Your Questions

Q: Dr. Eppley, For my right shoulder implant(s) for deltoid muscle atrophy which is better…measured custom or a  D custom implant approach? Which one do you think is more beneficial.  Cost is not an issue,  I just want to know which is better and why.

A:3D custom body implants, designed by the patient’s 3-D CT scan, would provide an accurate estimation of size and volume of the lost muscle mass in the right shoulder. This would be the appropriate treatment approach if the patient wanted a very precise estimation of the volume and shape of the muscle mass to be replaced and wanted to be able to see that visually. This also refers to the type of patient that views their surgical reconstruction as a mathematical engineering project.

Conversely designing the muscle restoration implants for the right shoulder based on external measurements and prior patient implant designs with a similar problem is for the patient who can accept that such is surgery is an approximation update volume of muscle mass that needs to be restored and are happy with substantially reduced asymmetry and that perfect symmetry between the two shoulders cannot realistically be obtained. There’s also for the patient who has more economic constraints.

All of that being said the result differences between the two methods is probably not dramatically different.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve been looking into treatment options for my sunken under-eyes—potentially fat grafting?

 A:Thank you for sending your pictures. You’re under eye hollowing, which primarily occurs along the infraorbital bony rim, can be treated buy a multitude of methods from fat injections to various implants placed along the bony rim. Each of these two fundamental approaches has their advantages and disadvantages. Injection fat grafting is by far the most commonly performed procedure for this problem and represents hey minimal invasive surgical procedure with little recovery. Its disadvantage is the unpredictability of How much fat survives and whether it will have a smooth contour. In other words irregularities or lumps and bumps are well-known to occur from fat grafting underneath the lower eyelid and upper mid face skin. The use of the implants to build out the informant to ram is a true surgical procedure and with that a more significant recovery of swelling and some bruising. There is a range of different implant options from tissue bank dermal grass to various forms of implants including custom-made implants. They have the advantage of adding a permanent volume with a much higher likelihood of being smooth throughout the augmented area.

The debate, of course is which one is better and that depends on both the patient’s anatomy and the patient’s preferences. The ethnicity of your facial bone structure is such that you have a flatter midface projection and, as a result, would be better served long term with a more assured permanent augmentation approach. The debate then becomes what type of material is best to use. From my experience this comes down to whether the patient wants to use something off-the-shelf or whether one wants to use a custom implant approach. That would be dictated by the patient’s preference and economic considerations.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, In general, I feel like my head is too small for my body (I’m 5’7’’ and about 150 pounds).

It’s kind of flat at the top and at the back, I feel like it lacks that roundness and volume at the top, I try to cover it with hairdos, fangs and such, I look more harmonious when I add more volume there.

As for the back of my head, it just seems as if the parietal bone simply didn’t develop enough in length and my head seems way too short, which doesn’t help the way my chin projects either.

A: By description and your pictures, you are describing a classic female top crown in back of the head, augmentation, basically between the two hairlines and the bony temporal lines to the side. Unless one only needs a few millimeters of implant thickness this would require a two-stage skull augmentation approach with the first stage being scalp expansion to accommodate a larger implant. This is particularly needed in blond and light brown haired Caucasian females, who often have the thinnest scalps which stretch the least.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a defibrillator but could I get breast implants under the muscle ???

A: When a patient is considering breast augmentation with an indwellng on  demand pacemaker or a defibrillator the followiong three pieces of information are needed:

1) Medical/cardiac history

2) Operative notes from the device placement

3) AP/Lateral chest x-ray

From this information it can then be determined whether breast augmentation in general and what implant pocket location is possible can be determined.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can the Pelvic Plasty procedure give stability to a females hips? I want to know if it will alter my balance.

A: The Pelvic Plasty procedure is an aesthetic augmentation procedure of the hip bone (iliac crest) and the subiliac soft tissue hollow. It is not intended to be a functional procedure (stabilize the hips) but it also does not compromise hip bone stability either.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, may I ask what materials are used in 3D printing? Is it primarily silicone?

A:3D printing can use virtually any material so that should not be the basis for choosing an implant material.  You choose an implant material based upon the most overlooked property by patients and surgeons alike… and that its ease of secondary reversibility/modification. When you look at the statistics of all types of facial implants the need for secondary revision and/or replacements approximates 40%. That shocking statistic, which is not shocking to those of us who do this work every day and most of these revisions or modifications or for purely aesthetic purposes, is a rank reality have any type of aesthetic facial implant surgery. Besides being able to achieve the desired aesthetic result you now can appreciate why the ease of placement, removal and/or replacement becomes the single most important implant material property.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I have had a sagittal bump reduction done in 2023. The bump gradually reocurred and reached the same extend 2 years after the procedure (pictures). If surgery was performed again: Is reocurrence as likely and are there any preventive measures?

