Your Questions
Your Questions
Q: Dr. Eppley, Hello. I am a transgender woman from England. i previously have had two jaw surgery and also mandible shaving as part of a few facial feminization procedures however they removed too much bone so i have a very weak mandible angle. would you be able to tell me if you do custom jaw implants? and how much roughly do they cost?
My issue is i have previously had jaw shaving v line but they removed too much bone so now i have very asymmetric weak mandible.
A: I have done many custom jaw angle and jawline implants for subtotal or total V line surgery reversals. Over resection in Non-Asian patients is not uncommon as the size and shape of the Caucasian lower jaw is often different.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello! I want to have rib removal for a smaller waist & I’ve previously enquired about shoulder narrowing surgery. I am set on having 2.5cm removed on each side. As for rib removal, I have a couple of questions. Would it be possible to remove both the 11th & 12th ribs during the same surgery? If so, would it also be possible to have the rib removal & shoulder reduction both during the same surgery? How much would it cost in total? Thank you so much & have a great day.
A: It is common to perform bilateral 11 and 12 rib removals at one time as well as combine that procedure with clavicle reduction osteotomies. Almost always 2.5cms of clavicle bone is removed per side.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi, I would like to inquire about a consultation for chin ptosis treatment. It’s congenital, I’ve had it all my life and never had any facial surgery. I tried Botox for the first time a couple weeks ago for it and I feel like it made it even worse.
A: I am not confident that congenital chin ptosis in its entirely can be improved…at least the lower lip position can probably not be improved. The overhanging chin pad and the deep siubmental crease can be improved by excision.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, 1. Would any cosmetic skin treatments like microneedling or Fraxel laser therapy pose a risk to my implants? (in particular the malar implants but also the chin or jaw implants)
2. Have you ever heard of apthous ulcers causing jaw hardware infection? I am taking rapamycin for longevity benefit, and this drug causes occasional canker sores. I want to make sure that I don’t put my jaw hardware at risk, and would stop the rapamycin if you thought there was a significant risk that a canker sore could lead to a hardware infection.
A: In answer to your questions:
1) Facial implants are not at risk from any ‘invasive’ skin treatments such as microneedling or laser resurfacing.
2) Apthous ulcers are a superficial mucosal (wet or dry) eruption that is far removed from the subperiosteal location of your facial implants. There is no infectivity risks to your implants from them.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Is it safe for someone to get Botox if they are allergic to cow’s milk, Casein & or egg?
A: Botox is a synthetically derived toxin in which its production does involve albumin, a cow’s mild protein. So if one has a true albumin allergy then one should not get Botox. However a lactose intolerance does not count as an albumin allergy.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, you did my breast augmentation back in February of 2017. I have had a wonderful experience so far! I am simply curious when or what I need to do to “check” to make sure they are good. I know it’s usually 10 years it is requested to get new ones, but can go longer. Just seeing if I should be planning for something in the coming years.
A: Good to hear from you after all these years. With silicone breast implants there is no reason to ever replace them unless they fail. (disruption of the containment shell known historically as a ‘rupture’) Unless you have implant symptoms (pain, change in breast shape) you just get your mammograms as you normally would do on that schedule which will also show implant integrity There is no need to replace them every ten years unless there is a compelling reason to do so as per above.
Short of any symptoms of implant failure you may live with them for many decades or even the rest of your life.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I wanted to ask you if there would be a change in volume compared to the extension, that is to say will there be more volume once the implant is placed? Or will the change not be very different compared to the scalp extension volume?
A: While a scalp expander and the skull implant may have similar volumes they have radically different shapes. Scalp expanders are round while the skull implant has a more oblong skull shape as you have seen in the design file. So don’t confuse the external effects of these two.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I hope you’re doing well. I have a lip deformity that developed after I underwent double jaw surgery and genioplasty almost a year and a half ago.
At rest, my lips don’t meet naturally and I need to force my lips closed since my bottom lip drags down and rolls outwards which exposes the wet mucosa. Forcing my lips closed causes me pain in my lower lip and chin area.
I’m thinking if I somehow can permanently augment my upper lip it will close the gap I need to force shut therefore reducing my pain. I’m interested to see what the doctor would recommend.
A: i think you have had too many alterations in the perioral region (subnasal lip lift, double jaw surgery, genioplasty) that the structure and elasticity of the lips has been adversely and probably permanently affected. The key for your lip incompetence is not to try and make the upper lip go down to meet the lower lip….as that will never happen and the upper lip already covers all of your upper teeth. The correct diagnosis for your lip incompetence is that the lower lip is pulled down as the excessive lower tooth show demonstrates. Therefore the correct approach, challenging as it is, is to free up the lower lip and try and raise up it higher up. In my experience the only effective approach is vestibular/scar tissue release, dermal-fat graft and a shortening vestibuloplasty.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My son is 6 years old has brachycephaly. At what age can this procedure be done?
