Your Questions

Q: Dr. Eppley, I hope you are well. I am writing to inquire about the aesthetic testicular augmentation procedure described on your website, specifically the technique in which an implant encapsulates the existing testicle to increase volume.

While researching this topic, I have noticed that several clinics appear to offer enlargement by placing implants beside the natural testicles. My initial concern with that approach is how it may look or feel to have two separate structures side by side in the scrotum. For this reason, the encapsulating (wrap-around) technique described on your website particularly caught my attention.

At the same time, I also appreciate the benefit of still being able to feel the natural testicles. From the examples I have seen, larger implants sometimes seem to push them out of sight.

Before arranging a consultation, I wondered whether you might have any photographs available of the side-by-side implant approach so that I can better understand the visual differences between the two methods.

I would also be grateful if you could let me know the estimated costs for either procedure, including surgery, anesthesia, and follow-up care. Based on the examples I have seen on your website, I suspect that the 7 cm option might be most suitable for me.

Thank you very much for your time. I look forward to your response.

A:Thank you for your inquiry and your questions to which I can say the following:

1) As you have correctly surmised there are two different techniques first testicular enlargement, the wraparound technique as well as the displacement one. Each approach has their distinct advantages and disadvantages. If one of them was truly perfect that would be the only one that would be offered. Typically the displacement technique is done most of the time for older men who have developed testicular atrophy and have a loose scrotum. The wraparound technique is typically reserved for the younger patient who has a normal size testes and a much tighter scrotum.

2) While I have no long-term concerns about the displacement technique in older man, I do have them for the wraparound technique in younger man. Besides the ability to feel the natural testicles it is unknown long term how this may affect fertility as well as the ability to detect testicular cancer. There is also the risk of displacement or separation of the implant from the testicle secondarily..\ None of these are concerns with the displacement method. For these reasons I’m very cautious about the use of the wraparound technique in men with normal size testicles.

3) Due to patient confidentiality I am not in a position to pass around patient photos.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Can the forehead part above but in between the eye brows be made even.

A:You are referring to the glabella or glabellar valley I assume which in some patients can be quite deep and can be filled in. But without seeing pictures of your forehead concerns I can not how this may apply to you.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am wondering if you’ve ever done iliac crest augmentation with medpor implants. I don’t really know if the shape of the titanium implant would look natural – even in the photo of the implant on the pelvic bone, on your page titled “Pelvic Plasty for Upper Hip Widening – Iliac Crest Plate Design”. … you can see that the implant does not smoothly extend the natural shape of the iliac crest, but instead juts out a little rearwards of the front outer corner of the iliac crest. Are you considering any other types of implants for this procedure outside of the standard titanium shapes on your website?

A: In answer to your Pelvic Plasty questions:

1) I would never consider the use of Medpor on the iliac crest, too brittle in a load bearing area.

2) There are no current plans for modification of the existing titanium iliac crest implants. It is not simple to change the product shape particularly in terms of the economics in a very infrequently performed procedure. For those seeking a different shape that is where the role of custom titanium implant design and manufacture comes into play.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m reaching out because I’m trying to understand whether increasing facial width is a realistic and established option in aesthetic facial surgery, or whether facial width is generally considered something that cannot be meaningfully changed in a natural way. My face reads as narrow in proportion, specifically in that the horizontal width of my face (sideburn to sideburn) is relatively small compared to the vertical height of my face (chin to top of head). From the front, this creates a narrow and elongated appearance rather than balanced proportions. What I’m trying to determine is not a specific procedure, but whether facial width itself is something that surgeons actually evaluate and, when appropriate, increase in order to bring proportions from narrow into the normal male range. I’m not looking to look wide or dramatically different — just to understand whether conservative increases in facial width are something that is realistically achievable in some patients without creating an artificial or overdone result. I’d really appreciate your honest perspective on: whether facial narrowness is something you assess clinically, whether increasing facial width toward normal proportions is something that is sometimes appropriate, and whether this is considered a legitimate, commonly treated concept rather than a theoretical one. My goal is simply to understand what is genuinely possible versus what isn’t

A:In the world of the aesthetic facial reshaping surgery, whose patients are primarily young, the treatment of a narrow face is very common. Whether that is of the forehead, mid face or lower jaw the addition of width , when determined it is aesthetically beneficial by imaging, is commonly done. How much facial with is appropriate is also determined by the same imaging process. In the vast majority of cases this is done using implants although there are some rare exceptions where autologous width augmentations can be done

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hi looking for cartilage  graft removal from a prior rhinoplasty. I do not want the grafts they added in my nose making it bigger. Graft removal possibly shave down of bridge. The bridge looks super strong and unnatural.

