Your Questions

Q: Dr. Eppley, Is it possible to have a brow ridge or glabella implant placed without using a scalp incision, maybe an upper eyelid incision? Additionally, could hydroxyapatite be an alternative to implants in this area?

A:Custom brow bone implants are usually placed with endoscopic visualization through a very small scalp incision (1.5cms) which may be aided by upper eyelid incisions. Hydroxyapatite cement has many limitations for brow bone augmentation but one of them is that it requires a full coronal scalp incision to place.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have had two previous reconstructive surgeries on my forehead. Originally a feminisation surgery was performed which went poorly, using an unusual technique of essentially recreating the conditions of a frontal sinus fracture and suturing it all back together. Following that surgery I had a revision with another surgeon to try to correct that defect and finish the feminization work using a type 3 approach. Unfortunately whilst the revision went well I still have a depression/defect from the original surgery which seems to be presenting with a loss of volume around the inner eye causing skin laxity and some concern to me long-term. I’m curious what approach you might suggest in addressing this given the proximity to the nerves in this area and my having fairly thin skin. I am fairly recently post surgery so I’m really just trying to understand better at this point.

I have attached some 3d images of the CT scans taken at each stage. Hopefully the issue is clear enough.

A: If the issue is a loss of brow bone contour (indented and not smooth) I would use hydroxyapatite cement to fill it in and smooth it over. This would be the most appropriate contouring material for the frontal sinus area as well as the most assured method of a completely smooth contour with seamless edging. It would only take about 5 grams of material to do so.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a L shaped malar osteotomy to widen the cheekbones and a chin wing osteotomy for my jawline 4 years ago.Both of these ostectomies have left me with visible bone gaps(depressions) on the bone as per pictures attached. What would be the best way to correct this issue? Would HA paste as a grafting on the bone be the best solution for this issue based on your experience?

A: These defects could be filled in/over with either bone chip paste or hydroxyapatite cement. Since you have undergone an autologous method of facial bone augmentation my assumption is that custom implant overlays would not work for you. (even though they would provide the best contouring method) 

In applying three types of putty like biomaterials their application is challenging in tight intraoral applications in terms of obtaining a smooth contour and getting a firm set.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I previously had Zygomatic Sandwich Osteotomies which left my cheeks very irregular. I would like to ask if its possible to use an off the shelf implant and place it over the cheek defects to cover it to act like a cover basically.   Or this has to be custom implant? The depth of the defects are around 2mm which is significant in my opinion but my previous surgeon believed that this shouldn’t be visible on the skin surface.

A: You certainly could use an off-the -shelf implant to cover over the defects if you weren’t opposed to an implant.  A thin 2mm implant is what you would need to do so.

2mms doesn’t sound like much but in the cheeks that is more than enough to be seen.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have Mild plagiochephaly. I’m looking to see what my options are about contouring my orbital rims possible reducing one side and planting and contouring the other , also maybe options about the asymmetry in the forehead to address the protruding side and the flat side.

A: The effects of plagiocephaly in the forehead can be treated by reduction of the more prominent side, augmentation of the less projected side or a combination of both. While ultimately the patient must decide of the three approaches is the most aesthetic change, the other important issue to consider is surgical access. (length and location of the incision)  Any bone reduction requires a much larger incision to perform. A custom left forehead-brow bone implant can be placed through a much smaller incision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have been looking into options for decreasing the width of my head. I really don’t want to do surgery now so was looking into non-surgical options. My head is exactly like the pictures attached. The picture attached is a patient of yours that had, “Bilateral head width reduction through excision of bilateral posterior temporal muscles”.

Can this be achieved through injection, nonsurgical? botox?

Thanks and hope to hear from you

A: Such a result can only be achieved by surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is it possible to reduce the appearance of maxillary alveolar protrusion with custom implants? Say like paranasal combined with custom cheek implants if someone was trying to avoid jaw surgery to reposition jaws?

A: Theoretically midface augmentation should make the maxillary alveolar protrusion look less so. Computer imaging in profile will provide better insight into that potential effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I am looking for information on chin ptosis surgery.I have had a number of chin and jaw surgeries and currently have a sliding genioplasty plus an implant on top. I now have bad lower lip incompetence and chin ptosis. From my understanding, the muscle needs to be resuspended and fixated to the chin bone/implant. I included some scans of my chin as it is right now.

