Your Questions

Q: Dr. Eppley, I have vertical orbital dystopia and I was hoping to receive resources for scheduling a head CT scan.

I’ve read your “Outcome from Comprehensive Six Step Approach to Vertical Orbital Dystopia Correction” case study, and I found it fascinating. Are there any other available resources out there regarding your VOD treatment?

I would also love to see a gallery of more results, especially in regards to seeing patients who also opted to have upper eyelid ptosis repair.

A: Your VOD is too severe for this form of aesthetic VOD surgery. The left eye is more than 5mms lower than the right eye and can not be significantly improved by this camouflage approach to VOD correction. You need an orbital box osteotomy technique through a frontal craniotomy to have an effective change.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can you do skull augmentation  surgery with bone grafting? No synthetic or artificial materials should be used.

A: The short answer is no. The long answer is… while skull defects are treated by autologous bone grafting aesthetic skull augmentations can not. Besides the wide open coronal scalp incision needed to do it there is the amount of bone grafting that would be needed and the associated morbidity of the harvest site. (e.g., a 150cc skull implant would require almost the entire fibula of the leg to be harvested for an equal volume or 6 ribs are needed) Then there is the biologic changes that happens to all onlay bone grafts to the skull or face…they undergo variable amounts of resorption and end up with a very irregular surface.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is the silicon implant for narrow head permanent? What are the most common complications for this procedure and how do these implants stay in place?

A:In answer to your skull augmentation questions:

1) All silicone skull implants are material wise and structurally permanent.

2) There are few complications with onlay skull implants but would include infection (not yet seen) and aesthetic issues of implant edging (most relevant risk in the shaved head male) and he scalp incision/scar needed to place it.

3) There has never been a case of skull implant migration because the sixe of the implant, the tightness of the scalp and the natural encapsulation process all work to secure it into the position it is surgically placed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello there, I would like to ask a question regarding otoplasty.  I had undergo complicated otoplasty in the last and ended up with a defect in post auricular area, therefore I want to recreate natural and proper anatomy of post auricular area. 

 To make natural convex shape from posterior side. I was wondering about 

 Own Rib Cartilage 

 Cadaver Rib Cartilage 

 Cadaver Ear Cartilage 

 Custom made thin silicone implant 

 Or whatever I dont know what may work for me but one thing I know it has to be super thin. 

 Thank you and let me know.

A:You are never going to make the postauricular sulcus normal again as it has been permanently surgically altered. But in the effort for improvement a thin cartilage graft is needed not an implant. One can debate between cadaveric vs autologous cartilage graft but a cadaveric one would be easier to care and make thin without a donor harvest.

Dr. Barry Eppley

World-Renowned Plastic Surgeo

Q: Dr. Eppley, I have a scoliosis that caused me to have deformity of my rib cage. Also, on my left side I have a rib that is causing me pain (I believe that it is touching a nerve or something) I would like your opinion on what are my options and what can be done to relieve me from my pain and make me look more symmetrical. Thank you!

A: Thank you for your inquiry and sending your pictures. Your scoliosis and and waistline asymmetry are very apparent. (see attached) Since your pain is on the left side (shorter side from the scoliosis) it is very possible that rib #12 is impinging on the iliac crest (ilio-costal syndrome)  While this can occur in any patients with elongated lower ribs the scoliosis patient is more at risk for it due to the twist in the ribcage. It would take either a plain x-ray ( or more ideally a 3D CT scan) of your spine and ribcage for confirmation. If so pain relief is usually achieved by shortening ribs #11 and #12.

From an asymmetry standpoint this is a bit more challenging since we can’t change the foundational position of the spine and the attached ribs. One option is to consider differential lower rib removals of #11 and #12…more on the right than the left. The effectiveness of that approach requires a good understanding of the lower ribcage anatomy from a 3D CT scan.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,You are a tremendously talented surgeon and I see you specialize in chin surgery. I emailed you close to four years ago, asking your opinion on a chin implant. And you recommended a sliding genioplasty. Here’s what you said:

“…You have a fairly short chin that is angulated backwards and is vertically long. With such anatomy you are not really a good candidate for a chin implant as implants are technically designed to sit on the front of the bone which will make your chin longer. The implant can be moved up higher, but this is not how they are ideally designed to work. You are a far better candidate for a sliding genioplasty which can bring your chin forward AND make it shorter. This may not be the operation you want but it is the better chin augmentation option from a dimensional standpoint than an implant with your anatomy.“

I’m still interested in surgery, however, I am not able to afford the genioplasty surgery or the recovery time as a mother. I am 43. During our correspondence, you mentioned that you could do an implant and fasten it to the front of my chin, to avoid lengthening the face (though it wouldn’t be fully ideal). I am wondering if you would be open to that as a different option? I am looking for very conservative results – natural, feminine, so you can’t even tell it’s done… and so the pre-jowl sulcus is gently filled in. Many thanks for your consideration. The way you help people is just amazing.

