Your Questions

Q: Dr. Eppley, I’m interesting in having the protrusion on the back of my head (as seen in the attached photos) removed.

A few questions/concerns I have are as follows:

1) I’m unsure if my case is only a skin fold or bone as well. There is definitely a skin fold that I can securely grab onto with two fingers, but I suspect the occipital knob may need reducing as well.

2) I’m in the process of losing weight and want to know if I should reduce my body fat before having any type of surgery to get the best results. For context, even when I was lean and in great shape there was still a protrusion there, albeit it may have been slightly smaller.

A: While there may be some excess scalp over it due to its size there is definitely a significant occipital bony knob underneath it. As to the merits of weight loss before the surgery that depends on how much weight loss is anticipated. Unless it is a large amount (greater than 25 to 30lbs) I don’t think it affects the aesthetic outcome of the surgery.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley,I am a 69 year old male with extreme, chronic lower back pain. I am certain that it is due to iliocostal impingement syndrome (I am 4 inches shorter than when I was younger, due to degenerative disc disease, scoliosis, and a vertebral compression fracture at L1). I have had a recent surgery to remove a portion of ribs 12 and 11 on the right side. The surgeon removed about 4 cm of each. It has not helped me, and I believe the reason is that he did not remove enough of #11. I am hoping you can answer just one question for me. You describe a case https://exploreplasticsurgery.com/plastic-surgery-case-study-subtotal-11-and-12-rib-removal-for-rib-tip-syndrome/ that is, I believe, exactly what has happened to me. You described that you would wait 4 – 6 weeks to assess the results of that case, but there is no more info. My question is, can you offer any more follow-up as to the success of that case…did the more extensive surgery help that patient? Thank you

A:I believe that patient went on to have substantial improvement. If you had an anterior approach to ribs 11 and 12 than the amount that can be removed is very limited. It takes a posterior approach to get out a substantial length of those ribs. If you really want to know the rib lengths that exists or have been removed you get a 3D CT scan.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I’m about 11 weeks post op from a 7mm horizontal advancement sliding genioplasty and have been left with a very deep labiomental fold. Not only that I feel as if I am a bit recessed still. I have been told to give it 3 more months of healing and that it should get better, but I just don’t see it getting any better with time. What are my options for fixing this? Should I get a revision or am I will that not make a difference with my deep labiomental fold?

A:Your deep labiomental fold will not improve with more time and healing. No soft tissue depression ever gets better with more time. I would agree that your chin projection remains horizontally and a bit vertically short. But that comment is made without knowing what you looked like to start and what chin bone movements were done intraoperatively.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can I have some papers about Dr. Barry Eppley’s Shoulder Width Reduction Surgery? I hope to find some more specialized literature about this.

A:There are no published papers on Shoulder Narrowing surgery in the medical literature. Everything that I know and have done on this surgery has been written about in many blog postings in the website www.exploreplasticsurgery.com which can found searching on the home page under Shoulder Narrowing Surgery or Shoulder Reduction Surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Both me and my partner are interested in either getting the scrotal enlargement or if our balls are small enough to not have the look of 4 balls having the testicular implants (pushing our natural balls up). I assume we would fall into the later category.Thank you.

A:I believe the question is whether the side by side testicular enhancement technique using custom implants would be effective. (not have a 4 ball appearance) That depends on two factors; 1) the size of one’s natural testicles and 2) the size of the custom implants being placed. As a general rule there needs to be at least a 50% difference in size and more ideally a 75% size difference for adequate displacement. For example a 3.5cm testicle is adequately displaced by a 6 cm implant.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a patient looking for clavicle shortening surgery. I would like to learn about the procedure and cost. I had a shoulder injury last week which causes right AC joint dislocation, with 100-200% displacement. I am resting at home and would like to know this specific injury will interfere with the possibility that I can receive the clavicle shortening surgery. Do I need to seriously consider a surgery to correct this dislocation, or it is fine without correction surgery to have the narrowing surgery in the future as long as I recover well in case of function and pain? Shall we setup an initial consultation about it？