A: Given the chin surgeries you have had I would doubt that ‘simple’ muscle resuspension would be effective at all. You have to be mindful that the two surgeries you have had intraoral sliding genioplasty and presumably an external submental incision for placement of the custom jaw implant have completely stripped off all soft tissue attachments AND expanded the chin tissues. Besides the scarring there is now a relative discrepancy  between the expanded structural support and the soft tissues needed to cover it. As a result the soft  tissues are not going to elevate in any significant amount and most certainly won’t improve lip incompetence. Ljke most soft tissue retractions this is a tissue deficiency problem and thus tissue rearrangement alone will likely fail.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in shoulder and waistline narrowing? Would it make sense the come back after shoulders are healed to have the hardware removed and the ribs done at the same time?

A: That would make perfect sense and is a very practical way to stage it with hardware removal in mind.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, So do implants made of metal guarantee no infection????

A: No material is better than another at implant infection. The surface characteristics are probably more important than the material as smooth surfaces are less prone to infection than textured/porous/irregular surfaces. (bacteria love to adhere to microscopically rough surfaces)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can the top of my head bene made less tall?

A: How much skull height that can be reduced is controlled by the thickness of the skull bone. But as a usual estimate the maximum bone that can be moved is in the range of 7mms. How that number transfers to your skull height requires imaging of your head pictures to show.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to schedule a consultation. I had a few questions,What is the implant material? Can Titanium be used? I had an orbital fracture when I was young and titanium screws are still in my orbital bone. Is this a problem?

A: For custom facial implants a variety of biomaterials can be used including titanium….but it would by far be the most expensive. Titanium screws in the implantation site are not a contraindication for implants over and around them.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I had a sliding genioplasty 8 weeks ago and I have a significant step off on my right side and a smaller step off on my left. I also had endolift laser which gave me submental fibrosis. I would greatly appreciate help with this issue.  Both the endolift and sliding genioplasty were done two months ago. The endolift is just small wires. There is no incision under my chin.

A: The inferior border defects from the sliding genioplasty have to be filled in and be done so in a variety of ways from allogeneic bone chips to implants. It is just a question of what the patient prefers. The most effective method in my experience is thin sheets of ePTFE placed over tham through a submental incision.

Through this same submental incision the tissues need to be released and a thin layer of fat grafting done. I can’t speak yet as to whether the wires/threads that were placed need to be removed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a misshapen skull due to a cyst that is in between my brain and skull. I am desperate for help to correct my skull. I live in Australia and I would love some help.

A: As is shown in your scan the upper temporal protrusion does have a bony component but that bone is very thin. It is too thin to be burred down. It would require a crsniotomy  for bone reduction and dural plication….which is going to require a neurosurgeon to perform.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is the muscle divided for a buccal lipectomy reversal fat graft?

A: The buccinator muscle is divided to enter the buccal space…just like is required for the original buccal lipectomy procedure. Rather than taking out fat a fat graft is out back in.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a question about the Iliac Crest Reduction surgery want to do this surgery but what about the side effects? Wont this surgery affect our flexibility? Body rotation? What about running and squatting? That would be very painful I think. But I dont know so im asking you. Will I still be flexible enough to live life comfortably after the surgery?

A: You are referring to the potential for long term functional effects from the procedure…which I have not seen. But that answer is modifiable based on how much of the crest has been removed. The less that is removed the less likely any adverse effects will occur.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I saw your good work on scalp reshaping on instagram, and was wondering if you do surgery like that in other country. I live in Sweden and it’s my dream to be able to change my head shape but unfortunately the distance It’s to far away and very expensive. If you only do surgery in America can you recommend me someone that does same surgery but in a nearby country.

A: I do not travel to other countries to do surgery and I am pretty certain no one in Sweden or even Europe does similar skull reshaping surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, When would be the ideal time to apply the allogenic bone chips for sliding genioplasty defects? (stepoffs) Would this be after the bone has healed, or while it is still healing? Are they place intraorally? If yes, how much does that disturb the muscle and nerve?

