Your Questions

Q: Dr. Eppley, I was born with a disproportionate facial structure where my head size overall is rather small but my forehead on the larger side. Complimentary to the larger vertical size, i think that, because my forehead sticks out (vertical slope, no incline) it amplifies the forehead too much.

My desired look would be something like when i raise my eyebrows to their fullest. Could such a look be achieved ?

Thank you in advance.

A: Thank you for your inquiry and sending your pictures. I am assuming that the lifted eyebrow maneuver is to simulate the reduced distance between the eyebrows and the frontal hairline…as opposed to a true eyebrow lift. Estimating that eyebrow lift to create no more than 10mms of decreased  brow-hairline distance I believe that is a realistic outcome/result. With that exposure the frontal bossing  can be concurrently reduced.

With the question of an achievable result out of the way the only remaining question is the acceptability of the frontal hairline scar to do so.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I have Perioral mounds corner of my mouth on both sides. It really effect my confidence and self esteem I would like to know more about this treatment and would like to proceed further

A: While micro liposuction is an effective and only treatment for perioral mounds this is not a surgery I do as a solitary procedure due to its limited scope.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I am a 33 year old female year old who about two or three years ago,I noticed that I started having a lot of facial pain and that my eye was sinking in on the right side of my face. My cheekbones on that side flattened as well. I have been trying to manage this with fillers but believe that I may have a mild case of Parry Romberg syndrome. I don’t have significant tissue loss but it’s enough that it is noticeable and I plan to see a neurologist and try to get some scans. In either case I feel I could be a candidate for an orbital rim implant. Am I a good candidate for this surgery?

A: With the spontaneous change in infraorbital-malar fullness it is reasonable to suspect PRS as a possibility. If the problem is active/progressive fat injections would be the appropriate as a temporizing effect. If the contour change has stabilized then an implant would be an acceptable approach.

Usually in these cases a custom implant is the preferred approach. At the least a 3D CT scan is needed to determine the extent of the bony infraorbital-malar asymmetry.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I need a skull graft operation (frontal cranioplasty) or frontal cranial bone reshaping.

I had previously been in an accident that led to the fracture of the frontal skull bones. I had the skull patched with a 3D print (peek), but it became higher than the original skull bone, so I needed to either sculpt or file the existing impression so that it was equal to the frontal skull bones, or replace the current impression.

A: In theory the existing frontal skull implant should be able to be burred down. But because it is a PEEK material this is an incredibly firm material so its intraoperative reduction can noi be assured.

Given its custom design and the obvious over correction/protrusion I am suspicious that this was originally a partial thickness bone defect. This makes the use of a material like PEEK ill advised since it simply can not be made very thin. It is more indicated in full thickness skull defect swhich requite thicker implant thicknesses.

I would need to see the implant design file which will show the original skull contour deformity so I can advise a more appropriate frontal skull contouring method.  (either bone cements or a different implant material.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a 32-yo male  looking for a custom jaw implant. I have a preliminary proposal from a NYC-based surgeon but am uncertain around the proposed design and his skill level. Dr. Eppley is highly experienced and I’d like to consult with him about what he thinks, including about having him do the surgery (scheduled for December).

Here is the morph they made me, attached.  I’m very focused on “fixing” the jawline from the side profile, like the first and third picture.  My mandibular angle is too flat – almost like a congenital condition – so that is what I want fixed and that is my key concern.  I don’t think I need much width and only want a tiny amount of new width, at most.

A: You would be astutely correct based on that imaged goal. When you add vertical length to the jaw angles you will by definition add width without even trying. Thus if the goal is minimal jaw angle width with vertical lengthening/reshaping, the custom jaw angle implant width should be minimized …like no more than 3mms. It is very easy to make the face look too heavy from the front view with the creation of lower aw angle even though the jaw angles may look great from the oblique and side view.  This third dimension (front view)  must always be factored into any jaw angle implant design.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am very close to arranging appointment for mandibular implant surgery. A consultation would be very helpful. Beforehand, could you please help me understand the difference between the vertical mandibular implants and the lateral implants. I am not sure which would suit me better. As photos show, I have a narrow face. I want a more chiselled, masculine look but want to avoid the bulkiness or full cheeked look that can sometimes be a result of jaw implants.