A:This is a good question to which I have to admit that I do not know the definitive answer since it is not a preoperative consideration I have seen before. I think the real question is whether shortening the clavicle on the AC separation side, once it is fully healed and recovered, will have any negative arm range of motion effects on what may be a ‘lax shoulder joint’. Does moving in the lateral clavicular head aggravate or increase the risk of subsequent AC separation? This is really a question for an orthopedic shoulder surgeon although they likely will not a have a definitive answer either unless they have done clavicle shortening on a patient with a similar history. (which has not been done to the best of my knowledge) My suspicion is it would not in a fully healed shoulder. But no one can say with absolute certainty whether it would or would not be an issue.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am contacting you because I am in very great pain. To redo the chronology of what happened to me, it turns out that I had a buttock implant placed 4 years ago by a surgeon who did not know how to advise me on the right volume. (remember) Following this, I found myself with 530 cc which literally made my buttocks fall with a crease under the buttocks, banana under the buttocks and a disgrace due to the excessive weight of the implant. Following this, I ended up having the implant removed in favor of a smaller one (370 cc) but in the meantime the buttocks had been enlarged and the new implant was moving inside. I have therefore undergone many procedures in recent months. (A Bodytite under general anesthesia) no results. A first butt lift -12 cm (no result). And a second butt lift 2 weeks ago, again -12 cm (again no results.) the skin is flaccid and the implant wanders around in the completely enlarged buttock pocket

What can we do? Thank you in advance for your response. 

A:To your buttock implant dilemma I can make the following comments:

1) When you downsize  a buttock implant in volume the diameter or footprint of the implant also gets smaller. With an established pocket size the smaller implant no longer ‘fits’ and it will slide around in the now larger pocket…this is exactly what can be predicted to happen. The pocket does not shrink down contrary to what most surgeons think and there is no practical way to surgically reduce pocket size. This is why when do go for a smaller implant volume make sure the implant footprint stays the same and only the projection gets smaller (custom implant), thus keeping the implant ‘locked’ into place. Or you will end up with what you have now.

2) In the correction of buttock ptosis (bottoming out, banana roll deformity, inferior migration of infragluteal crease) the only effective treatment is a lower buttock lift/tuck. Trying to pull it up from above is a conceptually flawed approach that never works. (as you have now proven x 2) The force of the pull/lift is to far away from the problem to be effective. In short you can lift away a distant problem, it has to be treated by direct excision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m so pleased with the results from my temporal artery ligation!! I’m having laser treatment to minimize the blue veins on my temples via V- beam laser. I’m considering scar treatment at ligation points but only if it’s cohesive with the ligations I’m curious to know if laser scar treatment at ligation points would be safe or not. I’m concerned with undoing anything you did and wanted to check to see if it’s a good idea or not.

A: You would be perfectly fine to do any form of scar treatment at the temporal artery ligation sites. It will not cause any undoing of the underling suture ligations. They lie much deeper than the effects of any laser can reach.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I am interesting in surgery to increase by brow ridge, and masculinize it that way. I’m wondering what an estimated price range would be for this procedure, and what implant options there are? I have heard of some surgeons using implants, and others using cartilage from other parts of the body.

A:The use of bone or cartilage grafts for brow augmentation is associated with irregularities/asymmetries and a generalized lack of a smooth brow augmentation effect. Not to mention the need to harvest the graft as well as requiring a full coronal scalp incision to place them. Custom designed brow bone implants create far superior aesthetic results as well as bypass all of these issues and can be placed through a limited scalp incision using an endoscopic technique.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have been looking into options to reduce the disproportionate nature of my head, specifically the convexity above the ears and am interested in pursuing a surgery through you after looking at your before / after results. I believe that my issue is due to a combination of thick temporal muscles (as the convexity of my skull noticeably changes when I open / clench my jaw) and bone around the parietal area. I was wondering how much more effective an open scalp incision would be as I am also considering skull reduction for the top of my head and would like to maximise the effectiveness of both procedures. I understand that due to the thinning of my hair across my scalp that such an incision would leave a significant scar, but I believe I would be accepting of this as long as a visible improvement is made. I have attached a couple of pictures displaying the convexity of the skull as well as the excessive height. Thank you in advance.

A:The combination of temporal (side of the head) and top of the head reductions can be done concurrently for a combined skull reshaping effect. (see attached) While that could be done through a full coronal scalp incision that is not how I would do it. I would do the temporal reductions through the traditional behind the ear incisions and the top of the head reduction through a superior scalp incision limited to between the bony temporal lines. The goal is to keep the incision away from the more visible side of the head.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a Medpor implant placed approx 12 years ago custom made into my chin.

I’ve not had any difficulties with it, but my surgeon should have also done my jaw too due to the asymmetry.

12 years later, I’d like filler to my chin to hide the jowls and increase it’s projections (overall shape). I’m wondering if this is too high a risk for infection? 

I did have botox injections to my chin to decrease dimplings a month ago and I’m concerned about the risk from that now too, although I have no symptoms and I am well.

Hoping you could offer me advice or options?