A: Good to hear from you again. The key to a chin implant in the severely horizontally short chin that has a backward slope is not to try to make it ideally normal in projection as this will also make it vertically longer. Choosing a conservative projection (5mms) will mitigate that risk as the implant will need to sit not right at the bottom of the chin bone but a bit further up. Be aware that any chin implant with wings (for the prejowl area) will from the front view make the chin a bit wider.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I’m just getting in touch on behalf of my husband. He is desperate to have this lump removed from the back of his head, is it possible to have it removed? If so, is it possible to have some information on this along with a price ect. Look forward to hearing from you! Many thanks.

A:Thank you for your inquiry and sending your pictures. I believe you are referring to the protrusion that lies between the two horizontal scalp lines which appears like an occipital knob. (see attached picture with arrow) That bony protrusion can certainly be reduced and he has the convenient horizontal line beneath it to do so. It may also require a bit of overlying scalp excision since there is some soft tissue redundancy over it…as an assurance that complete flattening occurs without aggravating the overlying scalp redundancy.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a torn bicep and it looks like I only have half the muscle. I was wondering if an implant could cover that up and look normal either with half the implant or the full one.

A: While an implant is the only option to create some restoration of bicep shape I would not consider that it would look normal compared to the other side. Bicep implants are placed either under the muscle on the bone or on top of the muscle under the fascia. With a torn retracted muscle neither of those standard implant locations exist. Now the implant has to be placed mainly in the subcutaneous tissues and be positioned up onto the residual bicep muscle mass. Thus the restoration of some muscle mass can be achieved  but how the implant-muscle interface would appear requires pictures from numerous angles with the muscle flexed and non-flexed for a more in depth analysis.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Happy new year! I hope you’re well. Your website is an incredible resource, I have some more questions about Facial Feminization.

I had an extensive mandibular osteotomy at another clinic and pursued a deep plane facelift with a platysmaplasty a year later to address jawline definition and redundant laxity. Due to the vector of the lifts in this case being more lateral than vertical, I still have a problem with my midface area which appears broad due to large/flat zygomas. I prefer a softer aesthetic and am seeking to avoid adding extra lateral projection, favoring more forward. To this end, as I consider zygoma reshaping (rather than reduction), I wondered what the differences are between a zygomatic sandwich osteotomy and a malar rotation (as performed more commonly in South Korea)?

That and whether any buccal fat pad movement, as a consequence of cheek bone adjustments can be mitigated by a mid-face lift?

A: Neither a zygomatic sandwich osteotomy which increases lateral cheek width nor a zygomatic reduction with malar rotation which decreases lateral cheek width will create more forward projection, only an implant can  make that happen. There is no bony osteotomy that effectively pulls the cheekbone forward.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a revision genioplasty because I believe that my chin looks too big in certain angles and I have the step off deformity. The doctor that I consulted said that he could cut and shave the bones to create a more regular jawline and a less prominent chin. I started to look for more information about this procedure and I found one of your blogs, in which you mention that when this is done, a hemostatic resorbable material is used over the bone. I would like to ask you then, what specific materials are used? How long does it take for the body to absorb them? Ar they absorbed in a predictable manner or can they leave jawline irregularities?

A: You are referring to the use of Lactosorb (PLA-PGA polymer) resorbable plates and screws for chin fixation. It takes 6 to 9 months for the devices to be fully absorbed. Whether the chin osteotomy can be fixed with a plate and screws or just bicortical lag screws depends on what amount of chin bone movement is needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Looking for pricing for a flat top of head and narrow forehead. Was looking to widen forehead and make top of skull taller and rounder.Have no idea if this is even feasible for me,

A: The area of skull implant coverage is not the question. it would be about how much of augmentation of the covered area can be achieved given the stretch capability of the scalp over it. (limited to 125 to 150cc implant volume) That can only be determined by doing the actual implant design.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a few questions.