A:Thank you for your inquiry and sending your pictures. Many cartlige graphs can be removed from the nose depending upon their size and location. In order to understand how successful that may be it would be important to see the operative note from your surgery. I think the other question to consider is in removing these grafts will they really make the nose smaller. That likely would be true for the bridge but I would be more cautious in that consideration for the tip of the nose unless the cartilage grafts are considerable in that area. The relevancy of that statement requires my reading of your operative note.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have some skull augmentation questions after getting a PMMA bone cement procedure.

1) What is a solid silicone skull implant material you use ?

2) Do you have a picture i can see to have a better understanding ?

3) How can it be attached, screws or glue?

4 Is it going to be stable when pressure applied to it like playing soccer or doing any activities can affect like if i fall is it going to stay stable ?

5) The other point will be infection possibility and risk

6) Is it doable with PMMA bone cement?

7) Finally for the most part is done i would say 20 percent left has a dent . since on left side my temporal muscle is big I don’t want to add on the top of it .roughly 2 to 2.5 inch length triangle part needs to filled outward ( convex ) like a segment of galic or orange shape to make it smoothly rounded . I have to wait few more months in order to make sure there is no swellings but I will forward you some pictures to let you estimate . Thanks in advance for your help .

A:Thank you for your inquiry and sending your pictures. When it comes to augmenting the triangular area that you have outlined this can only be effectively evaluated and done by 3-D planning with the custom implant placement. This is the only way to optimize the amount of augmentation, cover the area needed without over or under correction and blending it in to the underlying PMMA bone cement. The first step is always to go to the 3-D CT scan to make all of these evaluations. This will allow the determination as to whether the implant will need to be custom-made, which is optimal, or for the sake of economics be interested in fashioning it from other materials.

Regardless of how the implant is made it will remain structurally and positionally stable, it will feel like bone, is secured to the area with screw fixation, and is not going to prohibit you from ever doing any type of physical activity.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,  I saw your corner mouth widening, and i want to ask you if you perform a corner lip lifting (outer parts of vermillion border) combined with corner mouth lifing, i hope you do that and would like to know how much it would be, i would come from Italy, thanks in advance.

A:Thank you for your inquiry and sending your pictures. First, a sub nasal lip lift is a central upper lip procedure and will not make any changes to the outer mouth corners as you have noted. Secondly the results from another patient you have shown are known as lip curls, a significantly upturned mouth corner which is very popular in Asia but not here in the western world. Thirdly what you are demonstrating manually on your outer lip is a lateral vermilion advancement which is the only effective way to increase the outer third of the lip vermilion fullness and raise the mouth corner to some degree. Can you combine a lateral vermilion advancement with lip curls?  No, as the basis of achieving a lip curl is that the lateral vermilion medial to it is stable so you have a platform on which to turn it from.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m curious about the feasibility of using larger pectoral implant sizes; potentially in the range of 800cc (preferably more )per side. I understand this may be outside typical sizing, so I would really value your professional perspective on what is anatomically achievable and safe.Aesthetically, I’m aiming for a more pronounced and slightly stylized result rather than a strictly natural look.

Specifically, I’m interested in:

Noticeable forward projection of the chest

Clear definition between the pectoral muscles (cleavage)

A somewhat rounder contour rather than a square shape

An overall slightly androgynous, leaning masculine, appearance in shape.

I would appreciate your thoughts on whether this look can be achieved, and if so, what approach or limitations I should be aware of.

Thank you very much for your time, and I look forward to hearing from you.

A:Thank you for your inquiry and detailing your specific pectoral implant augmentation objectives. When it comes to large pectoral implants there is a standard size which fits into that description known as the Powerflex Plus pectoral implant, This has a volume of 600 ccs with a maximum projection of 4 cm. This is usually sufficient for most patient objective of extra large pectoral implants and for the patient that has never had a pectoral implant before may be about the biggest size that will fit. While I have made many custom pectoral implants that are larger those patients have to be selected very carefully to ensure that such a large volume can actually be surgically placed.