A: Based on this one picture alone I would suspect that you only need widening jaw angle implants. Buit a more informed opinion would require additional face pictures from the side and oblique views along with some imaging done to look at these potential changes.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, The procedure I had done was facial feminization surgery. I didn’t like the jaw and chin portion. I have post (initial plastic surgeon never gave me the before scans) CT scans of sliding genioplasty and Vline jaw contouring. The iover aggressive work left me with a sagging face along with chin ptosis. I went to another plastic surgeon who did a deep plane facelift to address the sagging. I’d like to see what can be done to correct over aggressive jaw and chin work.

A: Having seen a lot of V line surgery that is a very unusual angle in which the entire jaw angle was removed but the body of the mandible remains. In essence the bone cut was angled way back. So I would have expected significant soft tissue sagging and a disconnect between the angle, body and chin mandibular segments.

Restoration of some or part of the jaw angles and chin can be done and the restoration goal would be what makes the bone look more normal as opposed to what the original bone looked like since we will never known what that was.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Dr. Epply mentioned he removes the outer third of the ribs. Is there a way to request a more aggressive resection? Half or most of the ribs?  Has he done this on trans patients?”

A: 2/3s of the patients that have rib removals are transfemales in my experience.

There is no aesthetic benefit to taking more rib length and the risks of complications increases. The only part of the rib that affects the sides of the waistline and torso is what lies lateral or beyond the outer border of the erecvtor spinae muscle.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, – I’m also looking at doing a hair transplant will this be a problem or how long time should there be in between those procedures

Noticed first time when I was about 21 now 37 it has grown a bit too much for my liking.

A: Given where the occipital knob is located and how the surgery is done I don’t see much of a need for a large gap, either before or after, a hair transplantation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Since I have chin filler present that I opine would block placement of a chin placement, would it not then be necessary to use hyaluronidase?

A: Fillers do not block placement of any implant so dissolving the filler is not an absolute necessity….and thus I don’t routinuely have it done. But there never is any harm in doing so.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a couple of questions regarding the torso narrowing procedure performed by Dr. Eppley.

Is the surgery suitable for trans women?

How many inches will the thorax lose in circumference?

A: 2/3s of the patients who  undergo rib removal surgery are transfemales. (Type 2 Rib Removals)

I don’t think of rib removal surgery results as in circumferential inches reduction. It is more accurate tuse body pictures to show the typical results that can be expected.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, does the combination of temporalis muscle reduction and forehead implant reduce the possible need for an scalp expander (compared to only doing a forehead implant)? Thanks in advance.

A: If scalp expansion is really needed temporal reduction will not create enough scalp looseness to avoid it.

I have never seen a situation where a forehead implant ever needed scalp expansion.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Usually, when smiling, the blue line in the image is very short and the lips appear to be in approximately the same position. However, since I am Class II, my chin is receding and the blue line is longer. Would this be possible to try genioplasty, labiomental sulcus filler, etc. to shorten the blue line even a little?

A: No form of chin surgery can change the position of the lower lip, either at rest or in dynamic motion.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  have a bone spur,or piece of bone sticking out the back of my head it causes headaches , it hurt, and it stings been dealing with this most my life , and I never new there’s a alternative for this.

A: The spur on the back of the head to which you refer is known as an occipital knob and can have a sharp edge to it. While usually asymptomatic it can occasionally be a source of chronic discomfort. It can be removed in a straightforward surgical procedure done as an outpatient.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I need some advice from someone experienced with chin implants. I have had two failed surgeries in 7 months. Now I need a third one. I prefer if that is the last one.

I have been looking at Implantech for the third surgery. The one my norwegian doctor used is sebbin:

 My face was “long enough” as it was. I didn’t want any downward projection of the chin implant. I wanted forward projection. As Dr Eppley will see from the CT scans. Its the opposite of what I am after. Now its a lot of downward projection. An not much forward. This is due to the wrong placement downward and also that it has be sinking down after surgery as well. I prefer not below my own original chin at all if that is possible. Which implant would be best for me is the quest here.

My surgeon for the first two surgeries would be very happy to join med on a call 

A: As your scan clearly shows this is an implant placement problem not an implant style-size problem. It doesn’t matter what the chin implant is if it can not be placed properly.

I do not talk to surgeons to teach them how to handle their complications, that is not my responsibility nor what I am willing to do.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My right eye brow bone is getting a little larger than normal I feel like the bone has grown a little and I feel pressure between my eye brows all the time so if there is a doctor or a way to help this would be a lot.

