Your Questions
Your Questions
Q: Dr. Eppley, I want to ask how can i make my orbital rims more vertically compact to create hunter eyes????
A: To shorten the vertical interorbital rim height (brow bone to infraorbital rim), this requires a combination of brow bone and infraorbital rim implants that drop down (brow bone) and raise up (infraorbital rim) the bony edges.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Have severe plagiocephaly in the back of the head and would like advice on options.
A:Most plagiocephaly patients benefit from building out the flat side of the back of their head with a custom skull implant. How that applies to you is yet unknown to me since I have not seen pictures of your head or a 3D CT scan of your skull.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have had deep dark circles under my eyes since I was a baby. I am looking into tear trough implant surgery.
A :You are headed in the right direction to improve your lower eyelid fat herniation due to lac of infraorbital bony rim support. These would have to be custom infraorbital implants as they need to create a 3D augmentation of the underlying bone not just sit in front of the bone edge which is all that standard infraorbital rim implants. This would be combined with herniated fat removal through a lower blepharoplasty approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, After a custom skull implant, I am still able to get an MRI done, correct? I assume there is nothing metallic used for the procedure? You performed a cranioplasty on me in 2016 and I have been very satisfied with the result! Thank you for all you do!
A: There are no concerns with getting an MRI after a custom forehead implant. There are two small titanium microscrews initially placed to secure it which are MRI-compatible.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I previously got lower jaw surgery and genioplasty for a total of 14mm of movement. I am now considering more chin augmentation either in the form of an implant or genioplasty. Please recommend best next steps, thanks.
A: Having had two bone surgeries for your current chin projection it would make the most sense to build on top of what already exists with an implant for the final chin projection effect. The two prior surgeries and the amount of movement needed have made an implant possible at this point for your secondary chin augmentation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in getting a custom skull implant and I have long hair. Would the surgery cause hair loss in anyway since a silicone will be inserted in between the skull and scalp?
A: Skull implants are placed on the bone beneath the overlying five layers of the scalp. As a result it does not cause hair loss as the hair follicles reside between the 1st and 2nd scalp layers…the implant resides beneath the fifth layer of the scalp.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had radiation to my neck at 10 years old I’m 37 years old now my neck or trapezius muscle won’t grow. Is there any implants for neck and trapezius?
A: Trapezius implants do exist and are placed through a small posterior neck incision. (see attached)
Neck implants can be placed along the sternocleidomastoid muscle. They are a bit trickier because of the crossing of the greater auricular nerve in the midportion of the muscle so I might consider injection fat grafting instead…which may be preferable anyway because of your history of neck radiation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello. I believe my upper lips are too thin. Is there surgery to make te thicker?
A: In the thin upper lip male the best procedure for making the lip have more visible vermilion show (look bigger/fuller) is the vermilion advancement procedure. This is a particularly effective procedure when the sides or the whole upper lip are particularly thin. (have scant vermilion exposure)
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, i! I got some stock jaw and chin implants and am not 100% pleased with the results. I was wondering if you do contouring/shaping post install and how the recovery would be.
A: I am not sure of your question. When jaw augmentation is done with standard implants and are not happy with the results, how to proceed depends on the nature of the problem. Is the problem implant size, implant positioning or the type of implants used? In my extensive experience it is rarely that a few implant adjustments gets the patient to a satisfactory outcome. More times than not the problem is that what the patient wants to achieve could never have been achieved with standard implants and they then have to convert to a custom implant approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to inquire about rib removal surgery (shortening of ribs: #12, #11, #10) with latissimus dorsi muscle reduction. I am wondering if it’s possible to undergo this surgery if I plan to have children in the future.
A: Good question. Such surgery has no adverse effects on getting pregnant or carrying the baby to term.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m really interested in waistline narrowing, I’ve tried Lipo and had a BBL but I still do not have the feminine waistline I want . I saw there is such a thing as rib repositioning as opposed to traditional removal and wondered if this would be a good option for me since I really want minimal scar and to recover as quickly as possible so I can get back to my normal activities.
A: There is no real scar difference between rib fracture and rib removal for waistline narrowing as both require access to the ribs. The former relies on 3 months of postop compression to produce a result that averages less than 50% of rib removal outcomes. There is no real recovery difference as rib fractures take just as long to feel goods again as rib removal.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Would the muscle I have on my frame restrict the amount of length that could be attained from the surgery? If so would I be able to stretch my muscles out for a extended period of time prior to surgery to negate this?