A: 16 years of age is the minimum age with parental consent.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in midface and cheekbone implant but am not sure if I can afford it. I was wondering the range of cost of the procedure?
A: There are two strategies to midface augmentation in the Asian patient, standard cheek (modified for anterior cheek/infraorbital augmentation) and paranasal-premaxillary implants and a custom midface mask implant. The former is what is done when the patient’s budget prohibits the latter.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to ask if you are able to conduct buccal fat rejuvenation surgery.In a previous facial surgery,I had removed about 50% of my buccal fat and I would like to see if it’s possible to restore some of this fat in my cheeks. If there is any information you can provide it is much appreciated, thank you.
A: There are two autologous methods for buccal fat restoration or reversal, external fat injections and intraoral replacement with a solid fat graft. There are advantages and disadvantages with either approach. Fat injections are a scarless harvest and placement but their survival is not completely predictable. The solid fat graft method requires a donor site but the volume of the graft is more stable/predictable.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have lip tightness after genioplasty. Can it be corrected?
A: Most lower lip tightness issues after an intraoral genioplasty represent contracture/tissue deficiency. This is best treated by an intraoral release with a dermal-fat graft. (tissue addition)
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I want to get a large scale partietal skull reduction done. One of your patients on Instagram had great results. Can you please give me an estimated reduction possible in cm and also estimated price. To see if it’s realistic to continue the procedure. I will add the photos of your patient in the appendix.
A: Such skull reductions are done in mms of bone thickness removed (not cms) over the reduced skull area. How much bone can be reduced is determined by a preop 2D CT scan to measure its thickness.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am a female with alopecia who keeps my head shaved. I do wear hats and wigs sometimes but also like to be comfortable. I have not found any other information on hiding the scars from facelift and necklift surgery except on your examples of bald men. Have you ever operated on a woman with alopecia? Were you able to camouflage the scarring! Any information would be greatly appreciated.
A:The key to limit visible scarring in any patient with little to no hair coverage, regardless of their gender, is to not have the incision lines extend away from the folds/creases of the ear. That is the best way to not create a scar problem. With more limited incisions comes more modest face/neck lifting results. Whether that tradeoff is a reasonable one depends on the patient’s face/neck issues and their expectations. That would have to be carefully assessed before surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in a Custom Skull Implant to help with the top ridge on the side profile and make the back of the head more rounded like a typical skull shape.
A:While a custom skull implant can very effectively add volume to the flat back of the head, it is not clear how it would help the top ridge unless the implant design crossed over onto the top as well.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I plan on gaining weight as I’m not very comfortable with my current weight, I think I’m too skinny. So if i gain weight for the hip implant surgery id maintain that weight and then some probably, i don’t plan on staying this weight or getting any skinnier. Do you think hip implants are good idea of I gain weight?
A:I think even with any weight gain it will never be enough to significantly reduce your risk of hip implant complications.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi, I have got this skull deformity on the top of my head where it sort of just peaks upwards and looks like a lump. Wondering if it would be possible for you to do a reduction and cut it down to make my head shorter and then carve it so that it is a bit more rounded off instead of sharp and pointy? Or would I still need to have a custom implant to achieve this?
A:You have an uncommon top of the head skull deformity because it is both raised and flat. Usually raised midline top of the head shapes are peaked with a sharper angle. (not flat) The question as to whether an overall reduction in its height and shape can be done depends on the thickness of the bone which requires a CT scan to its thickness and how much of it can be safely reduced. A custom implant would only be used as a second option (and only option) if the bone is not thick enough to do a good reduction. It would very effectively create a more assured shape but it would make the head a bit taller.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I found your information from an online article I came across last night. I am reaching out to request information on your rib removal procedure. I am a middle aged male in very good general health. My 12th rib on my right side however is fractured and will not heal. This happened back in early 2023, so I have been dealing with pain on and off for just over over a year now. My primary care physician was confident in our last meeting that my rib would heal on its own, but this meeting was months ago and I’m still struggling with pain. I am not sure he will even agree to this type of surgery, but I just want to be able to live an active lifestyle again and be pain free once more. Which is why I’m reaching out to other specialists outside my network. My two questions are 1. Am I a candidate that you would possibly consider for this type of surgery even tho this is not cosmetic in nature and instead to alleviate pain? And 2. What type of cost would be associated with rib removal of a single (12th) rib? Thank you so much for your time.
A:The key question from my standpoint is where is the rib#12 fractured along its length? I assume this is shown in an x-ray. That would determine how effectively it could be removed. (get rid of the free floating bone segment distal to the fracture line)
Rib #12 is a very short rib with thin bone so I would doubt it ever could heal back as solid bone so the fact that it hasn’t healed is no surprise.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a Male Deep Plane Face and Neck Lift earlier thus year. I am pleased with the facelift, but not with the chin and jawline.