A: The time to apply bone chips is either at the time of surgery (which is what I do) or within three months after the surgery. Thereafter the bone is healed and the chips will merely dissolve away. This is when the use of implants is more effective. Bur whether it is bone grafts or implants the submental approach is best to access the area and fill in the defects accurately.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I am also looking in to premolar extractions on top and bottom and retracting the front teeth. If I were to also have custom mid face implants done, when in the process of the braces would you recommend having the implants done? Towards the end? Or after the braces are complete? And one last question. Can you do custom implants for the nasal bone area to project the nose more?

A: I would do midface implants on the back half of orthodontic treatment when the premolar spaces  have closed.

Nasal projection can mean a variety of different nasal areas. Implants work well for dorsal (bridge) of the nose augmentation. But for increased tip projection (which you may be referring) cartilages grafts are used. One never uses implant to increase the tip of the nose projection.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I’m looking for information about wrap around testicular implants, procedure, time frames for healing. 

A: Despite the appeal of the wraparound testicle implant concept, it is not without its problems. Postoperative detachment of the implant from the testicle is not rare and is a postoperative problem to which there is no assured solution. (as of yet) The one factor that I do know that lowers that risk is to use a preoperative ultrasound to accurately measure both testicle sizes  and then make the implant’s inner chamber size match it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Two years ago I got Medpor chin and mandibular angle implants, but there’s a serious degree of asymmetry which I would like to correct. But before eventual revision I need to do post-op CBCT scan and 3D visualisation of the inserted implants in order to properly recognize the problem. My surgeon ordered me to do a MRI scan of my skull, but we were unable to create a the result that would allow us to create a 3D model of my skull with visible implants on it.

How to visualise the implants post-op via CBCT the same way you do ? I ask because you did sucessfully visualise them as I saw on your website, but I couldn’t find any information about the method or settings used for CBCT device on the internet.

Thank you in advance for your answer

A:One of the drawbacks to the Medpor material is that you are simply not going to see it on a 3D CT scan which makes any type of revision blind. While they are obviously there the density of the material is changed by the tissue ingrowth so they can no longer be visualized as a solid implant. It is not a matter of setting or how the scans are taken. There are proprietary extraction methods to potentially get that information but that is not technology that is available on your end.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, And is there typically much visible bruising or pooling of blood afterwards from temporal artery ligations?

A: Significant bruising is not typically associated with temporal artery ligations. Each ligation site will be a little raised for a while afterwards and then settles down and smooths out over the ensuing month after the procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I got in a car accident and my leg got caught under the seat cutting my bottom as it was healing the my buttock fold unfolded making it uneven.

A:That is a most unusual mechanism to develop buttock ptosis but the entire inframammary fold and lower buttock tissues have lowered. This can be corrected by a lower buttock excision/lift. There will be the tradeoff of a scar line along the re-established fold line to achieve improved buttock symmetry.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am seeking vertical jaw angle implants to get a result like the attached pictures.

A:Thank you for sending your pictures. Before deciding on what type of implant to use the first step is to determine what type of jaw shape change the patient is seeking and what amount of such change is acceptable. This is the role of pictures and computer imaging. In looking at your pictures I have significant concerns that with your fuller tissues any type of standard jaw angle implant is just going to get lost (not seen) and may just make the face fuller/heavier/fatter.  If the goal is a more defined and visible jawline that does not appear likely to occur with the thickness/looseness of face and neck tissues you have.

Excess soft tissues can be overcome by jaw implants but it takes a lot of implant size to push the tissues out and then the issue potentially becomes ending up with too big of a result.  With fuller faces concomitant soft tissue reductions are usually done at the same time to help the jaw augmentation result be better.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley I had a consultation with you a few weeks ago and I’m in the process of booking the surgery but forgot to ask you what the recovery for a sliding genioplasty and custom angle implants is like. How long does the swelling last and is it significant? Also is there any bruising?

A: Jaw swelling from these procedures is usually fairly significant and takes about 10 to 14 days until enough of it goes down that the patient feels more comfortable out in public. While the swelling may be significant it is not usually associated with much, if any bruising.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am contacting you because after having studied I am sure that Dr. Eppley is the only one capable – especially since Dr. Botti (who created the Dynamic Canthopexy with drill hole) has retired – to perform the technique of Dynamic cantopexy with drill hole presented in the medical literature article that I attach.

