m concerned that building up this area might make the zygomatic prominence look less developed (protrude less). Is this concern justified? 

A: In answer to your questions about custom infraorbital-malar implants:

1) The shape and dimensions of any custom facial implant are a major reason for the external facial shape seen. I would not make any such implant with a square shape as that would appear unnatural.

2) A high anterior zygomatic projection never looks feminine, you are referring to a low submalar anterior projection which does so.

3) You can not separate the lateral projection of the zygomatic body from the zygomatic arch. They are closely linked.

4) Revisions of custom facial implants are not rare since there is not accurate method to correlate the actual implant design to the desired outcome.

5) The implant design would extend up onto the lateral orbital rim.

6) answered in #5.

Dr. Eppley

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found you on RealSelf and noticed you have a lot of experience in this area. (cheekbone reduction reversals) I had my cheekbones reduced in Korea over a year ago. I’m very disappointed with the results and incredibly depressed with this surgery. My question is:

1) Is it possible reverse this surgery by pushing the zygomatic arch and malar bone back out? 

2)if bone graft is needed is there a computer program tthat can make a mold of my cheekbones ad estimated how much bone graft is needed?

3)Have you done this or met anyone who reversed this surgery with pleasing results?  Thank You.

A: In answer to your cheekbone reduction reversal questions:

1) Cheekbone reduction osteotomies can be successfully reversed. The anterior osteotomy is almost always more important than he posterior osteotomy site.

2) The most precise way to do is with virtual planning. A 3D CT scan can be done and the cheekbones moved out digitally from which the bone grafts can be digitally created in design to be used for the surgery.

3) Most cheek bone osteotomies reversal that I have done (by osteotomy and one grafting or custom cheek implant augmentation are usually happy to be back ‘home’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, a friend of mine has had large prosthetics and augmentation in his entire forehead region and even supraorbital a while back. He doesn’t care for them now, however, and in fact, finds that his forehead is too prominent now and wants them removed. He is wondering what will happen to his upper eye area when this happens. Will his eyes become more hooded and his eyebrows descend? He actually prefers this because he feels his upper eyes at the moment are too hollow and eyebrows are too high at the moment 

He is also considering a hairline lowering procedure but was told by a doctor that his scalp was too tough. Would the removal of these implants also make it possible for him to achieve a hairline lowering without the usage of a tissue expansion?

A:I think it is fair to say that removing a large forehead augmentation will result in some potential brow ptosis and even upper eyelid hooding….which sounds like what he prefers anyway.

Whether he could get any significant hairline lowering without tissue expansion I can not say given that I have no idea what he looks like or have felt his scalp. Suffice it to say that hairline lowering is most effective when a first stage scalp expansion is done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have asked you questions before and I read your boards here and you seem very knowledgable in implants. I had a right cheek implant replaced from silicone to Medpor two weeks ago. Have Medpor in the left side as well. My Dr is well known and well versed in implants but not a good communicator and I really don’t want surgery with him again. My question is about pain. I have some swelling but not significant and some redness but not much, no fever and no heat at the site. However, I have a significant amount of pain. I will do an MRI to look for possible low grade infection. I think this is unlikely but possible. My question is, could things down the road be okay possibly? I mean, could things settle down and this pain be from swelling and tissue/nerve disruption of the infraorbital nerve? It is placed mid cheek (slightly higher) It is very bothersome (obviously). I don’t want to remove it, but also could not live like this the rest of my life either…Thank you for your input.

A: I think the fundamental question you are asking is whether the cheek implant is impinging on the infraorbital nerve…as this would be the only reason to have more than the typical pain associated with cheek augmentation which usually is not very significant. The best way to check cheek implant positioning, or any facial implant positioning, is to get a 3D CT scan. That will answer that question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a cartilage chin implant for 13 years and it was ok. A doctor convinced me to replace it for a silicone implant which I had for 15 years and caused bone loss and chin ptosis. I didn’t want a replacement but no plastic surgeon would remove it without a replacement. I had a plastic surgeon replace it with a Medpor chin implant which was AWFUL so three months later it was replaced with another Medpor chin implant with four screws. I have had two chin pad resuspensions as well. Now seven years later I am seeing my chin get pointy and believe it is due to bone loss. My body is not liking this implant. Would you be able to remove this Medpor chin implant without another synthetic chin implant. Do you do cartilage chin implants or is there something else I can do as my chin might look deformed?

