Your Questions

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

Q: Dr. Eppley,  I lost both my testicles due to a chronic pain condition and just recently had Torosa implants inserted. Unfortunately, the largest they have is only 4.5cm. I was a 5, but I’m looking to go up to an 8.

I need a revision surgery for the implants and was wondering if you would be willing to provide the implants to my urologist/surgeon prior to surgery?

Please let me know whenever you have a chance.

Thanks so much for your time!

A: I am not an implant manufacturer or vendor. I only make custom testicle implants for the patients in which I implant them.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I was just enquiring for if i’d be a candidate for Buccal fat reduction and/or perioral liposuction. Thanks

A: You have the type of face that should NEVER have any form of defatting done. You have a significant infraorbital-malar skeletal deficiency. (flat cheekbones, no infraorbital rim projection and a negative orbital vector. What you need is skeletal augmentation  (custom infraorbital-malar implants) to add projection and create a more defined midface/cheekbone appearance. Removing fat would make your face look worse not better.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Will I eventually need to replace buttock implants down the road as I get older?  Meaning am I going to need new ones like breast implants or can I keep these forever?  I wouldn’t want to go larger down the road and I just wanna make sure that they’re OK if I keep them?  I don’t want to have another surgery?

A: Buttock implants are different than breast implants in material composition. Buttocks implants are made of a solid material which can never degrade ot break down. Thus they will last a lifetime based on their material stability.. Conversely breast implants are essentially a bag filled will ‘jello’. (two part composition) TAs a result they will have a limited lifespan as the integrity of the containment bag (shell) will eventually fail and the implant will need to be replaced.

Therefore while there are breast implant patients whose implants do last a lifetime they are the exception unlike buttock implant patients whose implants do remain structurally stable for a lifetime.

The issue of buttock implant stability can be confusing as in non-US countries buttock implants are exactly like breast implants and thus failure does occur. The U.S. is one of the few countries where the buttock implants are solid and not gel-filled shells.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Epple, Hi doctor , thank you for your work!! What happened to me was that in my younger years I experienced a traumatic event . Now as an adult I’m still living with past trauma from my past . I’m highly self conscious of my head , in the back right side , as a result of that incident . I will send the pics and was wondering if I can correct that because it’s really hurting my life. Also , I’m self conscious of my nose and was terrified and concerned that if I get work done on the back of my head , that my nose is going to get more deviated because of the nature of the procedure in the back of my head . Since I will be laying face down . Is that true ? And also am concerned of the final results and any visible scars . Please comment

A:When back of the head skull augmentations are done the patient is in the prone position. But to protect the nose from pressure the head is placed in a special padded donut head rest that keeps the nose from touching the operative table. This is classic periooperative pressure sore prevention.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, For fat transfer to the forearms and hands, how long is the surviving fat expected to stay permanently? Would a retouch be necessary after a certain amount of time, or can we avoid this by transferring a significant amount of fat in one session? How much fat will be needed? Since the donation site will be the abdomen, I have attached pictures so that the doctor can let me know if there’s enough fat he can take from there (I think theres more than enough)

A: For fat transfer to the forearms I think it is very important you understand why it is being considered and what its limitations are. Here are the important concepts:

a) The reason fat transfer is being considered for the forearms/hands is NOT because it is an ideal procedure or that it has an assured permanent volume retention. It should be done with the understanding that it is the ONLY treatment option that exists and that it is safe and unlikely to cause any harm. This is actually the reason a lot of fat transfer is done anywhere on the face and body and why it is a widespread volume augmentation technique. But in the end it should be viewed as a roll of the dice surgical technique not one with an assured outcome.

b) Injection fat grafting has a highly unpredictable volume retention rate  (how much survives) based on a variety of factors which include how much fat volume is available for grafting and what is the anatomic site of implantation. As a general rule you need at least 100% more aspirate from the harvest site than what needs to be injected. (your abdominal harvest site is marginally acceptable) The forearms and wrists are very poor fat retention sites, the back of the hands do better. Also any fat that is injected across a movable joint (wrist) will have 100% resorption. Fat does very poorly in high motion sites.

c) Your forearm/wrist/ hand injection outline/goals are not a realistic outcome. You don’t have enough fat to do it and it will never survive with that amount of augmented contour retention.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m very interested in the rib removal process, can I get more information, 62 M2F 5ft 8 in 170lb in good condition.

