Your Questions
Your Questions
Q: Dr. Eppley, Regarding the head: – I would like to have a facial and cranial reduction and feminization procedure. This means shortening, narrowing, and filing down the bony prominences of the skull to make it more rounded and smaller, that is, more feminine. Among the things I want most is to reduce the lower sides of my head, which make it appear longer and more masculine because of the mastoid processes. Being larger and longer, these give the appearance of a thick neck and a long head. Clarifying that I desire all the procedures of a complete facial feminization, I want to use a more bony and deeper approach to the bone structure.
A: To do a proper assessment of your skull reduction goals, to determine what is and what is not possible, this will require a 3-D CT craniofacial scan to have a full understanding of the bony and anatomy as well as what limitations may exist for the degree of reductions desire. For example, there are going to be limits as to how much the mastoid process can be reduced due to the underlying air cells.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My face is wide and short. How can I fix it?
A: In the wide and short face the typical approach would be to lengthen it vertically at the chin area and do soft tissue reductions in the cheek and lower facial area. However your pictures shows a very prominent chin that already is too long and prominent for the typical female face. Thus this poses a bit of a quandary has to what approach would serve your best as the facial lengthening component of making the face less wide is synergistic with any facial narrowing efforts.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m looking into the temporal reduction for the width of my forehead.(temporal muscle reduction) Looks to be the most solid option from what I’ve researched. Seems like my width/corners of forehead are just wide and pop out too much throwing my face off if i dont have hair covering my forehead or a hat on.. Not exactly sure what is best etc, open to opinions and what not from the professionals.
A:Thank you for your inquiry and sending your pictures. You have a classic excessively convex shape to the side of your head due to enlargement of the temporal muscles. This is not a bony deformity but a soft tissue one. In your case of temporal convexity, as it appears to involve both the anterior and temporal components of the muscle, it would require a combination of posterior temporal muscle removal and transposition of the anterior portion of the muscle to create the most effective side of the head reductive reshaping.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I understand that the most common approach to treating VOD involves an orbital floor implant. I also note that he mentioned that performing a floor implant would likely require repositioning of both the upper and lower eyelids.
A:An orbital floor implant is the easiest and most predictable part of VOD surgery. However, it alone rarely addresses the problem and is just a part of the solution but not the complete one. If you just lift up the eyeball and don’t change the brow and eyelids around it you actually make the problem worse by burying the eyeball underneath the upper eyelid and increasing scleral show on the lower eyelids. Therefore, in almost every case of VOD you have to go ‘all the way’ to obtain a result where all the components fit together in for a more symmetric and natural looking result. This means, besides the orbital floor implant, the upper and lower eyelids need to be repositioned as well as a brow lift on that side.
In addition it will not change the position of the medial canthi although the inner eye corner at the junction of the skin and lacrimal lake can be adjusted for that.
Therefore, as you can now appreciate one has to make the decision as to whether it is best to leave the asymmetry alone or go all in and have the maximal surgery. for it.. with the understanding that the degree of eye symmetry will be reduced but will never have perfect symmetry to that of the opposite eye.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, how can I attempt to improve my asymmetrical eyes? You will note that the medial canthii are different to each other.
A: I assume that you realize that the differences between the two medial canthi positions is relfective of the more global issue of vertical orbital dystopia (VOD). The right eye and the structures around it (right VOD) sits lower than of the left eye. The question then becomes do you treat the one component of it that you asked about (inner eye corner repositioning) or would doing just unmask the other VOD components that exist.
Q: Dr. Eppley, I would like to know, in my case if an occpital bun reduction would be possible. I would also like to know if Dr Eppley use video consultation for clients from others country. Thank You
A: You have provided the definitive answer to the question of whether occipital skull reduction would be effective via your lateral skull film as well as the meaurements of the bone thickness shown on it. I have drawn how much bone can be safely removed from the occipital bun (red line) which indicates based on my experience a visible reduction in its prominence.
The virtual consultation method is how I consult with everyone initially no matter whether they are geographically located.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I do have a couple of follow-up questions as I think through which approach would be the best fit for my goals:
- For Rib Xcar, since the permanence is listed as dependent on corset wear, is there any updated information on how stable the results tend to be long term once patients stop wearing the garment?
- For rib removal, is there an estimate of the typical amount of waist reduction patients with a frame similar to mine can expect?
A: In answer to your rib remodeling questions:
1) is there any long term data about the stability of the ribs in RibXcar? Not that I have seen which doesn’t mean it does not exist…just that I have not seen it. Presumably after 3 months the ribs have healed in their new shape.