A:Recurrence after a sagittal skull reduction, or any form of skull reduction, is not a postoperative phenomenon that I have ever seen. In looking at your pictures that is a fairly prominent bump which should be able to be completely reduced. The location of the scalp incision to do it is a bit unusual in my experience both in location and incisional length. For such a skull prominence to have ‘recurred’ it was either never really completely reduced and only long term swelling prevented it from being initially seen or it was adequately reduced and due to failure to place a sealing agent over the open reduced bone recurrence has occurred. However in looking at the shape of the sagittal bump ‘recurrence’ that looks like to me probably what the  original sagittal bump looked like.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am looking for a specialist for a mentalis/lip resuspension after à terrible génioplasty years ago.  But if you have a real beautiful solution to my problem ( I cannot close my mouth, the lower lip is far too low in the resting position etc…)  Here are some photos.

A:Thank you for your inquiry and sending your pictures. The need for mentalis and chin pad resuspension almost always comes from prior chin surgery, albeit bone or implant related. I have performed many mentalis resuspension surgeries and it proves to be a challenging operation to achieve sustained uplifted results. It is done through a variety of intraoral resuspension techniques and, despite technically well executed operations, some patients do not maintain long term results. That being said there aren’t really any other options you Treat your problems than this surgery. It would be helpful to see hey lateral x-ray of your chin to show the shape of the bone in any hardware that may be present. This does not necessarily alter one’s candidacy for the surgery but it can provide some helpful insights as to what technical maneuvers need to be used.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Looking for implant as I lack bone in underye and looking for affordable treatment.

A:Based on your Picture infraorbital rim augmentation done through to a lower blepharoplasty incision would be a long lasting and effective treatment. Well ideally this should be done through custom infraorbital implants there also options for standard implants as well.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I was born with craniosynostosis and had a corrective procedure when I was only a few months old. As I aged, the shape of my head was always a concern for me. I am eventually seeking to get a large skull augmentation procedure performed in the near future. I have a pretty big scar running from ear to ear from the initial surgery and I was curious if this existing scar could be used for another incision or would a new one need to be created?

A:You are correct in that your existing by coronal scalp scar can be used for any secondary skull reshaping needs. What those needs would be requires an assessment of the 3-D CT skull scan, pictures of your head as well as a description of what your head shape concerns.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I have always had a rather large head that has a conical shaped section at the top. I would like to know if I could be a candidate for successful skull reshaping surgery. My desire is for my head to have a more rounded shape. I recently viewed a side profile picture of myself, taken during a vacation. I was not at all pleased with the look of my cranial profile. I’ve attached some screenshots of the picture along with a picture showing red perforated lines of the section of my skull that I would like to remove. Is this even possible to do? Thank you.

A:This is a classic overgrown or elevated crown of the skull enlargement that I have seen many times. The question is not whether it can be reduced but by how much based on the thickness of the bone. This requires a 2-D CT scan to make that assessment. It is safe to say without seeing a CT scan that I can be reduced at least 50% but it would be relevant to know if the bone thickness will permit a reduction like the ideal line of the skull that you desire.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I’ve spent countless hours reading your blog, and reviewing your incredible work. 

I had orbital rim, malar and paranasal implants (medpor porex) with accompanying midface lift ten years ago.  Although I was pleased at the time, and in the immediate short term, as years passed the extremely subtle intervention has been disappointing.  I would like to consider a “refresh” procedure (as opposed to “revision,”) as again, I was pleased at the time, and thankfully the surgery was safe, successful, and recovery was extremely smooth. Fourteen years later, I am still without any ill effects (other than the lack of result). 

As such, I started consulting with a number of surgeons, with advice ranging from “never touch porex, especially after that many years,” to those recommending I stack new implants on top of the old ones, to those suggesting removal of old implants and placement of new ones with new material such as PEEK.  As  I have read your blog, I observed that you do remove porex implants regularly, and suggest never to stack (although the one blog post I read about this subject was regarding silicone, so perhaps I shouldn’t assume that is the case for porex as well?). 