A:In rib removal surgery the question is not whether one can have it done but how much of a difference would it make if it was done. To try and make that important presurgical determination I like to do imaging on the patient’s pictures to show what I think can realistically happen as a result of the surgery. I would better pictures to do so. (front and back view pictures standing up with the waist exposed and the arms at 45 degrees away from your side) Admittedly at 5’8″ tall at 170lbs I have concerns about how much difference it would really make.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in the PARANASAL AND PREMAXILLARY IMPLANTS. I have pictures of the before and after (photoshopped). I hope your procedure is a good solution, as it is a pretty specific/niche procedure.

A:What you have imaged is nasal base augmentation with increased nasal tip projection. Such changes are very realistic from a surgical procedure that combines paranasal-premaxillary implants with an open tip rhiniplasty with columellar strut graft. The nasal base augmentation will NOT by itself cause nasal tip rotation as you have imaged. That requires a direct approach. This surgical combination is very common in faces that look just like yours for the very facial augmentation effect you have imaged.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I got a buccal fat removal 2 years ago. I am very unhappy with my results and very insecure.

A: When it comes to buccal lipectomy reversal there are two methods of fat volume restoration, fat injections placed more superficially than the buccal lipectomy space or an enbloc fat graft put back directly into the buccal fat pad space. There are advantages and disadvantages to either approach.

Fat injections – scarless harvest, injection approach, unpredictable volume retention

Fat Graft – small scar harvest site, open approach, more assured volume retention

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to know the cost of the skull reduction surgery and if you need to cut your hair for the procedure.

A: Cost depends on the location (extent) of the skull reduction surgery of which the name alone does not answer that question.

Hair is NOT cut for the surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a BBL in 2021 but have lost around 35 pounds since then and now have no butt. I also have a very prominent tailbone that causes me a lot of pain. The tailbone shape is an inherited trait, also worse since losing weight. Interested in discussing options for augmentation.

A:Thank you for your inquiry and sending your pictures. You have two buttock problems due to the weight loss which may also have exaggerated your natural buttock shape. First you have a vertically long buttocks with very low infragluteal folds and lax overlying skin folds and 2) a central lack of buttock projection. Your volume addition option as this point after having had BBL surgery and losing the weight are implants. But implants will not produce much volume projection or create a good shape when the buttocks are so vertically long and the folds are so low. As a result both buttock issues have to be addressed. You need a lower buttock lift to establish a higher fold and shorten the lengths of the buttocks followed by implant augmentation. While in theory both can be performed together I don’t recommend that combination for both the recovery as well as the best infragluteal scar outcome.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, is it possible to make a skull 1.5x or 2x bigger? I feel like my body rapidly outgrew my face. I feel so down and insecure to the point where I don’t leave my house unless I have to. My head is super tiny, like microcephaly tiny.

A: I can’t speak to percentages of how much the head size can be increased. I can only speak to what type of visible head size increase can occur with a two stage skull augmentation process.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a few questions about some concerns I have with my skull. I have a large occipital bone. I have a peaked shaped head and it is also very wide. I measured my head circumference and it is 63cm. If I was to get a surgery to reduce my occipital bone and temporal reduction surgery would that reduce a few cm from my head? Also how much would all three surgery’s cost or would it be best to get them done at separate times. 

A: In reference to the back and sides of your head:

1) You have a classic large occipital knob on the back of your head which can be removed.

2) For your head width temporal reduction usually removes 10 to 12mms of muscle per side

3) Technically with 1cmporal tissue removal on each side of the head and 1 cm oi projection from the back, in theory that should equate to a 3cm circumferential reduction. (although I doubt the measured reduction is linearly equal to the thickness of the tissue removed) Quite frankly I never measure a patient’s head circumference as these operations are designed to change the profile of the head shape (how it looks) as a determinant of success rather than a measured outcome.