A: What I have found is that in all shoulder lengthening patients the shoulder girdle is tight, whether one has muscle hypertrophy or not. (although it certainly feels tighter in the more muscle developed patient) Whether a stretched out shoulder helps or not for this surgery can be debated. But it certainly can only help particularly when significant muscle development is present.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I wish to pursue cheekbone augmentation. Is it possible to achieve that through a malar osteotomy rather than implants, or will I require implants?
A: The first step in any form of facial augmentation, cheek augmentation included, is to determine the dimensions of change desired. While you did not specify what your cheek augmentation goals/dimension were your pictures show a flat infraorbital and anterior cheek area but what appears to be adequate.
A malar osteotomy is a one dimensional operation as it only can create cheek width. A cheek implant has a three dimensional effect which appears to be more suited to your aesthetic needs.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am a 26 year old female and I have been researching how to fix my perioral mounds for a couple years now and cannot seem to find a solution that I find suitable for myself.
I’m not sure why this is such a hard issue to fix but it is becoming VERY bothersome to me and I’d like to find a solution. It does not matter if I am slightly overweight or in perfectly good shape my perioral mounds never go away.
I can tell they are definitely a combination of fat and very thickened mucosa, I feel like I could just bite off the very inside corners of my mouth and it would completely take care of the problem.
A: Based on your pictures you are referring to a combination of perioral mound liposuction for the external lower cheek bulge and an inner buccal mucosal elliptical excision to treat both sides of the cheek contour issue. Those insights are diagnostically correct and you are also correct in that this is a straightforward surgery to do. (at least for me)
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Am I a good candidate for hip implants?
A: 1) If you have adequate fat to harvest (and you do) you always try fat injections first. While fat retention in the hips is not known to be great you always try it first and see how much is retained. Even if the fat augmentation result is inadequate it prepares the hips better for implants…which needs all the subcutaneous fat thickness around them you can get.
2) The risk of complications in hip implants improves when one doesn’t get too ‘greedy’ in size and thickness…which I have illustrated in the attachments.The question thus is not whether one can have hip implants but whether the size that lowers the risk of complications is aesthetically acceptable.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am a 21-year-old young man. I get a lot of stress when I look in the mirror because my head circumference is 62cm, and I found out about your existence while looking for surgery.
I have a few questions.
First, is it possible to have a bone-cutting operation in every part of the skull?
I’m wondering is it possible to reduce the bone under my ear (so that the length between my two ears is reduced), and is it possible to reduce the skull bone under my cheekbones.
Secondly, I would like to ask you is it possible to reduce the Temporal bone and parts of the parietal bone attached to the temporal muscles above the ear (so that the length of the parietal bone decreases from the front),
and if you can, how much mm did you shave on average for the average patient?
Also, I would like to ask how long the cut bones were in the case of the patient who cut the most.
I would really appreciate it if you could answer a long and complicated question. Also, I hope everything I asked is possible.
A: In answer to your skull reduction questions:
1) Bone reduction can not be done ob every part of the skull. The sides of the skull have a large muscle component which is what is reduced. (temporal resuction) That is infinitely more effective than temporal bone reduction.
2) There is no skull bone underneath the cheekbones.
3) Parietal skull reduction can be done.
4) The average skull bone reduction is 5 to 7mms. The average temporal muscle reduction is 7 to 9mms.
5) I do not understand the question of ‘how long the cut bones were’. I assume you are referring to surface area of the bone to which I have seen/done entire surface areas of the skull reduced. The only limitation as to how much of the skull can be reduced is surgical access….where and how long does the scalp scar need to be done to do the amount of skull reduction wanted/needed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello. I have done blepharoplasties only on my left upper eyelid so I can’t close it fully and my left eye is more open. Could we put a tissue expansion for ”growing” extra skin?
A: Short of a skin graft (you can’t tissue expand an eyelid) time and stretching the eyelid is the answer to allow secondary tissue relaxation to help get back to a more competent eyelid closure.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, According to what I have seen in several web pages the orbital box osteotomy is the only way to separate the eyes. As I have seen this operation is very complex, so I was wondering if you do it in patients with close eyes but within normal parameters, simply for cosmetic reasons. I mean adding 6-8 millimeters between both pupils, making the inner canthal distance about 6 millimeters wider.