How this general statement about large pectoral implants applies to you I do not yet know. This will require seeing pictures of your chest as well as knowing what your body frame is (height and weight)

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’ve found your work and I’d like to inquire about a consultation about a reduction genioplasty. I had double jaw surgery to correct a class 3 underbite in 2015 and since then have had no problems, except aesthetically I do not think the position of the chin highlights my improved bite. I would like to discuss what reduction and shaping would entail. I am a professional musician- I play the clarinet. So this is a high consideration for me and it’s important that I make an informed decision. Hope to hear back soon.

A:Thank you for your inquiry, detailing your prior surgical history and sending your pictures. I can certainly see based on your profile picture of your interest in a reduction genioplasty. I can also see in your x-ray that you had an advancement genioplasty which I presume was done with your double jaw surgery. I don’t know the logic of why that was done at your double jaw surgery, particularly when it was for a class III malocclusion in  a female, but now it is an unfortunate over augmented chin.

In considering bony reduction sliding genioplasty there are two concepts about yours that I know for certain. First in general an intraoral sliding genioplasty reversal is usually a poor aesthetic procedure in that it creates a redundant submental soft tissue problem. Second as a professional musician in which lip sensation and lip competence is critical I would consider any intraoral chin procedure very cautiously. For these two reasons this is not a good approach to your chin reduction and I wouldn’t do it. The  more appropriate approach is that of a submental one where both the bony chin reduction and the resultant soft tissue excess will result can be simultaneously addressed. This is not only the better aesthetic procedure for pure horizontal chin excess but also avoids much of the potential lip issues which are so critical to your profession.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello sir I have scaphocephaly head problem what should I do? What surgery is possible to overcome this problem? 

A:The term scaphocephaly refers to an elongated skull from front to back. By the way you have taken your pictures my assumption is that the most bothersome part is the length on the back of your head. The question is not whether the back of the head squall bone can be reduced in projection/length but whether enough can be taken to make a visible external difference. This is determined from the 3-D CT skull scan with color mapping of the bone sicknesses to make that determination.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’d like to discuss a couple implants like chin implant, jaw implants and cheek implants. I’m not sure I will get all, but some, and I’d like to weigh my options. In combination with those I would really appreciate your input on double jaw surgery with bimaxillary advancement, assymetry correction (slight cant correction, and horizontal repositioning), all of which to align the jaws to facial midline and center it to the eyes. This would be crucial since this surgery would create the foundation for the implants. I plan to get jaw surgery in south korea as aesthetic jaw surgery isn’t done in my country, and your input would be strongly appreciated

A:If you were already certain that upper and lower jaw surgery is needed there is no purpose before that surgery to have some discussion about secondary implant onlay augmentation as the postop aesthetic needs, if any, are yet unknown. As you have correctly pointed out get the skeletal foundation correct first and then evaluate what secondary implant augmentations may be beneficial.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am writing to inquire about your expertise in facial contouring, specifically regarding procedures to achieve a more defined lower third.

I have been researching the various defatting techniques you offer, and I am particularly interested in a combination approach including Buccinator Mucosal Myectomy, buccal lipectomy and perioral liposuction. My primary goal is to address a persistent “baby face” appearance. Despite being very lean overall, I feel I carry a significant amount of fullness in my lower cheeks and jawline that is resistant to diet and exercise.

My main question concerns the extent of buccal fat pad removal. I would like to understand the anatomical limits of the procedure. To put it in concrete terms, if I had, for example, 10cc of buccal fat on each side, what is the maximum percentage or volume that can be safely excised? My aesthetic goal is to achieve the most dramatic reduction possible, as I am not concerned with the traditional risks of looking “gaunt” as I age. My philosophy is that if future volume loss were to become an issue, that could be addressed later with fat grafting.

I am very interested in your perspective on this approach.

Thank you for your time and expertise.

A:When it comes to defatting the face the procedures you have outlined are the appropriate ones including potentially submental liposuction. When it comes to buccal lipectomy in particular you take out as much of the central fat pad as can be safely extracted without injuring the closely attached buccal branches of the facial nerve. In most patients that is somewhere between three and 6 mL per side. I’ve never seen anybody in 40 years and hundreds of buccal lipectomies that had 10 mL on the single side.

