Your Questions

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

Q: Dr. Eppley, My midface is flat and downwards and my eyes are prominent having a huge lower scleral exposure.

A:You have classic negative orbital vector which means the infraorbital mailer complex of your upper mid face is horizontally deficient. This is best addressed by a custom made infraorbital-malar implant with lower eyelid lengthening with spacer grafts and a canthoplasty. Each one of these three surgical components not only provides horizontal augmentation but also serves to vertical lengthen and drive up the position of the lower eyelid to decrease the amount of scleral show.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m messaging you because for some time I’ve been unhappy with my facial symmetry but I can’t quite put a finger on what it is. I think it’s a combination of the dynamics between my nose, my eyes and my eyes brows being uneven but I’m not exactly sure. I have messaged you in the past with a couple of concerns that I thought might have been the problem I was unhappy with but I don’t think those were the issues since I couldn’t quite articulate what It was I was unhappy with. Long story short, rather than coming up with different “hypothesis” as to what I think is wrong, I’ve uploaded some photos and if you can, I’d like you to tell me what you think it is that I am seeing or what is asymmetric that is making me unhappy and could stand to be corrected. I definitely think it’s something to do with my nose, eyebrows and eyes. My nose I feel tilts to one side, one eyebrow is lower than the other and one eye appears opened wider than the other.

A:Your facial asymmetry is largely around the eyes, particular the right eye which is set back and a bit lower than the left side. In essence you have a right periorbital facial asymmetry. Such facial asymmetry’s are very apparent to people, even if it is minor in magnitude, because it is the first thing that you see and look at the most on your face.

That being said,  however, there is no good surgical procedure to make any improvement with this type of periorbital asymmetry. Meaning surgery is just as likely to make it worse as it is to have a chance to make it better.

Dr. Barry Eppley

Q: Dr. Eppley ,I suffer from a flat, even recessed, maxilla and would most likely benefit more from jaw surgery, however, my desired results could also be achieved through implants and I’d rather take the latter route as jaw surgery is way too extreme for my liking. As of now, I am definitely most interested in the paranasal implants as it is my main concern (nasolabial folds), but I am also interested in the premaxillary implant as well. I am not looking for an extreme change, but I would like an overall projection in the mid face, specifically around the base of the nose. The results I am hoping to achieve is a slightly lifted nose as well as volume in the upper cheeks right below the orbitals. Is this possible? Some concerns of mine include the upper teeth “disappearing” when smiling and talking. This is already something I have issues with because of my deep bite and would rather not emphasize it. This also includes the change of the smile. Another concern is with the implants moving, is that avoidable with screw ins? I have attached a before picture of my profile and an edited after picture of the results I am hope to achieve.

A: Thank you for your inquiry and sending your pictures. In looking at your pictures certainly jaw surgery would be too radical and based on what I believe your objectives to be would also not achieve that outcome in the way that you desire. Therefore implants are a reasonable consideration. In looking at your imaged objectives both pictures appear to be the same so it is not yet clear to me as to your exact objectives. That being said I can make the following paranasal implant comments:

1) I would be cautious about the premaxillary component as that will open up your nasolabial angle which may create an undesired effect in your case. Also when you cross the premaxillary area that increases the risk of affecting your smile and in particular having less visible to tooth show when smiling. Premaxillary augmentation should only be down when there is a clear premaxillary retrusion with a decreased nasolabial angle.

2) As you start to mention increased volume in the upper cheek area this is really beyond what a standard paranasal implant is designed to do. Such an augmentation effect requires a custom implant design to do so.

3) Implants don’t move or migrate after surgery, this is a common perceived fallacy. The surgeon and the patient may notice that the implants have a non-desired position two or three months after surgery when all the swelling goes down but this is reflective of placement not migration. The outcome of any facial implant surgery takes 2 to 3 months to fully see. Ultimately implant position is firmly established by the encapsulation scar process within six weeks after the surgery. Screws merely hold implants into the desired if the implant shape and the underlying bone onto which it is placed is not perfectly matched. Then once the scar process has occurred the screws serve no purpose. As it turns out the standard ePTFE paranasal implants have a  microporous texture which allows rapid tissue ingrowth and screws are generally not needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I took some pics where you can kind of see the slight difference in my jaw angle implants. I don’t think I can handle surgery right now, but in the future, do you think he could make it even for a fair price. the side with the added length is good and I like that side. lol it’s not that noticeable but I’m a perfectionist if you know what I mean.