A: It is not a question or whether orbital box osteotomies can be done in someone with ‘normal parameters’, but it how it should be approached. Doing traditional orbital box osteotomies using a coronal scalp incision and a frontal craniotomy seems to be a mismatch between the magnitude of the problem and the solution. A more acceptable approach, where the surgery seems better matched for the problem is a modified orbital box osteotomies which avoids a coronal scalp incision and a frontal craniotomy. Going through the combined approach of lower eyelid and intraoral incisions only the interpupillary distance can be increased by 3 to 4mms per side.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am currently suffering from sagging buttock glutes as a result from brazilian but lift surgeries, which I would like to get removed.
A: Thank you for sending your pictures to which I can make the following comments:
1) I would not consider fat injections to the buttocks (aka BBL surgery) reversible…or at least I would be very cautious about doing it. While liposuction can be used to remove fat from the buttocks that will undoubtably leave the buttocks with some contour irregularities and increased sagging. Like letting the air out of a balloon the decompressed tissues will collapse to some degree.
2) The only effective way to treat sagging buttocks is at the infragluteal fold level through excision. It doesn’t really lift the buttocks per se but does remove any overhang as the level of the fold…which is sort of a ‘lift’.
3) in looking at your pictures I believe what you may be trying to achieve is some reduction in buttock size (which is why the liposuction) with a lower buttock lift. (see diagrams)
That being said, some liposuction of the buttocks (don’t try and remove a lot of fat due to the risk of irregularities) with infragluteal excisional tucks/lifts.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am scheduled for my surgery and ready to go so far. A question I have is with my forehead reduction is will my hairline. Also be lowered with it, since the bony layer is being reduced?
A: The frontal hairline can not be lowered when a skull implant is being placed, either during or afterwards. A frontal hairline advancement relies on the scalp being able to be loosened and moved forward. In other words a frontal hairline advancement requires a total epicranial tissue shift. The skull implant ‘steals’ whatever scalp mobility exists to cover its volumetric increase.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, This surgery is known as corrugator muscle lysis or frown lines removal. It is a permanent solution because the procedure will surgically “disrupt” (cut and resect) the corrugator muscle. The surgical approach can either be done endoscopically (no scar) or as part of a conventional forehead lift or brow lift procedure. However I want the glabellar muscle between the eyebrow removed completely so that part of my forehead is flat again! because botox doesn’t work for me. Is this something you could do?
A: Of this concept I am familiar. However regardless of the technique used (an open approach is far better than an endoscopic approach for more effective muscle removal) you have to be careful about total muscle removal in the glabellar region as that will result in a visible glabellar indent. The muscle adds soft tissue thickness which is not insignificant so you want to avoid total removal.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My lower glutes sag & have about1-2 inches if not more of saggy loose skin that just hangs. I think I need lower glute skin removal.
A: I can certainly see the infragluteal fold overhang and agree that the only improvement will come by excision. My concern would be the heavy volume of buttock tissue above it and its potential adverse impact on incisional healing and the risk of postoperative wound dehiscence. (in an area which is already stressed in that regard because of sitting) The vast majority of patients that undergo lower buttock tucks/lifts have much smaller buttock sizes/weights above it. I am not saying it can’t be done but that potential complication in you is higher.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in a reversal jaw reduction and reversal cheekbone reduction procedure and would like to know how long I should plan to stay in Indiana before returning to my home country. Thank you for your time.
A: Most jaw and cheekbone reduction reversals require custom implants made to augment back part or all of what has been removed from the surgery. This requires the implants to be made from the patient’s postoperative 3D CT scan. That is a scan that is obtained where the patient lives which is then sent to me for design and manufacture, a process that takes several months to do and does not require a patient visit.
I assume when you refer to how long you would be here for the surgery and then able to return home….3 to 4 days after the surgery at most.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I`m interested in facial asymmetry correction using hydroxyapatite(I suppose my bone structure at right and left side of eyes and under eyes area are different a bit). And also I`d love to have my brow bones augmented using the same material.
A: Hydroxyapatite cement, while having biologic appeal, would be a very poor material for any facial bone asymmetry correction as its application is very imprecise. Plus as a general rule you don’t make intraoperative eyeball assessments of how to correct facial bone asymmetries. This usually just leads to ongoing asymmetry issues. The most accurate way to do facial asymmetry corrections is with a preoperative 3D CT scan to accurately determine what is the actual millimeter difference between the two sides. From which accurate custom implants can be designed to provide the best asymmetry correction.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My right clavicle is 1 to 2 inches shorter than my left clavicle. It causes my body to slant to my left side and makes weight lifting difficult and mentally takes a huge toll on me.
