Your Questions

Q: Dr. Eppley, I underwent a buccal fat pad removal surgery, during which approximately 5.0 ml of tissue was removed from each side. Unfortunately, I have since developed very significant adverse effects, including severe cheek hollowing, noticeable facial sagging, and what appears to be a collapse of the facial support structure. This has also led to concerning issues around my orbital area, such as a sensation of eyelid dragging downwards, potentially due to the loss of support. I learned that BFP is a structured, triangular fat compartment that provides essential upward and outward support to the midface. I am now desperately seeking a method to restore this foundational support as much as possible. I have consulted other surgeons, however, I was advised that standard particulate fat injection may not be a sufficient solution because it would be injected into the superficial or middle layers and cannot restore the deep structural support that the BFP provided. It would add soft volume but not stop the sagging, and may migrate downward over time. In my research for a lasting solution, I was profoundly impressed to learn about your advice in reserve BFP removal using en bloc fat grafting.This gives me much hope. Therefore, I would be incredibly grateful to know if you believe a revision procedure might be possible in my case. I am wondering is it possible to graft pedicled en bloc fat to the original compartment where BFP was in, potentially secured with material like fibrin net, to restore support? I seek your expertise with much respect and am available to consult. Thank you so much.

A: As most buccal fat pads are in the 3cc range it would be fair to say that at 5.2ccs a substantial fat pad removal was done. I have done several buccal liecptomy reversals where a solid or dermal-fat graft is placed back into the contracted and empty buccal space. To get it back in place (back as far as possible) a threaded suture technique is used to pull it in.  The fate of all fat grafts is unpredictable but dermal-fat grafts usually fare better than injected fat.

One element of the success of the procedure is how well the graft can be placed into the original buccal space. That is partially influenced by the time between the removal and the attempted graft implantation.

Dr.Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I am curious if the resorbable lag screws that can be used in a sliding genioplasty go unnoticed in dental x-rays and x-rays in general? If so, how long does it take for the complete healing and for the lags screws to be reabsorbed? Will it be 100% undetectable? Thanks!

A: Resorbable lag screws have a limited role in sliding genioplastics to more moderate sized advancements that follow the osteotomy line. But when used their resorption time is 9 to 12 months. At this point the residual screw hole will still be seen in an x-ray but that will go on to fully fill in with bone by 18 to 24 months after surgery. The resorbable screws are never seen in an x-ray, but it is the holes in the bone that will be radiographically visible for some time.

Dr.Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in jaw implant augmentation where a small external skin incision is placed either right at the back of the jaw angle or around the base of the earlobe.

A:A completely transcutaneous approach to jaw augmentation can be done provided at the amount of angle augmentation is not excessive. Such an incision is placed at the back end of the jaw angle. Coming from higher up at of the earlobe is not a good directional approach to placement of a bony implant.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, as you can see there is an obvious difference between the right side od the frontal bone and the left side. On my right side you can see concavity and lower brow bone . So im asking is there some sort of implant that can be inserted safely so i can get similar results like the left side and fill up the augumentation ?

A:Thank you for your inquiry and sending your pictures. Your brow bone asymmetry is a direct result of the right vertical orbital dystopia. As the right eyeball has developed lower than that of the left everything around the eyeball follows it down. Thus your right brow bone is lower and has less forward projection than that of the opposite left side. Such brow bone asymmetry can be improved at least in the filling in the concavity above the lower right brow bone. Whiel that some shape improvement I don’t think we could say that it will look exactly similar to that of the left side because the two brow bones alright completely different horizontal levels.

Assuming filling in the right front upper brow bone cavity is seen to provide effective improvement then the next question is what type of implant is needed to do so. In an ideal world we would make such an implant of of your 3-D CT scan to have the best possible implant design. Given that its size it Is likely to be small an alternative approach is to hand carved and implant based on visual estimates of the size needed. The reason to choose the latter approach is an economic one. Either way the brow bone implant would be placed through an endoscopic approach with a single microscrew fixation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a quick question about jawline implants and thick soft tissue. If someone has thicker coverage (skin, subcutaneous fat, and masseter muscle), does reducing some of those layers improve implant definition?