A:Thank you for the long-term follow-up to which I can make the following comments:

1) I never consider revision and its potential success in facial implants until I see a postoperative 3-D CT scan to know for certain where the implants actually are and what type of changes maybe needed to improve their position.

2) I would be very cautious about being a perfectionist in the jaw angle area. Due to the intraoral approach and the increased risk of infection as well as masseteric muscle dehiscence, both of which you have never experienced but may occur in secondary surgery, there is always the chance in the pursuit of perfection to end up with a postoperative complication that is greater than the original problem in which the surgery was designed to treat. That does not mean one should never do revisional  surgery in jaw angle implants just that you need to be mindful that the risk:benefit ratio is significantly increased in the more times you do the surgery. Another words the benefits are much less than the first surgery but the risk are much greater than the first surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My question is about ribxcar vs rib removal with the Latismus Dorsi muscle resection you do. I have scoliosis and my left side has much more muscle while the right curve is concave giving me a great curve on the right side but straight on the left. I’m actually seeing better results from the ribxcar remodeling procedure than the actual rib removal (which is confusing to me) but I’m thinking for me the problem is actually more the muscle on the left side. I’m wondering a) how is the ribxcar remodeling procedure yielding average 3-4 in waist reduction while rib removal seems to have very minimal change? And what is the recovery like for LD muscle resection? I’m also concerned that without that muscle I’ll have back problems since that is how my body compensates for the scoliosis. And if the muscle would just grow back. I’ve attached a photo of my torso as well as an xray of my scoliosis curve for reference Thank you!!!

A:I do not know where you’re getting your information that RibXcar is more effective than Rib Removal. In almost every case that I have seen RibXcar is always done in combination with other body contouring procedures particularly tummy tucks or BBL surgery. I have yet to see a case of RibXcar, and I have seen many, where it is done in complete isolation without any other associated body contouring procedures… so it never fully known which of the procedures had the actual effect or which one of them made the greatest contribution to the outcome. Conversely Rib Removal is almost always done as an isolated procedure. Thus it is virtually impossible to compare the effectiveness of the two procedures as they are usually done under different circumstances. (one is an ancillary procedure while the other is a prinmary procedure)

That being said improving the effects of scoliosis on torso shape/symmetry is always challenging. Without a 3-D CT scan of the rib cage it is hard to know what is creating the asymmetry although it almost always a combination of rib bone and muscle. Your plain rib cage x-ray shows the asymmetry between the two lower rib cage levels so you do know that there is a bony component. Whether the muscle is making any contribution to it can only be speculated as it would really require a 3-D MRI to fully see the shape of the LD muscle on both sides. FYI LD muscle resection is not associated with any functional limitations or causing back pain.

But looking at your body picture that you sent you are exactly the type of patient RibXcar may be considered when the torso asymmetry is more modest in magnitude.  Because it leaves minimal scarring and is a less invasive operation it is not unreasonable to first try some osteotomies of the lower ribcage (10 and 11) to see if that makes an improvement. So you can see RibXcar is not really chosen because it is the most effective procedure but given the scope of the problem a less invasive effort may be more appealing to try first. Remember, however, any success with RibXcar is critically dependent on three months of strict corset wear. It is not the operation that creates the effect it is that the operation allows postoperative molding to be done which is what creates the effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a 70 year old man interested in the least expensive method to reduce Turkey Neck. (wattlectomy)? Thanks