4) Both head surface procedures can be done at the same time.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Would I benefit from buccal fat removal during this? Would this fix my midface deficiency all together?

A: As a general rule you want to be cautious about buccal fat removal in midface deficiencies. You may benefit by buccal fat transposition into the midface to help with the implant augmentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in macrotia ear reduction surgery, in order to vertically reduce the size of my ears, meaning a reduction in both the upper third and the earlobe. (I am not interested in the traditional ear pinning procedure.)

However, I believe I have Red Ear Syndrome (RES), a rare condition where, for unknown reasons, on occasion, one or both of my ears will become red and hot (but not particularly painful). I am concerned with how this may interfere with the macrotia reduction surgery, particularly the recovery. One surgeon I talked to was not concerned. Another stated that if RES is triggered after recovery, it could cause an infection and abnormal scarring. However, because the underlying factors for RES are elusive, it is hard to quantify or predict the likelihood.

Do you have any insight about this? Should I be concerned about how RES may impact my recovery following the macrotia reduction procedure?

A: The question /concern of the potential impact of Red Ear Syndrome on any form of aesthetic ear surgery is a justifiable one given two basic issues. First I would assume that the surgical trauma will cause RES to occur whether during surgery or postop since ear manipulations are known to trigger it.  Whether the duration, intensity or frequency of RES will be less or more after surgery  is completely unknown. Secondly what is the impact of RES in a healing ear? Since RES is an abnormal dilation of the capillaries and has no known association with abnormal inflammatory activity I would speculate that it may not negatively affect healing.

The conclusion is, when you are uncertain how one condition may impact another, you have accept that as another surgical risk factor.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a mouth widening procedure + corner lip lift. I’ve always had a small lips. I’ve had a lip lift and lip filler done. In 2018 I had lip implants put in and loved how they made my lips wider (photo with green shirt and pony tail). But unfortunately they shifted over time and I had to remove them in 2023. I have has some filler done since them but I am not happy with my short width lips. (Ideally I would like the lip length of Margot Robbie.) I am coming from Houston so I was wondering the details of the surgery, pricing, and if it can be done under local anesthesia and I can hop on a plane the next day back home. I imagine it’s like a lip lift procedure which was quick and easy. I am very excited and looking forward to hear from you.

A: Between the scar from prior lip implants (corner incisions and residual capsule) as well as the chronic use of fillers I do not belleve mouth widening will be an effective procedure for you. This is a challenging procedure in which to get effective widening without excessive scarring  it is best done in pristine lip tissues that have never had surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a hair transplant over 20 yrs ago that I extremely regret. I have just had four sessions of micro scalp pigmentation that I am very happy with how it turned out. Except for covering the scar up. I want to make an appointment ASAP to see how I can diminish the appearance of the scar. Then hopefully with another session or two the scar will not be noticeable.

A: I would not be overly optimistic that your scalp scar can be improved. I have seen many back of the head hair harvest scars and yours is one of the better ones I have yet seen.  It is important to remember that scar revision essentially is about trading off one scar for another one…with the hope that the new scar is less noticeable than the one that was removed. The better the initial scar is the less likely the new scar will be better. Your scalp scar presents a dubious scar tradeoff.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have vertical orbital dystopia and I was hoping to receive resources for scheduling a head CT scan.

I’ve read your “Outcome from Comprehensive Six Step Approach to Vertical Orbital Dystopia Correction” case study, and I found it fascinating. Are there any other available resources out there regarding your VOD treatment?

I would also love to see a gallery of more results, especially in regards to seeing patients who also opted to have upper eyelid ptosis repair.

A: Your VOD is too severe for this form of aesthetic VOD surgery. The left eye is more than 5mms lower than the right eye and can not be significantly improved by this camouflage approach to VOD correction. You need an orbital box osteotomy technique through a frontal craniotomy to have an effective change.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can you do skull augmentation  surgery with bone grafting? No synthetic or artificial materials should be used.