1. If I had a particularly large genioplasty movement (done over 2 procedures), would a VLC implant still be able to cover the step-off or would it be too far back?

2. Would such an implant make the bottom lip sag more?

3. If the implant gets infected down the line, say decades later, what should I do? Would it need to be surgically removed?

4. Is there such a thing as a custom fitting VLC implant?

A: With a large sliding genioplasty movement the soft tissue chin pad is going to be tight. Thus only a minimal chin implant overlay could be done regardless of the movement dimensions. But regardless of the dimensional movement only a custom designed chin implant could do so.

It would not cause a lower lip sag

Like all implant infections anywhere removal is the definitive treatment.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had my left testicle removed about 22 years ago due to a sports injury. I had a saline testicle implant placed about 18 years ago. It is sutured in place and is very firm/hard. A couple years ago I started HRT to boost my testosterone and since starting that my right testicle has shrunken quite a bit. My right testicle is small and very soft, it also sits higher in my scrotum and feels like it’s not even in my scrotum sometimes. Last year I had HA filler placed in my penile shaft to add girth. The larger penis size now outshines the scrotum…honestly I just feel like I don’t have much of a “package” in my scrotum. I’m interested in replacing my left implant with something more realistic and bigger and also enhancing my right testicle to give my scrotum a better fill.

A: Besides having an inadequate testicle implant replacement you are describing classic penile-scrotal disproportion. The replacement of the existing testicle implant with an ultrasoft larger implant is obvious. For the shrunken right testicle I would use a displacement implant technique given its small size and high position in the scrotum. The only question is what size the new testicle implants should be. Usual implant size ranges in these situations is in the 6.0 to 7.0 range.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in improving my chin. I would like to get a square chin. I believe I need a genioplasty and would like a consult.

A: The only way to make a chin more square is with an implant. A bony genioplasty can not increase the width or squareness of the chin.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, ‘m 27 years old. I’m considering a surgical lip lift. My biggest concern is the length of my philtrum and the thickness from a prominent cupid’s bow (I think). Overall, I feel I have a large imbalance to my lower face and only see a mile long philtrum when I have a resting face. I’ve tried a lip flip botox and lip fillers in years prior, which made it worse. I had all filler dissolved a while back. I also had Invisalign a few years ago and wear my retainers religiously, so my teeth shouldn’t be the issue either.

A: You have correctly surmised that with your very long upper lip that only a subnasal lip lift can help. But with a thin lateral vermilion show the subnasal lip lift would need to be done concurrently with lateral vermilion advancements to avoid an A frame lip deformity.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have something like a bump or protrusion in the forehead as a result of many bruises in the same place…the bone itself has a protruding part in the forehead.

I wanted to know if this could be treated by like sanding or something similar to remove the part that has a protrusion.

I read a lot and  I saw videos and I think shaving it is the best option for me

I have attached pictures

A picture (drawing) to clarify the condition, the red line is what I should be like 

the other pictures of me, but it is not really clear in the picture, you can notice the shadow underneath it.

I want to know whether it can be done, how, what complications may occur, and all the information about the operation, in addition to the fact that if part of the forehead is opened, I will reduce it a little as well, because I have a large forehead too.

A: You are referring to two very different forehead reduction procedures, both of which can be done together, bit with very different aesthetic tradeoffs.

If the shaving is done remotely using large skull rasps this is done through one or two very small halrline incisions of 5 t0 6mmd in size.

If a frontal hairline advancement is done this is carried out through a frontal hairline incision from side to side. Such an incision provides obvious unlimited access through which high speed burring of the lower forehead protrusions can be done.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Dr. Eppley, I wonder if it is necessary for me to remove the titanium plate after a sliding genioplasty?

After mentoplasty, I have no discomfort except for occasional acne. However, I am concerned that an accidental impact might cause the titanium plate to loosen, leading to infection. Should I consider removing the titanium plate around one year after the surgery?

A: There is no compelling reason to remove the hardware after a bony genioplasty…unless there are symptoms associated with it. (pain, sensitivity, loosening, temperature sensitivity)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wanted to know if you could help me or have any services/procedures for this. I have this line/indentation on the back of my head, it’s sort of in the middle too. It feels like mostly skin and fat when I touch it. I wanted to know if there is a way to reduce the appearance of this indentation. I attached a photo for reference.