Specifically:

Would masseter Botox (to slim the muscle by ~25–30%) before or after surgery help the implant show better?

If someone gets very lean and/or does submental/jawline lipo, does that significantly improve the contour, or is skin thickness still the main limiting factor?

Lastly, does skin oiliness relate to thickness, or are they unrelated?

I’m just trying to understand if these combined approaches can offset soft tissue bulk, or if thick skin always prevents a sharp result.

Thank you for your time and expertise.

A:The external appearance of a jawline implant is a reflection of numerous factors including the thickness of the overlying soft tissue. The implant design, implant size and the thickness of the overlying soft tissues are the three main variables. Implant size can overcome thicker tissues but obviously you don’t want to have patrol augmentation diamonds up being too big. As a result for most reasonably sized gel implants many patients combine soft tissue reductions of fat in the cheek and neck area to help.

When you use the term developing a sharp result by that definition usually only patients with thin overlying soft tissues can never developed that outcome. No matter what is done to the patient with thicker overlying soft tissues a true sharp result is never going to be achieved.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Recently I lost some weight, and a family member was wondering why I am frowning, was I in a bad mood etc… On a side profile picture, I have a frown, like a hollow in my forehead. I have sent some photos for you to see. What can be done to improve this look? Thanks in advance.

A:Thank you for sending your pictures. Given that this frowning appears to have resulted from weight loss this is undoubtably due to the laxity of the soft tissues which is now falling forward driving down the corners of the mouth. Very likely your mouth corners were slightly turned down anyway but the dissent of the facial soft tissues behind it has exaggerated that effect. Given the origin of the problem this would really require a lower facelift (aka neck-jowl lift) to pull back the following tissues along with a direct corner of the mouth lift. When heavy tissues behind the downturn mouth corner exists at corner of the mouth lift alone is not going to be particularly successful.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Will the aesthetic outcome look like how it did before removing the buccal fat pad?

A:The simple answer is no. Whenever you have removal of tissues that are then secondarily reconstructed by the placement of new tissues one should never expect to return exactly to what they look like before the original removal surgery.  A more realistic outcome is how close could you come to your original appearance, whether that is 50% of what it was, 70% of what it was etc. cannot be precisely predicted. The outcome will be improvement but not complete restoration.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wound up getting pelvic plasty with the Korean yonsei baro chuk group that does it  as well. I went for a first surgery 6 months ago and then an attempted revision to fix the plastic portion again 1 month ago. Unfortunately neither helped at all, and now I am even worse off than before I got pelvic plasty.

Since my primary issue is the plastic implants sticking out exactly like before, I was wondering if you could help me with this issue? My old pocket is very big and likely needs to be adjusted to look normal. When I asked recently yonsei stated they did not alter the pocket because it was too deep to be sutured. I don’t know if I need new implants, or none at all plus fat transfer, or just a new pocket, but I was hoping to find that in a consult too. And to clarify I’m fine with my metal, my only issue is with the lower bulge. I have attached photos below.

Could I please get your opinion on this matter and what you would recommend? And how much you would charge roughly? Regarding a consult I’d prefer just an online one but if an in person evaluation is needed please just let me know

A:As can be seen in your 2-D CT scan there is excellent placement of the titanium crest implants as well as good adaptation of the silicone hip implant to the titanium crest one. But in looking at the external contour it is quite clear that the implant protrudes too far outward.  Whilethe implant pocket is clearly bigger than the implant, particularly on the right side, you can never adjust the actual implant pocket. That is simply too difficult or impossible to do. But I don’t think the implant pocket is the real issue. In my opinion it is the shape and size of the silicone implant that is the problem. Because the hooked design of the implant attaches to do the titanium crest implant, which is ideal, this also appears to be holding it out or pushing out the silicone implant and not allowing it to fall inward which creates the visible external contour deformity.

