Your Questions
Your Questions
Q: Dr. Eppley, I have a question about eye area; what procedures would be necessary to replicate those eyes? My eyes are not as deep set and instead of this angular shape are more almond shaped. Canthal tilt also sits lower. So I guess orbital implants with horizontal and vertical projection would be necessary. But how much vertical augmentation of supraorbital rim can be achieved and will brows come down?
I attach front and profile of my eyes and the ones I would like to achieve. Thank you very much.
A:I don’t think you can replicate that eye shape exactly. But certainly periorbital augmentation is the key with brow bone augmentation being the most important. The eyebrows will come down with brow bone implants particularly with a design that lowers the bone edge…just not as much as the example you have provided.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am writing to you because I have an asymmetry of the jaw, the right is more developed than the left, I am 28 years old and to have more symmetry I thought of one of your customized implants on the less developed jaw, but first I would like to have an idea of the result aesthetic of my face by temporarily adding volume to the jaw in a reversible way for this reason they advised me to do a test with a lipoffilling or the Radiesse, in his opinion which is better of the 2 products to fill the less grown jaw and understand the aesthetic result that would I have a fuller face waiting to do the custom implant?
A: While the use of non-permanent injectable fillers is a good first step in treating jaw asymmetry I certainly would not use fat as it can be hard if not impossioble to remove later if the long term plan is an implant correction.. Radiesse is a long lasting filler and would be fine if an implant correction is 18 to 24 months into the future. Otherwise hyaluronic-based injectable fillers would be a better choice as they last less long and are easily reversed. As an aside fillers or fat placed in the subcutaneous tissues do not have the same aesthetic effect as bone-based implants.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have what I think is brachycephaly with a very flat back of the head but also the sides of the back of the head are pointy and flat. My question is how much bigger and rounder can these areas become with a custom skull implant? Also does the silicone feel soft ? Like if someone touches those areas can they feel it ? Or if you lay down does it feel soft or just like bone?
it’s like my head doesn’t have a back, its appears cut in half. I think my case is very very very severe. I can’t go outside without a hat. I think if you can fix this it will be truly life changing for me ! I hope and pray and I’m waiting for your answer. thank you
A:Thank you for sending all of your pictures. You do have classic brachycephaly which accounts for the shape of the back of your head. That can be improved by a custom solid silicone skull implant which will feel just like bone. The amount of augmentation is controlled by the stretch of the scalp and I would estimate that to be in the amount shown. (see attached image)
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am wondering if I am a good candidate for rib removal. I am also looking to downsize my breast implants and was wondering how that would relate time wise to get rib removal.
A:Thank you for sending your pictures. Lean patients get the best waistline results from rib removal surgery of which you fall into that category. That would need to be combined with abdominal liposuction in your case. Breast implant size change can be done before, at the same time as rib removal surgery or after. If done before or after I would allow 2 months on either side of the waistline narrowing surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m sending this email as an inquiry into Aesthetic Skull Reshaping Procedures.
I’ll start with a bit of an overview of my situation and what I hope to achieve:I’m a bald male. I have a depression/groove in the top right side of my skull. As a result, the right-side profile of the top of my head is concave while the left profile has a gradual convex shape. I’ve provided photos to clarify my description
It is my hope that a small custom implant (about 5cc volume) can be shaped and inserted to fill in the depression, to give the right side of my head a more convex shape similar to that of the left side (though I’m not expecting perfect symmetry).
I do also have a couple of more specific questions:
- I’m concerned the filling material would be noticeable and unnatural looking with my shaved head (e.g. the edges can be seen). Are you confident this would not be the case and how do you prevent this?
- How do you ensure the implant is placed in the correct location on the skull?
- I live overseas. Would it be practical to undergo this process with online consultations and a single two-week trip?
Thank you for your time. I hope to hear back with your thoughts soon.
A: You have correctly surmised that a small custom skull implant is the correct solution to what is known as a coronal suture line dip. In answer to your questions:
1) Feather edging of the implant design is what prevents what is known as ‘implant reveal’ or visible edging.
2) It takes a lot of experience to know how to properly position skull implants through small scalp incisions. But the location of the incision and knowing how the implant is supposed to fit are the keys. (this is why a custom design is needed)
3) The entire process, except for the actual surgery, is done in a virtual manner.
