Your Questions

Q: Dr. Eppley, My son is now 7 years old,  he developed Plagiocephaly just two months after he was born. I was a young new mom with severe postpartum with no help and knowledge on soft skulls of babies. I noticed his head being oddly shaped. I informed his doctor at the time and he said do more tummy time and didn’t really express the issue as something abnormal. I was under the impression that it rounds out as he gets older.  As time went on, after tummy time, rotating his head, etc, it never rounded out at all and once I realized I needed to help him, it was too late. Everyone including family members, the doctor and my husband just brushed it off. It wasn’t until my friend who was a doctor who saw him when he was 9 months and said it was bad and he needed a helmet, by that point it was too late and my husband at the time still didn’t think much of it. Since that time I haven’t had a day of regret and depression over it. I feel sad, upset and resentful! for I feel let down and hurt by the doctor who didn’t treat it as a medical issue! Dr. Eppley is my only hope! I researched for hours and hours and cried for hours trying to find a solution for this. Please let me know if there’s any hope for him, my prayers will be answered.

A:I don’t treat plagiocephaly as an external skull augmentation technique until the skull has come closer to full maturity. (aka 16 years of age) It is an effective approach but one with un known long terms risks in the developing skull.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I got my Medpor jaw angle implant procedure over 2 years ago.  One year ago I had one side of the implant shaved down to make my face look more symmetrical.  But, the second procedure caused a mandibular nerve injury, which has impacted my smile and caused a dimple in my chin.  My smile and chin are improving, but very slowly.  I’m confident that my smile and chin will heal eventually on its own. 

If I go ahead and get these implants removed by Dr. Eppley, what are the chances of getting another nerve injury?  I was planning to get a 3D CT scan soon, which would probably help Dr. Eppley see where my nerves are and if it’s possible to safely remove my implants?

A: You  are referring to an injury to the marginal mandibular branch of the facial nerve. A nerve that is not seen on a bone scan unlike the inferior alveolar nerve that runs through the bone which is a sensory nerve not a motor nerve. It is not clear to me how that nerve got injured if the jaw angle implants were placed intraorally. It could have occurred if they were placed externally through a skin incision near the jaw angle but not intraorally.

There is a good motto to remember about recurrent surgical risks….past history predicts future behavior.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, The post cheek reduction X-rays look pretty even but the cheekbones seem off and there’s some hollowing I wasn’t expecting. I’m not sure how much is due to swelling. It’s been almost five months since the procedure. Some areas of skin seem to be very loose. And one cheekbone does seem to be farther forward facing than the other one. I’m not sure if a cheekbone or temple implant could fix this. I’m worried they took too much off my cheekbones.

A: These post cheekbone reduction issues are not rare. The execution of the operation is not easy in terms of bony symmetry and loss of structural support will cause some amount of soft tissue laxity/sag.

You are correct in that implant augmentation is how these issues are treated for which improvements are usually obtained. The only question is whether these should be standard or custom cheek implants.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello I was wanting to get your opinion if a Large vertical lengthening chin implant (VLC) can help achieve these results.

A: That will not create that imaged effect as that is a square chin result and the VLC implant has a rounded shape. That  specific chin shape effect requires a custom chin implant design to get both vertical length and a square chin shape.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, my skull has a congenital deformity, which looks like a melon (they say due to premature closure of the skull sutures), which is elongated from the back of the head and protrudes from the forehead and The width of both sides of the skull is small, and this matter has bothered me a lot in these 25 years. During school and in the army, I was ridiculed by others. Even now that I have reached this age, I don’t appear in the crowd much, I don’t have the energy to do anything, and my self-confidence has taken away Is it possible to make my skull rounder?

A: Thank you for sending your head pictures. While you have an elongated back of the head  and some slight forehead protrusion the actual diagnosis would not be a true sagittal craniosynostosis. Probably some lesser variant of it. But diagnosis aside all that matters is what can be done for it which is burring reduction of the upper forehead and back of the head. The question is not whether this can be done but the extent of reduction achievable. This would require a 2D CT scan to assess the thickness of the bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a few questions about sliding genioplasty surgery.

1. I had a sliding (osseous) genioplasty last summer, but I still have a decent labiomental crease. I am not experiencing tightness unless I really pull by lower chin down, but it’s not bothersome. My surgeon is suggesting hardware removal (since he says it’s pulling the skin in, and scar tissue accumulates there), some bone shaving, and fat grafting. Hardware removal doesn’t seem promising, and bone shaving seems counterintuitive. Do you think these suggestions will help reduce the fold?

