Your Questions

Q: Dr. Eppley, Hi, I’m looking to get an occipital reshaping. I saw a great case study done by Dr Eppley mthat looks similar to what I’d like to have done.

A:Thank you for sending your pictures. This appears to be a classic posterior fontanelle skull deformity where the original baby soft spot closed but did not develop the thickness of the surrounding skull bone. Hence the depression or indentation which id ideally treated by a custom skull implant design.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I recently had double jaw surgery & my ANS was resorbed by the plate. Is there a way a tiny para nasal implant could be placed?

A: A small modified paranasal implant or a bent titanium plate could be used to restore the projection of the anterior nasal spine.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I heard that it is unsafe to remove a facial implant, modify it and then put it right back in as it is then unsterile.

A:That is not an accurate statement. It is common to remove implants and modify them with immediate re-implantation for aesthetic purposes. This is standard practice in face implant revisions.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can permalip implants be put in at the same time as sliding genioplasty?

A:Lip augmentation (e.g. Permalip implants) can be placed during the same surgery as a sliding genioplasty. The combination will cause considerable lip swelling but those effects are temporary.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have been doing some reading on rib removal and LD muscle narrowing. From your professional opinion, could this have benefits as well? I have a lot of shoulder pain from bad posture over the years and I’m curious if these procedures would help with this as well. I’ve had MRIs and assessments, but nothing officially diagnosed. When I’m working out more consistently, the pain is reduced. Are there any health benefits to this? Are there any risks of making anything worse? 

A: These procedures are for cosmetic purposes only. They are not known to provide any functional or medical beneffit. Conversely they are not known to cause any adverse medical effects or functional impairment either.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, What is the tallest vertical chin implant that can be implanted? I don’t need much or any forward projection, but I do need a lot vertically. Dr. Eppley looked at my scans, but the procedure scared me – very tall genioplasty… I’d rather consider the tallest vertical implant instead.

A: The most vertical chin lengthening that can be done with an implant in most patients is 5 to 7 mms due to restrictions of the tightness of the soft tissue chin pad.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can I remove the titanium mesh that is covering part of the skull? I had a craniotomy six years ago and there has been ongoing and increasing pain at the location of the mesh which I believe is an inflammatory reaction due to internal fixation device. From what I am learning this could be due to galvanic corrosion of the metal. This might not be what is happening to me but the pain is specific to the location of the mesh and not internal like a headache.

A: The reason titanium is the sole metal used in craniomaxillofacial fixation for the past 25 years is its corrosion resistance. Titaniun is highly resistant to corrosion as a stable protective oxide layer forms on its surface after implantation which protects the metal from attack from corrosive agents. Thus I doubt your symptoms are from hardware corrosion. I have removed thousands of pieces of titanium hardware from the face and skull over the past 25 years and I have yet to see any evidence of corrosion. More likely the symptoms are due to its occipital location and the surface area of its coverage.

That being said there is only one way to find out if the hardware is the culprit…remove it. It is certainly possible that its removal will not eliminate your symptoms but then the most obvious source of them will be excluded.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have attached two photos for reference. I’m looking to have the extra skin removed which I’m not sure is visible in the photo. You can also see some horizontal stretch marks which I was wondering would be covered up during the vertical back lift. 

My plan in the next few months is to have lipo on my stomach which may also create more loose skin on my back based on what I’ve been reading (of course results may vary). I don’t have a definitive date booked yet as I had to reschedule my original date due to personal circumstances. I haven’t had excess weight loss but my goal is to find a way to tighten the skin on my bra line as I have issues wearing certain clothing. My surgeon who is performing lipo on my stomach advised me that lipo is not recommended and that I’d have to look consider a bra lift if I wanted to achieve my goals as lipo would not give me my desired results.

Do you also perform rib removal and is this recommended for waist reduction? Will this decrease any chance for rhinoplasty revision in the future as I understand ribs are sometimes used for rhinoplasty revisions? (I like to keep my options open.) Do you think this surgery is recommended for what I’m looking to achieve or are there other recommendations? Am I a good candidate?