FYI The vast majority of aesthetic skull reshaping patients are just like you, the male with a shaved head.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I am a young female 117 lbs and 5’5. I’ve always had a very round fat face despite being very skinny everywhere else. I think one of the main reasons for this is my recessed chin. I’ve been looking into genioplasty and chin implants, but i’ve read that through genioplasty it can also help my jawline. My dream results would be a pronounced jawline and normal chin that matched my weight (I feel like Ariana Grande is a very good example). I don’t know if such drastic changes would be possible with just genioplasty or if I would need filler or liposuction. I currently live in Texas, but so have heard such amazing things about you, so I am willing to make the commute.
A:I don’t think there is any question that a sliding genioplasty (10mm plus forward movement is the preferred chin augmentation procedure and would make a world of difference for you. That combined with some midfacial defatting (buccal lipectomy and perioral liposuction) with make a major facial transformation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I understand that a cheek implant is placed primarily on the bone, but I was wondering how far off the bone can a cheek implant hang? Especially in the submalar region?
Thank you
A: Cheek implants are commonly positioned off the bone onto the masseteric muscle fascia to obtain lower cheek fullness. It can go as far down along the masseteric fascia as the intraoral vestibular tissues will allow.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to discuss the options for a chin revision. I had a chin augmentation in January 2021 and the removal of the implant in May of 2021. Since then my facial structure has changed significantly, which the lower part of my face becoming wide along with issues regarding my smile. Therefore I’m looking to see if liposuction/mini facelift are options to correct this issue? Look forward to hearing from you! Thanks so much!
A:Thank you for sending your pictures. What has happened is rather classic from your chin implant surgery. Placement of the chin implant necessitated release of the overlying soft tissues. Once the implant was removed the soft tissues are never going to go back exactly to what they were before. Thus you went from a v-shaped chin to now a wider/flatter chin shape. There is not any way to directly manipulate the soft tissues of the chin to regain that appearance as it is a direct result of degloving of the soft tissues. While there may be some aesthetic benefits in your case to the options you mentioned (submental liposuction and a jowl-tuckup procedure (aka lower limited facelift) their effects would be to improve everything around the chin but I would not assume that will bring back completely the previous chin shape. It will definitely help, however, improve the wider lower facial shape.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, But I saw you comment on a question forum about my exact issue so what I think I have is chin ptosis! For years I have been getting filler in my chin to correct it and was considering a sliding genioplasty or implant but what I realized I really want is for the fleshy pad on top of my chin to be shortened, it is too long and extends even further when I smile and talk. I am in the process of trying to make my face “smaller” by reducing the fleshiness in the lower half of my face. My chin has really been standing out to me, I believe the filler is migrating too even though I’m adamant with the injectors to not place it anywhere in the lower part of my chin, I only get the filler to project it forward and fill in the hollow crease right below my lip which causes a shadow that really bothers me. I got x rays done at a dentist so I’m attaching that since it’s probably helpful! Please excuse the purple Halloween costume but that photo my chin looks crazy so I thought it would be a good example. Any way, depending on the price of this procedure I may make an appointment to travel to IN sooner than later and maybe combine it with one of the implants? Please let me know what you think.
A:You have a natural large soft tissue chin pad to bone ratio which can clearly be seen on your lateral cephalometric x-ray. This becomes more apparent when you smile as it pulls down creating hyperdynamic chin ptosis. You have correctly surmised that a soft tissue chin pad reduction is the correct procedure to improve it.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, thank you for your time. I know you are busy. I am an avid reader of your online content, blog, and responses on forums. I have a question I hope you can answer, as I feel you are the best expert on this.
I have long history of many intra-oral chin implant surgeries, which unfortunately resulted in me having lower lip incompetence. I then underwent a mentalis resuspension using a large PEEK implant with holes to accept sutures for the mentalis, as well as holes made in the alveolar bone to re-attach the mentalis. This resulted in shortening of the vestibular sulcus and restoration of my original lip height and labial competence.
However, my mentolabial groove is no longer as deep/pronounced as it used to be. I have read that this groove is supposedly an anatomically fixed site that cannot be made more shallow unless through fillers, fat grafting, or even implants, but I insist that I used to have a deep groove, and it is now shallow/less noticeable.
Oddly enough, I liked having the deep groove, as I felt it made my chin look more pronounced as a man. Everything I read online is about patients and surgeons attempting to minimize this groove and prevent it from becoming too deep, but I *want* the deeper groove I used to have.
My questions are:
1) Is it possible that intra-oral procedures and mentalis resuspension can inadvertently make the mentolabial groove more shallow.
2) Is it possible to make this groove *deeper*, perhaps through liposuction, or further vestibuloplasty.
I appreciate your time. I know you are busy. I am thankful for your time.