A: I see no issues with gettting injectable fillers and Botox around the existing Medpor chin implant. The risk of infection is so low that I consider it not significant. 

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, May I ask specific which kind of examinations (Endoscopic, CT-scan, through the nose, through the mouth etc.) do you perform on patients before you perform an Adam’s apple reduction surgery on them?

A: The most meaningful preoperative examination for thyroid cartilage reduction is a 3D CT scan of the neck.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi received 22units of botox in each side of my masseters and 0.7 ml in total of voluma in my upper cheeks on the 20th of April. I now see the slimming of my masseters and it looks terrible because I have a weak chin and already had prejowling. Now my face looks like a blob with no definition. I don’t look like myself now and the jowling is worse. What can I do to return to my previous look? I was trying to fix the signs of aging with the dermatologists suggestions but it’s made me look plain and older. How soon will my jaw return if ever and will chewing gum all day stop the atrophy? Can you offer any advice? Thank you, Lisa Boxell

First pic is last summer

This is last summer and a few weeks before I got the cheek filler and masseter botox. You can see face dropped

This is about 3 weeks after masseter botox and cheek filler. I lost how my face used to be. My eyes look smaller and when I smile that’s smaller too. Can I reverse all this?

A: Botox to the masseters will wear off in 2 to 3 months so I would let that natural process occur. (you can’t reverse it anyway by an ‘antidote’)

Fillers to the cheeks is a different story as that will last much longer (up to a year) so using hyaluronidase to dissolve it would be the more timely reversal method.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I understand this is kind of a new procedure, so I wonder how safe/risky it is, as well as how successful it can be, e.g., how likely the forehead can be completely smoothened.

I’m also wondering if there’s an age restriction for this procedure as I’m worried the bones will continue growing if I’m not old enough for example.

A: 1) Forehead horn reduction is not a new procedure.

2) It is a safe and successful forehead reshaping procedure.

3) How much the forehead horns can be reduced (and the forehead completely smooth) depends on the thickness of the bone and how much can be removed.

4) There is no age restriction for the procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is it possible to do a lateral commisuroplasty at the same time with the other procedures to achieve a wider mouth then with just the upper and lower vermillion advancements and lip lift alone?

Will these procedures change my current philtrum which is concave to one which is convex?

A:While technically possible to do upper and lower lip advancements with a mouth widening procedure, this increases the risk of adverse scarring at the mouth corner area.

To change the concave philtral area to a straight or even convex one this requires the placement of an Alloderm or fat graft through the subnasal lip lift incision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Already had neck lift with liposuction, nose job and lower eye bags removed. Have unusually large perioral mounds with a face fold right through them. They are biggest in the morning and reduce in size as the day progresses, so I took a nap for these pix. Also still have some neck wrinkles and sag.

Temple lift eliminates neck wrinkles and sag, and eliminates fold through perioral mounds. But, perioral mounds are still there.Want to get rid of perioral mounds, face folds in perioral mounds and neck wrinkle/sag.Very much opposed to any kind of facial volume injections or prosthetics. 

Very much want to avoid changing eyes the way they are. 

A:The perioral sag issue which you have is a difficult to resolve of which the only effective solution is a rotational lower facelift. Whether you have the sideburn/temporal hairline to support such a procedure I can not say from these pictures…but many men don’t. (it would take a true side view picture to make that determination) t is not going to be resolved by any form of liposuction or indirect temporal lift. Like your residual neck folds it requires a sweeping skin flap undermining and elevation up and back to redistribute what is essentially sagging skin.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have one vertical scar on forehead and one atrophic scar (dent; ) on top of nose which has broken my profile line. Forehead scar from a cyst and nose scar from a biopsy caused by sunburn incident..which caused skin cancer. Can you fix the scars and how can my profile be fixed. I feel really bad that I no longer have a smooth profile line. Also, I avoid photos because my dent catches the light which emphasizes it. Lasers? Surgery? Cost? I am not interested in fillers but would prefer a permanent fix.

A: The nasal indentation is obviously caused by the excision of skin from the biopsy. While putting back skin would be the logical anatomic approach I don’t think an obvious patch of skin whose color does not match the surrounding skin would create a favorable aesthetic improvement. Thus the approach would be to build up the structure of the nose beneath it to push the indented area…much like any nasal profile depression. This requires a cartilage graft to do so, probably harvested from the septum or the ear. I don’t know how flexible the skin in the depressed area is but I will assume for now that is has enough stretch to be able to be pushed out. Whether that is best done from an intranasal approach or reopening the external scar line is yet to be determined.