A: The current ‘problem’ with clavicle lengthening is that its limit is 15mm, maybe 20mms of lengthening that can be achieved. In the congenitally short clavicle who knows if even that amount is possible to be lengthened. That amount of change seems inadequate given the significant length differences between the two sides that you have described.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, what do you think of PMMA molding technique for skull augmentation. Is it really that bad ?
A; There is no redeeming qualities for PMMA Bone Cement Skull Augmentation
1) It is a plastic material so it is still an implant. What you smell in a nail salon is PMMA. It gets encapsuled like any other implant, it dfoes not bond to the bone or become bone.
2) It can only provide limited amounts of augmentation. (60ccs or less)
3) You can’t control its shape very well.
4) Edging is almost always an issue.
5) There is no modification of it once it is in place and cured. It can only be modified by complete removal.
For these reasons it is an historic material for skull augmentation for me. It was only good when there was nothing better.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I want my nose done fur sure… it doesn’t have a bridge going down and I have almost like pig nostrils. And I have this small mouth that droops down. I don’t have a symmetrical shape face. I never had. Plus I’m getting older. I would like to achieve a more symmetrical, shape, and chiselled cheekbones.
A: The underrotated/underdeveloped nose is part of the overall midface issue which is why the undereye-cheek area is deficient.The undereye-cheek area is best treated by the custom infraorbital-malar implant approach.
The saddle tyope nose requires a rib graft as the whole L-shaped dorso-columellar nasal line needs built up. While the dorsal line can be built up with an implant, derotating and lengthening the tip requires an autogenous grafts construct.
An extended corner of lift can also widen the mouth a bit as well.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m a 35 years old man with 2 hair transplants FUE and DHI done. Cutis Verticis Gyrata condition has been reported by more than one dermatologists, where I did the transplant and in the UK. Is it possible to remove the scalp folds and transplant the hair as beard straight after? Sort of FUT? Is it possible treat the scars once they are healed with pigmentation or FUE/DHI transplant?
A: While excision of the scalp olds can be done, and in deep CVG scalps like yours, this would be the only effective treatment. The ‘problem’ is that there are a lot of folds and the excisional areas would be close together so there is always a blood supply concern. Certainly if excisons were done you would never do them all at once for scalop survival reasons. Whether the scar tradeoffs would be seen as better is hard to say but what I would recommend is that do several of them that are far apart first to see what the result is.
I am not a hair transplant expert so I can not say whether any excised scalp will permit the hair follicles to be removed from it. (it is very dense scar-like tissue so extraction may be difficult)
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Was curious if high scrotal is possible compared to mid raphe for same low hanging effect, I heard high scrotal has low pain after and fast recovery. Whichever has lowest extrusion rate and least pain is preferred, other than inguinal.
Also, can you ask implantech for durability testing data? I’m curious how resilient the shape of these are after being compressed I am extremely active. This is important for me to know for peace of mind.
A: When it comes to an incision, not matter where it is placed, what is done inside remains the same. Thus an incision is a point of access and is not where most of the discomfort emanates.
The midline low raphe incision has the least discomfort and ensures the best chance for a desired low testicle implant position. I have never seen extrusion and would not consider it a likely risk. That would occur due to the combination of an inadequate implant pocket and poor wound closure techniques.
There is no biomechanical data that I am aware of that would provide what the required amount of compressive force that it would take for the implant to fracture/fail. But I would suspect it is way beyond twhatever force to which you are going to expose it.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello My interest is about entire midface augmentation. My wish is to avoid implants. want to try with hydroxapatite. I want to ask 3 things:1. Is it possible to use hydroxyapatite cement to augment complete midface
2. Is it possible to insert around 4 mm in thickness augmentation
3. Does it last forever or will it shrink over time. How l8ng will it stay is there any research on that
Many many thanks
A: Hydroxyapatite (HA) bone cement can be used to augment the midface as long as one understands what its coverage and augmentation limitations are. (see attached) It is a difficult material to use in the limited access than the intraoral incisions provide being an intraoperative putty that must be allowed to be placed, shaped and given time to set which requires a completely dry environment. As a result it works best in concave bone surfaces where it is more contained. A 4mm augmentation should be able to be achieved in the deepest part of the augmentation over the face of the maxilla.
Also HA is a structurally stable material that does not shrink or change structure over time. There are certain types of HA that are resorbable but when made as a bone cement they are non-resorbable.
HA cement has appealing biologic properties but it does not have the same surface areas of coverage or increases in projection that implants do.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