In terms of the rhinoplasty I’ve been reading that, based on my goals, a tip plasty and alar plasty are less invasive and more likely to be the way to go for what I wish to achieve (narrowing of nostrils and more refined tip). I also understand that the tip sometimes does require support so I will leave this recommendation up to you.

I look forward to hearing your feedback and thoughts.

A:Thank you for your inquiry and sending your pictures. Your surgeon is correct in that light perception of the back is not a successful approach for managing your redundant tissue issues. Neither would a traditional bra lift be successful either as a horizontal excision is not the direction in which your redundant tissue lies. The vertical backlift is a better orientation for your tissue excision as seen in the attached Image. Whether one chooses to have ribs removed and the LD muscle narrowed as part of a vertical bralift is based on whether one wants waistline reduction at the same time. That is a personal choice.

In regards to the nose I cannot comment on what your reshaping needs are as I have not seen any pictures of your face. The only general statement I can make is, while rib cartilage is sometimes needed for rhinoplasty, rib removal is largely bone and is not useful for rhinoplasty surgery. Therefore rib removal surgery does not compromise any future graft needs for rhinoplasty surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have dents on my buttocks due to most likely steroid shots administered to me as a child to regulate asthma attacks. Is it possible to correct these? Plastic Surgery Case Study – Dermal-Fat Grafting Of Buttock Indentations from Prior Injections

A:Fat injections or small dermal-fat grafts would be the appropriate treatment for contour defects of the buttocks. The depth of the indents would determine which one of the fat grafting methods would be best.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I’d like to have a quick consultation about the process of skull reshaping. The order of how it works, the cost for an initial 3D scan, ways you can pay for it. Also, I was told a couple of years ago that I needed a 3D CT scan of the skull to send to your office to determine what is needed. Is that still the process? If not, what is it?

A:The term ‘skull reshaping’ is a general one which refers to a collection of over 30 different specific skull procedures. To provide information on what skull reshaping procedure(s) would be appropriate for your needs I would first need to know your exact head shape problem from which I can then determine how to treat it. This will require a more detailed description of your concerns, and head reshaping goals and any pictures which so illustrate. From this information the skull reshaping procedure(s) needed can be determined.

The role of the 3-D CT scan varies based on the skull reshaping procedure needed. For example in skull augmentations the ccan provides the platform on which a custom skull implant is designed. For skull reductions it helps to determine the thickness of the bone and how effective and safe any skull reduction procedures would be. Therefore the scan can be a critical part of the surgical planning process but it is not initially needed to determine what any specific patient needs from a procedure standpoint.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi do you offer just rib remodeling without the removal of the ribs ?

A:As you know structural waistline surgery can be done buy rib remodeling which includes either their subtotal removal or the osteotomy or fracture method. Each approach to the ribs has its advantages and disadvantages but, in the end, it is the patient’s choice as to which method they prefer. While by far the vast majority of my patients choose the rib removal method I certainly have done the fracture technique which is surgically less complicated and operation of less duration. the key to the rib fracture method is the use of postoperative compression using garments which ultimately is responsible for the final result.

But with either rib treatment method it is first important to qualify the patient to determine if Either approach can provide some benefit. To that end I would need to see some pictures of your body as well as an idea of what you’re trying to accomplish.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Two years ago, I had cheek/infraorbital rim implants as well as jaw and chin implants placed using Medpor material. Prior to that, I underwent orthognathic surgery, and the implants were custom-made. Since the procedure, I’ve been dealing with a low-grade, chronic infection at the site of the right cheek implant, with occasional flare-ups. About a year ago, I had surgical debridement and antibiotic treatment. However, I suspect that the implant may ultimately need to be removed. I would like to ask your opinion on whether it might be advisable to remove both cheek implants and replace them with silicone implants, given the lower risk of infection and the relative ease of removal if needed. Additionally, I am wondering how long the process would take—from removal to replacement—whether this is something you could perform, and if you could provide a rough estimate of the cost. Thank you very much for your time. I look forward to hearing from you.