A: Your assessment of the anatomic makeup of the linear indentation is correct. This is a classic linear indentation of the upper neck (it is below the nuchal line of the skull) due a scalp roll above it. (excess skin and fat) This is best treated by excision of the indentation and scalp roll and closure is done creating a smooth contour. There is a fine line scar as a result but you already have the appearance of a scar now due to the indentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I read your article about the custom skull implant correction of a coronal skull depression, and was relieved that something like this could be a possibility for me. This would be absolutely life changing. How long does it take to perform? Any information would be greatly appreciated.

A: Coronal dip depressions are treated by a small custom implant to fit into the defect and blend in smoothly to the surrounding skull. It is inserted through a small scalp incision. (2cm in length) It is a one hour surgery done under general anesthesia as an outpatient procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi! I had an underbite growing up. It was fixed by braces but still my lower jaw is still protruding. Dentally, I am edge on edge but skeletally and aesthetically, underbite. My cheeks are weak too. I am looking for other option aside from jaw surgery. Came across with your cheek maxillary implant, do you think it’d work for me?

A: You have correctly surmised that , as long as you can accept the edge-edge bite relationship, a custom midface mask implant is the correct surgery to improve the projection of the entire midface including the cheeks.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m wondering if you hasve any longer term follow up photos of patients after getting custom testicle implants. The only ones I can find are from the day of surgery, which shows a tight scrotum. I’m curious to see how the scrotum relaxes and the implants drop over time…what the end esthetic result is. Let me know if you can help me with this.

A: I can not. Since we don’t see any patients long-term back in the office for visual inspection (no patients are from here as they are from all over the world) I can not speak to the exact aesthetic outcomes of their long-term results.

I do encourage patients to begin the use of ball stretchers  beginning 30 days after the surgery and it takes 3 to 4 months to see maximal stretch and relaxation. (e.g., just like breast implants)  I have yet for a patient tell me that they have remained too high.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, After going through the amazingly detailed information on your website regarding the posterior temporalis muscle removal, I just had one question that was still in the back of my mind – does this surgery remove\disrupt any of the arteries\blood flow to that area of the head (like the superficial temporal artery or carotid artery)? Just wondering, as I’m not sure what the health effects of that type of disruption would be.

A: This surgery does not disrupt any arteries to the scalp. These arteries run above the temporal muscle fascia while the muscle removal is below it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My question is what’s the outcome of the differences between shaving the zygoma and the radical surgical method of cheekbone reductions? How much on average is each one? Do you have a before and after results/pictures of the shaving method being used on patients? Lastly, how invasive or risky is the other one like does it require screws and plates to keep the fractured zygoma in place or can it all be shaved to the back ends of the arch?

A: For cheek reduction shaving the zygoma is almost always a bad idea as that strips of all the soft tissue attachments, denudes the bone surface and prevents any soft tissue reattachments….i.e., cheek ptosis will assuredly result. And I assume you are referring to the zygomatic major part of the cheekbone and not the arch where no surgical access is possible as any shaving attempt is limited to the front end of the cheek bone only. Only cheekbone osteotomies can reduce the width of the entire cheekbone length with less risk of soft tissue cheek ptosis.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Interested in correcting rhinoplasty surgery.

A: To do a proper assessment I would need some information about your prior rhinoplasty surgery:

1)When was it done?

2) How was it done? (open vs closed)

3) What do you not like about the result?

4) Need before and after pictures of your nose.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I was wondering your thoughts or if you were using verteporfin with the idea of helping treat and or reducing scaring and conserving hair in incisions made during surgical procedures. I know it’s a new treatment being used in some hair transplants clinics with what looks to be great results so I was curious on your opinion on the subject and if you think it’s something that would be beneficial. Thank you very much for your time.

A:Verteporfin, aka Visudyne, is anFDA approved injection as part of Photodynamic therapy for leaky blood vessels in ophthalmology. Its mechanism of action is cytotoxic to endothelial cells when activated by light in the presence of oxygen. Its off label use for scars, while more commonly done now, is being espoused as having a positive effect presumably through its antifibrinolytic action and inhibition of collagen cross-linking. I have no experience with it so I can not say if it has a positive effect or not. The evidence for its benefits is certainly anecdotal but that doesn’t mean it does not work.