That being said, while that is the most fat you can remove in the face, will that achieve your desired effect? No one can say precisely before hand but it’s probably fair to say that it probably won’t achieve as much as you would like simply because you don’t have a fat face. What you do have, is a vertically short chin with a deep labiomental fold, which works against optimal facial contouring. Ideally you need to have the chin vertically lengthened which always makes a major contribution to thinning out the lower face (see attached imaging)

To put that in perspective I would argue the vertical lengthening of the chin makes a more major contribution to thinning out the lower face then the defatting procedures will. Ideally you do both together to achieve a maximum change and that is the best approach.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Can my prominent bony forehead be reduced?

A:The question is not whether you can have bony reduction of your forehead protrusion… as you can. The two pertinent questions are as follows:

1) Is the bone thick enough to allow for an adequate reduction? In other] words is this bump due to thicker bone or is it due to thinner bone in which the brain has merely pushed it out. While in my experience it is always the former it is always prudent to get a 3-D CT scan of your fore head with Color mapping of the bone thicknesses which will clearly show the thickness of the bone and how much can be safely reduced. This then provides one of the qualifiers for forehead bone reduction.

2) The second question, which is an aesthetic one and it precedes even getting a scan. is where are we going to put the incision to do the forehead reduction. Most four head reductions require a frontal hairline incision for adequate linear access. That obviously is not going to work in your case which means it would have to be a more posterior scalp incision that is adequately long to be able to turn down the forehead flap for access. Whether the scalp scar is a reasonable trade-off for the aesthetic benefits of the forehead bump reduction is one that has to be determined on an individual patient basis.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, The goal is to feminize the body of course.  I will let the doctor tell me how to go about doing that.  Once I have his recommendation I can decide how to proceed.  As of now, I am leaning towards fat transfer to hips/butt/thigh rather than hip/butt implants.  That is a flip from my original thinking.  I think I would rather have a softer body than the firmness that comes with implants.  Of course a combination of implants and fat transfer is possible but the cost of surgery starts biting at some point.  Rib remodeling and clavicle reduction are also something to consider.

Anyway, that’s the laundry list.  I look forward to hearing back.  I will reiterate that I don’t mind making the flight to see the doctor if he believes that it would be helpful.

A:Thank you for sending all of your pictures. My initial reaction is I think your perception of the proper approach, liposuction and fat grafting to the hip and buttocks, would be how to proceed first. While it is always unknown as to how much fat is going to survive in the hip and buttocks. But what is more assured is the reductive effects from the donor sites, abdomen flanks and back, which s going to help with body contouring.

Do this procedure first and then see what you think. The fat harvesting in particular is really necessary before you consider any structural body contouring as that as always the rate limiting step in their effectiveness. Structural body contouring procedures are often combined with liposuction anyway so you might as well get that done before considering any other procedures.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, “Hi, I’m interested in a procedure that isn’t available in my country and exploring options overseas. I’m looking at getting infraorbital rim implants to correct my under eye hollowing permanently. Please get in touch when you get a chance with information regarding the procedure.

A:Thank you for your inquiry and sending your pictures. I can certainly appreciate your objectives given your prominent brow bones, cheeks and jaw with comparatively recessed infraorbital rims. Successful infraorbital rim augmentation requires an implant to saddle the rim and to add increased height as well as horizontal projection. This can only be done by a custom implant design.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,Thanks for taking the time to answer prospective patient questions! I have congenital prominent eyes and 1mm of inferior scleral show. Would lower lid retraction repair with a graft reduce my staring/occasional bug eye look at rest? When I smile or squint, my eyes look much better. However, I’m also wondering if I have a negative orbital vector, and whether this would be the best procedure for long term durability or if I’d be better off with infraorbital implants (if I were to only do one). If a graft- would you you use material like tarsal, hard palate, etc.? If implants, what would be the estimated cost for standard vs custom? Thanks!