So, my question is essentially after so many years, is it possible to remove medpor porex orbital rim, malar and paransals without considerable risk? Or at this point, should I explore other alternatives?

Thank you for any guidance.

A: Thank you for your inquiry. When it comes to indwelling Medpor facial implants and any subsequent surgery all options are on the table that you have mentioned including stacking new implants on top of the existing ones or removing and replacing them for new implants. These are simply surgical techniques and, in and of themselves, should not guide what one does.  Nor should what surgeons prefer to do or are capable of doing should be what one does. What matters is what exactly are you trying to accomplish and how much change is needed to the implants you already have. It is easy to see that if you needed some minor or modest amount of additional augmentation then removing and replacing may be more surgery than is warranted. Conversely if you need a significant change in the footprint of the implants and/or projection or a change in the implant concept, then you can see that remove and replace would be the more appropriate strategy. In otherr words first determine your goals (the problem) before deciding what the solution should be.

There are some caveats to the prior statements which include the following. One problem with revising or replacing Medpor implants is that they rarely can be seen in a 3-D CT scan. This can make an  understanding of what their current effects are difficult and making new implants that offer more improvement over what they are is less predictable since you cannot see them. But the first step is to always get a 3-D face CT scan and see what can be seen.

Lastly, it does not matter whether Medpor implants are in for 14 years or 14 weeks once the tissue in growth has occurred it remains static. Thus longer indwelling  Medpor implants are no more difficult to remove than those of a shorter implantation time.

Dr. Barry Eppley

World-Renowned Plastic Surgeon 

Q: Dr. Eppley, I’m interested in s head implant to be taller but I’m not sure how it would look. It’s this a common procedure and does it turn out looking normal? I would like to be about an inch taller

A:At a full inch of height it may or may not look unnatural. At less than an inch it will not. But the best way to determine whether it looks natural or unnatural is to get some head pictures of you and do some imaging with the potential head height changes to see how it looks to you.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi!!! I’m super interested in a few procedures (Clavicle Reduction, Hip Augmentation, and Rib Contouring/Narrowing) and have a few questions! Would love to schedule a consultation to discuss! I’m curious for the Rib Contouring/Narrowing if you all use the RibXCar method or a different procedure for it. I’m also curious about cost and whether any of these procedures can be combined into the same surgery day!

A:While technically the procedures of clavicle reduction, hip implant augmentation and rib waistline reduction surgery can all become combined in a single operation, that would make for a very tough recovery for most patients. As a result I would recommend any two of the three procedures to be combined inthe single surgery.

When it comes to rib modifications for waistline narrowing there are two fundamental approaches, rib removal and rib fracture. Each has their advantages and disadvantages and the differences depend on which you value more…. maximal waistline reduction or a slightly shorter recovery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a fan of your blog articles – thanks for all the helpful information. I’m looking into getting a midface lift as I have sagging In that region from cheek implant removal. I would love to see someone who specializes here such as yourself, but am considering local options for consults to widen my net. One thing that has confused me, is one surgeon had recommended both temporal and oral incision while the other only temporal. When I enquired why (to both surgeons) they either did or didn’t incorporate the oral incision, the first said the oral incision has more nerve damage risk and can look more unnatural. The second said the oral incision is more effective in the area of the nasolabial folds and next to the nose and more of a purely vertical lift there. I’m a bit confused by the conflicting answers and would hugely appreciate any thoughts you had on this.

A: There are different techniques used in mid face lifting. One of the most common is the obliquely oriented temporal approach. The purpose of the intaoral incision in temporal-based mid face lifts is to maximize the mobility of the cheek soft tissues. This may be needed in some patients based on their history while in others it may not be. Because of your history of cheek implants removals you may either have good mobility of the cheeks soft tissues due to the presence of residual capsular tissues (and don’t need the intraoral incisions or, conversely, it may be more scarred down from capsular resorption and you may need to do so. This usually requires an intraoperative judgment to determine that need.

Certainly the intraoral incision is not avoided due to increased nerve damage or because the result may look unnatural.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can i have 5 sessions of Iliac crest reduction?