A: You should have a 3D CT scan to evaluate the fractured brow bone area to see if it is really bone overgrowth or just scar tissue/nerve injury.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a couple questions about my eye area:

1. The first two pictures show my current eye area completely relaxed. Do I have ptosis of the upper or lower eyelid? If not, would ptosis surgery or any other procedure work to lift my lower or upper eyelids a bit?

2. One of my desired outcomes is moving the inner corners of my eyes a couple millimeters inward, as shown in picture 3 as a slight morph of the second picture. I notice I get this result when I pull very slightly with my fingers inward, and the eyelids still remain attached to the eyeball. This makes me think I have loose skin or medial canthal tendons. I have seen mixed opinions online, and you stated in a post that this would be difficult to achieve without risking scarring. Suppose we didn’t really care about scarring. I have seen procedures designed to achieve this effect, such as C-U plasty (picture 4), which cuts the medial canthal tendon and moves one end inward, as shown in picture 6, and W-V plasty, which simply removes some skin to tighten the area. These generally are designed to correct telecanthus. Would one of these procedures, or any other ones that tighten skin or the tendons, realistically work for my case?

A:In answer to your eye reshaping questions:

1)Do you have true ptosis….not really. Maybe a 1mm. But one does not have to have true ptosis to have ptosis (upper lid elevation) surgery.

2) Lengthening the inner eye corner towards the nose is not done by any medial canthal tendon surgery or any of the procedural diagrams which you shown. (those are for webbing/hypertelorism surgeries) It is done  by a tissue rearrangement technique known as a Y-V lengthening surgery. This has more favorable scar formation than its cousin, V-Y narrowing.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want to get the rib removal done, I’m wondering if I’m a good candidate and if I’d be one of those patients that would have a dramatic difference or subtle difference. I’ve looked into getting a BBL but I’m hoping maybe a rib removal will slim my waist enough where I wouldn’t care to enlarge my hips. My waist currently is about 25in and my hips are about 33/34. I would like my waist to go down closer to a 21/22 so wondering if that’s possible with my anatomy. 

A:Thank you for your inquiry and sending your pictures. Your question is a good one in that with your body type (tall and thin but with a vertically long buttocks) you could go either direction of a BBL or rib removal. I don’t think either one is a bad choice. Whether rib removal results are subtle or dramatic is open to personal interpretation. But what I can say is the following: 1) Dio I think your waistline results will drop from 25″ to 21″… no (tall and thin patients do get the best results but that would be expected too much in my experience) and 2) an expected change in your waistline shape I have shown in the attached image prediction.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a 42yo Male to Female Transgender Person. Im intrested in your Scrotoplasty. Do you also offer Orchiectomy Surgery ? As atm im using Androcur as a Testosteron Blocker.

A:Testicle removal can be done with scrotoplasty although if the eventual goal is to have SRS (sexual reassignment surgery) then this procedure would be unnecessary. The transfemale that may be considering such a scrotoplasty usually is not progressing onward to SRS.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My head big size 61 sm. Can it be reduced?

A: The question is not whether it can be reduced but whether it can be done enough to justify your efforts and goal. In reality skull reduction is best suited for spot area reductions rather than a major overall head size reduction.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello. I have a flat spot located at the parietal area. It is very noticeable to my hairstylists and although it also is not appealing cosmetically I would like to get this looked at by someone as I believe it could be a cause of my migraines. Does your office have the ability to a virtual approx. 30 minute free consultation via Zoom meeting? Is it possible for my severe flat spot on my head to be causing migraines?

A:I am not aware of any association between a flat spot in the skull and migraines. Augmentation of such areas is done for cosmetic purposes.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had orthognathic surgery in April to correct jaw misalignment and a pretty serious overbite. I now have hollowness in my midface and some asymmetry of soft tissue between my left and right side of my face, and I am looking to get opinions on which midface implants would be the best option for me.

A:This is a pretty common sequelae post LeFort I, particularly if one had some infraorbital-malar deficiency to start. This is treated in many such cases by a custom infraorbital-malar implant design as per the attached images.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, How safe is the rib removal surgery? I’d it safe to have those ribs removed and gone?

A: Despite its name and misconceptions about the surgery. it is a very safe procedure in experienced hands and very few complications or side effects. (an occasional self-resolving seroma is the only ‘complication’ I have ever seen. It is far fewer side effects and risks compared to more well known body contouring procedures such as tummy tucks and BBL surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is it possible to tell just based on the photos I sent earlier alongside these pics of my design if the implant can be totally camouflaged with those techniques as well as perhaps with a midface lift? I notice when I simulate one it improves not only my nasolabial folds (which seem to have gotten more pronounced after this implant was installed in addition to the double jaw surgery I had at the same time which included 8 degrees CCW and 2mm impaction) but also improves the step off beneath the implant. The upper portion of the infraorbital contour is still visible though.