2) The range of 1″to 3″ of waist reduction base on what patients have told me.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi I wanted to ask does this top of skull surgery make the face look visually longer once it’s shaved down I can’t see the patients full face but I have a feeling the face could look longer after this surgery? Im trying to work out if it’s suitable for me or not. Thank you
A:Thank you for your inquiry and sending your pictures. In theory one would think that of the top of the head is reduced that the face may look longer. However I think that is only true if one shortens the vertical length of the forehead which is not what occurs the top of the head skull reduction. That being said the best way to answer that question is to take your pictures and do a top of the head reduction and see what you think about its impact, if any, on facial length.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, here are picture of my cheeks. Two are obviously when I went for a consultation for implants, these are the highest profile ‘off the shelf’ implants & I would go with them if a custom option wasn’t available. Third pic is of natural cheek, you can see the flatness on the point, this is what I want corrected. BUT, the fourth pic shows the lumps that I have on my face (right side is narrower & harder than the left…..left hasn’t shown up in this pic).
These lumps are why I am thinking custom implants would be best as can they be tailored around these lumps (which I am now thinking must be ligaments) in order to hide them, they do really bother me as people are always mentioning them, am I tired etc etc!
A:Thank you for sending your facial pictures. When it comes to cheek augmentation the first thing to determine is where is the zone of augmentation and how much augmentation does the patient prefer. Based on your picture my interpretation of your cheek flatness is in the attached imaging. I’ve looked at two different degrees of cheek augmentation in that area one of which is stronger than the other one. Based on the zone and cheek augmentation I would think standard implants as you have shown would be effective. The role of custom implant designs is used when; 1) the degree of facial augmentation change is not achievable buy standard implants, 2) there is significant asymmetry between the two cheek sides, 3) there are adjoining facial areas that also desire augmentation such as the maxilla or orbit or4) standard implants have been used and they have proven to be unsatisfactory.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in a consultation for back of the skull reshaping to make it more round. What the procedure options? Is there any hair loss involved?
A:Thank you for your inquiry and sending your pictures. Flat back of the heads are the most common skull augmentation procedures performed using custom skull implants. Hair loss is not an issue as long as one does not try to make the skull implant too big or do too much. It is important to remember that in any flat skull area the overlying scalp tissue is genetically tight and, well it can be expanded, there are limits and one does not want to generate excessive stress in overlying hair follicles in the upper scalp players. That is a design judgment that I know best and in some skull augmentation patients I have to temper their enthusiastic goals with this concept in mind.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m reaching out to request your professional opinion regarding my chin projection and whether a conservative sliding genioplasty would improve overall facial harmony. I do not have functional issues with my bite or jaw, and this is strictly an aesthetic evaluation. I have been told previously that my chin may be slightly under-projected, but I would value your objective assessment on whether it is meaningfully recessed or simply within normal variation. If appropriate, I would be interested in: Your opinion on whether a sliding genioplasty is indicated A morph showing what a subtle, balanced advancement (not aggressive or over-masculinized) would look like on my face Guidance on what range of advancement (if any) would best harmonize with my existing facial structure My goal is natural balance, not dramatic change. I am happy to provide standardized photos (front, profile, ¾) or any additional information you require. Thank you for your time and consideration.
A:Whether chin augmentation is beneficial and, if it is, what amount of increase chin projection does the patient see as aesthetically pleasing. The terms natural, harmonizing, not too aggressive etc., while well-meaning, will have widely different interpretations by different people. Thus it is important to create a visual assessment of what these terms mean. In that regard I have attached two potential chin augmentation changes which generally are trying to convey the differences in modest and more substantial amount of chin augmentation. That will help guide you as to the results that look best to you regardless of how it is described.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m interested in clavicle lengthening and would like your opinion on whether the amount of widening I need is surgically achievable. I’m a trans man and I’m trying to bring my shoulder width into a more masculine proportion relative to my hips. I’m 152 cm tall. My bicristal breadth is approximately 26.5 cm and my hip breadth is about 30.5 cm. My current biacromial breadth is around 32.5–33 cm. Based on these measurements, I’d like to know: 1. What shoulder width would be considered a realistic masculine proportion for someone my height and hip breadth? 2. How many centimeters of width increase are typically achievable and safe with clavicle lengthening? 3. Whether the amount of widening needed for a balanced masculine ratio is within the range that can be obtained surgically.