A:Thank you for your inquiry and sending your pictures. Quite frankly you have a severe negative orbital vector what I would classify as a type III which is just about as severe as it gets. This fundamentally means this is a skeletal problem of which the live retraction is just a symptom of it. Therefore isolated eyelid surgery alone is the equivalent of putting a Band-Aid on the real problem and its effects would be very modest at best and probably not well-maintained. The correct approach is custom infraorbital-malar implants with lateral canthoplasties and lower eyelid spacer grafts.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have wide side skull (wide face) and flat head. Is it possible to be corrected (change) 

A:Thank you for sending your pictures. What you have is a classic type of head shape that we see and treat. When the back of the head is a bit flat (brachycephaly) the sides of the head will naturally widen during development. This is treated by a combination of a custom back of the head scholar implant combined with Temple reduction on the sides of the head. This creates changes similar to what we see in the imaging done on your attached pictures.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am very much leaning towards keeping my existing medpor implant and adding only custom jaw angle implants. However if a custom implant can be designed to extend from the jaw angles through the chin region, adding vertical dimensions on top of the Medpor, that would be ideal.

A:Trying to make custom jaw angle implants to extend far forward and fit on top of/underneath the existing Medpor chin implant is not a viable option. While that can be designed on paper executing it is fraught with complications particularly with an implant such as Medpor. You either remove the Medpor chin implant and go all the way with the custom wraparound jawline implant or settle for the ajw angle  implants coming forward and touching the back of the Medpor implant.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in getting XL silicone implants. I currently have  800cc UHP Mentor silicone implants.. I am 5’4” tall and weight 116lbs. I am looking to get at least 1200cc silicone through the areolas.

A: When it comes to XL breast augmentation it is very common to see a patient with 800ccimplants wanting to go beyond that into the > 1000cc range. Well this can be done there’re certain important concepts to understand about doing it.

1)  it is important to recognize that currently you have fairly symmetric implant placement and breasts. In putting larger implants it maybe necessary to expand the existing implant capsules as the base diameters of many XL implants are larger than the current 800 mLcc implants that you have. This runs the risk with much heavier implants (50% heavier)  of developing bottoming out and asymmetries which may require secondary revisional surgery. Such revisional surgery can be very difficult when you have implants with weights of close to 3 pounds. Weight and gravity winout over surgical technique many times. Ideally you would like to have larger breast implants that do not exceed the base diameters of what you have where the increase in volunme is totally in projection which allows you to keep intact your current capsular boundaries. But this often is not the case. Therefore it would be important to know the base diamter of the implants you have compared to the newer larger silicone breast implants that exist so you can properly assess that risk. While breast implant asymmetries are a well-known risk in any breast implant surgery that risk is increased as the implant sizes become larger

2) XL silicone breast implants are currently available but it is important to recognize what the FDA approved indications for their use are. Currently they are approved for breast reconstruction. While it is common to use them now for breast augmentation needs this is done on what is known as an off label basis. This is perfectly legal and medically safe. There are many medical devices that are used on an off label basis.

3) FYI you will not get XL breast implants XL breast implants place through placed through the areola. That is just a physical impossibility unless they are saline and not and silicone implants.

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,  Can my head shape be fixed? How long does it take for the healing process on the skull to come to fruition after procedure?

A:This appears to be an overgrown frontal bone with a protrusion in front of the coronal skull suture line. This is treated by a frontal bone burring reduction technique. Whether that can be successfully done, AKA enough bone removed to create a smooth contour, requires a preoperative 3-D skull scan with bone thickness measurements.

It generally takes 2 to 3 weeks for most of the swelling from any skull reduction procedure to allow the benefits of the surgery to be seen.to allow the benefits of the surgery to be seen. It takes a full three months for the true final result It takes a full three months for the true final result two BC two BC

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Can My too large chin implant be replaced with a sliding genioplasty keeping the natural shape of my chin?

A:Certainly a sliding genioplasty can be a good substitute for a chin implant as it will also help narrow the chin. On a  technical note you have to realize that a sliding genioplasty alters your natural chin shape rather than keeping it. I think what you meant by preserving as much of your natural chin shape you were referring to keeping the existing horizontal projection.

But in the intent of keeping the same horizontal projection but with a more narrow shape than having the existing implant in place it can be effective.

