Your Questions

Q: Dr. Eppley, Quick question before I book the CT. I had some hyaluronic acid filler in the infraorbital area about a year ago, and there may still be minor residual present.

A couple of questions:

1. Is the 3D cranio-maxillofacial CT sufficient for planning, or would you recommend additional imaging (e.g. high-frequency ultrasound) to assess soft tissue and any residual filler?

2. If there is residual filler, do you typically recommend dissolving with hyaluronidase prior to surgery and planning based on a clean baseline?

Want to make sure I sequence this correctly so Dr. Eppley has what he needs.

A: 3D Ct scanning is adequate. The filler does not obstruct the bone images.

Usually I don’t recommend  the dissolution of the filler unless a very large volume has been placed. But for typical low volume filler I don’t feel that it makes any difference in the implant designing process.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m very curious about this kind of fat graft for moderate lines of the glabella but without the release component. Had a hypersensitivity reaction after many year of using it to filler and to botox. Not interested in fat injection due to embolism risk so your procedure looks promising. Can you provide a potential price range? And can this be done under local anesthesia?

A:Dermal-fat grafts are solid fat grafts that require a release and pocket creation to be placed. They would not be indicated for moderate glabellar lines but for larger soft tissue indentations.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Wondering if the chin augmentation and rhinoplasty procedures could be completed in same session.

A:It is very common to perform nose and chin surgery together. it would be the norm and not the exception.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m looking to get revision bimax surgery and some implants to make it look more harmonious

A:Secondary Bimax surgery and custom facial implants should be done separately for the best results. Any facial bone repositioning should be done first followed secondarily by custom facial implants for optimal aesthetic enhancement.

Bimax surgery are procedures that I no longer perform at this point in my practice and focus exclusively on custom facial implants for facial structural enhancements. You should revisit me after you have had your revisional Bimax surgery.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,I am interested in a consultation on quad implants. I am specifically interested to hear about placement outside inner the muscle fascia. My quad muscle bellies are very short and I would like to hear if its possible to place an implant below the vastus lateralis muscle belly. The goal is not to thicken the existing muscle, but to thicken the area below the muscle.

A:Thank you for your inquiry and sending your picture. Your short quad muscle poses a treatment conundrum. The placement of all extremity based implants for muscle enhancement is underneath the muscle fascia. This provides the best implant coverage as well as stable positioning inside the contained fascia. It is not usually a good idea to place implants about the fascia in the subcutaneous space for a variety of reasons including increased risks of implant show, postoperative migration as well as chronic seromas.

To put that into context of what you want to achieve here is what I do know:

1) You definitely do not want to place an add on implant extending the appearance of the muscle in the subcutaneous space

2) You also probably do not want to place a long subcutaneous placed implant on top of the fascia of the short muscle to elongated its appearance towards the knee. Although this option is certainly better than #1.

3) Placing a longer implant in the subfascial plane of your existing muscle and then breaking through the fascia at the bottom of the muscle  to elongate it on top of the fascia below it is the third option. Whether this option is better than #2 can be debated. The problem with this option is that the existing muscle is already large enough and it doesn’t really need to be any bigger. Custom implant design and couldn’t get around that issue by making the implant thinner on the existing muscle and thicker below it.

As you can see your  thigh shape concerns are novel in my experience and I have yet to see a similar case. Therefore I cannot tell you definitively which option is truly better than the other or whether anty of these options could be effective.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am writing to inquire about a standalone paranasal/premaxillary implant procedure.

My situation: I have a recessed premaxilla with no support at the nasal base, a flat philtrum, and an acute nasolabial angle. This creates the appearance of a dorsal hump and a downward-rotated nasal tip, which I believe are largely optical illusions caused by the lack of skeletal foundation rather than true nasal deformity.

I am specifically interested in a standalone paranasal or combined premaxillary-paranasal implant (peri-pyriform) to address this — without rhinoplasty at this stage.