A:To properly answer the question as to whether you see what the shoulder widening effect may be based on the amount of clavicle length thing that is surgically possible requires seeing shoulder pictures and doing some imaging. Measurements and numbers alone do not really help answer that important question.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley I am interested in vertical chin reduction and if I proceed with the surgery I don’t want any titanium or steel screws I want the dissolvable screws is that possible??
A:Vertical chin reduction can be done by intraoral osteotomy which requires some form of hardware fixation. Resorbable screws will not work for this type of dimensional chin change.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I just had customized jaw angle implants done one week ago. I suspect the result will not be of my liking. I wanted a wider jaw from the front (along with more defined angular jawline from the sides), and to enhance a more “broad like” or harmonic jawline that has a smoother transition from the chin to the ramus. My chin is small and pointy so the transition in between the jaw angles and chin (ramus) was not smooth and harmonic, and that gave me a non aesthetic appearance. When I asked them for a wider jaw, I insisted that I will like the implants to reach my chin so that it will be balanced, but after the intervention, my face looks like a hamster (I red your page though about how the first week looks disproportionate and should wait more weeks) but my fears are the following: 1. The jaw angles now looks massively wider in comparison to my chin which is very thin, so the look is not harmonic. 2. There is no smooth and aesthetic transition between the jaw angles and the chin! 3. My jaw angles don’t look “defined”. They are bulky, round and doesn’t add up definition and “angle-ness”to my jaw angles, so it just looks bigger, but not aesthetically sharp like a model.They are custom PEEKk material and now I’m scared as they’re harder to remove later. I am scared this is somewhat what the result might end up looking like.Thank you for your response in advance.
A:As you have noted in your inquiry, you are absolutely correct, it is impossible to know what your results will really be at 10 days after surgery. At this early postoperative time period you have less than 50% of the swelling that has gone down and it will take six weeks to see what the 90% reduction in swelling will be. This does not even account for the shrink wrap affect which causes further size reduction over the following 2 to 3 months. Many patients freak out at 7 to 10 days after surgery because there is no way to prepare someone for the massive swelling that will occur particularly in the jaw angle area.
Therefore it is important that you give the postoperative process 6 to 8 weeks before even making a preliminary judgment about the result. There should be no concerns about tissue ingrowth into PEEK implants as that simply does not occur no matter how it is touted. I have removed many PEEK implants and I find their removals to be very similar to that of silicone material with little to no tissue ingrowth or adhesion.
With the fear of secondary removal being more difficult later eliminated it is in your best interest to let the recovery process evolve and wait to see what the real result is. Even if you knew right now that they were too big and absolutely needed to be replaced that simply would not happen in the first 6 to 8 weeks after surgery as the tissues have not properly healed. Reopening incisions before proper healing has occurred will result in secondary wound breakdown and implant exposure and infection.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I need to get forehead reshaping done. I have a narrow forehead.
A:Thank you for sending your picture. When you have a narrow forehead widening of it requires frontotemporal augmentation. You cannot just augment the side of the forehead alone because the temporal area adjacent to the forehead is also narrow and that would cause a very aquare blockish look. This requires a frontotemporal custom implant to smoothly augment the side of the forehead and blend it into the temple area in a natural manner.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I am interested in a cosmetic occipital skull augmentation to correct a flat posterior skull shape. I have a symmetric but significantly flat occipital area, which affects my side and back profile.I would also like to ask if it would be possible to combine the occipital cranioplasty with a rhinoplasty during the same surgical session, assuming I am an appropriate candidate. My goal is a natural, proportionate result, particularly improving overall head and facial balance rather than an exaggerated change.
I would like to know:
• If I am a suitable candidate for cosmetic occipital augmentation
• Whether you consider combining occipital cranioplasty and rhinoplasty
• If a virtual consultation is available
• What type of CT scan would be required
A:Thank you for your inquiry and sending your pictures. In answer to your questions:
1) The question is not whether you are a good candidate for cosmetic occipital augmentation, as you are, the key question is whether the amount of change possible that the scalp stretch will allow will be acceptable to you. In that regard I have attached some Sideview imaging to give you a few for the type of augmentatuve change that may be possible.
2) it is very possible to combine any form of skull implants with rhinoplasty surgery.
3) A virtual consultation as always we proceed after this initial response.
4) A 3-D CT skull scan is required for the design of a skull implant. That is a imaging study that you get in your local area and we provide you with the doctors order for it.