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’ve noticed that with many wraparound jaw implants (implants that extend along the mandibular body), the final visible contour often doesn’t match the implant design because the soft tissue doesn’t drape tightly enough over the new hard-tissue shape. For an aesthetic lower third, I think soft-tissue tightness and angularity from the antegonial notch through the chin corner is critical. Beyond the obvious masseter dehiscence problem, I’m specifically concerned about the mandibular retaining ligament. In a wraparound dissection, this ligament sits over the inferior lateral mandible where the implant typically lies, so it may be released/detached. My concern is that releasing it without any compensatory/restorative reattachment or pocket control can leave the soft-tissue envelope too loose, allowing bridging/sagging so the implant shape isn’t expressed. When you place this type of implant, do you perform any form of periosteal/soft-tissue resuspension, reattachment, or other technique to recreate the stabilizing effect of that ligament and ensure tight drape? Or do you mainly rely on added volume to stretch the tissues to achieve angularity—and if so, is that only reliable with very large-volume implants?

A: Adequate subperiosteal dissection and the creation of the implant pocket is critical and, by definition,  implant placement is about ligamentous releases. The ligament to  which you refer is released all the time without any adverse aesthetic effects that I have ever seen. There is no known method to restore it even if one desired to do so.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello. My overall goals are to figure out the actual cause of my concerns with my face and figure out the best possible path forward for a natural healthier look and my best overall self but not to a point where I look like a completely different person. I wish to correct poor under eye support, scleral show and negative eye hooding, nasal labial folds and possibly a recessed maxilla, excessive buccal fat since birth thats purely genetic, a large platysma muscle due to low hyoid, thin and downturned lips, and a soft jaw + also potentially getting botox to allow atrophy to occur in the masseter muscle and create a less bulky face look.

A:Thank you for your inquiry and sending your pictures. Your facial problem is fairly straightforward from a diagnostic standpoint. It is a structural issue where your entire mid face is recessed compared to the upper and lower thirds of the face (brow bone and chin projections). Ideally you should have a LeFort one advancement osteotomy followed by secondary infraorbital-malar implant augmentations for total correction of the issue.

The first place to start is to get a maxillofacial consultation to evaluate the potential for upper jaw advancement. Total midface implant augmentation should only be considered if it is determined by a surgeon or you that you do not desire to go through the initial upper jaw advancement surgery.

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’ve noticed that with many wraparound jaw implants (implants that extend along the mandibular body), the final visible contour often doesn’t match the implant design because the soft tissue doesn’t drape tightly enough over the new hard-tissue shape. For an aesthetic lower third, I think soft-tissue tightness and angularity from the antegonial notch through the chin corner is critical. Beyond the obvious masseter dehiscence problem, I’m specifically concerned about the mandibular retaining ligament. In a wraparound dissection, this ligament sits over the inferior lateral mandible where the implant typically lies, so it may be released/detached. My concern is that releasing it without any compensatory/restorative reattachment or pocket control can leave the soft-tissue envelope too loose, allowing bridging/sagging so the implant shape isn’t expressed. When you place this type of implant, do you perform any form of periosteal/soft-tissue resuspension, reattachment, or other technique to recreate the stabilizing effect of that ligament and ensure tight drape? Or do you mainly rely on added volume to stretch the tissues to achieve angularity—and if so, is that only reliable with very large-volume implants?

A: Adequate subperiosteal dissection and the creation of the implant pocket is critical and, by definition,  implant placement is about ligamentous releases. The ligament to  which you refer is released all the time without any adverse aesthetic effects that I have ever seen. There is no known method to restore it even if one desired to do so.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, What materials do you use for custom facial implants? Some surgeons I’ve spoken to use mirror polished titanium, some use PCL? Thank you.

A: There are four materials available for custom facial implants, solid silicone, PEEK, porous polyethylene and titanium, which all differ in cost.  But it is also relevant that they do not perform equally as each material has its implant design limitations….which most surgeons do not consider due to lack of experience with all implant materials. You don’t want the material to control the design, how it is able to be placed or how effectively it blends into the surroinding bone.

For the infraorbital-malar area solid silicone is ideal most ideal as the need to saddle the rim is almost always needed and the thin eyelid tissues require feathered edging to avoid palpable and/or visible implant show. PEEK can also be used but hard to get feathered edging in a machined implant.  Porous poluyethene and titanium have too many disadvantages to use in this facial area.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’d like to schedule a virtual consultation to discuss options to revise or replace a PEEK wraparound mandibular implant that’s malpisitioned by 3-6mm vertically and 2mm laterally. In the attached pictures, the rough, yellow implant is the 3D render from CT scan of the implant that’s implanted in my head and the smooth, tan implant is the planned position of the implant.