This is certainly a new pelvic plasty problem that I have not seen before and I don’t really have an obvious solution to it. Since you can’t adjust the implant pocket to pull the implant inward this suggests that either a different length and shape of the silicone implant is needed or, maybe it is best to have the silicone implant removed and let it heal and then see what it looks like. For all we know maybe you have an implant size that is really bigger than what you need or maybe you really don’t need the silicone hip implant at all. Given that you have had one effort at silicone implants adjustment with no resolution I would favor the latter as opposed to the former approach.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My goals are to get rid of the under eye exposure maybe through orbital rim implants and to get a sharper jawline that still looks natural and a wider lower jaw.

A:For under exposure an orbital rim implant is certainly needed but that alone will not completely elevate the lower lid. This usually requires the combination of a lateral canthoplasty with a spacer graft for the lower eyelid as a more comprehensive and assured approach.

For augmentation of the jawline the concept of natural is a relative one and that must be determined individually for each patient as to their tolerance for the magnitude of change. The attached imaging represents one type or flavor of augmentative change.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I don’t have any pictures but I do have cd’s of scans of my entire skull and face.. I’m interested in the services the Dr. Eppley provides. He must be the only one in the country that can help me.

A:To determine of what you need is something in which I may be of help I would need a description of your specific concerns and goals along with some pictures to make that assessment. CT images, which may be helpful secondarily, are not enough information alone to make this initial assessment.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, do you do jawline shaving to where you make me look more feminine?

A:The question is not whether you can have chin and jawline reduction, as you can,  but whether in doing so it would make you look more feminine. This type of potential change is best assessed in the front view or with a frontal picture. In that regard I have done some imaging of what I think could be accomplished by the surgery and the change of your jawline. You would have to make the assessment as to whether you see that as a more feminine look or not.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want to reduce the skull. There are prominent bones and a lot of asymmetry. The skull is wide.

A:Thank you for sending your illustrated pictures. On the one picture with the drawling I am going to assume that these are the desired general areas of reduction not necessarily how much you think the skull can be reduced to. While  the bony temporal line and the side of the head  and the posterior crown areas can be reduced by bone removal the key question from an aesthetic standpoint is that it would take a coronal scalp incision to do so. In this type of skull reduction surgery to narrow the  wide head this degree of surgical exposure needed requires a coronal scalp  incision . While this incisional approach is not a debate to be had for many more major craniofacial surgeries  when it comes to aesthetic skull reshaping surgery this issue becomes much more paramount. In other words would a fine line scar across the top of your head almost from ear to ear be acceptable trade-off for the skull reduction improvements?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had custom infraorbital implants placed earlier this year and it did not make my undereyes look a lot less hollow. Why is this? I have good lower eyelid position with no sclera show. Is this because I have no fat pads under my eyes and need a fat transfer, or because I need a different implant?

A:When you have had a custom implant placed in which there is a postoperative disappointment in the outcome, in your case not enough augmentation results, the question is whether the implant design was ultimately an adequate for your needs or whether your understanding of what could be accomplished was too optimistic. Without seeing your implant design file and looking out before and after pictures I cannot provide any insight into explaining your current result as well as how you might improve it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like a very dramatic midface transformation; I have been insecure of my strong nasolabial folds and premature genetic jowls since I was a child. I would like the implant to be at least 2-3 cm thick in some areas, for example the under-nose area, where my recession is evident. 

A: Thank you for your inquiry and sending your pictures. By description what you are seeking is a midface augmentation effect. But you are way overestimating the amount of augmentation you would need. Besides that the midface soft tissues could never accommodate a 2cm to 3cm implant expansion no one has ever had or needed more than a 6 to 7mm (less than 1 cm implant thickness) augmentation to achieve a significant effect.

The same applies to the chin where a sliding genioplasty is the preferred procedure for best soft tissue expansion.

It is common that patients over estimate their augmentation needs by the numbers as they can not appreciate that implant volume is more important a linear number. 

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, What kind of suture technique  does Dr. Eppley use in the forehead reduction ( hairline lowering surgery) to reduce suture tension?