5) When it comes to a recovery time line it depends on how do you choose to define recovery. Functionally you will be fine to do most of your normal activities within 7 to 10 days after surgery. From an aesthetic standpoint, particularly with a reductive operation like a rhinoplasty, the true final result is going to take many months to see. Conversely the skull augmentation result is one that you will see immediately.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have been reading on the internet that the problem that I have around the corners of my mouth are called perioral mounds. I would like to get those removed (microlipo?), or whatever I need to do to fix that area.
A:Like anywhere else on the body the success of liposuction is based on the skin’s ability to contract down after the fat is removed. While that can be very effective in the younger patient with tighter facial skin in the older patient with facial skin laxity this is not going to be effective. If the perioral liposuction is not combined with skin tightening, aka some form of a lower facelift, the mounds are not going to disappear as there is a skin laxity component to them.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to know if you perform rib remodeling specifically in the area under the breasts, as I have ribs that are visible from the side and affect my lateral profile. I am not referring to the waist, but the floating ribs under the chest.
A: I believe you are referring to subcostal ribcage flare. This is when the cartilaginous subcostal ribs 8 and 9 protrude outward. This is treated by either a cartilage scoring and bending/infracture technique vs excision/resection through a more open approach. Each method has its advantages and disadvantages.
I would need to see a front and side view picture for evaluation and a better idea of which method may be best.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am writing to inquire about the possibility of aesthetic cranioplasty to correct my head shape. I have concerns regarding the dimensions of my skull. Specifically, I have significant protrusion on the sides (above the ears) and a noticeable flatness at the back of my head. My goal is to achieve a more rounded and proportional head shape for aesthetic reasons. Could you please let me know if this type of correction is possible surgically? Thank you for your time and expertise.
A: The types of skull reshaping procedures to which you refer are done all the time, whether done alone or together. These procedures are Temporal Reduction for the sides of the head above the ears and a Custom Skull Implant for augmenting the back of the head.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,Do you do CT scans to see facial bone structure/recession?
A:All facial bone surgery, or considerations thereof, require a 3-D CT facial scan for both assessment and treatment planning.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had cheekbone reduction surgery 3 months ago. However, there is misalignment where the cheekbones are cut and reattached, causing a visible dent especially on the right cheek. The left and right side are also slightly asymmetrical. I’m looking for infraorbital malar implants to cover up the dents and make the 2 sides more symmetric.
A:Thank you for your inquiry and sending your pictures. It appears that you had a vertical oblique cheekbone reduction osteotomy but without a posterior zygomatic arch osteotomy it can make the bony step off through the body of the cheekbone evident… particularly if the created anterior lip of bone is not reduced as the segment moves inward. How to camouflage the step off can be done by different methods but there is no question that the ideal approach is to get a 3-D CT scan and then make coverage implants that not only fill the defects but also improves the cheekbone asymmetry. The differences between the two sides is undoubtably but a few millimeters and it takes preoperative precision planning to make such ‘fine tuning’ of the cheekbones.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Here is a photograph of my shoulders for consideration for clavicle shiortening.. I was also wondering if he offered scapula reduction with the clavicle since they can both use the same incision.
A:Thank you for sending your pictures and in preparation for your upcoming consultation I can provide the following comments:
1) I have attached an image of what I predict the operation will be able to achieve from the front view.
2) You have very prominent clavicular show particularly towards the sternum. In such patients hardware prominence is likely which may require secondary hardware removal.
3) Scapular reduction is not done through the same incision as that of clavicle reduction osteotomies. In fact it is done in a completely different intraoperative position. Clavicle reduction is done in the supine position through small incisions just above the clavicle’s in the supraclavicular fossa. Conversely scapular reduction is done in the prone position through back incisions as shown in the attached picture. Unlike the incisions from clavicle reduction such scapular incisions often do not heal well for a scar standpoint due to the very thick back skin. Therefore one has to be particularly motivated to make that scar trade-off.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m post-op DJS and looking for one more procedure to enlargen and fix lower third asymmetries to meet ideal facial ratios, in addition to providing additional undereye support to infraorbital rims and potentially zygos. How many months post-op would I need to be and how soon could this procedure take place?
A:Pursuing secondary facial enhancements after double jaw surgery its common in my practice experience. When to do so depends when one certain that there is a need which is usually known 3 to 4 months after the double jaw surgery (some may know sooner) and would be the soonest one would undergo surgery anyway to be fully healed after their initial jaw surgery. Custom facial implants take 3 to 4 months to design and prepare for surgery so that time frame can also be factored into the decision as to when to start.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a right neck dissection with many lymph nodes removed. They thought I had cancer but it was benign. I have a large neck scar and would like it to be less noticeable and a lot of fluid has collected under my chin since the surgery.