Thank you.

A: While I don’t know what you look like or the size of your existing chin implant, a synthetic chin implant can be replaced by either an autologous (your own tissue) or allogeneic (cadaveric) cartilage or bone grafts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am strongly considering a temporal reduction in the near future due to my wide head, but i have a few questions.

1. Is this procedure dangerous in any way?

2. Will the temporalis muscle grow back once it is reduced?

3. With my age being only 19, am i too young for this operation?

4. How often do you perform these procedures?

5. Roughly, what is the cost for this procedure?

I hope I am not asking for too much, but a response would be greatly appreciated. Thank you.

A: In answer to your temporal reduction questions:

1) This is a very safe procedure

2) The muscle will not grow back

3) Age 19 is not too young for the surgery

4) I perform Temporal Reduction surgery on a regular basis

5) My assistant will pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, it looks like I’ll be moving forward with the custom infraorbital-malar and jawline implants next year.

I am seeking temporary improvement before I see you. I find that when I pull my skin in an upwards/diagonal vector, I see large improvements in the nasolabial area and my overall appearance. Would a PDO threadlift (I know its effectiveness is debated, but the nurse I’d be seeing uses a newer thread and had compelling before and afters) be contraindicated given implants with you in May?) My understanding is that most of the effects of the threadlift would likely dissipate by May, but there is a chance some of the sutures won’t have completely dissolved.

A: Pulling your skin upward by fingers is not representative of what a thread lift can really do. It will have a much less significant effect than that simulation and will never make the nasolabial folds appear less deep. Such digital manipulations way over estimate what is possible with any thread lifting procedure. 

Otherwise any threadlift done now will not impact any custom facial implants planned for next year. The effects of the thread lift will long be gone by then.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really dislike the lower-mid portion of my face, which seems to be getting worse (sagging) as I age…the area closest to the nose around the nasolabial fold.

I’ve asked many doctors about this bulge and they all suggest cheek implants or filler. I’ve had filler in the cheekbone area and while that helps to hide it, I still want to address the bulge because with the filler in the cheekbone I just end up looking too bloated for my liking. 

No one seems to have an answer for how to address the fullness in those areas. I’ve gotten a couple of mid face lift suggestions but from what I understand,  the lift will move some tissue up over the malar area but not really attack the bulge because the incision too far away to reach that area of correction. An I correct here?  Could a modified lift be done with your ingenuity with an incision closer to the area? 

I consider myself a highly motivated patient and would be willing to undergo a two or three or multiple stage surgery where after the fat or muscle or whatever it is removed, then the area and skin is tightened and then scar revision done if the scar is more visible to my liking in a young patient like myself. I wear make up and am fine with revising scars with lasers, injections and even scar revising surgeries if I can get a good aesthetic pay off. 

Also do you think it’s more muscle, skin, or fat that is there? 

Thank you. 

Attached are photos of the issue I’m speaking of and following photos circled are areas where it is flat and in my opinion, ideal

A: Thank you for sending your pictures and detailing your concerns. Unfortunately the facial area (lower midface fullness reduction) to which you refer is a very difficult if not impossible area to significantly improve. While some slight reduction of it is possible, if your goal is the male picture in which you have circled, such a result is not remotely possible with any surgical method. While small cannula liposuction can be done in the nasolabial fold/perioral mound area I would expect the result to be very modest. This is a facial area in which the buccal branches of the facial nerve exist eliminating the possibility of any excisional approach regardless of a lack of concern about scars..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i’m looking to do skull augmentation and I noticed you often use PMMA material for implant but other doctors refuse it saying it causes inflammation in 40% of cases and only use PEEK. In your experience how safe is PMMA and do you overcome its sterilization issues when prepared? My target is large skull augmentation since my problem is small head/face.

A: Thank you for your inquiry. Let me provide you with some clarifications on some of your skull augmentation biomaterial statements in your inquiry.

1) For elective aesthetic skill augmentation today, I primarily use custom made silicone skull implants from the patient’s 3D CT scan. That is a far superior method to the use of any form of bone cements or PEEK material for a variety of reasons.