I have researched your work extensively and believe you are one of the few surgeons with deep expertise in this specific procedure

.A:Thank you for your inquiry and sending your pictures. I would agree with you that there is some skeletal deficiency around the nasal base. And such deficiencies can create the appearance of a dorsal hump and a decreased nasolabial angle. As a result there is merit to a combined premaxillary-paranasal implant augmentation in which hopefully that would be enough to avoid the desire later for any desire for rhinoplasty changes.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Seeking midface implant. I am 3 months post revision jaw surgery, my mandible a has been advanced twice and mid face now feels like it’s been left behind and looks very flat.

A:It is very common after bimaxillary advancements to develop a midface deficiency. The lower midface of the LeFort I dentoalveolar level has come forward but the rest of the midface above it including the cheek and orbital rims will remain where it creating a midface deficiency that did not exist previously. This can now only be addressed by a custom midface implant whose exact design is going to be based on what your external midface needs are to balance out the advanced bones beneath it.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am seeking treatment for self harm scars using the autograft method that Dr. Eppley discusses in “Treatment of Self-Harm Forearm Scars with a Rotated Ultrathin Autograft.” I was hoping to find out if I would be a candidate and approximately how much the procedure would cost. Attached are photos of scars on L forearm which are greater than 10 years and no previous treatment attempted. I am very grateful for any information. Thank you very much for your time.

A:Thank you for your inquiry and sending your pictures. One of the qualifying factors in the decision to trade-off a skin graft scar from that of self-inflicted scars is how close are all of the scar areas. Your left forearm scars are in a discreet area closely packed together. That is a far better situation than and if they are widely spaced apart all over the arm. The very outline you have drawn is exactly be excisional pattern and skin graft replacement area. The second qualifying factor is whether you would consider a skin graft scar better than the four our scars that you have. I would not consider skin graft scars necessarily better looking than the existing scars, as you are never going to be able to restore the normal appearance of the skin. The reason some patients may consider it a reasonable trade-off is the ability to explain it is much easier and it is obvious that the skin graft area no longer looks like self-inflicted scars. If one expects a skin graft to look like normal skin that would not be a reasonable expectation.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, what can be done for my facial asymmetry?

A:In facial asymmetry the initial step is to go to 3-D CT facial scan on which treatment planning can then be done. It is clear that your right facial side is short from top to bottom as evidenced by the lower eye and the higher jaw angle on that side. Such facial asymmetries are treated by custom implant designs on which the 3-D CT scan provides a platform on which to design and build those implants.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I want to reduce the jaws and chin and expose the face with Malar Shell filling to make the face square.

A:The procedure that you have described, specifically chin and jaw reduction, is not going to help make your face more square. You can never do a reduction procedure to get that type of shape change. The excess overlying soft tissue is not going to shrink down to any type of reduced bone shape to establish more definition. Making the face more square requires an augmentation approach not a reductive one. For the cheek area you have the correct surmised that a augmentation approach is best but it is not going to be achived with a malar shell implant. You have a very significant negative orbital vector which requires custom infraorbital-malar implants to make an effective midface augmentation change.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, i have a bit of lower eyelid retraction on my right side and was considering getting custom zygoma/cheek implants anyways (placed intraorally). If i extended the implant onto the infraorbital rim, increasing its vertical height by 1-2mm, could this eliminate or improve the retraction and sclera show without any canthoplasty, ect? Thanks

A:Lower eyelid retraction is a soft tissue structural deficiency most commonly associated with an underlying skeletal deficiency. So you are partially correct in that infraorbital rim augmentation may be helpful improving the position of the lower eyelid, although by itself that would be very modest. However the key to such infraorbital rim augmentation in a case like yours is that the implant must vertically heighten the rim by saddling  along the infra and lateral infraorbital rim areas. Such an infraorbital – malar implant design is extremely difficult to successfully get it into proper position through an intraoral approach for two reasons: 1) the large infraorbital nerve is in the way which sits right below the rim and 2) getting over the edge of the rim to successfully release it on the inside to allow for proper implant positioning coming from below is the wrong direction to do the dissection. Any infraorbital rim implant you see placed intraorally never saddle the ram, they merely sit in front of it only providing horizontal augmentation.

