Your Questions
Your Questions
Q: Dr. Eppley, I am hoping that you can help. I have previously had Medpor Malar cheek implant surgery done through the mouth, upper/ lower eyelid blepharoplasty procedures in the past 6 months. However I am not satisfied with the results, one implant is oversized to the other. Would you be able to help correct my condition to help improve the asymmetry in my face?
Thanks
A: Thank you for the implant info. Because two different cheek implant sizes were placed I assume you have some cheek asymmetry to start. Like many ‘eyeball’ implant techniques for fixing facial bone asymmetries the asymmetry is not solved and is often more apparent than before. While it would be prudent to get a 3D CT scan to understand the bone and implant differences between the two sides, Medpor material rarely shows up on 3D CT scans. So there is no way to know with accuracy whether the right cheek implant has a size, placement or a combination of both problems which account for the asymmetry from the left side.
The ‘simplest’ path forward is to eyeball the asymmetry correction, remove the implant, modify in size if needed and do an immediate replacement in the same or different position. While this is not mu usual recommended facial implant modification technique it is the most practical one given the implant’s material composition.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I was tested for Noonan’s syndrome and tests came back negative. I have lived with a relatively mild variation of a webbed neck since I was an infant. Judging from the pictures attached to this email.
A: In cases of mild/moderate webs in a male I am less than enthusiastic about webbed neck surgery in these cases for 2 reasons:
1) The indirect central diamond excision on the back of the neck leaves a visible which, while in a female with long hair remains hidden, that would not be the case for a male.
2) In my experience moderate non-syndromic neck webs are the most resistant to sustained change because the tissues are often stiffer and less mobile which makes for the potential of some relapse.
I would not say I would never do webbed neck surgery in the non-syndromic patient but we have to be careful about creating a visible scar if we can’t get significant improvement.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Upon reading your jaw augmentation page I stumbled upon the Chin wing osteotomy. I was wondering if you do this procedure yourself.
A: I do perform the chin wing osteotomy provided the patient is properly qualified for it which requires two criteria:
1) That they understand that the chin wing osteotomy is an incomplete or partial jaw augmentation procedure. It does not change the jaw angle area in either width or vertical length. It provides moderate horizontal and vertical augmentation to the chin and body of the mandible but makes no changes to the posterior or jaw angle area. Think oif it as an extended sliding genioplasty noit a total jaw augmentation change. This is why it is appropriately called chin wing and not a jaw wing procedure.
2) A preoperative 3D CT scan is needed to determine the location of the inferior alveolar nerve in the lower jawbone and thus where to safely placed the osteotomy cut.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Seeking Chin Implant Revision, Custom Implant for a more square, symmetrical and masculine appearance.
The implant was placed about 4.5 years ago. The implant was in a size ‘large’ and was a silicone material; placed sub-mental (small incision under chin). The brand of the impact was Implantech Associates, Inc. Some information: Reference: CEAC-L
Although I have no regret about getting this implant initially, it did bring the necessary harmony to my overall appearance by bringing my chin forward however, the reason for seeking a revision is because I believe the implant had either shifted slightly (based on images from a CT scan) or was placed in a position that caused some asymmetry (the chin leans more towards my left side) which was not an issue I had before the implant. My natural chin was receded however, was more symmetrical and had a square shape to it. Which brings me to my second reason for a revision, I would like to see what my options are for a square-shaped implant. I would like to have a more masculine square chin shape instead of the rounded one I currently have. I do believe that it would complete the facial aesthetic goals that I have for my face. I have read some articles by Dr. Eppley online and am excited to see what he believes a realistic goal would be for me.
A: You have a Conform Extended Anatomic Chin Implant – Large – 6mm projection
Between getting the implant centric and achieving a more square appearance, the two options are:
1) a custom chin implant design
2) a standard Type 1 square chin implant
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a few questions – could you please help with these?
- When I smile, I have creases that form under my eyes every time. Would the under-eye implants eliminate or reduce these?
- Is there anything that can be done to the under-eye implants to further minimize my nasolabial folds? If not, I understand, but I’ve heard of injections along the cheekbone to reduce those folds, so wondered if that was possible with the implant
- Is it possible to create a chin dimple with the custom jaw implant?
- The image that perhaps looks the strangest to me is this one (below). If I had to be critical, it makes me look a tiny bit like a witch because of how pointy the chin seems to be. Perhaps the surgery results would look better / slightly different. But a couple of related / follow up questions:
- Is it because perhaps the chin is too narrow / pointy from the front (needs to be wider?)
- Is there a different procedure other than a sliding genioplasty that would split my jaw / mandible between the chin and the gonion, thus advancing the entire jaw and lower lip, and therefore make the chin less pointy but still giving better projection? I would trust Dr Eppley’s opinion if this is ill advised. My family has a big problem with double chins so wondering how to address this
5) Finally, I recognize it may be very difficult to get my facial shape to change so drastically, but I’m wondering if there’s something that can be done to approach an aesthetic closer to the image below. Is it a matter of making the cheekbones higher and the front of the face more flat? I don’t expect I can be turned into the below very easily, but just wondering if Dr Eppley has any insight if there is anything else that could be done to get closer to this.
A: In answer to your questions:
1) No. That is a dynamic issue while the implant provides static volume enhancement.
2) IOM implants will not improve nasolabial folds. This is a soft tissue issue not a bone-based one.
3) Chin dimples are muscular defects in the soft tissue chin pad, they have no bony basis for them.
4) That is an imaging artifact and not what the surgery would do.
5) You can become that picture or even close to it. All you can do is simulate the bone structure on the face you already have.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’d like to inquire about procedures for improving narrowly spaced eyes. My narrowly spaced eyes have been a lifelong insecurity and it increasingly negatively impacts my disposition. I understand that procedures to improve this trait are risky (orbital box osteotomy), but I am tremendously motivated. To put the extent of the trait into numbers, I have measured a few lengths:
intercanthal distance: 27.5 mm
interpupillary distance: 59.5 mm
bizygomatic width: 141mm
eye spacing ratio: 59.5mm/141mm = 0.421
My intercanthal distance alone is below the range considered normal in the population (>28mm), and is thus abnormal. Furthermore, having narrowly spaced eyes makes my face appear longer and thus more masculine, making it more difficult to live as my desired gender.To provide an actual goal in numbers, I’d like to aim for an ES ratio of 0.46 – 0.47. To achieve this, I’d like my interpupillary distance increased by 5mm.
A: You are referring to orbital box osteotomies as you have noted. This is not a ‘risky’ surgery medically, it is just a procedure where the ‘effort vs reward’ ratio is tilted a bit unfavorably. Meaning you have to do a big operation to make a small change. (5mms) The most effective orbital box osteotomy is a transcoronal approach using a frontal craniotomy for exposure with a 360 degree osteotomy…but that is a bit extreme for a 5mm interpupillary change. The more appropriate technique is a modified subcranial 180 degree orbital osteotomy which has less aesthetic risk and can be done through a combined lower eyelid and intraoral incisional approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am a 55 year old female located in Oklahoma. I recently had a small button chin implant removed after 30 years along with a neck lift. My surgeon replaced it with a large terino chin implant. I was not expecting it to be so large. It was very uncomfortable and the wings pulled downward. After a great deal of pain, my surgeon removed it and replaced it with a medium anatomical implant. This implant is off center with the midline on the right corner of my chin. It is also under the skin and not the periosteum. My surgeon said that it must have shifted but I don’t think the midline was ever centered. Anyhow, it does not stay in position and it falls below my jawline. I am having to hold or push it back it to position constantly.
My first implant never gave me any issues. It stayed in place and didn’t move.
My surgeon said he would remove it but he would not replace it. I don’t know if I should let him remove it as I’m sure my chin will sag.
Or, should I have another surgeon replace it at the same time that it is removed?
Can you advise? Thank you!
A: I am not sure what the compelling motivation was for the original chin implant removal and replacement but not that such a large implant pocket exists and the implant is not secured with screws….it is going toi move around. This is the result of downsizing from a larger implant where the ligamentous attachments have been released. (and they don’t reattach)
Given that you have always had a chin implant there siomply removing it will ljkely create some chin pad sag. I would replace it with a more appropriate chin implant (no wings) and secure it into position with microscrews to an end to this chin implant saga.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I wrote to you a while ago that I was interested in replacing Medpor mandibular angle implants with custom implants.The thing is that after visiting a surgeon he told me that the medpor implants I have caused my masseter to tear and the area has become too skeletal.
Therefore, I wanted to know if you have experience repairing the masseter after removing the implants. Also, I wanted to know if this operation could be performed at the same time as the placement of the new implants or would we have to wait for the masseter to heal properly. Thank you very much for your time.
A: As a general statement once the masseter muscle is dehisced /torn it becomes shortened and scarred and its repositioning is very challenging. I have found masseter muscle repair to largely be an operation with a low chance of success.
That chance of success is improved if implants are being removed but those chances decrease significantly if implants are placed at the same time.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hey!! I have seen cheek arch implants done by dr eppley!! I just wanna know can cheek arch implants be 1 inch in size ?? As i have read on your website that it must be 5 mm in thickness, but i wanna know can it be 20 mm in thickness??
A: I have done cheek arch implants as large as 15mms but not 20mms.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to ask, in general, what is the maximum upper jaw advancement movement in mm (Lefort 1) that will not cause discrepancy between the lower and upper midface and that will not disrupt the facial harmony?
A: This is a question that would be affected by many factors most notably the shape of the face. Thus a specific answer can be provided to a general type question without pictures to understand the basis of your question.
Dr. Barry Eppley
World-RenownedPlastic Surgeon
Q: Dr. Eppley, I am interested in getting a combination of surgeries done. The surgeries I am interested in consist of shoulder narrowing plus rib removal and iliac crest implants.
Could these surgeries be done at the same time? And would I require assistance from another person (ie family member) or friend to be present for my recovery?
A: All three such body contouring surgeries, shoulder narrowing, rib removal and iliac crest implants, impose a lot of stress on the body and make for a very difficult recovery, particularly when you have early limited use of your arms. Thus these trio of body contouring surgeries should not be done together. Any two of them at the same time is commonly done and that is enough of a recovery on its own.
In regards to coming alone or with someone it can be done either way and we see both commonly. Suffice it to say, particularly with shoulder narrowing surgery, that having someone with you makes the recovery a bit easier and you would likely return home a few days sooner due to the added assistance. When you come alone we just have to put more forethought into your immediate postop recovery management as we have to provide some support for it.
Dr. Barry Eppley
World-RenownedPlastic Surgeon
Q: Dr. Eppley, I am curious about ribcage narrowing. Removing my floating ribs wouldn’t make much difference I don’t think. It’s my side ribs that bulge out making my back too wide for my narrow frame. I have no fat really.
It’s rib 10,9,8. My floating ribs do not show much because my side ribs stick out. The sides of my ribs feel hollow.
My hips and legs are extremely small My ribcage is narrow from the side. Looked like the ribs squash sideways slightly.
A: Rib removal of the non-floating ribs is more limited than the floating ribs. Rib #10 can be partially removed as it wraps around the side of the torso and rib #9 can be shaved down in the same side torso area. This is the maximal ribcage reduction/.narrowing that can be done. I would also agree that removal of ribs# 11 and #12 is of no benefit to you in what you are trying to achieve.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I wan to reduce the size of my face as it is larger than a normal human being as its size is extra large.
A: I don’t see any effective method for reducing the size of your face. What makes your face ‘large’ is the amount of thick soft tissue over it. There are numerous defatting procedures and even that of skin reductions (aka facelift) but the question is how effective they would be in making an overall facial size reduction. I suspect they would help make it a bit less full/thinner but not necessarily smaller in size.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Here are some pictures of my face. Based on these would it be possible to say that the lefort 1 surgery affected my facial harmony?
A: Every Lefort I osteotomy alters the natural shape of the face essentially leaving what lies above it behind. (infraorbital-malar region) Your current facial pictures certainly reflects that postop issue.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My breast implant size, I think there is 250 in one and 235 in the other. They are saline, probably close to 15 years old. Yes, I would like to go up in size.
A: Thanks for the info. To see an appreciable/visible increase in breast size you should at least go into the breast implant sizes of 300, probably 350 to 375cc. Always more than a 30% volume increase its needed to see a difference.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, As you can see I have the side of the skull on the right in the photo and on the left in life larger than the other. What I would like would be to refine and reduce this side so that it is homogeneous with the other side.
A really flattened skull on the left with a bump while the other side is normal. I would like to know if it was possible to do something or if it is impossible.
Know if we could raise the skull at the back of the left side so that it is less flat and much more aesthetic.
A: As part of your plagiocephaly there are differences between the shape of the two sides of your head. The options are to either reduce the larger side or augment the smaller side. That is a personal choice based on one’s aesthetic preference.
The flatness on the back of the head is a classic concern in plagiocephaly which is commonly treated by a custom designed skull implant.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi, I’m interested in both the cheekbone reduction and double eyelid surgery. Therefore, I was wondering which one should I do first? Lastly, how soon could I have the plates and screws removed and is shaving of the Zygoma cheaper than L-Osteotomy method?
A: The order of cheekbone reduction and double eyelid surgery is a personal one and the two, while anatomically close, are not related or affected by the other. The one you do first is the one that is most important to you.
Shaving of the zygoma is usually a poor choice for many cheekbone reduction patients as its effects are more limited and is a procedure that is not aesthetically interchangable with cheekbone reduction osteotomies. They each have different indications for the cheekbone reduction patient.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am a 42 year old male. I follow you on Instagram. I would like a consultation about my right clavicle. When I was 8 years old, my father had me fire a rifle that caused a greenstick fracture on my right clavicle. The callus makes a prominent bump as you can see in the pictures attached. I work out a lot, but there is asymmetry. I would like to know if it’s possible to fix the clavicle and add chest implants that would improve the appearance of the upper chest.
‘A: Clavicle Reshaping and pectoral implants can be done together. I suspect the bump is either a hyperostosis at the fracture line or it developed a slight bend at the fracture site. Either way the bump can be likely be shaved. down/smoothed over without compromising the integrity of the clavicle. I would check a clavicle x-ray to have a full understanding of what the bump is.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, For my plagiocephaly compared to the side of the skull I think reducing the bigger side is a better solution. The back of my head will have to be cohesive with the side reduction by increasing the flatness. I also have a few questions to ask you about the risk of this delicate operation since it touches the head. Are there any infectious risks or any other risks? The intervention keeps the desired outcome alive. I mean, aren’t implants changing over time? and Does this procedure present a risk on the nature of the hair or causes it in loss. Recovery after the operation is it essentially pain or difficult? And keep your big scar for life ?
A: The amount of the bigger side that can be reduced will be determined by the CT scan but almost assuredly it can not be done enough to match the other side. As a result reasonable symmetry is not going to be obtained by bone reduction alone.
I have never yet seen an infection from any form of skull reduction or skull implants.
Skull Implants are structurally stable and do not change over time.
Skull reshaping surgery does not adversely affect hair growth.
Recovery after skull reshaping surgery is neither painful or difficult.
Scalp scars from incisional access are permanent.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have two inquiries, the first wanting to know which option testicle implants of side by side and wrap around allows for the largest sizes? I was also wondering if surgical steel or something could be included to make them weight more?
A: Both testicle enhancement techniques allow for the same increases in size but the wrap around technique has a much higher complication rate with not infrequent implant separation.
Metal can be incorporated into a central hollow chamber in the implant but it is important to recognize that this is an off-label implant technique.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My question is relate to a 5mm genioplasty reduction i had done 25 years ago. As a result I’ve lost some contour as far as the muscle below the lip fold. I’ve read that tissue can be tied up to create the natural curve. In a second procedure A small chin implant was placed to restore the fold but I’m still a bit flat. The area looks great when I add filler to that muscle but I’d love to not have to continue to do that. Is it possible to ‘tie up the tissue’ so that I’m not quite so flat from front and side and as a result the chin would be a bit shorter? Thank you!
A: I would not confuse the aesthetic effects of filler with soft tissue resuspension. That is not the effect tissue suspension would create and, even of it could, it would not be a sustained effect. Such tissue resuspensions frequently fail after a few months.(fall back down) The potentially more effective approach is submental chin tuck to make the chin shorter and fat injections to the labiomental fold.
The other option, since fillers works so well, is fat injections with the hope that some of the injected fat survives.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a question about the general behavior of implants when removed. Perhaps you can answer this: Does removing implants after 6 months cause any permanent tissue damage and face changes? Does it create saggy skin or slightly change your appearance, etc? Or will the face and muscles go back to normal with some very minor tissue damage (only where the cuts were done during surgery, etc)?
A: The best way to think about any implant removal in the face is that the face will never return to 100% normal after implants are removed. It is just a question of how close it returns to normal which will be dependent on what type material composition) of facial implants have been removed, their size and shape and their facial location.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have recently had a canthoplasty to fix my eye asymmetry and tilt 6 months ago. I’m at the point now where I believe I need more volume with infraorbital implants. Is this possible after me having a canthoplasty?
A: Having a prior lateral canthoplasty does not preclude getting infraorbital implants secondarily.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Can i still get infraorbital malar implants if i got a cheekbone reduction before?
A: That is not an implant limitation. Custom infraorbital malar implants can be placed over any bony anatomy regardless of its prior surgical changes.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am writing to inquire about potential surgical options to address my lifelong condition which I believe to be Brachycephaly. Please find attached photos and a video for reference. The key concerns I have are as follows:
1) Bulb-like appearance due to protrusion above my ears on both sides of my head.
2) Asymmetry caused by one side protruding more than the other.
3) Different protrusion of my ears, causing an imbalance.
4) Brachycephaly causing a noticeably large head with a circumference of 59cm/23.22 inches, often inviting unwanted attention and comments.
5) Flat shape at the back of my head, deviating from what is considered typical.
6) Abnormally high, top part of my head.
A change in my head shape would significantly impact my life in various ways. After discovering your work while researching similar cases, I am optimistic about finding a solution. Your expertise in this field is truly life-changing for individuals like me who have faced social challenges.
As a resilient and positive person with a strong support network, I am eager to explore options to address this condition. I appreciate your time and dedication to your profession.
A: You are referring to these procedures:
1) Bilateral Temporal Reductions
2) Left Setback Otoplasty
3) Custom Back of Head Skull Implant
4) Sagittal Ridge Skull Reduction
Any combination or all of them can be performed during the same surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, . I was born with a left-side form of facial asymmetry due to underdevelopment of various facial structures. My left eye sets lower than the right and my left cheek bone is flatter than the right. I also have some chin asymmetry. I am not looking for my face to be perfect just hoping for more facial asymmetry. I look forward to hearing from you.
A: Based on your comments your primary areas of facial asymmetry concern are: 1) left eye, 2) left cheek and 3) chin. The correctuve procedures would be: 1) Left cheek implant, 2) chin asymmetry osteotomy and 3) left orbital floor implant with eye corner adjustments. You have correctly surmised that improvement is the realistic goal not perfect symmetry.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a webbed neck. I have dealing with it for 50 years. I always wanted to improve the appearance of my neck. I’m unsure if I can gain more natural movement but I’m interested in finally achieving a goal of having a smaller neckline.
A: You have what appears to be a mosaic type of webbed neck which typically has less wide neck webs. But the skin and deeper soft tissues are tight and, as a result, does not respond well to webbed neck surgery.
FYI. Webbed neck surgery does not improve the range of motion of the neck.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I read your post regarding filling the step-off that occurs with sliding genioplasty.
Does this bone fill eventually become solid bone that is fused to the chin structure? Or does it remain bone chips? I’m fascinated by this technique as I worry that the step off of a sliding genioplasty will be visible and noticeable, especially in the jawline. How does this technique address these concerns?
A: I assume you are referring to the central stepoff of a sliding genioplasty as opposed to the lateral stepoffs that occur along the inferior border. The blog post to which you cite refers to the central stepoff as opposed to your description which refers to the potential lateral jawline stepoff.
As a general answer to your question about the fate of the use of cadaveric bone chips, if placed during the primary procedure, some of it turns into bone and some of it becomes fibrous scar tissue. But in either case it serves as a volumetric fill which its primary objective.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in potentially getting skull reshaping as I feel my head (temple area) is very narrow at the top instead of round. I have a heavy bottom/jaw that’s wider than my forehead. Would like it to be more balanced. Can I get information and range of potencial cost?
Thank you
A:Thank you for your inquiry and sending your pictures. What you are referring to are extended temporal or head widening implants that wrap around the side of the head to create increased width. Attached is an example of the concept as well as potential changes in you. (which can also be more or less)
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a question about chin reduction through the submental approach. From a lateral view, the protruded chin should be brought to the level of the lower lip. However, from the frontal view, what changes can we expect? Will the shape change considerably? If the patient wants it, could the shape of the chin be preserved? For example, keep a square chin square after the bone reduction.
Please advise
A:In a horizontal chin reduction the bone is reduced back and its shape can either be maintained or changed based on the patient’s aesthetic desires. Keeping a square bony chin shape is a predictable outcome.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