A:As you have undoubtably learned by now once an implant gets infected the long term success of resolution of that infected implant  is rarely if ever achieved short of removing the implant. Based on your history that time appears to have arrived. What you need to do is first have the infected implant removed which may or may not include the opposite unaffected side. You then need to let the tissues heal before re-implantation. That time should be about three months. That will also give you time to design new implants for the secondary re-implantation. It would not be prudent at this point to do an immediate removal and replacement of the infected implant in the face of a long term chronically infected implant.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello! I am interested in surgical removal of a large tattoo on the back of my left shoulder. A staged process is perfectly acceptable to me and scarring is only a minor concern. I prefer not to pursue laser removal as it is a lengthy process and doesn’t completely remove certain colors of tattoo ink. I look forward to hearing your assessment. Thank you!

A:That is a very large shoulder/arm tattoo that is not appropriate for a staged surgical excisional approach. Shot of excision and skin grafting, which seems questionably appropriate given the trade-off of a large skin graft patch, you are left only with laser treatments. I would not disagree that is a long an expensive process for probably what would turn out to be incomplete removal of it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Good day. Would it be advisable to do jaw implant surgery before or after a deep plane neck and face lift?

A:I would definitely advise doing jaw implant surgery before any type of facelift procedure. This is due to the swelling that results from the placement of the implant which can have a negative effect on the face and neck tightening results from a facelift procedure. There are some rare indications for during a jaw implant and facelift surgery together but how that may apply to you I would not know without some additional information such as pictures and your surgical goals from which I can make an assessment.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I figured out i have plagiocephaly but i don’t think a severe case because anyone have ever noticed it in 27 years of my life. Now i started loosing hair and it has mecome more visible so i am looking for a resolution. 

A:The definitive and most effective treatment for plagiocephaly is a customs skull implant made to augment the flattened side of the back of the head. 

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, For my vertical lengthening bony genioplasty do I need to arrange for any imaging/CT-Scans before coming over? Or will any required scans be done during the pre-surgery consultation as well? How and when is the total vertical lengthening estimated? Is it during the surgery, or is it through prior scans during the pre-surgery consultation?

A: Unless one has had prior chin surgery there is no need for preoperative 3D imaging of the lower face.

The amount of vertical chin lengthening that is needed/desired is determined the day the before the surgery with clinical measurements. X-rays do not provide any help in determining what is the most ideal amount of vertical chin lengthening. You have to walk into surgery knowing the exact amount of vertical length needed done to the millimeter.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am looking for a possible spiral thigh lift and butt implant. Address excess lower butt sag.

A: Thank you for sending your pictures. When it comes to buttock and thigh implants, based on your pictures, I believe what you’re trying to achieve cannot be done by these implant considerations. In the back view what you are showing his lower buttock ptosis and loose skin in the upper thigh. This will not be improved with buttock implants. Buddy came plants treat and augment the upper half to two thirds of the buttocks and will not change the loose skin in its lower third. The only way to treat loose tissue in the lower third of the buttocks iand n the upper thigh is with a lower buttock lift. One may get buttock implants with a lower buttock lift but that would only be because they wanted overall buttock augmentation as well.

In the thigh area you have loose skin in the medial thigh s as well as in and around the knees. Thigh implants will likely not change that significantly except maybe in the upper knee area…. but even in this area it will not completely make the loose skin go away. One gets thigh implants because their main goal it Is to improve the appearance of a small upper leg not to get rid of loose skin.

In addition I do not recommend any form of thigh lift in your case. The scars from the thigh lift would be worse then the skin problem you now have.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I was looking to try and find male pec implants before and after in the photo gallery but wasn’t able. Can you provide me with a direct link?