2. Does hardware add any projection, and will removal reduce projection?

3. Does cutting into the mentalis muscle and soft tissue again increase the chance of nerve damage? (Luckily I had no permanent numbness from the first procedure.)

4. Unrelatedly, I’m considering jawline implants, but I am fearful of bone resorption. (This is why I avoided chin implants.) Is this a risk of jawline implants?

Thanks so much!

A: A deeper labiomental fold is not going to be improved by hardware removal or bone shaving after a sliding genioplasty. That is a failure to appreciate the anatomic basis of the problem. This is the resilt of a change in the shape of the chin bone which now has a deeper concavity or stepoff beneath the labiomental fold. This bone area needs to be built up on top of the plate for which a dermal-fat graft works well for this problem.

Numbness comes from injury to the mental nerves which lies way to the sides of the mentalis muscles.

The best way to avoid the remote risk of bone resorption with jaw implants is to not do them.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Given your vast experience within every type of jaw implant, and all the designs on implantech are made by you, I thought it would make sense to ask you these questions.

Out of the standard implants, I noticed in a previous blog you had mentioned you would not recommend the conform mandibular angle implant (CMA) for the given male model look that the question was asking and would rather go for the widening angle implant (WMA). My 1st question is, what instance would make the CMA an appropriate implant? Given you said it gives a rounder/ fatter shape of the jaw which is usually undesired for people going for this type of surgery. My 2nd question, is in your experience have you found that the WMA is harder to attach and higher chance of migration than the CMA since it lacks the inner piece that looks into the jaw angle? (I have attached a photo of the CMA and highlighted in yellow the part I am talking about) Lastly, what is your preferred off the shelf implant design from implantech when trying to achieve a more defined angle, from the front and highlighting the jaw line from the side as well?

Thank you so much for your time

A: You have to separate whether one is trying to achieve primarily a widening effect or a vertical lengthening effect when choosing a jaw angle implant style. Your question appears to be directed to the former to which the WMA style has a more pronounced and lower jaw angle shape. I have only designed the WMA and VLA implants for the specific reason that these are my preferences for these two jaw angle augmentation effects.

Proper placement and prevention of migration has nothing to do with implant designs. Those issues are ones of surgical technique and experience.

The jaw angle implant picture you have attached and the highlighted yellow areas at its perimeter is an original jaw angle implant design from the early 1990s…with the flawed premise that this rim of material will catch the edge of the bone and hold it into place. Fixation today is more assured using screws and does rely on implant design which does not work.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wanted to increase chin width and mandibular length and I wanted to ask based on the pictures attached which procedures could make sense. I already consulted with a few surgeons and I got varying answers and I am unsure what to do. The left side shows my current face and the right side shows the desired result. I am also not entirely sure if it’s achievable. Your input would help me a lot! Thanks!

A: What you are demonstratng by your own imagung is a vertical and horizontal incdease of the chin that extends back along the jawline but does not augment the jaw angles. (widens the jawline behind the chin) This dimensional chin-jawline change can only be achieved by an extended custom chin implant design.  (see attached implant design examples) The oinly question is how far back along the jawline from the chin does it need to go.

No form of an osteotomy can make a smooth transiiton back along the jawline from the widened chin.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a 22 year old female with prominent brow bone looking to correct this issue as it’s an insecurity of mine that weighs me down on a daily basis. Also wondering if an transpalpebral brow bone reduction would be possible for me, and the average cost of that procedure. I would greatly appreciate this information to direct me. Thank you

A: Transpalpebral brow bone reductions are only effective for the tail of the brow bone. While your brow bone tail is prominent your central brow bone is even more so over the frontal sinuses necessitating a superior hairline or scalp approach.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Does the doctor practice reduction of the temporal muscles on the sides of what is on both sides of the eyes (so i don’t mean only skull reduction on the sides of the Head, but temporal reduction like the botox Can Do for an hypertrophy of the temporalis of what is on the face, not around the skull).

I didn t see results of that on his website. I know that this Can be achieved by botox but Can it be achieved permanently with that operation. Does that skull reduction Surgery include thé reduction of that region of the temporal muscle as well. I sent to you a picture to get what i mean.

A: What you are referring to is reduction of the ANTERIOR temporal muscle region of the side of the head. This is different than reduction of the POSTERIOR temporal muscle  in which the muscle is fully removed. Such muscle reduction can NOT be done in the ANTERIOR  temporal muscle as this is the thickest part of the temporal muscle and there is no open surgical access to do so.