In short the only real way to get lower lid retraction of any significance is to place the implant through a lower eyelid incision in which you might as well place a spacer graft and perform a lateral canthopexy for to be really successful.

The only reason to place an infraorbital-malar  implant through intraoral approach is if the goal is to primarily augment the rim and cheeks in a horizontal fashion and any improvement of the lower eyelid, limited as it may be, will only be seen as a secondary bonus.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, i have a bit of lower eyelid retraction on my right side and was considering getting custom zygoma/cheek implants anyways (placed intraorally). If i extended the implant onto the infraorbital rim, increasing its vertical height by 1-2mm, could this eliminate or improve the retraction and sclera show without any canthoplasty, etc? Thanks

A:Lower eyelid retraction is a soft tissue structural deficiency most commonly associated with an underlying skeletal deficiency. So you are partially correct in that infraorbital rim augmentation may be helpful improving the position of the lower eyelid, although by itself that would be very modest. However the key to such infraorbital rim augmentation in a case like yours is that the implant must vertically heighten the rim by saddling  along the infra and lateral infraorbital rim areas. Such an infraorbital – malar implant design is extremely difficult to successfully get it into proper position through an intraoral approach for two reasons: 1) the large infraorbital nerve is in the way which sits right below the rim and 2) getting over the edge of the rim to successfully release it on the inside to allow for proper implant positioning coming from below is the wrong direction to do the dissection. Any infraorbital rim implant you see placed intraorally never saddle the ram, they merely sit in front of it only providing horizontal augmentation.

In short the only real way to get lower lid retraction of any significance is to place the implant through a lower eyelid incision in which you might as well place a spacer graft and perform a lateral canthopexy for to be really successful.

The only reason to place an infraorbital-malar implant through intraoral approach is if the goal is to primarily augment the rim and cheeks in a horizontal fashion and any improvement of the lower eyelid, limited as it may be, will only be seen as a secondary bonus.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in an estimate for a back lift. I would also like to know if a vertical back lift would work for me

A:Based on just this one static back picture I suspect that you would be a good candidate for a vertical back lift. The real indication is the pinch test seeing how much loose skin down the midline of the spine can be gathered up together.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, At 3 months post infraorbital malar implant surgery is it safe to get under eye/cheek filler? I never had a lot of fat in that area so I need the soft tissue augmentation. Also is getting botox, microneedling (at home or in clinic) etc pose any infection risk to the implants?

A:With any facial implant any form of injection over it is safe as long as the injector knows that an implant is underneath it so they can avoid going to deep and encountering the implant capsule or the implant itself.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had a chin reduction (0verdone) and now have chin ptosis when I smile. Will a chin implant help correct it?

A:You have correctly surmised that augmentation of the chin, in essence a reversal of the chin reduction, will treat the dynamic chin ptosis through the addition of structural support. How it is done, implant or bony genioplasty, is not relevant as any of these methods provide structural support for the soft tissue chin pad. I see no advantage of a PEEK versus a silicone chin implant.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, The procedures I’m considering are: Zygomatic Reduction Osteotomy, Supraorbital Implants, Custom Jaw Angle Implants, Infraorbital Rim Implants, Bilateral Lateral Canthoplasty, Rhinoplasty, and a Bullhorn Lip Lift. I am also planning a trimax (bimax + genioplasty) separately. Some of these are major, others more subtle.

What matters most to me is figuring out how all of these work together in terms of proportion and balance. I don’t want to approach each procedure in isolation — I want to understand how they all relate to each other and how to achieve a result that is harmonious overall. I don’t have the expertise to figure that out on my own, which is why I would love to get Dr. Eppley’s take on the full picture, including how the trimax fits in.