A: The short answer is no. The long answer is… while skull defects are treated by autologous bone grafting aesthetic skull augmentations can not. Besides the wide open coronal scalp incision needed to do it there is the amount of bone grafting that would be needed and the associated morbidity of the harvest site. (e.g., a 150cc skull implant would require almost the entire fibula of the leg to be harvested for an equal volume or 6 ribs are needed) Then there is the biologic changes that happens to all onlay bone grafts to the skull or face…they undergo variable amounts of resorption and end up with a very irregular surface.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is the silicon implant for narrow head permanent? What are the most common complications for this procedure and how do these implants stay in place?

A:In answer to your skull augmentation questions:

1) All silicone skull implants are material wise and structurally permanent.

2) There are few complications with onlay skull implants but would include infection (not yet seen) and aesthetic issues of implant edging (most relevant risk in the shaved head male) and he scalp incision/scar needed to place it.

3) There has never been a case of skull implant migration because the sixe of the implant, the tightness of the scalp and the natural encapsulation process all work to secure it into the position it is surgically placed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello there, I would like to ask a question regarding otoplasty.  I had undergo complicated otoplasty in the last and ended up with a defect in post auricular area, therefore I want to recreate natural and proper anatomy of post auricular area. 

 To make natural convex shape from posterior side. I was wondering about 

 Own Rib Cartilage 

 Cadaver Rib Cartilage 

 Cadaver Ear Cartilage 

 Custom made thin silicone implant 

 Or whatever I dont know what may work for me but one thing I know it has to be super thin. 

 Thank you and let me know.

A:You are never going to make the postauricular sulcus normal again as it has been permanently surgically altered. But in the effort for improvement a thin cartilage graft is needed not an implant. One can debate between cadaveric vs autologous cartilage graft but a cadaveric one would be easier to care and make thin without a donor harvest.

Dr. Barry Eppley

World-Renowned Plastic Surgeo

Q: Dr. Eppley, I have a scoliosis that caused me to have deformity of my rib cage. Also, on my left side I have a rib that is causing me pain (I believe that it is touching a nerve or something) I would like your opinion on what are my options and what can be done to relieve me from my pain and make me look more symmetrical. Thank you!

A: Thank you for your inquiry and sending your pictures. Your scoliosis and and waistline asymmetry are very apparent. (see attached) Since your pain is on the left side (shorter side from the scoliosis) it is very possible that rib #12 is impinging on the iliac crest (ilio-costal syndrome)  While this can occur in any patients with elongated lower ribs the scoliosis patient is more at risk for it due to the twist in the ribcage. It would take either a plain x-ray ( or more ideally a 3D CT scan) of your spine and ribcage for confirmation. If so pain relief is usually achieved by shortening ribs #11 and #12.

From an asymmetry standpoint this is a bit more challenging since we can’t change the foundational position of the spine and the attached ribs. One option is to consider differential lower rib removals of #11 and #12…more on the right than the left. The effectiveness of that approach requires a good understanding of the lower ribcage anatomy from a 3D CT scan.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,You are a tremendously talented surgeon and I see you specialize in chin surgery. I emailed you close to four years ago, asking your opinion on a chin implant. And you recommended a sliding genioplasty. Here’s what you said:

“…You have a fairly short chin that is angulated backwards and is vertically long. With such anatomy you are not really a good candidate for a chin implant as implants are technically designed to sit on the front of the bone which will make your chin longer. The implant can be moved up higher, but this is not how they are ideally designed to work. You are a far better candidate for a sliding genioplasty which can bring your chin forward AND make it shorter. This may not be the operation you want but it is the better chin augmentation option from a dimensional standpoint than an implant with your anatomy.“

I’m still interested in surgery, however, I am not able to afford the genioplasty surgery or the recovery time as a mother. I am 43. During our correspondence, you mentioned that you could do an implant and fasten it to the front of my chin, to avoid lengthening the face (though it wouldn’t be fully ideal). I am wondering if you would be open to that as a different option? I am looking for very conservative results – natural, feminine, so you can’t even tell it’s done… and so the pre-jowl sulcus is gently filled in. Many thanks for your consideration. The way you help people is just amazing.