The vertical scar in the forehead is in a good location and is not that wide but its white color and straight line make it more visible. I would do a irregular broken line scar revision on it to make it less visible.

Dr. Barry Eppley

Q: Dr. Eppley, I had 22 units each side of my masseters last month and I’m almost 41. Now I have jowls and a double chin. I am no longer attractive and losing sleep over losing my face and identity. I only had it once. Will my masseters visibly come back and hold everything up again? I already had full cheeks it’s all falling forward. It’s been a month. Will it get worse and how long until my original face returns?

A:Botox to the masticatory muscles generally wears off in about 3 months and the full muscle size returns on most patients.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can I combine jaw surgery with upper eyelid and endotine brow lift?  That would make it much easier for me since I was planning on doing an eyelid surgery due to drooping of eyelids. 

So here’s a couple of questions I have:

1-upper eyelid with endotine brow lift. An eye doctor told me he would lift my eyebrows from the incision made in the eyelid.

2- one question I have about my jaw implant is how will Dr. Eppley determine the size of my chin implant if the scan doesn’t show my actual chin since it’s covered my current implant?

A: In answer to your questions:

1) An upper blepharopasty and endotine brow lift can be done at the same time as the R/R custom jawline implant.

2) By definition an endotine browlift uses the upper eyelid incision to place the device onto which the brow is lifted onto and attached. While this is a valid brow lift technique and it works best in men, it only affects the outer half of the eyebrows and its effect is modest in the amount of lift achieved…which is consistent with the type of browlift most men want done…not too much and no superior incisional scars.

3) What we care about is the size of your current implant as that tells me how much more dimensional changes you need/desire. For the actual design the existing implant is digitally removed so the bone is fully seen.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q:I have a question about intraoral sutures opening after surgery for Jaw Implants. I hear this is common and a concern I have. Can you let me know if that is something that happens frequently? I would love to hear about that aspect before scheduling a consult for a jaw implant.

A:That is not a postoperative problem on jaw implants that I see since I use long lasting braided Vicryl sutures for intraoral closures as opposed to smooth faster dissolving chromic sutures. I would rather have the patient complain about why the sutures are still there a month later than to encounter an early intraoral wound dehiscence with an implant underneath it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am trying to achieve a more masculine facial look – With a strong jawline, more pronounced cheekbones, slight cheek hollow

I have a weak lower third – slightly recessed chin and less zygomatic width which makes my face look rounded even at a low body fat level ( I exercise 6 days a weak, moderately muscular build, ~13% body fat – 23 years old, 175cms tall, weighing 66kg)

Attached are some mockups I made for my face in photoshop as a guide to what I/m trying to achieve. Please suggest if it’s possible, and if yes, what would be the best plan of action.

A: While I like your morphed images that is not a completely realistic surgical outcome. The side view is closest to what may happen. But the front view is an over skeletonized/sculpted face for what your tissues will not allow with the combination of custom IOM and jawline implant augmentation and facial defatting.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a female with uneven and irregular thigh skin. Will thigh implants make the skin smoother and more even?

A: The problem with a thigh inplant approach to solve that soft tissue contour problem is that it takes a lot of volume to achieve that goal and then one ends up looking too big. Implants, whose main function is to create an overall enlargement, work best in tighter smoother skin not loose skin with irregularities.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I had double jaw surgery 4 months ago. The surgery was for health reasons and was a success and has improved my sleep apnea but I am unsatisfied with the aesthetic results. I already had very little cheekbone definition but now with my upper and lower jaw moved forward, my mid face/under eye area is even more “flat” and not very defined. My maxillofacial surgeon suggested malar implants but I only want to go to the best if I am getting a cosmetic procedure. I am curious if you have experience with crafting implants for jaw surgery patients that have my complaint? Apparently it is not uncommon for men to have their upper eyes/cheekbones to be “left” behind compared to the new jaw. I am not looking for a “done” look – I want a conservative but definite cheekbone augmentation and potential fat grafting for under eye support. Is this something you can do? Also, how soon after a previous surgery can someone get implants?

A:As you have correctly surmised advancement bimaxillary surgery induces an upper midface to lower facial disproportion. It is very common today with such large jaw advancements and I have seen and treated it many times. Custom infraorbital-malar implants are the best solution given their large and complete surface area coverage of the deficiencies. That could be done at anytime after 3 months from the original surgery since all that matters is how clearly the deficiency is seen. Going through the lower eyelids to place them is a fresh surgica field that is not impacted by the scar tissue and hardware fixation below it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, sometimes when I smile or laugh, I tend to do so from ear to ear, forming a double-chin. I just want to make sure this point doesn’t slip through the cracks, and I can’t remember if you said whether this issue would automatically be addressed once the implant is placed as my skin would have to cover more surface area.