A:Without a full assessment of yourpictures and understanding of youraesthetic objectives and concerns I can only provide a general statement about the staging of the procedures of interest

In looking at the collection of your procedures of interest the Bimax osteotomes should certainly be done first before the jaw angle implants, lip lift and rhinoplasty… as all of these will be affected by the repositioning of the maxilla. When it comes to the procedures located above the horizontal level of Lafort I osteotomy, zyg9onatic reduction osteotomies, periorbital implants and lateral canthoplasties these are not affected by the Bimax procedures directly and could be undertaken beforehand…. with the caveat that depending upon the type of movements of the Bmax procedure would that change how these procedures may be done (degree of augmentation etc)

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, But was curious about the 180* orbital box osteotomy for orbital widening/interpupilar distance increase.

A:For the patient who has decreased interpupillary distance 360° orbital box osteotomies will make a significant difference (8 to 10mms). The question is not whether that would be the correct operation but whether the patient’s level of motivation is such that they are you willing to undergo the transcoronal incision and the front craniotomy that is needed to adequately perform this procedure. There are alternatives to this classic approach that does not need a frontal craniotomy which is more of a 180° orbital box osteotomy, as you have mentioned, which moves the lateral and inferior orbital rims more laterally. It’s effectiveness is not as profound as the 360° version, a 3 to 5mm IPD increase, but does spare the need for a frontal craniotomy and medial wall orbital osteotomies.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m a transwoman, and due to some mix of genetics and terrible luck, I’ve had little to no fat redistribution or bone changes even though I started HRT at 15 and have been on it for 10+ years 🙁

My figure has broad shoulders and extremely narrow hips, both of which have been a constant pain point. I’m looking to increase the hip/shoulder ratio, either via hip implants, shoulder shortening, or some combination thereof.

Note that I am about to engage in a fairly intensive diet program, so I am likely to lose weight in the near future. Unsure if that will affect things, but seemed worth mentioning.

A:Thank you for your inquiry and sending your pictures. In consideration of shoulder narrowing  surgery and or hip augmentation a patient’s body size and weight are important considerations. I do not know what your current height and weight is, which would be useful to known, but certainly any amount of weight loss is going to be favorable in your case. The question is not whether  you may benefit from these surgeries but, at your current weight, how successful will they be both from an aesthetic standpoint as well as limiting the risks associated with this surgery (which are a greater consideration in an implant based surgery like Pelvic Plasty than it is for an autologous procedure like clavicle reduction osteotomies).

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley ,I’m interested in a consultation regarding structural jawline enhancement using custom implants.

I have mandibular retrusion with an overbite and I’m looking for a patient-specific solution rather than a standard chin implant. Specifically, I’m interested in a custom wraparound mandibular implant (chin + mandibular body) to improve projection and jawline definition in a balanced way.

My goal is to avoid an isolated chin projection and achieve a natural result from both side and front views.

A:Thank you for your inquiry and sending your pictures. First, when you have a known mandibular retrusion with an overbite, which causes a deep labiomental fold, the ideal structural jaw procedure should be an advancement sagittal split ramus osteotomy +/- sliding genioplasty. Besides normalizing the position of the lower troll and chin it will also soften the deep labiomental fold as the lower teeth come forward.

Undertaking implants in a lower jaw that has a significant structural deficiency is reasonable provided the patient is aware that is not the ideal structural jaw treatment. I am going to assume for now you are well aware of this option and I have researched it out and decided that you would like to seek an alternative to a lower jaw osteotomy.

With a chin that is both vertically and horizontally short with the deep labiomental fold the better treatment is a sliding  genioplasty to make this type of chin projection change. The bony genioplasty will also help lessen the depth of the labiomental fold. While a chin/jaw implant can be used for the same type of dimensional chin change it will likely deepen the labomental fold rather than improving it.

However the chin is treated it still requires an implant behind it to augment the rest of the jawline.

In conclusion you have to two approaches to a non-orthognathic structural jaw enhancement:

1) a custom wrap around jawline implant which will likely deepen the labiomental fold, or

2) a sliding genioplasty combined with the wraparound jawline implant which will either not make the depth of the fold worse or may actually lessen it somewhat.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My biggest insecurity is my bulging and asymmetrical eyes and excessively round face shape, and right now I am looking for professional opinions from different experts to decide what procedures will be the most optimal for me.