A:Thank you for your inquiry and sending your pictures. Besides the scar what you have under your chin is not a fluid collection but a soft tissue redundancy. The removal of tissue from the right neck area has magnified the typical signs of jowl and neck aging and lipodystrophy. In essence deeper tissues have been removed but the overlying skin in terms of the amount has not changed. This causes the neck area under the scar to be contracted inward which then causes a tissue redundancy to occur under the chin.
The only way to improve that problem is a lower facelift approach to redistribute the tissues and work out the excess the next car poses some challenges in that regard but does not eliminate that as a surgical approach. This then creates an issue about the opposite side in terms of symmetry.
In short you really need a lower facelift for a substantial improvement. It may initially seem like an unusual approach for the problem. But at the heart of the problem is tissue redundancies in the central neck area, and although the origin of it is unusual, working out the problem remains the same as someone who develops central neck tissue excesses from facial aging.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Temporal reduction – is it effective does it actually reduce majorly the side of the head or just a little bit?
A:Temporal reduction surgery can be very effective at reducing the width and convert shape of the side of the head improperly selected patients. Its effectiveness is based on the anatomy and what are the exact patient goals. The critical element of the anatomy is how thick is the temporal muscle and what contribution is it making to the width of the side of the head. Well this can always be determined buy a preoperative CT scan it can also be largely determined clinically by the patient’s skin pigment and their ethnicity. The more skin pigment one has and, particularly if one is not Caucasian, the odds are very high that the temporal muscle can be incredibly thick and a substantial reduction can be obtained. The patient’s I have learned you must be the most cautious about are Caucasians with thin body builds which indicates a minimally thick muscle over the posterior temporal area.
In essence you have to evaluate each patient individually based on their anatomy as well as how realistic are their goals to determine the effectiveness of temporal reduction surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Can you decrease the length of my head?
A: The height can be decreased as much as the thickness of the bone will permit. That requires a 3D CT skull thickness analysis to see how much bone can be safely removed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I was wondering when the additional implant wouldn’t be necessary for the pelvic plasty. I’m trying to not have to get any silicone implants when it comes to cosmetic surgeries. thank you for taking the time to read this
A: Pelvic plasty can be done with or without the attached silicone hip implant. In soime cases the iliac crest implant may create or accentuate a subiliac crest hollow (concavity between the iliac crest and the greater trochanter of the femur) which is where the role of the attachedhip implant comes into play. In other patients based on their anatomy the iliac crest implant may not have a negative effect on the shape below it.
How this applies to you requires seeing a picture of your pelvis/hip and doing imaging of the pelvic plasty procedure with and without the hip implants to see which looks better to you.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, i want to get a wrap around jaw implant already have the money according to what other people have paid on reddit. what’s my next step to be ale to get this surgery do i need CT scan?
A: The basis of all custom facial implants, including wrap around jaw implants, is a 3D CT scan which is the platform on which the implant is designed. That is a scan that is done in the patient’s local area at an imaging facility.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to know what type of scan this is that shows previous implants and even hyaluronic acid fillers? Because I had a CT scan, but my right jaw angle implant and the fillers didn’t appear, only the implant screws.
A: The only aesthetic facial implant material that can be seen on a 3D CT scan is silicone. HA fillers can never be seen as they have the density of water.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have questions regarding forehead reduction. I have very prominent frontal bossing. I would like to only do a forehead reduction but i was wondering if it would can look botched by such a procedure. Can you look at my forehead and tell me if a forehead reduction would solve my problem. I don’t want to shorten my forehead, as i love big foreheads, but I’m insecure about it being protruding.
A:Thank you for your inquiry and sending your pictures. The only effective treatment for frontal bossing reduction is bone shaving. The question with bone shaving is how thick is the fore head bone and how much reduction to be achieved. While you have expressed concerns about what I would call overcorrection, a.k.a. what you call a botched forehead, the reality is overcorrection is never possible in the fore head and a female because of the very thin bone. Conversely it is the opposite concern of which one should be aware, meaning can you do enough bone reduction based on the bone thickness to make the procedure worthwhile. In that regard I have attached some imaging of the most amount of frontal bossing reduction I think is possible. The purpose of the imaging is to help you answer the question if that was the result you achieved would that be enough of a reduction?
Dr. Barry Eppley
World-Renowned Plastic Surgeon