A: Bone anchored flap scalp advancement…that is the most effective method of reducing tension on the scalp-forehead suture line closure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I always thought my head is really wide and weirdly shaped. I think I didnt look like that when I was a child and now It looks like its huge and rounded. Is it possible that my bones grew up and thats the reason I look like this or it could be my temporal muscles? I feel like its very wide and uneven. Its a huge problem for me beacuse it makes me insecure and I compare myself to other head shapes but never saw something like mine. I’m searching for all the things that could make my head smaller but i fail. I would be glad if you gave me any answer if something could help reduce my problem.

A: The side of the head is composed of the convex temporal bone and the thickness of the temporal muscle. While considerable muscle reduction can be done on the side of the head only a limited amount of bone can be removed. Thus to determine whether surgery may be beneficial a 2D CT scan is needed to evaluate the bone to muscle ratio at various locations on the side of the head.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Interested in knee lift and lower buttock lift ( ptosis case II) I had failed thigh lift and my buttock dropped.

A: Thank you for sending your well illusrated buttock and knee pictures. Your buttock pictures show a low infragluteal crease with a resultant elongated buttock appearance. The type of buttock lifted is what I call a Style 2 version where an excision is done and the crease ie elevated shortening the vertical length of the buttocks.

Unlike the buttocks the knees are not as favorable for an excisional approach. I see no excessive suprapatellar skin folds or redundancy and, as a result, no favorable placement area for a scar line. Small cannula liposuction for selective reshaping of the knee would be a less risky treatment consideration.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve been interested in getting a rhinoplasty as well as a chin implant/genioplasty. My question is, in your professional opinion, does a genioplasty have an advantage over a chin implant when it comes to breathing/opening the airway? My understanding it that it stretches the muscles out more which improves sleep apnea. Wouldn’t chin implants do the same? I’m getting a rhinoplasty and my surgeon uses medpor chin implants. Thank you in advance.

A:In looking at your side view picture you definitely need a sliding genioplasty over a chin implant. Your chin recession is significant and a sliding genioplasty will also keep the chin narrow. A chin implant is definitely not what I would do and, even if a teaching implant was indicated, I certainly wouldn’t use one composed of Medpor which is going to leave your chin wide and bulky an, when you were unhappy with the result, going to be very difficult to remove later.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q:Dr. Eppley, Hello, Im looking into skull augmentation focused on temporal and forehead areas. i believe i have an underdeveloped skull and facial structure. please see attached pics and video. my overall skull seems underdeveloped and grown downward. i was planning on getting cheeks and a chin implant for forward projection and width to help correct the “long narrow face” appearance but i wonder if the temple and forehead bone structure needs correction too; and which is more important for my facial structure.

the back of my skull seems quite flat too but st the moment what i really want corrected is the long narrow 2-D facial appearance. would appreciate the doctors opinion on my case. thank you

the space between the end corner of my eyes and my hairline is very very small, maybe that contributes to the 2D effect.

A: Thank you for your inquiry and sending your pictures. You have the classic narrow skull shape which also influences the longer and more narrow facial shape. In looking at weather for head and temper widening being effective I have attached some initial imaging to evaluate that concept. Such a head widening implant design may or may not need to meet in the middle of the forehead, probably in your case it would not need to being a female, but attached is an implant concept in how to make the type of imaged change.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My eyes are uneven and I’m looking for something to help with it. Would you be able to help? Here is a picture for reference. Thank you! is a pic. Please let me know if he thinks he can bring one eye up higher and if he thinks I would look drastically different. Also, if you know the cost that would be great. Thank you so much!

A:Thank you for sending your picture. This is a classic case of aesthetic vertical dystopia (VOD) where the ride I is 3 to 4 mm lower than that of the left. It is important to understand that in VOD it is the entire orbital box and all of the overlying soft tissues that are lower. As a result it is not just lifting up the right eye only that will be successful. The lower eyebrow and upper and lower eyelids must be repositioned as well if the eye is moved up or otherwise the blog gets buried under the upper eyelid and a lot of scleral show above the lower eyelid.