 If I opt to have the implant removed, do you think I would experience midface sagging based on the design shape and my anatomy? I am 27yo for reference.

A: A midface lift has zero chance of making any improvement in the visible outlines of these implants. Lifting with your fingers is not replicative of what will happen from a midface lift in a young person with otherwise taut skin.

Camouflaging implant edges comes from volume addition.

The question is not whether you will have tissue sagging after implant removals, as you will, the more pertinent question is how significant it will be and whether the sagging is a better aesthetic problem than that of the implant show.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello is there a procedure to make the chin less prominent and not make the smile look so “forced”? I don’t want that under bite look. I got cheek filler and it looked how I wanted.

A: I could see how cheek implants would make the chin look less prominent as it helps ‘pull out the midface above it. Fillers a good test to see if that effect is a positive one which clearly it was. You might also combine those with paranasal implants to enhance the midface augmentation effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Looking for solutions to eyebags and darkness under the eye at 18 years old.

A: I can appreciate the undereye hollows, the darkness not as much. Undereye hollows can be treated by synthetic fillers, fat injections or implants. As a very young person the first step is to try fillers to be sure augmentation provides the proper aesthetic effect. If it does then a more permanent solution with implants can be done.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have very large temporal muscles that I want reduced. They stick out significantly from the side of my head after yawning as well as chewing when I haven’t for a long time. It is not normal to look like this with such bulges. What is involved in reducing the temporal muscles. I have attached some pictures for you to see what I mean. I also feel an extreme tightness/discomfort whenever I’m chewing when I haven’t for a long time.

A: While removal of hypertrophied temporal muscle can be an effective procedure, not all of the temporal muscle areas can be reached from an incision behind the ear and certain areas need to be avoided to prevent jaw dysfunction. (see attached diagram which in yellow shows the area where temporal muscle ca be removed)

You have a uniquely distinct area of temporal muscle hypertrophy that I have never seen before in its precise location. This is exactly where surgical muscle removal can not be done. as the aforementioned diagram shows. This can, however, be treated with Botox Injections  which can effectively shrink down the size of the muscle in a non-surgical manner. A good 50 units per side as an initial treatment will produce a visible reduction.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, . I’m interested in hip augmentation and I have the following questions:

1- I know that you advise having fat injections first on the hips but, is it possible to augment the hips with custom implants first and, if implant edge reveal becomes an issue, to come back and fix it with fat injections?

2- If the answer to the previous question is “yes”, then how soon can one have fat injections on the hips after having custom hip implants?

3- Would the fat be injected just on the edges that can be seen?

Thanks in advance

A: The reason that I advise fat injections before hip implants is the hope that the fat will create enough of a hip augmentation result that implants will not be necessary. Hip implants have a high rate of complications so they should only be done when autologous augmentation is not an option. (don’t have any or enough fat to harvest)

Fat injections are a treatment option (along with synthetic fillers) for the most common hip implant complication of inferior edge show Such show is not evident until 8 to 12 week after placement when all swelling has resolved and the soft tissue shrink wrap effect has occurred. Fat injections are placed around the visible implant edge to try and camouflage it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I am assisting in research for my girlfriend regarding a breast lift. She wants her breasts to be higher profile (more northern pole mass). We kind of understand that a normal breast lift will not achieve what she wants really.

She has 500cc silicon implants already. I was researching the REFINE tissue anchor and stumbled across your practice.Can you provide a little information on the REFINE system and if you think she can achieve that real high profile look she is wanting?

A: I would not have confidence that the Refine Breast Lift can produce sustained breast lift results on top of a large implant. Not to mention the difficulty of navigating around  a implant to do so. This needs assured volume like a different and larger breast implant or upper pole fat injections.

As a general rule you can’t lift your way into increased permanent volume.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Looking to get six ribs removed to get smallest waist possible. Wondering if this is something you would consider doing or if it’s too dangerous. Thanks so much!

A: You are referring to Type 2 rib removal which I do frequently. The question with any form of rib removal is not whether it is dangerous, as it is not, but how effective it will be for the patient’s waistline reduction goals. I would need to see pictures of your torso to help make that determination.

Dr. Barry Eppley

World-Renowned Plastic Surgeon