A:Thank you for sending your pictures. You have a negative orbital vector which is why your eyes appear protruding and the lower eyelids are rounded and sag due to lack of bony support. Infraorbitral-malar implants are needed  to create a brownie reconstruction/ augmentation. The key is that the implant must saddle the rim to allow for needed vertical augmentation. The material of choice, PEEK versus silicone, is not really important. The fact that it is custom-made to saddle the rim is. The placement of this implant must be coupled with spacer grafts to the lower eyelids to provide support and elevation.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello, I’m interested in a custom 3D-printed implant focused specifically on enhancing my chin projection and mandibular angles only, rather than a full wraparound jaw implant. I’m looking for a natural, balanced result with improved definition in the chin and jaw angles without adding bulk along the entire jawline. Do you offer partial custom implants for this purpose, and would I be a good candidate? Also, do you provide 3D imaging or simulation to preview the expected outcome prior to surgery? Additionally, could you provide an estimated price range for this type of procedure, including surgeon fees, anesthesia, and implant design?

A: Three corner jaw implant augmentation can be done if that fits into the patient’s aesthetic objectives. The question is not whether you would be a good candidate but what are your very specific jaw augmentation goals as custom implant designs are based on a good understanding of the exact dimensional changes the patient is seeking. This is where the role of imaging comes into play, determining the patient’s aesthetic objectives, not showing patient actual surgical outcomes since no one can predict exactly what that will be. This is a common misunderstanding of the role of imaging in facial surgery.

Determining the cost of surgery depends on multiple factors which as of yet are not known. Most specifically what is the implant material to be used of which the two most popular choices are solid silicone and PEEK.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Here are the X-rays . You should be able to view my front, side and 3/4 view from my earlier email but lmk if not. Overall I find my face is quite long, flat and a bit droopy. I believe my resting face looks a bit sad and I don’t have many “features”

I’d like to talk about what can be done to give my face more “structure” specifically around under eye and paranasal / maxilla area. Potentially reducing the roundness of my face. 

A:Thank you for sending your  X-rays whose only purpose is to serve as the platform on which to build custom implant designs. They, in and of themselves, do not tell us exactly what is needed for the dimension of any implants to try to achieve the desired effect. The most important piece of information is facial pictures on which imaging is done to determine not only the patient’s aesthetic goals but what some of those potential effects may be on the overall facial shape.

In other words I need face pictures to do imaging to evaluate a variety of potential augmentation changes.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Of the custom facial implant material options, PEEK makes the most sense to me. Could you tell me the long-term advantages and risks of PEEK compared to Medpor? Is the implant custom-made using a 3D printer?

A: All custom implants are made by 3-D design and printing.

The main advantage of PEEK compared to Medpor is, should the need for removal or modification of the implant become necessary, the Medpor material is by far more challenging and traumatic material remove or revise. Quite frankly I wouldn’t use Medpor for any type of augmentation above the jawline. It has more inferior material handling properties than the other facial implant material options.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I recently came across your work regarding frontal bossing reduction and found your approach very informative. I would like to inquire about the procedure, particularly in my case as a 27-year-old male considering this surgery.

Could you please advise on the following points:

1. How safe is frontal bossing reduction surgery for someone my age?

2. What are the potential risks or complications associated with this procedure?

3. What side effects should I expect during both the short-term recovery period and long-term?

4. Are there any specific considerations or increased risks for male patients?

I would greatly appreciate your professional insight to help me better understand the procedure and make an informed decision.

Thank you for your time and expertise.

A:Thank you for your inquiry and sending your pictures. You have classic forehead horns which is a more limited of frontal bossing. This is treated by one of two methods: 1) by far the most common is burning or shave reduction of the forehead horned prominences, and 2) less common but a viable approach if indicated is to build up the forehead around the horns to create a smooth contour. Based on an assessment of your pictures the most common approach, burning reduction, would be indicated in your case.