A: You should be looking at the Body Implants gallery on Eppley Plastic Surgery and search under Pectoral Implants on Explore Plastic Surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Would Dr. Eppley be willing to remove titanium mesh that is covering part of the skull? I would be paying out of pocket but what I would like done is essentially removal due to infection and inflammatory reaction due to internal fixation device. The mesh was placed five years ag0 after a craniotomy & there has been ongoing and increasing pain at the location of the mesh

A:I would need to see some x-rays that show the location of the mesh as well as the size of the bone defect that it is covering. In removing this mesh it would need to be replaced with split thickness cranial bone grafts as you obviously can not leave the dura/brain exposed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I saw your case study on iliac crest reduction in a male patient and am interested in more information about this. I am in my early thirties, and I am thin with an athletic build but my iliac crests are overdeveloped and this ruins the harmony of my physics, since I have a small waist and broader shoulders and chest, it creates more of an hourglass shape rather than a V shape. I’m looking for more information about the price for this procedure, recovery, functional implications and to what extent the soft tissue that is mentioned in the case study (TFL Fascia, etc) is damage / removed / altered, as well as what other risks may exist, how long recovery timeline, etc. I had no idea this was possible so I was excited to see your article!

A: As I have learned from doing iliac crest augmentation there are no long term functional issues with iliac crest reduction. The small amount of  fascia that is released along the crest to do so is not significant enough to cause any functional problems. There is some discomfort with ambulation in the first few weeks after the surgery but that dissipates quickly and one is back to normal activities within 30 days after the surgery.

Whether iliac crest reduction would be effective for your anatomy and aesthetic goals would require hey picture assessment of your iliac crest prominences.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in getting the Hunter Eye look. I have attached some information from using titanium brow and infraorbital implants with a patient who had the surgery with his result.

A:First and foremost I would need stand to see some pictures of your face and eyes to determine how realistic such a change may be. The custom implant example that you have shown is quite deceptive in the way the pictures are presented. In the before picture the head is tilted slightly back while in the after picture of the head is tilted down which overestimates the exact change that may have occurred making the brows look a lot lower than they actually are. Patients need to be wary of such false advertising.

Custom periorbital implants often have a roll often have a roll in trying to achieve the Hunter Eye look outcome. But that does not mean every patient can achieve it or can achieve the type of change that may make the surgery worthwhile. This has to be determined on an individual patient basis. This is where the role of predictive imaging is useful to show the patient what type of changes based on their facial anatomy.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I do have injected silicone on my butt not on my hips can that still be possible?

A:As long as in placing hip implants there is no silicone material in the path of placement it is fine.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I always thought the size of my head is a bit big and I would like it to be smaller. So no medical issues here and I just want to achieve a smaller head size. Is this at all possible and if so what would the cost be? Would the results be noticeable? 

The part im pointing to, I always thought. That part could be smaller. Is facial contouring/reshaping is also possible along with skull reduction as I think one side of my cheek is bigger than the other, thanks.

A:Thank you for your inquiry and sending your pictures. What you are pointing to on your head is known as the temporal line of the skull. This is often the widest part of teh upper temporal/ side of the top of the skull. That is the junction of the bony top of the head with where the upper temporal muscle attaches. This is why it is often a prominent line along the side of the skull which can clearly be seen in a 3-D CT skull scan. That can be surgically reduced to desquare the top of the head into a more round shape as per the attached picture. Not to be too obvious but there would be a little purpose in doing the surgery if the results were not visible.

Your more prominent left cheekbone can be surgically reduced by a procedure known as a cheekbone reduction osteotomy. That can be performed at the same time as the skull reduction.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have this scalp roll in the back of head. What should I do about this fat? What is the solution?

A:These scalp roll at the upper back of your neck to which you refer is not just fat alone. Scalp rolls are composed of excess skin, fat, and muscle of which fat makes the least contribution to it. Such scalp rolls are treated by excision which can be very effective albeit leaving a fine line scar as the aesthetic trade-off for its removal.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Attached please see images of face prior to accident 20 + years ago and current. implants that aren’t too bulky and cheek projecting. More refined, higher, and angular up the side. Refined and medium, not too big. I already have a square jaw so I don’t want a block face.