A: Thank you for your inquiry and sending the jawline implant images to which I can say the following:

1) Who designed this implant? As such an implant design was bound to  have a misplacement problem. How they got it even this close to the designed alignment is a miracle in my opinion.

2) I can see that the implant was designed to replace the bone removed in either a prior V line surgery or sagittal split osteotomy. But you never make a pure vertical lengthening implant that only expands the inferior border as exact placement is almost impossible.

3) You have to have at least some lateral flange areas to optimize placement and implant fixation.

4) The only way to salvage this implant is using an external jaw angle incisional approach with plate fixation to the angle.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, So I was thinking of endoscopic brow lift, with pinch blepharoplasty. I don’t like the wrinkles in my forehead, and I would like it to be less heavy. My eyes have quite a bit of crinkling on the sides. I’m also interested in some other procedures, but I’d like to start there. Thank you.

A: Skin wrinkles that occur in the forehead and at the outer eye are not going to be solved by browlifts or blepharoplasty surgery. Those are best treated by Botox injections. Browlifts lift the eyebrows and make them less heavy. Blepharoplasties remove skin and fat.

Both can be useful for you but you have to understand what they can and can not do.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m most concerned about the thickness of the orbital rims. I’ve always felt my eyes looked sunken and I never really understood why, but now that I’ve been researching it seems to be that I have very thick orbital rims.

I feel the center area, at the glabella, is not nearly as prominent as the rest of the orbital rims.

I have had a minor upper blepharoplasty  probably 20 years ago.

And my eyebrows are tattooed.

I have not liked my hairline either and do feel it is pretty high and masculine looking as well.

The only thing I feel I couldn’t do is the type 3 forehead reduction. That just seems too much for me for cosmetics.

I also don’t love the idea of the full hairline incision, but do realize that may be necessary.

A:Thank you for sending your pictures. I can certainly appreciate your orbital rim prominence concerns. Whether they can be reduced by shaving or requires a bone flap setback depends upon which areas of the brow bones you feel need to be reduced. In the attached picture I have noted the two different areas of the brow bones, medial and lateral. Their bony composition is quite different with the medial being created by the aeration of the underlying frontal sinus and the lateral being created by solid bone. As a result the techniques needed to reduce them are different. Medial brow bone prominence reduction requires a bone flap setback while lateral brow bone  prominence reduction can be done by shaving. Well these techniques are different I don’t think to the patient it really makes much difference in terms of the surgical recovery but it could make a big difference in the aesthetic outcome depending upon the brow bone areas that need to be reduced.

With either brow bone reduction technique this does require superior incisional access which in the high frontal hairline would be done through a hairline approach. Given that you already have concerns about a high hairline this does provide the opportunity to do some frontal hairline advancement at the same time. Without a frontal hairline incision this would require a full bicoronal scalp incision placed way behind the hairline from ear to ear.

In addition to the brow bone reduction there probably is also some benefit of upper forehead reduction as well in the spirit of an overall forehead feminization effect.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Does fat transfer to the brow bone area work?

A:Fat injections as a method of brow augmentation can be effective depending upon what your brow augmentation goals are and whether you can accept the variability in terms of take and persistence of the injected at. Like injectable synthetic fillers it can be viewed as a temporary procedure to determine whether you like the effect which can then be converted to a more permanent implant solution later if desired.

As to what these general statements on fat injections to the brows mean for you I would need to see some current pictures of your brows as well as what your brow augmentation goals are. In other words determining whether you are a good candidate for the procedure.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My current alar width is approximately 43.5 mm, and my intercanthal distance is 33 mm. Using a combination of procedures—such as alar base cinch, wedge excision, weir incision, and sill excision—how much reduction in alar width could realistically be achieved? I understand I have thick skin, so I just want to get a sense of what would be possible with the most extensive surgical approach to bring the alar width closer to my intercanthal distance.

A: The question you are asking is whether a 10 mm bi-alar reduction can be achieved. Until I see some pictures of your nose and face I am going to assume that such  nostril width reduction is possible until proven otherwise.

Dr. Barry Eppley

Plastic Surgeon