A: Good to hear from you again. The key to a chin implant in the severely horizontally short chin that has a backward slope is not to try to make it ideally normal in projection as this will also make it vertically longer. Choosing a conservative projection (5mms) will mitigate that risk as the implant will need to sit not right at the bottom of the chin bone but a bit further up. Be aware that any chin implant with wings (for the prejowl area) will from the front view make the chin a bit wider.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I’m just getting in touch on behalf of my husband. He is desperate to have this lump removed from the back of his head, is it possible to have it removed? If so, is it possible to have some information on this along with a price ect. Look forward to hearing from you! Many thanks.

A:Thank you for your inquiry and sending your pictures. I believe you are referring to the protrusion that lies between the two horizontal scalp lines which appears like an occipital knob. (see attached picture with arrow) That bony protrusion can certainly be reduced and he has the convenient horizontal line beneath it to do so. It may also require a bit of overlying scalp excision since there is some soft tissue redundancy over it…as an assurance that complete flattening occurs without aggravating the overlying scalp redundancy.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a torn bicep and it looks like I only have half the muscle. I was wondering if an implant could cover that up and look normal either with half the implant or the full one.

A: While an implant is the only option to create some restoration of bicep shape I would not consider that it would look normal compared to the other side. Bicep implants are placed either under the muscle on the bone or on top of the muscle under the fascia. With a torn retracted muscle neither of those standard implant locations exist. Now the implant has to be placed mainly in the subcutaneous tissues and be positioned up onto the residual bicep muscle mass. Thus the restoration of some muscle mass can be achieved  but how the implant-muscle interface would appear requires pictures from numerous angles with the muscle flexed and non-flexed for a more in depth analysis.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Happy new year! I hope you’re well. Your website is an incredible resource, I have some more questions about Facial Feminization.

I had an extensive mandibular osteotomy at another clinic and pursued a deep plane facelift with a platysmaplasty a year later to address jawline definition and redundant laxity. Due to the vector of the lifts in this case being more lateral than vertical, I still have a problem with my midface area which appears broad due to large/flat zygomas. I prefer a softer aesthetic and am seeking to avoid adding extra lateral projection, favoring more forward. To this end, as I consider zygoma reshaping (rather than reduction), I wondered what the differences are between a zygomatic sandwich osteotomy and a malar rotation (as performed more commonly in South Korea)?

That and whether any buccal fat pad movement, as a consequence of cheek bone adjustments can be mitigated by a mid-face lift?

A: Neither a zygomatic sandwich osteotomy which increases lateral cheek width nor a zygomatic reduction with malar rotation which decreases lateral cheek width will create more forward projection, only an implant can  make that happen. There is no bony osteotomy that effectively pulls the cheekbone forward.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a revision genioplasty because I believe that my chin looks too big in certain angles and I have the step off deformity. The doctor that I consulted said that he could cut and shave the bones to create a more regular jawline and a less prominent chin. I started to look for more information about this procedure and I found one of your blogs, in which you mention that when this is done, a hemostatic resorbable material is used over the bone. I would like to ask you then, what specific materials are used? How long does it take for the body to absorb them? Ar they absorbed in a predictable manner or can they leave jawline irregularities?

A: You are referring to the use of Lactosorb (PLA-PGA polymer) resorbable plates and screws for chin fixation. It takes 6 to 9 months for the devices to be fully absorbed. Whether the chin osteotomy can be fixed with a plate and screws or just bicortical lag screws depends on what amount of chin bone movement is needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Looking for pricing for a flat top of head and narrow forehead. Was looking to widen forehead and make top of skull taller and rounder.Have no idea if this is even feasible for me,

A: The area of skull implant coverage is not the question. it would be about how much of augmentation of the covered area can be achieved given the stretch capability of the scalp over it. (limited to 125 to 150cc implant volume) That can only be determined by doing the actual implant design.

Dr. Barry Eppley

World-Renowned Plastic Surgeon