A:You have correctly surmised that only a custom cheek implant design has any chance of achieving that aesthetic outcome. The key component of that is the design of which I done many times before. As a male your request for this type of cheek argumentation is not rare in my experience.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is eye asymmetry surgery worth pursuing? Am I likely to see worthwhile improvements from it? I was also wondering whether you think it could be one of those surgeries that will improve in the relative near future? What I mean by that is perhaps technological improvements like custom implants or things that can make the surgery more precise and effective? Is that far away? 

I really, really appreciate this because nobody has given me this level of insight yet.

A:This is exactly how I do the surgery. Custom implants is a foundational basis for VOD surgery based on the patients 3D CT scan.

To understand contemporary VOD surgery concepts you need to go ti www.exploreplasticsurgery.com and search under Vertical Orbital Dystopia and read all about the surgery.

In terms of surgical outcome can you improve vertical orbital dystopia and lessen the asymmetry between the two eyes… absolutely. But can you make teh eyes so symmetric that the VOD is essentially undetectable or nonexistent and that answer would be no. Like all asymmetry surgeries it’s about improvement not absolutely the attainment of a perfectly symmetric outcome. There are just some differences between the two sides that can never be surgically eliminated.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My goals is to not have a bulbous chin and a more defined jaw line.I wanted a more squared off sharper chin and sharper jaw line and to remove the “divots” right past my chin and make it one linear plane to my jaw, instead it kind of concaves in. I just had the terino “square” style 1 implant put in with a platysmaplasty, and it is not at all what I wanted. Even with swelling I can tell it only will accentuate what I wanted to get rid of.

A:Your surgical results is a classic example of surgeons doing what they know rather than what the patient actually wants. This occurs simply because the surgeon does not really know how to get what you want which can only be achieved with a custom jawline implant. Adding a spot implant augmentation onto a short and high angled lower jaw is only going to accentuate what actually existed beforehand. Standard chin implants are most effective when the general augmentation needs are very modest and the jaw structure behind it has a good shape. It also illustrates the common problem that I’ve see that preoperative imaging to determine the patient objective was probably never done. I would be pretty certain that had these potential results been shown to you before surgery you would’ve said that is not what I want to accomplish.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m seriously looking into skull reshaping. I’m just not happy with how my head looks—it’s a real confidence killer. My forehead’s too long, the back of my head’s uneven, and it’s not that nice oval shape I want. Plus, I’ve got this depression on top that bugs me. I’m aiming for something smooth and normal, like Chris Brown’s head, you know? I want to ditch the hats and feel good about myself. Can you break it down for me—exact costs, financing options, the whole deal? I need the facts so I can finally get that perfect head and walk with confidence. I have attached photos of my head for your review.

A: Your skull shape has multiple contour issues including a protrusive frontal and occipital bones and a central sagittal dip. The occipital bone can be burred and the sagittal dip augmented with a custom skull implant. Both can be treated with a single incision at the top part of the occipital bone.

The real challenge is the protruding forehead because of the need to have a different incision which must be placed at the top of the forehead. In the shaved head male the location of the incision location is a questionable aesthetic tradeoff.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a flat skull at the back and a flat forehead, and I don’t have a defined chin. Is it possible to have surgery to reshape my skull and define my chin more (neck lift?)? Thanks.

A: It is not uncommon to do combined skull and facial augmentations.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m hoping my brow bone can be fixed back to original 1st picture with CT scanned bone cement implant.

A: While hydroxyapatite bone cement would be the appropriate material to augment a previous brow bone reductionit can not be made as a custom implant as that technology does not yet exist for that material. Even if it did exist HA could not be manufactured as a thin implant as it is too brittle to do so.

Hydroxyapatite cement is applied as a putty when mixed, shaped and then allowed to set.

Dr. Barry Eppley

World-Renowned Plastic Surgeon