I treat the ANTERIOR temporal muscle by release and transpositon which does have a reductive effect although not one as dramatic as that of the POSTERIOR muscle removal procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Interested in a chin implant. Have had Botox/Radiesse injections in the area previously, seeking more permanent treatment. I have attached photo which show the effects of Radiesse. Other photos are most recent with Radiesse having gone away.

A: There is not a true matched side profile of a before and after injectable filler outcome. The only black and white jacket outcome that i see is an oblique view,..,.,which does not tell me how much chin augmentation change you have achieved with the filler or some indication of what you are seeking.

I would question the wisdom of an implant given your very recessed chin with hyperactive mentalis muscle. Its indication in your type of chin would only be if the amount of chin augmentation was small/modest. (e.g., under 5mms) Anything more than that in your chin type is better off long term with a sliding genioplasty.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in having testicles implanted. I currently have an empty scrotum. Years ago I had one testicle removed due to suspected testicle cancer that proved to be false. Long story short, I have had both testicles removed, implants placed, and then those removed due to two different reasons.I now have an empty scrotum and would like to have new implants placed. 

A: The only question then is whether these would be standard or custom size implant. Given that the scrotum is empty I would assume that standard size implants (up to 5cms in size) should suffice.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I am still thinking about trying to get some volume to the back of my head using fat grafting.

It sounds quite promising that it could work for smaller changes even though it is not safe to say how it will stay on long term.

However, I think I have enough fat available for harvest.

Since you also used fat for some of your patients to achieve more volume in some areas of the head/neck – would you say that there are good chances I could achieve a volumce increase like shown in the attached picture?

I have also heard of the possibilty to prepare the fascia of the skin and double it in the area where some more volume is needed to create a rounder head shape. Have you heard of this technique and could you please give me your professional feedback on a combination of this and fat grafting for a (longterm) volume increase?

Your opinion is highly appreciated. Thank you very much for your education and sharing the knowledge and experience.

A: There are several fundamental concepts about injection fat grafting that are universal no mattrer where the fat is injected. First and foremost it is a gamble, no one can tell you with any scientific precision how much fat will or will not survive.  It could be 0% to 100%. It is a metabolically active tissue in which there are dozens of factors that affect its transplantation survival. But what is known is that it survives best in tissues that have some fat natuirally present and in tissues that are not overlying tight. (two factors which don’t bode well for the scalp recipient site) Thus you undergo fat grafting under two specifics circumstances…..when no other procedure is available for the desired effect or whether the alternatives are so unappealing that you want to try something ‘simpler’ first. Second, any fat that survives is metabically response to numerous influence like that of fat anywhere in the body. Thus its long term volume retention is suspect…whether that means it can get bigger, smaller or remain the same is unknown.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interestedIn a genioplasty full reversal but I was wondering if it’s necessary to leave 0-11mm of movement forward because of the genioplasty cutting tool thickness or is it a non factor once the bone heals? I know the hardware also leaves some 1-2mm projection forward during a reversal but I’m still young enough that I’m hoping I can have my hardware removed after a 1 year healing period without significant nerve damage.

A: Your assumptions are correct  on both counts:

1) The thickness of the bone cut with healing will be irrelevant.

2) After 6 months the hardware can be removed. There is no risk of nerve damage from hardware removal.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have seen your comment about swelling and the timeline it takes to go down on a weekly basis for jaw augmentation. However since this is based off the custom implant, I was wondering if you could give a similiar breakdown for a standard implant and how long the swelling would take to come down?

A: The recovery process is the same regardless of the implant type. The only difference between standard vs custom facial implants is usually size and the scope of the swelling.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I was born with craniosynostosis and I think that I need full skull implant. But Im from Europe, Croatia.

What is procedure with scalp expander when patient is from another continent because it is highly unlikely for me to be 3- 4 months in USA? What do you usually do in that case (if you had similar cases)?

A: Patients do their own tissue expander inflations. Thus they return home immediately after the surgery and only return when the inflations are completed and ready for the permanent skull implant placement, regardless of their geographic location.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, To summarize briefly my concerns, I have a strange collection of subcutaneous fat on my left side, to the left of the modiolus. Several surgeons have examined it and ruled out buccal fat as the culprit. Most drs have said it’s very superficial descended tissue, due to the fact that I have a small facial skeleton, and because of this, a FL would give very temporary results.  I don’t have money for multiple facelifts, starting at 42, and don’t really need one otherwise. I have a similar lump on the right side, but it’s deeper, and pulling down my mouth corner. This lump probably couldn’t be excised as easily as the left, I’ve been told. So I am hoping to address the side that could be excised, so that I could have just one normal looking side. Currently I hide both sides of my face with my hair all day. To have one side free of cover would change my life.