A: Whatever amount bone reduction that can be done to the iliac crest is accomplished in a single surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Please allow me to provide the context and reasoning for my case. I have a slightly recessed midface but a prognathic upper and lower jaw (SNA angle of 102 degrees), and because of this my upper midface looks significantly recessed compared to my lower third. I would like a cosmetic correction to this issue, but there’s a problem – I don’t believe I can get custom midface implants on their own because my nasion is also recessed and my nasal projection is therefore not sufficient to accommodate midface implants – I would have a sunken/flattened appearance of the nose. In my opinion, trading one disharmony for another is bad practice. Given this state of affairs, am I correct in believing that a Lefort 2 coupled with custom midface implants would be (at least theoretically) the only way to resolve my aesthetic issues without creating new ones? While I understand that this surgery is invasive and not typically offered for cosmetic reasons only, I believe my anatomical situation is somewhat unique and warrants the consideration of this type of operation. What’s your take?

A: A LeFort II osteotomy would seem like a very invasive approach to correcting a recessed nasion, which is the primary reason you are considering it. A nasal implant or rib cartilage graft would achieve the same effect when combined with lower pyriform aperture implant augmentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Would love a consultation around reducing the overall size of my head please.

A: Thank you for sending your video of your head. When you speak of head size reduction that could mean overall head reduction or spot areas of reduction. I am going to assume it is the former. When considering such change the key consideration is surgical access…how do you get there to do it? The only way to do so is a bicoronal scalp incision. Trading of a scalp scar for a head size change must be considered very carefully.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I just want my skull to be symmetric and normal because  unfortunatelyI have hereditary baldness stage 6 so my head will be shaved all the time. I need reducing from the top and augmenting at the back left.

A: The augmentation of the left back of the head is done with a custom skull implant most commonly placed through a low small scalp incision over the nuchal ridge.

Conversely reduction of the higher top of the head (crown area) requires a different surgical approach done from an incision on the top of the head.

When these skull reshaping procedures are done together then both are done from the incision on the top of the head at the crown area.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had chin implant surgery that I am not happy with as it makes men look too masculine.

A: Female with ‘male’ chin implant that wanted a more feminine the line shaped chin. This case represents a classic example of surgeons not understanding the aesthetic impact chin implants in the front view or what women are actually seeking. very few women ever want a wider or broader chin. Well there are patients that do want that change they make that very clear from the beginning. Chin implants as they exist today off the shelf are really for men and of all of the seven styles of implants that exist only one is appropriate for most females. But a good aesthetic guideline for female chin augmentation in the front or top view is to make sure the sides of the implant does not violate the aesthetic lines as the jawline come forward. As you can see in this patient’s existing chin implant who seeking a more V-shaped chin effect. it violates this basic principle for the female who is seeking a V shape change in the front view. A new custom chin implant was designed that created a more V-shaped by simply not having wings on the side of the implant. It was also positioned lower on the bone to add vertical height it also contributes to a more narrow and V-shaped look. (Katherine Sanford) this case also illustrates that evening 2025 surgeons continue to only look at chin augmentation in the side view and never look at it from a 3-D perspective which includes the front and three-quarter views as well.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a 21 year old healthy male looking to enhance the visual appearance of my lower third. I improve width, definition and masculinity of my jawline by lowering my gonial angle and lengthening my ramus. I have roughly a $10,000 budget. I am am looking to get the procedure done very soon. Pease let me know if there is a time I would be able to come in sometime so that we can go over goals and expectations together. I’m very excited and look forward to hearing back from you!

A:Thank you for your inquiry and providing details about your facial augmentation goals as well as your budget. By definition of your budget you are referring to the use of standard vertical lengthening jaw angle implants as any custom implant design would be beyond your stated budget. While I am not knowledgeable about the cost details of surgery, although I have assistants who are and will provide you with this information, I can give you some important conceptual concepts to understand about elective aesthetic surgery particularly when it involves implants. You need to be aware in considering the cost of elective aesthetic surgery what happens should you need a revision of it. This consideration is not rare as all face and body implants have a revision rate of close to 40% for a variety of aesthetic reasons including symmetry, size and shape of the placed implants. While such revisional surgery is not done at the cost of the initial surgery it is also not free. This is a well known risk of the surgery. Therefore when you consider the cost of such surgery all patients would be wise to ensure that should revisional surgery be needed/desired they are not placed in an adverse financial position.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I’m looking to shorten the upper jaw (le fort 1 procedure) along with custom jaw/chin implant to give a chiseled jawline look. Ive had a few botched jaw/chin implant surgeries before and been through hell. I admire Dr Eppley’s work and looking to get the result i always desired. Looking forward to discussing further 

A:I am going to assume when you speak to shortening the upper jaw that the main objective is to close down your anterior open bite. This would be important not only from an occlusal standpoint but it also would allow the lower jaw to rotate a bit forward which would change any subsequent ijaw mplant considerations. While I have significant experience in such jaw osteotomies these are procedures that I no longer perform. Thus you would need to seek out a maxillofacial surgeon who performs these procedures regularly. Certainly in California there are a lot of surgical options. What I can say is that no form of facial implants should be considered until you have a corrected skeletal base. The only reason to consider implants now is if you are willing to accept your facial bone structure and the  open bite that you currently have.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, he is interested in a Temporal Artery Ligation, however he would like to know if the artery near his eye could be ligated as well.