A: Given what you have been through to get to this point, I would accept the tradeoff of a less shallow labiomental sulcus for the lower lip competence improvement., Trying to make it deep again risks a return of some of the very improvements you have now obtained.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am a 27 year old trans woman and I am very interested in having rib removal surgery for waistline narrowing. I have a few questions:
1. How long must patients stay in town before flying home?
2. Is it possible for me to have this procedure on my own without a support person? Does the clinic offer any nurses for aftercare? If not, can you recommend any locally?
Thank you so much for your help.
A: Thank you for your inquiry in regards to rib removal surgery. In answer to your logistical questions:
1) Most rib removal patients return home 3 to 5 days after the surgery.
2) It is very common that patients come by themselves for this type of body contouring surgery. We have a nursing service that gets you back to the hotel the morning after surgery as well as can provide some intermittent support for a few days after the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a broken zygomatic arch that was not repaired in time which has resulted in loss of facial symmetry. What can I do to correct it now?
A:To determine the best corrective approach for a displaced zygomatic arch fracture a 3D Ct scan is needed so there is a clear understanding of the actual bone position and how best to repair it. In some situations, unless the infractured bone segment is impinging on the masseter muscle (causing pain), a camouflage approach (leave the bone where it is) may be used for facial contour restoration.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a question regarding the combination of standard chin and jaw angle implants.
How do they connect? I´m aware that they are 3 separate implants, which are not connected by screws or anything like that. But will there be visible gaps between them if you wrap the skin around them very tihghtly?
How can it look like 1 uninterrupted jawline instead of 3 “hills”? Or is another technique like wrap around custom jawline implants better regarding that concern?
A: The wrap around jawline implant is the only jaw augmentation method that makes for a smooth connection between the chin and jaw angles. That is one of its many features/advantages.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Can I get an advancement sliding genioplasty if my chin is not recessed? Like its perfectly lined straight with my lips but i want to advance it for an even more forward grown look. Thank you.
A: A sliding genioplasty can be done just as easily/effectively in a chin with normal projection as in the recessed chin.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi, could you tell me all of the risks involved with your post-genioplasty procedure of intra-oral release and fat graft? Also how long does recovery generally take? And can this procedure help to raise the lower lip a bit to cover the lower incisors more / reduce lip incompetence?
Thank you!
A:The only real risk of post-genioplasy release and fat grafting is how well/effective it would be.
One of the goals of the procedure is to raise the lower lip a bit….the hardest post-genioplasty sequelae to improve long-term.
Recovery is much more rapid than the original sliding genioplasty,. being a week to 10 days at most.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I have had a Le Fort Osteotomy for sleep apnea in 2020, and am unhappy with my jaw appearance after (too narrow, undefined). I tried a jaw implant in 2021 but it became infected and had to be removed. I am wondering if a custom jaw implant would be an option for me?
Thank you
A: Almost always a custom wrap around jawline implant is the most effective approach for jaw augmentation after orthognathic surgery. I would need to see some pictures and do some computer imaging to see what type of changes is desired/possible.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I’m interested in clavicle shortening. However, I’m wondering if this would make my collarbone a lot less visible. I already have not really visible collarbones and I’m worried they will fully disappear.
A:Good question and actually the reverse of your concern, becoming more visible, is more likely to occur due to the application of the superior fixation plate.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I recently had custom peek jaw implants in Europe, they look great and have healed well. The only issue is that the right hand side implant was ever so slightly malpositioned, such that at the point of contact along the mandible (about half way between gonion and chin) the implant edge is raised maybe 1-2mm off the bone (such that I can feel (but not see) a little lump along the bone)
I know jaw implants are meant to last for life (correct me if this is not a correct asumption), but is that longevity at risk if the implant is slightly malpositioned? I’m worried that if I press hard on the notch at the end, if I press hard enough the implant will snap into the 1-2mm gap toward the bone and break or the screws will be pulled out or something (eg if i got punched in the face). Can I still expect the implant to last for life?
A:Even custom jaw implants can be malpositioned, most commonly at the jaw angle region. Such malpositions do not affect the longevity of the material. PEEK is a very strong plastic material that you can not bend or break.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have an initial video consultation scheduled with you already. My question is, can all the procedures I am wanting be performed on a single day? Tentatively, I am planning to get infraorbital-malar implants, nasal tip rhinoplasty, buccal lipectomy, and sliding genioplasty (bilateral where applicable). Of course, I won’t finalize plans for any specific procedure until I get your ultimate recommendation at the consultation, but, for scheduling purposes, I am wondering if it is possible to perform all of these in one operation. In particular, I would like to know whether it is safe to be under anesthesia for the duration of these procedures. Thanks, looking forward to speaking with you.