2) When I did use PMMA bone cements I never see any problems with inflammation or infection…and I have used it in hundreds of cases.

3) You should not confuse aesthetic onlay skull augmentations with reconstructive cranioplasties which are done to fill in a removed or lost full-thickness skull defect. These are completely different patient populations which have different risk profiles and tissue makeups. It is that population to which other surgeon’s comments are most likely directed. 

4) If large skull augmentation is your aesthetic goal, you will require a first stage scalp expansion followed by a second stage skull augmentation with a computer-designed skull implant. That is the only effective way to achieve that kind of skull enlargement in a safe and predictable way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was under the impression that there would be some discussion regarding the testicular enlargement implants, especially regarding sizing and fit, before surgery.  Maybe that is not necessary?  I assume they are ordered since they require three weeks to manufacture. 

A: The timing to determine the design of any custom testicle implant is about six weeks before the surgery so your email is timely.

The two dimensions that are needed to determine the design of custom testicular enlargement implants is the outer and inner diameter. The outer diameter is the desired final size of the testicular enlargement. This is typically between 5 and 6 cms as measured in the north-south or longitudinal direction. The inner diameter is the relief need to accommodate the existing testicular size. Most men are in the 3.5 to 4 cm range. You simply need to measure your own and let me know what it’s measurement is. Most testicles are slightly different in size but that doesn’t matter since the inside of the custom testicular implant is modifiable during surgery. The outer diameter, however, is not. (or should not be as its smooth surface will be lost)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a unique ear condition that I can’t seem to find anyone with a similar case. I always had prominent, asymmetrical ears that made me slightly self-conscious, but grew to live with them and be comfortable. The prominence was due to me not having an antihelical fold on either ear. In January of this year, I was diagnosed with a cholesteatoma in my left ear which required a mastoidectomy and reconstruction. The surgeon used cartilage from my concha bowl to reconstruct my ear canal which worked fine. What I wasn’t prepared for was the cosmetic toll this would take on my left ear. The surgeon removed a large part of my concha bowl, and I also suffered from post-surgical bleeding due to the amount of trauma from the surgery that left me with some additional scarring/shrinkage of my concha bowl. 

This left my left ear almost flush with my head and created massive asymmetry between my prominent right ear and stuck to my head left ear. In May, a plastic surgeon performed an otoplasty on my right ear to bring it more in line with my left ear. He also performed a scar release on my left ear to bring it out. Both of these procedures were successful. My right ear looks great and my left ear did come out some from my head with the scar release, but I’d still like a little improvement. I’m curious if there is a type of implant that can be placed behind my ear where my concha is located to bring out my ear a few more mm. I’m not looking for perfect symmetry as my ears have always been asymmetrical, I’m just looking for more improvement. I don’t want a big jump, as I like my ears closer to my head, since my ears protruded a lot. Since there is no antihelical fold on my left ear that needs to be released and the concha just needs to be boosted, is this easier than a typical reverse otoplasty? Can this be done under local anesthesia? Thanks in advance.

A: Based on your description I suspect that a ‘wedge’ placed behind the ear to help push it out is what is needed. This is probably done best by a cadaveric cartilage graft rather than an implant. This would required that there is adequate soft tissue cover to do so. I would need to see pictures of the left ear to provide a more qualified answer. Regardless of how  it would be done, it could be done under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have read several of your comments on Realself.com. It seems the popular opinion is that fat transfers are better than silicone implants for hip augmentation. But my research suggests otherwise – fat transfers on hips don’t last no matter what technique the surgeon uses. Can you please advise if you have compared the two? Thanks.

A: It is not really a question of whether fat injection or implants are better for hip augmentation as they are very different treatments for the same problem with different risk profiles. As a general rule, if you have enough fat to use for the hips then that should always be attempted first as it has little risk other than partial loss of some hip volume. If one doesn’t have enough fat or has failed fat grafting, then implants are the only options with the typical risks of infection and a scar bit also offering an assured volume retention.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a number of facials reshaping procedures I want to undergo I am interested suborbital/chin/malar/paranasal/midface/jaw/cheekbone implants, rhinoplasty, some aspects of FFS (hairline advancement, blepharoplasty, slight jaw and chin reduction to reduce broadness/squareness) Apologies for the laundry list of procedures but I didn’t want to miss anything I might benefit from changing.