A: Thank you for sending your pictures. There is no question that the most surgically effective, quickest recovery and most economically efficient procedure for a turkey neck is the direct necklift. While this has all of the associated benefits over that of a traditional lower face/neck lift the one trade-off or liability is the final line scar down the center of the neck. So any patient being considered for a direct necklift has to be especially aware of this aesthetic trade-off. For this reason the direct necklace does almost exclusively used for a limited number of older man above the age of 65 who is willing to except this trade-off as opposed to the more traditional lower facelift procedure which avoids the neck scar but has a much higher cost and recovery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a consultation for a unilateral cheekbone implant revision. I currently have Medpor cheek implants on both sides. I am very happy with the appearance of one side, but the other side has a visible asymmetry in size/projection that I would like to correct. In the photos I am sending, there is an image with a red arrow pointing toward the cheekbone area I would like to fix. That side is the one I would like to improve so that it more closely matches the other cheekbone, which I am very satisfied with. What I am hoping to achieve is: • Removal of the current Medpor implant on the problematic side • Replacement with a custom 3D-designed implant that is mirrored from the “good” side so that both cheekbones match as closely as possible.

A:Thank you for your inquiry on secondary cheek implants surgery. When you have asymmetry and bilateral facial implants, such as cheek implants, that typically occurs due to placement differences, natural bony asymmetry differences between the two sides or some combination thereof. Thus you are correct in that the ideal approach is to make a 3-D design based on the good side to be placed on the undesired side. The problem with this approach with Medpor material is that it simply is almost never seen on a 3-D CT scan and even if it is visualized only part of the implant usually appears. Only in very rare circumstances, and I have seen thousands of 3-D CT scans with the implants on them, is a Medpor implant ever really adequately seen. Thus this throws a wrench into the best way to treat your cheek implant asymmetry.

There are alternative strategies to this ideal plan to treat your cheek implants asymmetry but these or not is optimal as the 3-D mirrored approach. But before delving into what the less than ideal treatment optiokns are it is reasonable to first get a 3-D CT scan to be certain that these other less than ideal approaches may need to be considered.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Does you perform the “Vertical Restore” facelift?

A:Yes. But patient selection for this type of facelift is absolutely critical. The more vertically oriented facelift requires a superior vector in which the incision must run along the temporal hairline. This is what allows for the lift to be largely vertical rather than more posterolateral direction that is seen in more traditional forms of facelift surgery.  You can’t run this incision into the temporal hairline as in other facelift surgeries as you are  going to eliminate any preauricular tuft of hair in females which is usually very undesired. In men this can be overcome by growing out the sideburns longer but the appearance of the temporal  hairline scar may also be perceived as worse in the male patient.

The point being is every surgery has its benefits and trade-offs. One just has to be certain that the trade-offs for the benefits are worthwhile. Certainly the vertically oriented facelift is one of these surgeries where this issue has to be considered very carefully.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in shoulder widening surgery. My height is 188cm, waist measurement 72cm weight of 69kg and bideltoid measurement of 47cm. I have already tried the gym but even with 15kg of added muscle weight my shoulders look the same.

A:Thank you for your inquiry and sending your pictures. Unlike shoulder reduction, shoulder lengthening is more challenging due to the soft tissue attachments of the shoulder girdle. As a result there are limits as to how much shoulder widening can be done buy clavicle lengthening. In my experience that is usually 15 to 18 mm per side, and rarely 20 mm per side. While I always would like more, at least 25 mm per side, I have yet to see a patient in whom I can make that occur. Therefore in looking at shoulder lengthening one has to decide is the result that can be achieved worth the effort. In that regard I have attached some imaging of your shoulders and what I believe the outcome of the surgery would be.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want a more aesthetically pleasing forehead. I have a high hairline and a narrow forehead. What can I do?

A:Your goals indicate a desire for both forehead-temproal widening and hairline lowering. The problem is each one is contrarian to the other. Meaning they can not be done at the same time. When you augment the forehead-temporal area you limit how much, if any, the hairline can be lowered.  And vice versa. Thus to achieve both it needs to be a staged procedure. My recommendation  is to do the frontal hairline first which by itself will make the forehead look wider.

Dr. Barry Eppley

World-Renowned Plastic Surgeon