A:The inner orbital vasculature is not a facial area in which I would perform ligation.  I have never had a request for it and thus have never done it.  I am certain that it can be performed and probably done so safely without any adverse effects. However that is a theoretical statement not backed by any clinical experience.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have questions about cheekbone reduction surgery. What sides of the cheekbone are able to be shaved and minimized. I want it to not protrude out from my face.

A :Cheekbone reduction surgery is performed by osteotomies, usually of the anterior main body of the cheekbone as well as the thin posterior zygomatic arch, to allow for inward movement of the entire cheekbone complex. Cheek bone reduction is not performed by shaving due to limited access, the thinness of the bone, and the occurrence of soft tissue cheek sagging from the stripping off of all soft tissue attachments.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in nuchal ridge reduction.  My only concern would be any visible scarring from the burring down or reduction at the back of the head. I could theoretically get it tattooed over but it depends how large these scars would be?

A: The scalp incision needed for nuchal ridge reduction is kept as small as possible. But the further laterally one has to go to access all of the enlarged nuchal ridge the Incision will become longer.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had double jaw surgery with a bony genioplasty that has left me with some jawline irregularities and a chin that is ma bit too bulbous.

1) Would he advise doing a a bone graft into the boney gaps created by the BSSO to improve the indention in the jaw line?

2) Would he advise a genio set back of 2mm here to make the chin less bulbous and improve the chin fold and concavity above it?

A: Provided there is good bony union/healing bone grafts are not contouring materials as they have a high rate of resorption/irregularities. If the goal is a smoother jawline a custom implant design addresses those issues more  successfully. This is a common post double jaw/genioplasty problem that I see. (see attached picture)

For the chin all you can do is a 2 – 3mm setback (50% reduction) of the original advancement to make any major difference in its over projected shape or lessening of the deep labiomental fold.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had custom CT-designed midface implants placed originally 4 years, and then a new set of midface implants was designed and placed in 2 years ago. which were larger than the original implants (the current implants both provide ~7 mm in projection, while the original implants each provided ~5 mm and ~3.5 mm of projection). I like the general design of the current implants but feel they may be a bit too large. I noticed that Dr. Eppley has an article discussing the process of shaving down custom midface implants to reduce projection.  Thanks

A:You have left out two important pieces of information. First what is the design of these midface implants as I would need to see their design file. Secondly what is the implant material?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have attached some facial images. My main goal is to address my lip incompetence which causes a strain on my chin. I hope to correct my mouth breathing and grogginess/ sore throat in the mornings after sleeping. I’ve spoken to a few orthodontists about this concern, and they have told me I should consult with a plastic surgeon to review what options I have since it is outside of their scope. I would just like to know what options, if any, there are to address my lip incompetence!

A:You have lower lip incompetence and nocturnal mouth breathing issues because your lower jaw is underdeveloped. Your chin recession is merely a symptom of your lower jaw under development. The optimal approach is a combination of orthodontics and lower jaw advancement surgery. This will rectify all of your associated symptoms to the best that can be achieved.. Short of this ideal solution your only other option is a sliding genioplasty chin bone advancement which will help some of these concerns but will not completely solve them.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, What do non-custom skull implants start at? I read one of his posts where this was a less expensive option.

A:You are referring to special design (SD) skull implants which are custom implant designs from other patients with similar skull shape conserns where we already have a design file made and just have to print out the actual implant for surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I feel like the inner corner of my eyes is too long, it makes my eyes look very close set. The after picture is how I want my eyes to look. Is something like that even possible? Is it possible to shorten the corner? What procedures would you recommend for a more pleasant looking eyeshape? Would this require the position of the inner core of the eye to be altered? Is that predictable/safe/possible?

A:You are referring to a V-Y inner eye corner shortening which involves closing down the corner by partial excision of the lacrimal lake area. How this may apply to you requires some eye pictures for my assessment.

Dr. Barry Eppley

World-Renowned Plastic Surgeon