A: I do not think there is much a mystery here as seems to be made of it. This is a classic perioral mound. While most people who have them occur on both sides of the face yours is more prominent on one side. Removal of this subcutaneous fat collection is done by small cannula liposuction through the inside of the corner of the mouth…not by open excision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a large bulge on my forehead and this causes me depression and I do not love myself. I have thought about committing suicide for this reason.

A:What you have is a not uncommon excessive over development of your frontal sinuses which is a very treatable condition. Such brow bone protrusions can be reduced by a commn bone flap setback procedure with a fairly quick recovery and minimal postoperative discomfort.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’d like to get your thoughts on whether I’d benefit more from a genioplasty or chin implant with scar release and fat transfer. I’ve spoken to another surgeon because I want a revision rhino but he said he thinks the biggest improvement would come from the chin/fat transfer combo. The other surgeon I spoke to doesn’t do genios and more concerningly doesn’t have examples of chin implants on his website. I am concerned that the implant might look great in profile but make my face too long straight on and masculinize it. I want to look super feminine and soft.

A: My first comment would be that you should be cautious…the more refined the aesthetic goal is the harder it is to achieve. (in other words smaller aesthetic changes have to be perfect in outcome or there will be revisional surgery)

My second comment is before you determine what procedure is needed you first have to determine the aesthetic goal. While I think your case is pretty clear to me (horizonal augmentation while keeping the chin narrow/tapered in the front view) it still is essential to see what that looks like. (see attached imaging)

A final general facial augmentation comment is that when no standard augmentation approach is ideal for the goal the ore likely a custom implant design is needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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Q: Dr. Eppley, I plan on having my pectoral implants performed by Dr. Eppley.  I will likely want to go with custom implants.  Since receiving my consultation, I had a blood clot in my leg which as of yet is unexplained and I am waiting on my hematologist to get some answers, which I want to understand prior to having surgery. 

I had one other question.  I apologize if I asked this before, but I could not recall.  At some point in the future, I have to have shoulder replacement.  Would you please find out for me if this in any way will be complicated by the pectoral implants? I do not plan on having the shoulder procedures anytime soon.

Thank you in advance for your assistance.

A:1) I would agree that any elective surgery be postponed until the origins and/or the treament of a DVT be fully clarified.

2) I don’t think shoulder replacement surgery would be complicated by having pectoral implants. BUT this is a question more accurately clarified by the shoulder surgeon. They obviously will be close but I just don’t know how close.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am looking to get custom jaw and chin implants. I can send you my 3D CT scan. I have an asymmetrical jaw, but I am not able to come to USA for the operation. So I was wondering if I can get the transplants customized to my needs and sent to my plastic surgeon in Lebanon for the procedure.

A: That is not a service I provide. I only custom design facial implants for the patients in which I implant them.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in getting a brow bone reduction.

A:Thank you for your inquiry and sending your pictures. While it is true that our brow bones are over developed you have a significant backward slope to your forehead which contributes to the protruding brow bone appearance. The relationship between the two is important and it can affect what are the best procedure(s) for your forehead reshaping. If the slope of the forehead is not an issue for you then a Type 3 or bone flap setback technique is needed for your brow bones as the primary treatmen. (see attached imaging) If, however, correction of the forehead is also deemed aesthetically beneficial then a Type 2 brow bone reduction technique is needed where lesser brow bone reduction is done by burring only and some forehead augmentation is done above it. (see attached imaging)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a fairly prominent occipital knob on the back of my head, and came across your website. I noticed some documentation of you performing these procedures all the way back in 2017. Could you tell me how many you have done to date? And also, have your patients reported any long term side effects from the procedure (neck pain / headaches / etc)?

A:I have done hundreds of occipital skull surgeries, at least 75 have been knob and bun reductions. No one yet has reported any side effects nor would I expect there to be any in this type of aesthetic skull surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello. I really appreciate your write-ups about various plastic-surgery topics. For curiosity, have you posted or published anything regarding the risk of facial implants causing foreign-body granulomas or getting encapsulated? I read you text stating that the risk of infection is low, but what about granulomas? I am interested in infraorbital implants. Thank you.

A: The reason that I have never written about granulomas and facial implants is that they do not occur….or at least I have never seen one.