As a result there is usually a five procedure approach to treating VOD. But the first and most important question is how much improvement can be obtained. Or will the surgical effort be worth it for the patient based on the outcome that can be achieved. That, of course, depends on each individual patient and how one defines the term ‘drastically different’. As a general statement it would be fair to say that achieving ideal symmetry of the right eye to the left cannot be obtained. Improvement or reduction in the amount of asymmetry is what is achievable and that is probably best defined as halfway between perfect symmetry and where the eye is now. Will you see a change… yes. Will it be ideal…. no.

The other way to think about the problem is what is the patient’s level of concern. If it is not overly bothersome and the inquiry about surgery is more explorative then I would not do the surgery. If it is a major issue of concern and the patient is willing to do about anything to get some level of improvement then the surgery would likely be worth it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like a very dramatic midface transformation; I have been insecure of my strong nasolabial folds and premature genetic jowls since I was a child. I would like the implant to be at least 2-3 cm thick in some areas, for example the under-nose area, where my recession is evident. 

A: Thank you for your inquiry and sending your pictures. By description what you are seeking is a midface augmentation effect. But you are way overestimating the amount of augmentation you would need. Besides that the midface soft tissues could never accommodate a 2cm to 3cm implant expansion no one has ever had or needed more than a 6 to 7mm (less than 1 cm implant thickness) augmentation to achieve a significant effect.

The same applies to the chin where a sliding genioplasty is the preferred procedure for best soft tissue expansion.

It is common that patients over estimate their augmentation needs by the numbers as they can not appreciate that implant volume is more important a linear number.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, , I have been on corticosteroids for around 20 years due to kidney disease, and I had a kidney transplant 12 years ago. Over time, long-term steroid use has significantly changed the shape and size of my face and head, as shown in the attached photos (age 16 before steroids vs. age 35 now). The facial changes are quite noticeable, but I’m not sure if the change in head size is clearly visible due to the head covering. In reality, my head has noticeably shrunk in a way that feels disproportionate to my body. I’m unsure whether this is due to bone structure changes or loss of muscle and soft tissue. I had considered a custom implant, but my doctor advised against it due to the high risk of infection related to immunosuppression. Would fat grafting to the face or skull be a safer alternative to improve appearance? Or is there any other low-risk option suitable for a kidney transplant patient? Thank you for your time.

A: Under the consideration of immuno suppression, in terms of cranial facial augmentation, whule fat grafting would be considered the least risky treatment approach I would expect that there would be 100% loss of the injected fat, even if you had enough to harvest to do it. Thus, any chance of success requires implant placement. While there is always an increased risk of infection with any surgical procedure on a patient on high-dose chronic steroid use I do not share the opinion that the risk of infection and implant placement makes it an impossible procedure to consider. Of course, there was always going to be some increased risk of infection in an immuno suppressed patient over someone who is not on these medication. But fortunately, the craniofacial area is well vascularized and tips the balance in a tissue bed that is otherwise less than ideal.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello! I was wondering if you perform surgeries that can increase the space between the eyes? My eyes are too close together, and I am interested in getting a surgery to make them more wide-set

A: The type of procedures that can make a significant difference in increasing interpupillary distance, orbital box, osteotomies, or not generally considered aesthetic procedures due to the scope of the surgery. Meaning the aesthetic trade-offs of a bicoronal scalp scalp scar to perform an effective orbital box translocation must be considered very carefully.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I am interested in your large skull reduction procedure. My head circumference is about 23.5 inches, and it looks disproportionately large compared to my frame. I was wondering if the burring method could be used around the entire skull to reduce the size, and if it would be possible to get the circumference under 23 inches, which I know depends on my anatomy, just hypothetically speaking. Also, if you could tell me an estimate of the cost, that would be great. Thank you!