I am wanting to redo the following:
– Custom chin jawline Implant (Chin Augmentation), I want a longer masculine face (about 3/4 inch down) with a strong jawline (As per before and after pictures included). .
– Upper Eyelids – Eyelid Surgery (blepharoplasty).
I’ve included the following my marked photographs with the dates before and 60 days after surgery, as well as the day of the procedure. I’ve also included before and after photos of third-party custom customised jawline implants to demonstrate my intended outcomes.
A: Thank you for your inquiry and sending all of your pictures to which I can make the following comments:
1) As you have learned, although it was not your primary intent, you can’t lift or defat one’s face into a more defined or stronger jawline. It will merely reveal whatever shape/size jawline that already exists.
2) Your face has thick heavy soft issues, unlike the examples you have provided, so we have to be aware that this is a ‘problem’ in terms of showing jawline shape/definition. Like putting a covering over a ball there is a big difference in how it will look with a thin sheet vs a quilt. In the former you will know it is a ball, it is the latter you would have no idea as to its shape.
3) The method to partially overcome the negative side effects of thick tissues is to expand them or stretch them out. The more you do so the more the underlying shape of the jawline can be seen. But there is a delicate balance between the positive effect of a lot of jawline augmentation and looking too big. Thus more is better to a point. But size tolerance is one of aesthetic preference so in that regard I have attached some potential imaged changes to try and determine your change tolerance.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, i understand i have to gain some weight but i’d never be able to gain enough to get a BBL but i think i could deff gain enough to bring me out of the high risk level for implants if i got hip implants. how much do you think i should aim to gain? i weigh 121lbs right now at 5’10
also what would high risk mean exactly, what am i at high risk for ? implant rupture or my body rejecting it ??
A:You never want to gain weight for a BBL or hip implants as, unless you maintain that weight forever, will simply be lost. But that issue aside it is clear from your pictures you are ultra thin so gaining weight is not a viable option for you even if it was a good idea,
The risk of hip implants in a very thin person is implant edge show not implant rupture (these are solid implants so they can’t rupture) or that of rejection. (infection is possible but not true immunologic rejection) There is no way with a thin subcutaneous fat layer that you will not eventually see some of the implant edging eventually, particularly the lower half of the implant.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have this one face on that shows the issue with a bump on my right side.
Ill take better ones this weekend but from the sides and back it looks fine, seems to just be in certain lighting.that my head shape looks really weird. Could be the camera too, don’t really notice it in mirrors.
Unfortunately my hair is too far gone and have to have a shaved head, insecure about it.
A: Thank you for sending your pictures. I believe you are referring to a right temporal protrusion seen above the right ear. (see attached picture) That area of excess muscle mass could be reduced from an incision in the crease of the back of the ear.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My goal is to have the back of my head, flat without any dip or separation.
A:This is a back of the head problem that I have seen many times. This is due to an excessive of bone and an overlying roll of scalp tissue, both of which have to be removed to get a smoother transition from the back of the head into the neck. There is the tradeoff of a fine line scar across the area and I would need a back of the head picture to show you its location. But as a general rule its length is the same as that of the scalp roll.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have been aware of my plagiocephaly since I was 12 and I wish I had neither recognized nor investigated it. Since then, I have had the same haircut, which I cut myself. But now, approaching 30 years old, I am tired of buying hair products, using straighteners, and spending so much time in the bathroom.
So, I would like to have cranial symmetry and a nice skull shape like my mother’s. I don’t really care about facial symmetry, haha. I would like to go to my younger brother’s hairdresser, get the same haircut as him, and travel with him without having to pack hairsprays, straighteners, or anything like that. I want to go boxing with him and wear a helmet on my head (I can’t stand any pressure on my head, it’s like having tickles, I move away from the stimulus at lightning speed). Sometimes I feel ridiculous, to be honest.
A:It appears he has a right flat back of the head, usually the most significant deformity from plagiocephaly, for which a custom skull implant is the best method currently to treat it.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, the picture I provided I was wondering how likely can you reduced the width of the head like that I basically have the same wide head that this guy have ? Thank you was very interesting in reducing my width drastically.
A:I don’t know if the picture you are showing is an actual before and after result or just an imaged one. But with temporal reduction surgery that is probably close to what I predict will actually happen. However when it comes to any elective aesthetic surgery the trigger for surgery should not be the best result one could hope for….as that result may not happen. Rather it should be the minimal result one can expect…as that is what is most assuredly will happen. Thus the question then becomes of you got half of that result would you still have the surgery?
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I would appreciate your thoughts on the below given expertise across the below techniques.