In answer to your specific questions:

1) forehead horn reduction is not about safety but effectiveness. This is a very safe surgery since it is performed on the outside of the skull. The more critical question is whether the bone is thick enough to allow for an adequate reduction. This is determined preoperatively by getting a 3-D skull CT scan and using color thickness mapping of the bone thicknesses the thickness of the forehead horns can be measured,

2) The only risks of the surgery are aesthetic in nature. 1) how effectively can the forehead horn prominences be reduced and 2) how well does the very fine line anterior scalp incision heal.

3) There are no side effects of the surgery other than some short-term swelling which is largely gone in 7 to 10 days after the surgery.

4) The only consideration differences between male and female patients for forehead horn reduction is the location of the frontal hairline. Some men are going to have a frontal hairline that is way posterior to the fore head horns or they may not have a frontal hairline at all, both of which poses challenges in terms of incision location. This does not appear to be an issue in your case.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My face is marginal and atypical, and it harms my life because people think I am stupid because of my close eyes and very narrow face. I heard that you are the only expert capable of making cranioplasty (heavy surgery) an aesthetic goal. My question: is it possible to reshape my face by widening it and widening the gap between my eyes? And is it risky?”

A:Thank you for your inquiry and sending your picture. I believe you are referring to a decreased intrapupillary distance (IPD), otherwise known as close set eyes. While the definitive treatment his orbital box osteotomies with the expansion as an adult that is a major craniofacial surgery an it must be considered very cautiously. The first question in that consideration is are there other more minor procedures that may provide enough benefit that such a major surgery is not needed. Such minor procedures include narrowing the nasal bones between the eyes and decreasing the medial extension of the lacrimal lake of the inner eyes. This can provide 3 to 4 mm per side of increased IPD that may be enough to make a significant visual difference. I have taken your picture and done some imaging of that change to see how that looks to you.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had cheek implants placed years ago and believe their positioning is off — they create an unnatural, harsh look rather than enhancing my natural bone structure. My primary goal is removal or repositioning to restore a more natural, balanced midface.

Clinically relevant: I can palpate the implants both intra-orally and externally along the inferior border near the lip line. There is noticeable mobility — I can feel movement when pressing from outside. This suggests possible malposition, capsular loosening, or migration.

I also want to note that the distortion I’m experiencing is documented — not self-perceived. I have professional photographs taken within the last seven months where the asymmetry and unnatural contour are clearly visible. This is a structural issue with measurable, photographic evidence, not a body image concern. I’ve included those photos for comparison alongside my current images.

A:Thank you for your inquiry and sending your pictures. When it comes to your cheek implants you are undoubtably have the classic male cheek augmentation problem. The history and design of current off-the-shelf cheek implants is largely more for females than males because of where the implants are designed to be placed and the effect that they are intended to create. By definition most standard style cheek implants are placed with a significant part of the implant off of the bone in an effort to create the apple cheek affect that many females historically have wanted. While there are some males that may see seek a similar aesthetic outcome that would only be in the minority of men in my experience. Thus the symptoms you are experiencing, a non-bony augmentation effect and being able to palpate the implants along with being able to feel the flexion of the implants is consistent with my aforementioned supposition. This can be confirmed by a 3-D CT scan which will clearly show where your implants are placed as well as their size and shape.

That being said the question is not whether you would like these implants to be removed and replaced but what should their replacements be.  Should standard style cheek implants be used and placed in a higher and total bony location or should custom design cheek implants be used? I think the definitive answer in that regard will be guided by what we learn from a 3-D CT scan. This time we have a lot more information to help guide the implant selection process since you have a known implant effect that can be completely understood.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,Do you use MMA skull reshaping method for plagiocephaly (one side back head flat correcting method ) ? if yes most of my skull is corrected but I have a dent small area on back left which is the edge part connects with the left side part the previous Dr left to fill that area coz he ( thinks ) said its very risky to touch the temporalis muscle . Since my case is plagiocephaly I want to know if it’s ok to do it ? Is that going to affect my chewing process or the temporalis muscle movement ? Since there is only a small portion left i want to know the price and how long it will take me to heal ? Thank you !!