A: Thank you for your inquiry and sending your picture. Like all major facial reshaping procedures where many changes are desired, it becomes important to establish a priority list or levels of importance for the various facial procedures. This become relevant because in most cases patients are unable to under all of them at one time. Therefore I recommend to patients to establish three levels of priority from most important, to important but it can wait, to nice if done but could live without it. I would then place just three procedures in each category. This will be a very useful exercise for you to do and will enable me to help you in a more useful manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could you help me with a problem I have ?  Somebody told me that you are a top doctor. I can´t reach my surgeon. I got a facial fat transfer to the temples ( 2ml each side ).

The day after the operation, I was in the city and I walked around slowly for 3 hours . 

Now I am afraid that it was too long and the fat could have migrated downwards, due to the vibrations from walking slowly.

Could that fat migrate / move one day after the OP due to walking for 3 hours  ? 

I hope you can calm me down.

A: Such fat migration is not a phenomenon I have seen. There is the inevitable occurrence swelling from the surgery which takes 2 to 3 days to reach its fullest extent which would always occur lower on the face due to gravity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Most transwomen need a quite a bit of width at the hips to be able to balance their shoulders – we are looking at 2.5 -3 cm added projection on each of the sides. This means a very substantial amount of fat needs to be transferred. I do have ample, (un)fortunately!

I understand the vast majority of people are happy with what stays in their butt after fat transfer but I honestly dont know a single person who had enough left at the hip one year after surgery! 

What percentage of patients do you think can retain an inch of extra fat on each of the hips permanently? Won’t quote you on this! If the odds are not great, I would much rather consider implants. I understand they need “maintenance” – how often do you see displacement? I would assume they are at high risk because of the range of motions our hips go through! 

A: I would not disagree with you on the hips and the lack of fat retention, It is a very different recipient fat site than that of the buttocks. My general statement is that if you have enough fat you always give that a go first as, even if much of the fat is lost, you are making the hips a better recipient site for implant placement later.

But in the long run a 2.5cm to 3 cms increase is only going to be obtained by hip implants.

With custom made hip implants I haven’t see any worse issues that what occurs in buttock implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Papers on buttock augmentation strongly recommend placing the implants between the muscle to avoid implant palpability and displacement.  I understand this is not possible with hips and the implant has to be placed below fascia. I found the following piece of information regarding hip implants. What do you think?

“Hip implants are problematic in several ways.  There is not much tissue to hide the implant so they can look fake.  Also, there’s significant risk that the implant may migrate because there is no natural pocket to constrain it in place.  It also has to be placed over the femur (leg bone) so that it is not subject to flexure when sitting.”

A: I find that commentary on hip implants erroneous on every level:

1) The way to avoid a hip implant from looking fake is to actually have a custom hip implant made that is designed specifically for that area. Since there is no such thing as a standard hip implants surgeons use body implants made for something else, like a buttock implant on the hips. No wonder it ends up not looking natural.

2) With a custom implant design that favors tissue ingrowth and a well made pocket for it, migration is not an issue.

3) Custom hip implants are commonly placed over the femur and its superior trochanteric extension. This does not interfere with flexion when sitting, standing or any other bodily movement.

Such comments are made based on an historic or a complete lack of a contemporary approach to hip implant augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I  am planning rib removal surgery but i want to combine this with a breast augmentation with another doctor on the same trip. My question was I plan to have rib removal surgery first and then a week or 10 days later have the breast augmentation. Would that be workable? Regarding the infraorbital rim implants I am gonna have double jaw surgery. Would you recommend doing the implants before or after the jaw surgery? And how long would you recommend between these surgeries?

A: In answer to your rib removal, breast augmentation and infraorbital implant surgery questions:

1) Breast augmentation can be performed during or anytime after rib removal surgery. It is a common combination body reshaping surgery so it can be done as a staged approach also.

2) Infraorbital rim implants should be done six months after orhognathic surgery. You want to get the lower facial bones moved forward first as this may affect the shape and size of the infraorbital rim implants.

Dr. Barry Eppley

Indianapolis, Indiana