All implants, including facial implants, become encapsulated which is a natural response to their presence. Rather than natural encapsulation I believe you are referring to capsular contracture, an abnormal thickening of the capsule that distorts its shape and creates a form feel to it. While this pathology is very relevant in breast and buttock implants in which a round shape and soft feel of the  implant are desirable external feature, it is not an issue in facial implants in which a firm feel is the end goal and their firm non-round shapes  are not prone to capsular distortions.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a cheek implant booked for March. However, I am finding that the standard implants dont enhance to the zygomatic region. Is this something you have experience in? Thank you

A: I believe that you mean standard cheek implants do not provide any augmentation to the zygomatic arch and you would be correct in that assessment.  Only a custom cheek implant design can do so as in the attached example.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello just wondering do you have any surgeries to remove or reduce the hourglass shape because I’m a trans man and I have always wanted a rectangle torso shape but even with being on testosterone for 8 years whenever I try to lose weight it just makes my waist smaller without reducing the hip shape I want a permanent fix because with a very noticeable hourglass shape I have I have never been shirtless even though I’ve had top surgery 7 years ago.

A: I assume you are referring to reducing a widened hip shape, otherwise known as iliac crest reduction. I would need to see a front view picture of your torso to see if this would be an effective procedure for you.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to know a bit more of the testicular augmentation. My testicles are small and my sack is a bit loose.Can I go for xl implants? Do you removed my testicles or placed them inside of the implant? How long is recovery time? Thank you in advance

A: While their is great appeal to a wrap around testicle implant my experience has not been very good in terms of prevent postop implant-testicle separation.

As young man you are not/should not have your testicles for an aesthetic augmentation procedure.

This leaves the side by side implant technique which has none of the two prior issues.

What XL in testicle implant size means is a matter of personal aesthetic judgment. But that usually starts at 6.0 and upward. To have an effective displacement effect the implant generally has to be a minimum of 75% and more ideally 100% bigger than your natural testicles.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a sliding genioplasty 4mm forward about 6 weeks ago. The swelling has gone down and now I am seeing my mentalis muscle become asymmetry and bulging whenever I talk. The muscle looks overly hyperactive and detach from the bone especially prominent on the left side of my chin that looks deformed. Prior to surgery, I had very mild dimple chin but nothing like an over active muscle bulging out when making expressions. The surgery has ruined my face.

Is this a common complication for genioplasty? Other than Botox that requires on going long term treatment, is there any surgical option to fix the bulging mentalis muscle?

A: It is not a complication I have yet seen after a sliding genioplasty x greater than 500 cases so I would say it not common in my experience. That does not mean it has never happened, just that no one has yet brought it to my attention.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi- on 2/14/23, you wrote a case study on soft tissue pad excess removal after chin implant removal and I’m curious if you know the results of her healing. The case study said results were TBD if it affected her smile and/or speech. I have the same issue as your patient and would like the same surgery but want to know how this turned out for her. Please let me know or can you post an update on her results to the case study. Thank you

A: Of the many female chin reductions I have done (and I would have no way to remember who the patient is in that particular  published case study) the one thing I do know is that I have never seen any postoperative adverse effects on smiling or speech….and I am sure this case was no exception in that regard.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in skull reshaping. In particular skull reduction on the top of my head, and maybe some implant on the back of my head.I do however have prior history of hairline lowering through an incision in the hairline, and a coronal incision from ear to ear, which has been opened twice.My question is if these prior surgeries would complicate the skull reshaping? Could results be seen at a later stage, and would swelling etc be more prolonged ?

Would it be possible to go beyond /into the diploic matter if the burring is done over two separate skull reduction procedures?

Also i would be interested in maybe some burring of the frontal bone, but am not sure if i feel okay with doing all of this in the same surgery. Could the frontal burring be done in a later stage, and through the coronal incision? Would this also effect a potential prior top of the head reduction?

A: In answer to your skull reduction questions:

1) The benefit of a pre-existing coronal scalp incision is that at least the scar location/tradeoff in male skull reshaping surgery has been decided. Its repeated use does not increase healing time or the amount of postoperative swelling and provides convenient access for whatever skull reshaping procedure is desired. In short it doesn’t complicate secondary skull reshaping surgery, it actually is of benefit.

The only question I have about the coronal scar is why was it done. This is not an incisional approach used for hairline lowering. And why was it opened twice?

2) Bone burring in the skull can not safely goes past the diploic space.

3) Whether one does bone burring on top and in front together or in two separate stages is a personal choice.

Dr. Barry Eppley

World-Renowned Plastic Surgeon