A: What you are experiencing with PMMA skull augmentation is the exact limitation of the material. When it comes to treating plagiocephaly implant augmentation is two thirds on the bone but one third onto the temporal muscle on the side of the head. P MMA material must stay on the bone and cannot be placed on top of the muscle. Your surgeon may have told you it was too risky to touch the temporal muscle this is not a remotely accurate statement. I have done hundreds of skull augmentations where is the material used is directly on top of the muscle on the side of the head and it has never caused any temporal muscle movement or functional problems nor would I expect it to do so. The key is not whether you can put an implant material on top of the fascia covering the muscle but what should that material be. Therein lies the limitations of P.MMA bone cement. As the name implies it is a bone cement not a soft tissue cement. It requires a bone surface to which it must be applied. As soon as you need to cross over the bony temporal line anywhere on the skull onto the temporal muscle area this requires a solid silicone material. This is why for almost any significant skull augmentation need the use of custom solid silicone skull implants are far superior as they do not have surface area limitations not to mention preoperative control of the augmentation areas actually needed.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have a bit of a flat face and the outer ends of my eyes hang lower than they should for sure. So I’m wanting to get them lifted a little as shown by my finger in the second picture. I think a lot of people go crazy over wanting cat eyes or siren eyes. That’s not me I still want to look like myself I just want slightly more narrow oval shaped eyes.

A:Thank you for sending your pictures. There is a correlation between your flat face and your lower eyelids position as there is a near one-to-one relationship between the position of the lower lid and the shape of the bone that is underneath or supports it. While I have not seen a side view picture you most likely have a negative orbital vector which is the classic indication of a significant skeletal deficiency. This is why to help reposition your eyelids the skeletal deficiency needs to be addressed through custom infraorbital – malar implants. These almost have to be combined with spacer grafts to the lower eyelid and then some form of a lateral canthoplasty. While it is easy to take your finger and push up the lower eye lids it is not so easy to do so surgically and have it stray there over time.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I currently have pectoral implants which are Hansons ACP 2-3 large. I would like to go bigger with new implants.

A:Thank you supplying the information on their existing pectoral implants. Your existing pectoral implant dimensions are 16.5 cm in height by 13.5 cm in width and 2.5 cm in projection and an approximate implant volume of 270 and 300 cc. This manufacturer does have a larger size but it only is adding 0.5 cm of projection and 35 mL of all, a difference that you would not see. When I compare it to the US manufacture, Implantech, I do find that there is one standard pectoral implant that comes reasonably close to your existing implants footprint with 17 cm of height by 14.5cm of width with 3 cm projection for a total implant volume of 410 mL. That is providing a roughly 25% increase in projection. I do have a general rule that if you’re not adding at least 30% of increased volume minute implant you really don’t see that much of a difference. So you can see that the use of that one standard implant is sort of borderline for whether it makes enough of a difference. I think it comes down to her how much augmentation difference you’re seeking. If it’s just a little van this standard implant may suffice. However if you’re seeking something a bit more substantial than we will have to go to custom implant design route. At least we have the exact measurements of your implants so that could be done without the need for 3-D CT scan.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in improving my facial structure and am looking into surgical procedures for that. I have a good amount of facial fat even though I weigh 155 lbs at 5’11” height (age 28). I want to have a defined jaw line and cheeks instead of the oval shape right now. Can you please suggest procedures for me that could achieve this.Thank you!

A:You don’t really have a lot of fat in your face it just appears so because you lack good bone structure. The classic facial masculinization approach is midface (infraorbital-malar) and jawline augmentation. This may or may not be combined with some cheek fat reduction although I would question if you really need it  once you augment the surrounding bone structures.

Dr. Barry Eppley

Plastic Surgeon