A: It is very common to perform many facial procedures at the same time. So the combination of IOM implants, tip rhinoplasty, buccal lipectomies and sliding genioplasty do not pose any medical risks or any undue physiologic stress on the patient through both the surgery and the healing process.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I had a chin burring procedure intraoral approach in November 2020 but when the swelling went down my chin was noticeably long and flatter, my main concern is that the tissues are now drooped and filler has made it less unsightly but still drooped and long, smiling makes it worse. I would like to discuss excision and tightening of the chin pad to help this issue, thank you!
A: Chin reduction by intraoral burring is always a poor treatment choice which creates exactly what you have…a flatter wider chin with soft tissue chin ptosis which is why it looks longer. Why surgeons continue to do this approach to chin reduction when this is an expected outcome is a mystery to me. It can now only be improved by a submental chin pad excision/tuck now.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have untreated plagiocephaly which has caused several asymmetrical features of my face and head And I’ve only started to notice as I got older.
The right side of my face is pushed forward and the left side is pushed back affecting my eyes, cheekbones, ears, jaw and head. The right side of my jaw appears smaller and higher up whereas my left side of my jaw appears larger and further down. My right side eye appears larger and positioned normally whereas my left eye is slightly slanted more and pushed further back making it noticeably asymmetrical. My right side cheekbone is pushed further out compared to my left. The left side of my head is pushed further back and sticks out noticeably looking at me from the front, whereas my right side doesn’t stick out but is flat at the back , my right ear is placed further forward compared to my left. How many of these problems would you be able to fix please and make me look as normal as possible I know if I was to get most of these asymmetrical features fixed it would be a long expensive process but I’m willing to fly over for however long it takes.
A: Every skull and facial shape abnormality that you have described is very typical in plagiocephaly. Potentially every one of them can be treated/improved to varying degrees. The first step is to establish a treatment plan for them based on your priorities. I would make a list of the most to least bothersome of these craniofacial features and then we will match that up with a 3D Craniofacial CT scan to create a surgical approach to your plagiocephaly concerns.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have had a testicular implant since 13. There is a large size disparity between my real testicle and the implant.
I am about to have a urologist insert a larger implant. In researching the Coloplast, the largest size is not even close.
What are my options?
A: The beet approach would be to have a custom ultrasoft silicone testicle implant made that matches the other side in size. Given your statement of ‘the largest size is not even close’ would indicate the need for a custom implant design approach. Since the largest saline testicle implant is 4.5ms and the largest silicone testicle implant is 5.0cms, the need for a custom testicle implant design is obvious.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a botched genioplasty and I am wondering if you could fix it? My doctor said I had to wait 6 months for a revision but 1) I really do not trust him to do the revision and 2) I have seen other people have revisions/reversals before 6 months. Thank you.
A: What type of bony movements were done in the sliding genioplasty and what concerns are there now? This will guide how you would revise your genioplasty. But it can be done anytime before 6 months as what matters is whether you have a clear idea as to the changes you want. The timing is not based on how well healed the bone is.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, i want to know after a surgery like skull reshape how do you feel your head because I’ve had some surgeries and all the zones of the cut feels like electricity and numbness. It is the same for the head?
A: In my experience skull reshaping patients will experience some temporary scalp numbness which fairly quickly returns to normal in a month or two after the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Can The Plates and Screws and Hydroxyapatite Granules Be Removed After A LeFort I Osteotomy Surgery?
Q: Dr. Eppley ,I am writing to you because 3 years ago I had Lefort 1, BSSO and a cheekbone augmentation with hydroxyapatite granules.
Since this year, I have noticed the cheekbone (implant/granules) grew much larger, mainly on the left side. It has been getting bigger still and it protrudes much more from the side. Especially in the last 6 months, it seems like the “implant” is migrating upwards towards my eye; or a new bone layer is growing near and/or around my eye socket. My left eye is closing up as new bone grows, or hydroxyapatite moves underneath and on de outer corner of the eye as well.
Another issue is that my face, especially in my cheek area, has been swelling up slowly over the past year as well. On the upper jaw, the area where the plates and screws were placed, it feels sensitive and is more swollen. I believe this is due to an infection of either the plates or the implant.
Could there be new bone growing on and around the hydroxyapatite implant, years after placement?
Could this be the reason for the possible plate infection?
I am very worried about what is happening in my face, and I was hoping we could have a consultation about the removal or at least reducing of the hydroxyapatite implant and the plates and screws.”