Like all therapies being used that have uncertain benefits the real question becomes not its benefits but the risks of using it. If the benefits are uncertain (touted but not scientifically proven) and the risks are zero of any side effects than the only question to be debated with its use is economic. (how much does it cost) This explains the historic use of PRP, for example, and more currently TXA. But if there are adverse side effects in the face of questionable benefits then I would say don’t use it. When it comes to Verteporfin used as a direct injection into the incisional closure/scar I am not aware of any significant adverse effects. The unknown variables are dose and frequency of injections.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have two different eyeball heights. I think that lowering the left eye to the right eye’s height would make for a better look. It creates a better FWHR ratio from the lowered eye height. It is pretty invasive but it is worth it.

A:Then you are referring to a left orbital decompression procedure in which the orbital floor is dropped anteriorly which will make the eye drop down a bit. Be aware of two things in regards to unilateral orbital decompression:

1) It is not completely predictable/controllable in terms of how much globe drop may occur., In words it is not 1:1 in terms of how much the bony floor is lowered vs how much the eyeball drops. You have to know that orbital decompression was developed in thyroid eye disease for extremely bulgy eyes in which both sides are treated similarly. When applied to aesthetic vertical orbital dystopia (VOD) it now becomes a unilateral procedure in which a very specific target I(e.g., 3mms of pupillary line discrepancy) is sought and by which the result can be very critically assessed. (the opposite desired eye position) In short this is really a ‘macro’ procedure being used for a ‘micro’ outcome….which means perfectly symmetric eye levels is nit likely be achoved. Better…yes, perfect….no.

2) As the eyeball is lowered the upper and lower eyelid positions do not change. Thus the relationship between the lid levels and the iris will change. (lower lashline moves up on iris closer to the pupil and the upper eyelid moves up on the iris away from the pupil. Unlike elevating the eyeball where lids can be adjusted upward as needed, when lower the eyeball there is not good way to adjust the eyelids downward.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I had a quick question regarding thigh implants under the quadriceps muscles. Due to them being placed inside the quads will it result in decreased muscle gain in the thighs or decreased strength long term?

A: In regards to thigh implants they are placed under the fascia but on top of the quadriceps msucle. (rectus femoris and lateralis) not under them. I am not aware that this  causes any long term muscle injury, atrophy or weakness.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a few questions for you about temporal reduction surgery if that’s alright:

1) Are there any visible scars that result from the surgery? Would they be permanent?

2) Have any adverse events (especially health concerns) been reported from patients who got the temporal reduction surgery, and if so, what did they report?

A:1) The incision is placed behind the ear in the postauricular sulcus so there are no visible scars.

2) They have been no postoperative functional concerns of lower jaw motion, discomfort and limitations in chewing/eating.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Are you able to provide information on the dimensions of the simulated custom facial implant used to generate these picture predictions? Is it possible to see the simulated implant overlaid on my skeletal structure (from CBCT scans)?

A: This picture imaging is done under the following  concept:

‘The purpose of computer imaging is frequently misunderstood by patients. Computer imaging is done to help determine what the patient’s aesthetic goals are. It is a method of interactive visual communication between the patient and surgeon to help establish what their specific facial reshaping goals are. Your task is to evaluate this initial imaging and determine what you like and don’t like about it. Then I adjust the imaging to make it the way you eventually like it. This then establishes the aesthetic target from which the operation can be designed to try and come close to the target.

In answer to your specific question:

1) As you now can now see based on the imaging purpose description the imaging is not done with any specific implant dimensions in mind.

2) Only when the formal implant design process is initiated is the implant designing done on the 3D CT scan.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m very insecure about the loose skin hanging down my cheekbones under my temples. This problem started after cheekbone reduction surgery. The loose skin makes my face asymmetrical and seem wider than it is. Attached are photos showcasing my problem. The photos where I’m using my hands to lift the problem areas is the look I want to achieve. What are my options? 

A:You have a not uncommon sequelae from cheekbone reduction surgery particularly if wide periosteal undermining and releases are done. The only option to treat it is a temporal browlift of which different techniques exist to do so but the most effective is the hairline method.

Dr. Barry Eppley

World-Renowned Plastic Surgeon