I had a lateral canthoplasty in September 2023 but it did not elevate the 3-3.5mm of congenital inferior scleral show, and hardly improved the canthal tilt (relapsed to original position largely after 3 months) – would periosteal flaps with lower lid retractor recession as a standalone procedure; be able to correct the scleral show and canthal tilt? I have read studies where this worked in reconstructive cases of facial palsy – but wondering if it can also be used aesthetically.
I have seen three surgeons with differing opinions:
- Infraorbital rim implant + and/or Orbital decompression., revision canthoplasty with thin spacer graft
- lower lid retractor recession, medial and lateral horn lysis, periosteal flaps and release of arcus marginalis (no spacer graft)
- upper to lower lid Hughes flap with revision lateral canthoplasty and an alloderm spacer graft in the centre of the lid, with ptosis surgery.
Questions
1. Would appreciate if possible to review the second opinions below, and share thoughts
2. Thoughts on an infraorbital rim implant, and/or orbital decompression – to correct scleral show with longer-term results (noting negative vector and anatomy, Hertel measurements). Know we only got to briefly touch on the latter.
3. Different opinions have been given on using an additional spacer graft – one doctor is against this, and feels it would add ‘bulk’ or compromise aesthetically. Is this something you would recommend or not, in terms of desired outcome aesthetically and functionally?
4. s i) the Hughes tarsoconjunctival flap reconstruction, or ii) lower lid retractor recession medial and lateral horn lysis, periosteal flaps and release of arcus marginalis, release of arcus marginalis – more appropriate to address the residual scleral show I still have? I have seen studies stating this can be feasible, albeit unclear if also applicable to patients with a slight negative vector profile.
A: These various and diverse opinions in regards to treating your congenital scleral show are common and are a reflection of the surgeon’s experience, training and how they see the problem. As you have learned and was completely predictable a lateral canthoplasty is going to fail for scleral show and that procedure is best viewed as an adjunct to the needed surgery rather than a primary procedure for it.
The basic concept to grasp is that your scleral show issue, and I seen no pictures so these are general statements, is very challenging and represents a tissue deficiency at multiple levels. (bone and soft tissue) Thus tissue addition is essential not just tissue rearrangement. (e.g., lateral canthoplasty) Also in such challenging issues it is essential to do multiple maneuvers that are diametric in nature to assure some substantial improvement.
To answers your specific questions:
1) An infraorbital rim implant is essential. As opposed to a standard infraorbital implant which merely provides horizontal augmentation, the implant needs to saddle the rim to raise the level of the rim upward as well as forward. This requires a custom implant design.
2) A spacer graft is needed for the lower eyelid with a double hole lateral canthoplasty. A medium thickness Alloderm graft is fine, a palate graft is not needed and is very bulky.
3) The addition of orbital decompression is the diametric maneuver as dropping the eyeball a bit will help make #1 and #2 more effective.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’ve been heavily considering the brow bone reduction surgery for the majority of my life. I’ve come to realize it’s too hard for me to accept the way I look and I really want some minor adjustments. I want to look more feminine when it come to my forehead. I’d like to know what my most accurate grand total would be based off these images, please.
A:While you do have a low nasal radix/bridge, which always contributes to making the central brow appear bigger, you do have an overall bigger forehead/brow bones. Their reduction would likely produce the attached imaging improvement. The only questions for the brow bones is whether a burring reduction or a bone flat setback would be needed to achieve that effect. This requires a lateral frontal sinus x-ray to make that determination.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, do you perform infraorbital custom implants, more specifically 3D-printed bone scaffolds that gradually transform into real bone over time through the process of bioresorption, effectively replacing the implant with natural bone?
A: There is no such implant technology that currently exists to achieve that biologic transformation. It is a great concept and would be of immense clinical use but it does not yet exist.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, How do you think a ligated temporal artery turns into connective tissue? For example, if after a few years the nodules unravel, will blood flow through them again?”
A: Once blood flow is cut off by the sutures the blood flow is stopped and does not return even if the sutures dissolve as the internal lumen of the vessels is now clotted and fibrosed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,Will my lip swelling on the right side subside in time or is this a permanent complication at 8 months post op? I had v line surgery with aggressive contouring on the right side, and a genioplasty to shorten length of my chin 8 months ago. I still feel the swelling in lips, on the right side, with a slight pull to the right and down. Will this swelling improve on its own?
A:It would be fair to say that whatever you see at 8 months postop is probably permanent. This is not swelling at this point.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My nose bridge looks low on the upper side. Can a forehead reduction help give a raised nose bridge appearance?
A:Your nasal bridge is low and our brow bones are protrusive so it is the combination of both that contribute to your concerns. While brow bone-forehead reduction would be beneficial you are never going to do that procedure due to the long scalp scar that would be needed to do so. Thus the only acceptable option is nasal dorsal augmentation (see attached imaging)…which not only addresses the low nasal bridge but also makes the brow bones-forehead look less protrusive.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