A: In a more complete skull reduction procedure based on the need for a circumferential reduction, the bone burring technique only applies to the bony forehead and back of the head.  For the sides of the head, it is the temporal muscle that is reduced as that is the dominant tissue over the thin, temporal bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’d like to make my face more angular. I thought that a three level facial augmentation could be my best option. Is it a good idea or does It risk too look “too much” for me? I’m not sure about brow bone augmentation btw. I’ve had double jaw surgery and rhinoplasty in the past and some facial fillers and I’m quite satisfied about the results. My face Is more harmonious than before. This is like an extra to bring some angularity and I’d like that to be natural. Thank you!

A: Thank you for sending your pictures. You are correct in that to make your face more angular ideally it involves all three levels. Technically the upper and mid face are the most needed in that regard as they lack projection unlike your lower drawl. Because of your prior jaw surgery major strides in lower jaw shape improvements have already been achieved. You’re also correct in that a ‘little bit’ in each area goes a long way and it is the composite overall augmentation that makes the more angular face change. Anytime you do two or three levels of facial augmentation almost always one has to be most cautious about excess  projection as opposed to when one has a singular major facial level deficiency.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have VOD (right eye lower). I will send (attach) photo. can it be fixed? I am planning on getting the right eyebrow lifted with botox next week (I have done this before), which kind of helps to even things up, but as you can see, the pupils do not line up horizontally at all.

A:Thank you for your inquiry and sending your picture. When the eyebrow is raised the perception of VOD becomes more apparent. Unlike raising the eyebrow with Botox injections, however, lifting up the eye requires more effort. Elevating the eye also requires adjustments of the upper and lower eyelids that drape over and around  it. As a result it takes a combination of four procedures to satisfactorily do so including an orbital floor-rim implant for globe elevation, lateral canthoplasty for raising  the outer corner of the eye with spacer grafts of the lower eyelid and upper lid level elevation. (ptosis repair)

I never few VOD surgery as a ‘fix’ as ideal symmetry between the eyes can never be achieved. Rather it offers an improvement than lessens the perception of the VOD.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to know more information about scalp rolls removals and wrinkled skin at back of head.

A:Thank you for your inquiry and sending your pictures. In looking at your pictures my suspicion is that this scalp roll may be associated with a bony overgrowth of the occipital knob or nuchal ridge line. It would be very unusual in a young person with your neck shape to have true excessive scalp  rolls alone. The determination if the scalp roll is caused a bony projection is how it feels. If the scalp roll feels fixed and minimally mobile then it is due to a bony projection which needs to be reduced with a little bit of excessive scalp removal. If it is soft and mobile, moves up-and-down, then it is a soft tissue issue alone where excision of the scalp roll is needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I’m interested in undergoing a reverse otoplasty targeting the lower and middle portions of my ear. I previously had otoplasty and part of the ears are too close to my head. From my research, I believe this may require the use of a grafting material to achieve the desired projection. Given your extensive experience with these procedures, I’d greatly appreciate your insight into a few questions I have: 1. Is it possible to achieve the desired ear projection without using an implant? In other words, could existing ear cartilage be harvested and repositioned to act as a structural strut? If so, would this compromise the aesthetics, structure, or shape of another part of the ear? 2. If cartilage harvesting is not viable, what materials are commonly used as struts, and what are their pros and cons? I’ve researched several materials and would like to know your thoughts on each: • Cadaver Rib Cartilage: This seems quite stiff—comparable to a popsicle stick. But this is just my uneducated opinion in looking at online pictures and reading that ear cartilage is elastic while rib cartilage is hyaline (and much stiffer). Could this rigidity become problematic or painful/irritating when side sleeping? I’ve also read that cadaver cartilage may reabsorb over time. If that happens, would the ear lose its projection? And what does reabsorption mean in these cases? Additionally, why is cadaver ear cartilage not commonly used? Could it provide subtle support in projecting while preserving the natural softness of the ear? • Implantech ePTFE Ear Implant: This material appears to mimic the flexibility and texture of natural ear cartilage. However, it doesn’t seem to be widely used. Is there an elevated risk of infection associated with this implant? If so is it a lifelong risk or just for a period of time after surgery? • AlloDerm: While not commonly used for this purpose, could AlloDerm serve as a strut to project part of the ear outward? Is it strong enough to act as a buttress in the cartilage? Does it carry a significant infection risk? Is its texture similar to ear cartilage? Meaning it is softer/ flexible. Can it reabsorb like rib cartilage? It says this can promote tissue regeneration. What does this mean? Can something natural regrow to take its place and maintain this buttress in the ears? • Medpor Ear Implants: What exactly is Medpor? Is it a rigid plastic or something more flexible like the ePTFE material from Implantech? My primary concerns are: • Will the graft material remain stiff permanently if using cadaver cartilage or another material? • What is the long-term risk of infection? Is infection only a concern during initial healing post-surgery for some time, or can an infection on some materials develop years later even without injury to the area such as a cut? Thank you in advance for your time and guidance. I look forward to your thoughts.