A: Surgery is a static procedure while this smiling issue is a dynamic one. No one can predict how a static operation will affect a dynamic problem. A jawline implant adds volume along the transition of the face and neck and stretches out tissue in that area. Theoretically it may improve that concern but the wise position is to view that as an added bonus if it solves that problem rather than an expected outcome. You can’t design an implant to address that dynamic concern.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I am interested in a custom skull implant for the flat back of my head.

1- does the filling made behind the head reveal my permanent and any discomfort in the future?

2- if I fall asleep, if I sleep on my back or lie on my back, does it pose any problems, is there any problem if I get hit on the head from behind?

A: A custom back of the head skull implant will feel just like bone and has none of the postoperative concerns to which you have described.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a male interested in getting a sliding genioplasty to advance my chin both horizontally and vertically, as well as making it wider. How stable is this procedure short and long term? Is there a chance for bone resorption or the need to do a second surgery due to the chin shifting/non union between the bones? Have you seen such cases? Or simply put, would the results I get after the procedure most likely stay for life without any further complications? Would love to know. 

A: The one piece sliding genioplasty is a very stable procedure that is associated with minimal resorption (less than 5%) but that will vary with the degree of movement. But in general it is clinically irrelevant. However when you split the bone into two pieces to widen it you introduce an additional variable which leads to a higher potential for asymmetries and irregularities. 

Non-union of a sliding genioplasty, while an item on the all-inclusive list of potential complications, is not a problem I have ever seen in the past 30 years with over 500 bony chin procedures performed. Nor would I expect it to since the chin is not a functionally loaded bone, it has only aesthetic significance.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I had cervical spine surgery via anterior approach about eight weeks ago. I had internal stitches and external Steri-Strips. I was allowed to use mederma and silicone scar sheets 4 weeks postop and I have been doing that. Do you have any recommendations as to what I can do for my scar? It is bumpy in some parts and depressed in the others. And dark. I massage it twice a day and use silicone scar sheets I tried to attach pictures, but I’m not sure if it worked or not. Thank you.

A: Such scars take 9 to 12 months to fully mature. Time and patience is what you need. If by 6 months it is not trending towards good aesthetic improvement then have a scar revision done.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am writing to inquire about the possibility of reversing a cheekbone reduction procedure that I underwent about a year ago. The procedure was called “high L osteotomy,” where a part of my cheekbone was removed and pushed in. However, I have been experiencing tightness around my cheeks since then and I am unhappy with the results. I am wondering if it is possible to reverse the procedure by doing reversal osteotomies and bone grafting.

A: The short answer is that it largely can be done. The long answer is that a L-shaped osteotomy is a little bit more challenging to reverse due to the pattern of the osteotomy (as opposed to the old style vertical oblique cut) but it can be successfully done. The posterior zygomatic arch part of the osteotomy can be as successfully reversed as the more significant anterior osteotomy but its main purpose is to allow the anterior segment to move it since it is not really important to try and reverse it.  It would first require a 3D CT scan, or perhaps you have already had one done postop, to make a careful assessment of what was exactly done.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve had a major accident that resulted in 4cm cut (about 0,5 cm deep) to my brow ridge (photos attached). After the accident stitches were put in for 7 days. The injury in question is approximately 19 days old at the time these images were taken. Can this be somehow improved surgically.

A: Scars will naturally start to turn very red within a few weeks after surgery which is a normal part of the healing process. How the scar will look when it matures (heals and the redness fades) and whether scar revision would be aesthetically beneficial is hard to project at this early time period after the injury. Usually good insight in that regard is known by 3 to 4 months, which is the time period you need to wait anyway to allow the tissues to heal to sustain another trauma. (scar revision) I suspect that scar revision will be desired based on how it looks now and given its prominent location.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a question about working out after getting implants. I’m 19 years old and if my bones were to get become bigger either from growing up to age 25 or working out then would the implants become smaller and cause problems? For example I got forehead implants and nasal implants my actual facial bone structure were to get bigger. Could the implants be designed to not become small if facial bones grow and become bigger or something like that? Thank you!

A: At age 19 your bones are not going to grow further to any significant degree nor will working out make them get any bigger either. Thus the concerns about any facial implant becoming too small later because of growth around is not a concern.

Dr. Barry Eppley

World-Renowned Plastic Surgeon