A: The first place to start is to get a 3D CT scan of your face in which all metal hardware as well as the sites of HA implants can be seen. This will then provide a guide for surgical removal. There is no indication that you have any infection as this is not how infections present nor would they occur in such a delayed time period. This is all due to scar tissue buildup and how the body has responded to the HA granules.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, thank you for all your information about skull reshaping surgery that you provide which is very useful for us. I would like to know if it is possible to reduce the width of a human skull by reducing the thickness of the parietal bone by about 3 to 5 mm on each side of the skull knowing that the parietal bone has a thickness of 1.7 cm on average and if so, what are the risks.
A: A parietal bone skull reduction of 3 to 5 mms can be effectively achieved without significant risk…other than the aesthetic compromise of the fine scalp scar line (incision) required to perform it.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a sliding genioplasty to advance my chin 6mm forward 7 weeks ago. I know that I am still early in the healing phase but I hate my chin so far and I feel like it’s not so swollen anymore. It makes my face seems a lot longer and narrower. From a 3/4 view, it looks too pointy and doesn’t match my face. I know that with facial cosmetic procedures it can be hard for patients to accept their new faces but I feel like I won’t ever like this chin. I am thinking to reverse it (3-4mm backwards) but I would like to know when is the best time to get it done. Some surgeons say that it’s best done 6-8 weeks after the surgery or that I should get it done between 3 and 6 months while other doctors say that I should wait 6 months for the bone to heal. My surgeon said that a new surgery so early is too risky and that it could end with a bone necrosis. I am ready to wait a few months because I don’t want to take a hasty decision. When is the best time to get it done ? Is 4mm too much? I am 18 years old, I don’t want my skin to sag. Thank you
A: At 7 weeks out you can do it anytime now. The so called risk of bone necrosis is a non-factor in my opinion and experience. Just get it done as soon as you can at this point after surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am very interested in the procedure that I see you are an expert in, forehead augmentation with custom implants.
My question is the following, I have a very backward sloping forehead, and I want to increase considerably in volume that area, I have read that in the case that it is required and the patient wants something much more significant should be implemented an additional procedure (tissue augmentation, extension), I think that would be my case. I want to increase my forehead about 5 cm of volume approximately, with temporary extensions and completely cover the eyebrows.
Will it be possible to augment to that extent? Up to how many centimeters will it be possible?
I attach photos of what my forehead looks like and how I would like to have it.
Best regards, I look forward to your answer!
A: Thank you for your inquiry and sending your pictures. You have made two correct assumptions in regards to your forehead augmentation goals:
1) The desired amount of forehead augmentation is going to require a first stage scalp expansion and
2) When you add that much change in the inclination of the forehead the implant must, to look natural and blend in with the rest of the head shape, wrap around the sides (temporal regions) of the head. In essence this forehead implant design would really involve the entire front half of the skull.
You have made one incorrect assumption, that amount of forehead augmentation is profile is closer to 10 to 15mm of projection not the 50mm or 5 cms which you have stated.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My head is flat on the back and underdeveloped on sagittal and frontal, and it’s been troubling me and cause I h me depression just being aware of it 24/7. I got a few questions about the procedure. 1. Is it bone cement you’ll be using for skull reshaping surgery, or silicone padding? 2. Is possible to go through one anesthesia and have three incisions and reshaping my forehead, back of my head and my sagittal area in one procedure? 3. I’m a trans women. Does skull reshaping surgery count as part of my Facial Feminization surgery, and if so could that be covered by insurance?
A: In answer to your skull augmentation questions:
1) Only a custom made solid silicone skull implant can create effective 3D skull augmentation changes.
2) Yes it is possible in a single surgery to reshape/augment numerous skull surface areas…provided the volumes being added do not exceed the stretch of the scalp to accommodate them. If the scalp’s ability to stretch is questionable or there is absolute certainty that it can’t, then a first stage scalp expansion procedure is needed.
3) We do not accept or process insurance.
4) To accurately provide the cost of #1 or #2 (one vs two stage skull augmentation) I would need to do some computer imaging on your pictures to determine what your precise skull augmentation objectives are.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Does the burring method, which, from what I gathered, removes the outer layer of the skull, result in a weaker, more vulnerable skull which can increase the risk of hurting one’s head and brain (cracking, piercing skull, etc)?
A: Removal of the outer layer of the skull as is done in skull reduction surgery does not make it more susceptible to injury due to the double layer cortical bone that comprises the full thickness of the skull.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