I’m sure Dr. Eppley knows about that and that is the only tecnique able to give an “extreme” and stable result. Consequently, I would like to undergo this surgery with Dr. Eppley and obtain a result equal to or superior to that shown in the last image of the medical journal article i’ve attached.

So I would like to know:

1) If Dr. Eppley performs this specific Cantopexy technique (which he rightly calls canthoplasty) and if he can guarantee me a result similar to the one obtained by the girl in the last image of the article.

A:I am very familiar with the dynamic or double hole lateral canthoplasty as it is the most secure method of a lateral canthoplasty and certainly the only technique to use in extreme outer eye corner lifting. In these extreme efforts I would combine that with a spacer graft whose lateral tail is secured up along the lateral orbital rim. In answer to your specific questions about it:

1)  No surgeon can guarantee a specific result as there are other variables than just technique that contribute to an outcome. What can be guaranteed is the maximal effort to try and achieve a specific outcome.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello! I am a 26 Female who has chin ptosis. My chin to me doesn’t not seem overly large, but when I smile, it droops quite dramatically, creating a weird shape along with a double chin from my side profile. 

A:I think the reason you have dynamic chin ptosis is because of your small chin. There is no support for the chin pad as it gets pulled back when you smile, thus it gets pulled down. This is a natural congenital origin of the problem rather than an iatrogenic one. (from prior surgery)  A chin augmentation procedure in your case is going to probably be more effective than an excisional submental chin pad procedure. The only question in that regard is whether the aesthetics of a chin augmentation would be acceptable. You don’t need much of an implant augmenttion (5mms or less) but it would provide a physical block to prevent the chin pad from being pulled down.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, what’s the % of muscle detachment or displacement that happens with jaw angle implants? it seems muscle issues are the main issue and can ruin ur face.

A:The question you are asking is what is the risk of postoperative masseteric muscle dehiscence after jaw angle implants. That risk depends on many factors including the experience of the surgeon, the type and size of the jaw angle implants, the natural shape of the patient’s jaw angle bone and strength of the ligamentous attachments (as seen on a 3D CT scan) and prior jaw angle surgery. (e.g. V line or SSRO osteotomies) So there really is no specific accurate % you can assign as a general nunber. The significance of that risk has to be assigned on an individual basis which I classify as low, medium and high. For example if it is a primary jaw angle implant surgery and it is a standard widening implant style I would assign that risk as low. Conversely if it a prior V line reduction patient who wants to restore their jawline with vertical lengthening implants I would assign them as a higher risk.

It is being overly dramatic to classify masseteric muscle dehiscence as ‘ruining a face’.  This is a soft tissue contour issue which in many cases is mild and often only seen when chewing or biting down.

And no masseter muscle dehiscence is not the risks of jaw angle implant surgery…..infection and implant asymmetry are the far more significantly encountered complications.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a trans woman who is interested in having surgery with you. Specifically clavicle shortening surgery and hip implants. I was wondering if I am a good candidate for them? If you can get them at the same time? And any other information you can provide me. Thank you!

A:Thank you for your inquiry and sending your pictures. Your shoulder reductions are straightforward.  (see attached imaging)( For your hips I would not first jimp to implants. With your body type I would first do circumferential liposuction and take all that fat and invest it into the hips and see what you get. (see attached imaging) Hip implants are reserved for those patients who have either failed fat transfer or do not have enough fat to do a fat transfer procedure. Hip implants are far from a perfected procedure and they have their own unique risks of complications so you want to maximize any autologous surgery method before going to implants.

Regardless of the chosen hip augmentation procedure it can be done at the same time as clavicle shortening.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,You have correctly surmised that with a long upper lip and many vertical lip lines that an excisional approach would be helpful with two caveats: 1) the amount of vertical lip line improvement will be limited to what is removed in the excisional area (see attached image) and 2) by doing a combined subnasal lip lift and upper vermilion advancement the upper lip will become bigger than the lower lip so a lower lip advancement may need to be considered as well.

A: You have correctly surmised that with a long upper lip and many vertical lip lines that an excisional approach would be helpful with two caveats: 1) the amount of vertical lip line improvement will be limited to what is removed in the excisional area (see attached image) and 2) by doing a combined subnasal lip lift and upper vermilion advancement the upper lip will become bigger than the lower lip so a lower lip advancement may need to be considered as well.

Dr. Barry Eppley

World-Renowned Plastic Surgeon