A:You have correctly surmised that in a reverse otoplasty it takes a strong strut of material to push the ear out and maintain that position. I have used a wide variety of materials from titanium plates to cadaveric rib cartilage. They all have had various degrees of success but the rib cartlige has been the most successful as it provides the strongest strut. As you have also surmised the trade-off for its use is that it will be stiff on the back part of the ear. It is also a graft does not resorb as it acts more like an implant even though it is a biologic material.

The other most successful option would be an ePTFE wedge material from the ear implants that I developed for implantech. That could be placed in the released anti-helical fold and would avoid the stiff feeling strur on the back of the ear. Its trade-off is that it is an implant with associated higher risk of infection/extrusion. But in my experience to date that risk is very low. No implant material, however, can never better the negligible risk of infection with a biological material.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I have currently have silicone implants, size medium. Please see link to the model below:

https://www.implantech.com/product/conform-terino-malar-shell/

Previously to this, I had the combine malar shell implants in size small:

https://www.implantech.com/product/combined-submalar-shell-2/

I absolutely loved these implants and feel they really suited my face. Unfortunately I developed a small infection, so the surgeon opted to remove them and do a wash out. When he reinserted the implants, they had ordered a different model by mistake which is what I have now!

I feel the projection is not quite right and would like something that projects a little lower in my mid face.

I have had the current implants for over a year now. My goal would be to either remove these implants and do a custom implant, or remove these implants and replace with the original model.

A:The effects of any facial implant is a function of the implant’s shape and size as well as its placement. You are assuming in looking at these two different cheek implant effects that they have identical placement both times and the only difference is in the two implant shapes and sizes. Assuming  that to be true, which is a big assumption in facial implant surgery, if you were happy with the first set of implants logically that would mean you should just replace what you currently have with the original malar shell implants.

Oner of the benefits of custom implants is the ability to create implant designs which do not currently exist as an off-the-shelf available implant.One of the other benefits of custom implants is the ability to see exactly where’s your current implants are placed and then designs can be made around to specifically create the optimally desired implant shape.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, https://exploreplasticsurgery.com/case-study-correction-of-eyeorbital-asymmetry-with-hydroxyapatite-cement/ Hello, I found you through this article. The man in your post is experiencing the same problem with my eyes. I live in Türkiye, and I don’t know if there are any doctors specializing in this. If I were to come to you for an examination and surgery, could I inquire about the average cost for the same or similar procedure?

It’s visible in the photo I sent you. I think it’s called Orbital Dystopia. I’m curious about what can be done and how much it costs.

A:VOD improvement rarely comes from a single procedure such as orbital floor augmentation regardless of the material used to do it. It usually requires a combination of bone augmentation and management of the upper and lower eyelids as well as the eyebrow that drapes around the lwoer eyeball and orbital socket. All structures have to be addressed for a satisfactory improvement. It usually takes a combination of five individual procedures done doing a single surgery which include orbital floor– rim implant augmentation, endoscopic brow lift, lower eyelid elevation with spacer grafts, lateral canthoplasty and upper eyelid elevation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon