Your Questions
Your Questions
Q: Dr. Eppley, I’ve always been self-conscious about my weak chin, but am unsure what the right solution is. I’ve received multiple consultations about options, but surgeons can’t agree on what type of implant is best. I’m curious whether you think an implant or a sliding genioplasty would be better. If an implant is the right choice — what type? Extended anatomical, flowers mandibular glove, something else? And what size?
A: The major decisions in chin augmentation are the method (implant vs sliding genioplasty) and the amount of changes desired (dimensions of augmentation….projection, height and width considerations). The method chosen is more emotionally driven in whether one is a more of an autologous person (anti-implant) or whether a ‘less invasive’ technique (implant) is preferred. As long as the dimensions needed fall within what each can do hen either technique is acceptable. Based on your pictures I would say that 10mms or less of chin projection is needed with no vertical change so either technique can achieve this type of dimensional change.
There are certain caveats in female chin augmentation that are important. First, less is always more when in comes to a horizontal projection. The most common error is overprojection. Females tolerate less change than men. The second most common error is a chin that becomes too wide. This is an implant related problem as winged chin implants are usually not a good choice for females.
That being said the actual dimensions of chin augmentation are determined preoperatively by imaging of the patient’s pictures of various types of dimensional changes to see what looks best to the patient.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in rib contouring to fix this protruding rib and to create a more narrow upper body.
A: You appear to have a unilateral subcostal rib flare. That can be treated by either cartilage cuts and bending of the flared segment (requiring 6 weeks of banding to ensure that it heals in an inward position or a more open shaving/excision of the flared subcostal rib margin.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I was wondering if orbital box osteotomy to increase my IPD, this is for cosmetic purposes, as my eyes are too close together, and I don’t like how I look.
A: The magnitude of orbital box osteotomy surgery is excessive and not appropriate for your IPD problem. It is a reconstructive procedure more than it is a cosmetic procedure.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I wanted to enquire if there’s any surgery/ treatment that would be able to soften my labiomental crease in my chin? I’ve been advised about lengthening my chin vertically but I’d be worried it would look too long from the front view. Could a fat transfer or bone graft to the fold area work? Or a intraoral release as most of my chin is soft tissue/ muscle. I have attached a picture below of my chin along with an edited version without the fold, which I’m wanting to achieve. Thank you
A: Thank you for your inquiry and sending your pictures to which I can say then following:
1) There is no question that your deep labiomental fold is due to the vertically short chin and a soft tissue chin pad that is bunched up on the short chin bone. In other words too much soft tissue for the amount of bone that exists tio support. This is also evidenced by the curved mandibular plane angle and a chin projection for a female that brings out toi the lower lip level. As a result any treatment that avoids dealing with the real problem is going to be limited in its effectiveness.
2) That being said the only non-bony lengthening treatment option is an intraoral release with an interpositional dermal-fat graft to help push out the depth of the fold. That will not create the degree of depth reduction you have shown, as that is not achievable, but it will help
Dr. Barry Eppley
World-Renowned Plastic Surgeon.
Q: Dr. Eppley, I am wondering if it’s possible to “heighten” the mentalis fat pad and mentolabial fold, and shorten the sublabial subunit using fat grafts to create the look of a more robust, masculine chin. I’ve made this mock up in photoshop and am curious to hear your opinion on whether it is plausible to emulate with surgery or not. I am also curious to hear from you from an anatomical standpoint on what exactly causes the variations in it’s height & position. Is it the mentalis muscle insertion? Or is it just the fat distribution? Thank you!
A: I think your chin appears that way due to the soft tissue distribution of the chin pad.
To potentially achieve that type of change it would require a combination of an intraoral dermal-fat graft underneath the labiomental fold and external subcutaneous fat injections.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Based on your experience and where craniofacial surgery is realistically headed, do you expect limited orbital widening for normal anatomy (beyond very small changes) to become meaningfully safer or more justifiable for cosmetic use in the next decade or do you see the risk–benefit balance staying essentially the same?
A: For eye widening using limited orbital box osteotomies already exists (inferior orbital box osteotomies) or can be done with 3/4 orbital box osteotomies using a coronal scalp incision if the patient can tolerate the fine line scalp scar. Both approaches avoid a frontal craniotomy which is what separates a more limited approach vs a major craniofacial surgery which is more justified in more severe craniofacial deformities.
It is eye narrowing on which the intracranial orbital box osteotomies can not be avoided for any degree of effectiveness.
I don’t see these approaches changing much in the foreseable future. The partint demand is low so the need for innovation for a limited market is likewise very low.
Dr. Barry Eppley
World-Renowned Plastic Surgeon.
Q: Dr. Eppley, I am interested in discussing testicular implants. I have read that Dr. Eppley does this procedure, and does it differently than some other surgeons, however, I see no evidence of this procedure on his website. Please confirm that Dr Eppley performs this procedure before I book a consultation.
A; I am not sure where you are looking. Between the Testicle Implant page on Eppley Plastic Surgery and all the content on the topic on Explore Plastic Surgery there is voluminous content available on how I perform the procedure and the implants used.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Can Mms chin be augmented successfully with less than 10mms projection?Also, I’ve found that almost no one mentions using Glasgold wafers or Flower mandibular glove implants. Are they just not as common? Or do they not work for my anatomy?
A: The relevance of the 10mm number is that is what creates the absolute separation between a chin implant and a sliding genioplasty. Any chin augmentation 10mms or greater can not be done with an implant as those sizes do not exist in standard implantys and would look odd in most patients with a large mass of implant sticking on top of the chin bone. This then enters sliding genioplasty territory.
Once under 10mms projection and no need for vertical chin shortening a chin implant is then possible. The reality is that all stahdard chin implants are not good for females becaiuse they widen the chin…which few females want. Only the anatomic chin implant style works for most females and even that style has to be modified to make sure the chin does not look too round.
Be aware that most plastic surgeons and patients focus exclusively on the side profile change in chin augmentation which is a 2D approach to a 3D facial structure.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a vertical line on my upper lip when smiling. I consulted a board certified plastic surgeon about options. He recommended “frenulotomy”. Stayed the only impact on smile would be “more incisor show” no other significant impact. My entire smile changed with drop of upper lip. I believe he did a tota frenectomy, releasing the connection of my nose to my face. Question: can anything be done to resecure my nose to face creating a bit more anatomically correct smile?
A: A maxillary frenulectomy is usually done in adults for a lip restrictoin. One of its potential adverse effects is upper lip lowering….not raising it. Once the frenum is released it is difficult to recreate it witout causing potental restriction in the smile
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I think the problem with my eyes is that the cheekbones are flat and wide. I would like to reduce my cheekbones a bit and maybe also the temple width or contoured. I need my eyes to look bigger and more open.
My cheekbones are flat and too prominent. I notice this more when i take a picture from below.
A: Thank you for your inquiry and sending your pictures, It appeatrs the lateral orbital rim and the cheekbones are wide. But I don’t find the temporal area to be wide. I think you are likely interpreting the prominent lateral orbital rim as the temporal area.
That being said a cheek bone reduction osteotomy wouod be the correct approach with the caveat that the anterior cheekbone osteotomy cut should include a portion of the lateral orbital rim as well.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello there, I have a tattoo going around my right wrist that I would to remove via surgical excision and skin graft replacement.
A: Thank you for your inquiry and sending your pictures. Excision and skin grafting of your circumferential wrist tattoo is one treament option for it. Whether that is appropriate for you depends on your understanding of the following:
1)With an exclusive black pigment this is the most responsive tattoo to laser treatments for removal albeit with the need for multiple treatments.
2) Excision and skin grafting offers immediate tattoo removal in a single treatment with the tradeoff of a skin graft appearance rather than that of the tattoo.
3) A split-thickness skin graft, while replacing the undesired skin area, does not create normal looking skin compared to the surrounding skin. It will create a wristband like appearance.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, how long I would need to wait after temporal artery arterial ligation to consider doing a brow lift? Or should I just wait and get the ligation done after the brow lift? It really makes no difference to me, I just want to do whatever will yield the safest and best aesthetic outcome for me!!
One concern I had was if I get the ligation and then do the brow lift, can the brow lift aggravate the ligated area in any way, or cause a new artery to pop up to feed the healing skin (from the brow lift incisions).
A: There are arguments to be made either way about doing the temporal artery location before or after the brow lift. I don’t really know what the exact correct answer is since this is a situation that I have not seen before. The brow lift is done at the subperiosteal level so it does not really influence the temporal artery per se. However, since the order of the procedures does not matter to you, I can certainly make the argument to getting the more extensive trauma of the brow lift surgery done first since it is no way interferes with the conductance of that operation and then do the temporal artery ligation afterwards. Then you would have the most assurance that surrounding trauma will not exacerbate the reduced prominence of the artery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Are you able to repair the greater auricular nerve that was damaged in a neck lift?
A:That depends on the nature of the nerve injury. Was it cut? Was it trapped in a suture/scar? Can the nerve or its ends be found amidst the scar? These are all questions which can not be known beforehand as there is no nerve imaging or tests that can identify the type of injury that the nerve has sustained. This information can only be known by intraoperative exploration which would determine what would be possible.
The symptoms you are having may provide some insight (numbness vs pain).
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, just inquiring. I don’t actually think there currently is any option, but is there any procedure to improve sacral sloping? Currently I have a very flat upper butt/lower back, but don’t think I’ve seen procedures for it. Closest is bbl, but that often seems to make the flatness more prominent in my opinion. Thank you for your time.
A:Not 100% certain as to exactly what you mean by sacral sloping, although I think I do, this is an area of very tight tissue attachments. As a result BBL surgery is going to make it look more flat and trying to inject fat into this tight tissue area is never going to work. It Is an area that likely could have an implant placed as this would be the only way to provide sustained augmentation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Adore Dr. Barry Eppley’s work! I have been a big fan for many years!!! I have never had a breast augmentation. My breast tissue growth is related to hormones. Because of that I have noticed significant reduction in volume on the top of the breast and would like an implant to help with this. I know that Dr. Eppley is a genius when it comes to implants and there is no one I would trust more!! I am very tall and my rib cage is set on the bigger side. So I am looking for a larger sized implant, I am afraid of a lift. Hopefully this helps get the ball rolling! Hope to hear from you
A:Thank you for your inquiry and sending your pictures. I can certainly appreciate your desire to avoid a lift with any form or amount of breast augmentation. The first statement I should make is that, by classic breast augmentation standards, you should never have breast implants without a lift. When the nipples of the breast mounds sit south of the inframammary fold (below the equator so to speak) no size of an implant is going to drive up the breast mound or nipples.. Actual lifting of the breast mound only occurs with breast implants when the nipple sits above the inframammary fold or when there is little breast tissue and the nipples sits at the inframammary fold. Clearly neither of these situations apply to you. What actually happens when you put a breast implant in when the breast mound is situated lower is that it actually drives the breast mound down further rather than lifting it.
That being said I have been ‘coerced’ to put breast implants in breast mounds like yours and usually the patient ends up regretting it as it gives the breast mound a peculiar double bubble shape and then the patient is almost obligated to have a breast lift later to rectify the iatrogenically created problem…. and the breasts lift becomes very difficult and limited because of the large implant
Thus my best advice is to either: 1) don’t have any aesthetic breast surgery and accept the breasts the way they are, or 2) come to grips with the reality that you really need a breast lift and have that done first. Then you can come back later and put in large breast implants with an the overall result that is going to be so much better. Don’t try to do the two together as it leads to adverse scarring and limits the size of the implant you can place. Staging such a lift and implant breast reshaping approach is clearly the far superior way to go.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I want to get the tail of my eyebrows and eye corners lifted. Is this possible in me since they are already a bit high?
A: Imaging is a very important step in considering any type of facial reshaping surgery. However it is first important to understand what imaging is and its role in that surgery is. It is NOT done to show patients actual surgical outcomes as nobody knows exactly with that could be for anyone with any surgery. Rather imaging plays two important preoperative considerations. In some patients, where a multitude of differing outcomes may be possible, imaging is done to determine the patient’s tolerance for the amount of change that could be done. In other words how much change are they seeking. Conversely in other patients with the outcomes by their anatomy is going to be more limited, another words you can’t just do anything, is done to show what the surgeons think is the most that is possible. It is the latter that applies to you when you have are ready high brow and lateral corner positions. In other words in this situation imaging is done to help the patient determine that if this the best result that could achieve would they still consider having the surgery. The immediate patient reaction to such imaging will determine the patient’s candidacy for the procedures.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, mTo complement rib removal surgery, I would like you to perform resections of the dorsal muscles, liposuction, and a corset-style back lift to amplify the effects of the surgery.
A: The vertical backlift to which you refer can be done provided one has adequate lax back skin to make it effective without creating undue tension on the mid line resultant back scar down the center of the spine.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, In the shoulders, I’d like to have a shoulder reduction with scapular filing. I’d also like to know if you file down the acromion? And if you can change the angle of the clavicle to a more feminine one, since the angle between men and women is different.
A:For shoulder reduction the typical clavicle reduction osteotomy’s are done. Whether that changes the angle of the clavicle to what you call feminine is not an element of the surgery in which we have any control. The change in the clavicular angle will be whatever the osteotomy creates. One can reduce the height of the scapular spine on the back but this will require a separate incision to do so. When you refer to reducing the acromion process most likely you are referring to the upper end of the distal clavicle before it becomes part of the AC joint. That superior clavicular knob can be reduced.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,In the pelvis, I’d like to have a pelvic scraping to improve the waist-hip transition. Another question: do you file down the iliac spines? Because mine are very prominent and pronounced.
A: for iliac crest reduction this is done from the anterior superior iliac spine back to the mid-portion of the crest where it turns inward at 45 degrees towards the spine.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I’ve been looking at your posts and I’ve noticed that you can modify the ribs up to the 7th or 6th, if I remember correctly. So I’d like to have a rib removal from the 12th to the 9th or 8th, and for the other two ribs or the rib above, an osteotomy to reduce them.
A: For modification of the lower rib cage I have expanded the level of the rib reductions up to nine and eight with osteotomies at these upper levels. This can certainly be done as long as one can tolerate the longer vertical lateral back scar to do so.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I want to have a mouth narrowing procedure.
A While mouth narrowing surgery is possible I would be cautious about it due to the scar line that will result in the wake of moving the mouth corners more inward.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I desire all the procedures of a complete facial feminization, I want to use a more bony and deeper approach to the bone structure. That is, common facial feminization addresses the bone, but mostly by filing it down. In contrast, I have observed that the male face, in its physiognomy, is not only defined by volume but also by projection and position. For example, the forehead joins with the zygomatic bones, forming the orbital cavity, creating a masculine shape that cannot be eliminated by filing. In other words, in craniofacial surgery, modifications are made to the facial frame, the orbital rim, and the orbital cavity, reducing facial projection. Furthermore, I want to achieve a smaller, more rounded face.
A: The first apace to start in considering facial feminization is to do an assessment comparing your 3D facial CT scan with imaging of your facial pictures to see what is and what is not possible. By definition facial feminization is a reductive bony reshaping of the face based on a collection of bony contouring and osteotomy/ostectomy procedures.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Regarding the head: – I would like to have a facial and cranial reduction and feminization procedure. This means shortening, narrowing, and filing down the bony prominences of the skull to make it more rounded and smaller, that is, more feminine. Among the things I want most is to reduce the lower sides of my head, which make it appear longer and more masculine because of the mastoid processes. Being larger and longer, these give the appearance of a thick neck and a long head. Clarifying that I desire all the procedures of a complete facial feminization, I want to use a more bony and deeper approach to the bone structure.
A: To do a proper assessment of your skull reduction goals, to determine what is and what is not possible, this will require a 3-D CT craniofacial scan to have a full understanding of the bony and anatomy as well as what limitations may exist for the degree of reductions desire. For example, there are going to be limits as to how much the mastoid process can be reduced due to the underlying air cells.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My face is wide and short. How can I fix it?
A: In the wide and short face the typical approach would be to lengthen it vertically at the chin area and do soft tissue reductions in the cheek and lower facial area. However your pictures shows a very prominent chin that already is too long and prominent for the typical female face. Thus this poses a bit of a quandary has to what approach would serve your best as the facial lengthening component of making the face less wide is synergistic with any facial narrowing efforts.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m looking into the temporal reduction for the width of my forehead.(temporal muscle reduction) Looks to be the most solid option from what I’ve researched. Seems like my width/corners of forehead are just wide and pop out too much throwing my face off if i dont have hair covering my forehead or a hat on.. Not exactly sure what is best etc, open to opinions and what not from the professionals.
A:Thank you for your inquiry and sending your pictures. You have a classic excessively convex shape to the side of your head due to enlargement of the temporal muscles. This is not a bony deformity but a soft tissue one. In your case of temporal convexity, as it appears to involve both the anterior and temporal components of the muscle, it would require a combination of posterior temporal muscle removal and transposition of the anterior portion of the muscle to create the most effective side of the head reductive reshaping.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I understand that the most common approach to treating VOD involves an orbital floor implant. I also note that he mentioned that performing a floor implant would likely require repositioning of both the upper and lower eyelids.
A:An orbital floor implant is the easiest and most predictable part of VOD surgery. However, it alone rarely addresses the problem and is just a part of the solution but not the complete one. If you just lift up the eyeball and don’t change the brow and eyelids around it you actually make the problem worse by burying the eyeball underneath the upper eyelid and increasing scleral show on the lower eyelids. Therefore, in almost every case of VOD you have to go ‘all the way’ to obtain a result where all the components fit together in for a more symmetric and natural looking result. This means, besides the orbital floor implant, the upper and lower eyelids need to be repositioned as well as a brow lift on that side.
In addition it will not change the position of the medial canthi although the inner eye corner at the junction of the skin and lacrimal lake can be adjusted for that.
Therefore, as you can now appreciate one has to make the decision as to whether it is best to leave the asymmetry alone or go all in and have the maximal surgery. for it.. with the understanding that the degree of eye symmetry will be reduced but will never have perfect symmetry to that of the opposite eye.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, how can I attempt to improve my asymmetrical eyes? You will note that the medial canthii are different to each other.
A: I assume that you realize that the differences between the two medial canthi positions is relfective of the more global issue of vertical orbital dystopia (VOD). The right eye and the structures around it (right VOD) sits lower than of the left eye. The question then becomes do you treat the one component of it that you asked about (inner eye corner repositioning) or would doing just unmask the other VOD components that exist.
Q: Dr. Eppley, I would like to know, in my case if an occpital bun reduction would be possible. I would also like to know if Dr Eppley use video consultation for clients from others country. Thank You
A: You have provided the definitive answer to the question of whether occipital skull reduction would be effective via your lateral skull film as well as the meaurements of the bone thickness shown on it. I have drawn how much bone can be safely removed from the occipital bun (red line) which indicates based on my experience a visible reduction in its prominence.
The virtual consultation method is how I consult with everyone initially no matter whether they are geographically located.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I do have a couple of follow-up questions as I think through which approach would be the best fit for my goals:
- For Rib Xcar, since the permanence is listed as dependent on corset wear, is there any updated information on how stable the results tend to be long term once patients stop wearing the garment?
- For rib removal, is there an estimate of the typical amount of waist reduction patients with a frame similar to mine can expect?
A: In answer to your rib remodeling questions:
1) is there any long term data about the stability of the ribs in RibXcar? Not that I have seen which doesn’t mean it does not exist…just that I have not seen it. Presumably after 3 months the ribs have healed in their new shape.
2) The range of 1″to 3″ of waist reduction base on what patients have told me.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi I wanted to ask does this top of skull surgery make the face look visually longer once it’s shaved down I can’t see the patients full face but I have a feeling the face could look longer after this surgery? Im trying to work out if it’s suitable for me or not. Thank you
A:Thank you for your inquiry and sending your pictures. In theory one would think that of the top of the head is reduced that the face may look longer. However I think that is only true if one shortens the vertical length of the forehead which is not what occurs the top of the head skull reduction. That being said the best way to answer that question is to take your pictures and do a top of the head reduction and see what you think about its impact, if any, on facial length.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
