Your Questions

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

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

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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

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

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

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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

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

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

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

Thanks in advance

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

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

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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

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

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

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

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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

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

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a pretty healthy and lean person overall with a low body fat percentage. However my face holds a lot of face that isn’t proportionate to how much overall body fat I have. As a result, my cheeks are chubbier then they should be and I have received buccal fat removal but that did not really impact much as the fat is above the buccal fat area. My question is there anything that can be done to remove the fat, not sure what other procedure would even work but is there anything that would spot target that?

A: In the upper cheek area to which you refer there are no significantly effective methods of fat removal. This fibrofatty area is not a great area for liposuction and there are branches of the buccal facial nerve so the risk vs reward benefit is not great.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  Can I get orbital box osteotomies if I have had prior orbital decompressions?

A:As for the close set eyes the only effective procedure in an adult would be a subcranial 180 degree orbital box osteotomy. But having had orbital decompression with bone removals, both medially and laterally that is a procedure that would probably not be effective now. (the bone would probably fracture)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, what are the side affects of skull reshaping surgery?

A: This patient failed to provide what procedure to which he refers. Skull reshaping is not a procedure, it is a broad term related to a collection of over 30 procedures done to augment or reduce parts of the skull/head. In other words I can’t properly answer the question unless I know the exact procedure to which he refers.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in hip implants. I am tall and lean with little fat.

A:Thank you for sending your pictures. With a very lean body and with decent thigh musculature despite the lean frame  I can certainly see why the interest in hip implants. My initial general comments in hip implants based on a lot of patient experience is the following statement:

Hip implants have a fairly high rate of complications so patients have to be selected very carefully to try and lower those risks. There are two major risk factors, 1) thin patients with little subcutaneous fat (inadequate soft tissue cover) and 2) implants that are too big. (too thick for the tissues to adequately support them) The key to lowering these risks is to avoid putting in an implant size that exceeds their soft tissue capability to adequately handle it. (aka provide good camouflage of its edges)

While these hip implant issues certainly apply to you (thin subcutaneous fat layer) the key to lowering these risk is keep the implant projection at 1.0 to 1.2cms and the vertical length of the implant not overly long. (less than 20cms)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m just wondering in clavicle reduction (shoulder narrowing) surgery will this cause long term side effects like hunched back or muscle pain or upper body motion restriction?

A: No it will not.Such effects would only occur in longer segments of clavicle bone removal than the procedure is capable of doing.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have some other follow up questions relating to a skull implant. I’m trying to get a better idea of how this will impact me in the long term if any medical issues arise that I would need testing or imaging for. Would this affect my ability to get an EEG, especially measuring any activity in that frontal area where the implant is placed, either from the screw or the implant itself? Have you had any patients that have reported any impacts or limitations to diagnostic testing of the head/brain due to this kind of procedure?

A:When it comes to CT and MRI imaging a skull implant or its titanium screw(s) do not pose any restrictions on getting it or affecting the obtained images. When it comes to an EEG this is not a question that I have ever been asked before or have ever had a postop patient who needed an EEG.  So I can not provide a qualified answer in that regard. I suspect that neither pose an issue, particularly the implant. But if any doubt don’t use a titanium screw for fixation. (it is nit usually an absolute necessity in some skull implant cases)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi can you guys do a male to female head/ skull reshaping to make my head more like a female shaped head, if so how much would that cost?

A:Feminizing the head is largely a function of reducing prominent areas such as the bony temporal and particularly the forehead since it is the most visible part of the head given hair coverage. But determining one’s skull reduction and its potential benefits has to be done on an individual basis so there is not a standard formula for doing so. This process starts by first getting some pictures of your head, getting a description of your head shape concerns and then doing some imaging if the hair permits it. Thus what your specific skull reshaping needs are remains undetermined presently and until that is better known we can provide a cost for doing so.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, as you can see in the photos i have an irregular shaped forehead. I’ve gotten CT and MRI scans and they say nothing is wrong. But I’ve always had discomfort in this area, all my life. Unfortunately I’m not located in Indiana, but I can’t find anyone that can do this. I have a copy one CD format of my CT scan. Please help.

A:What you have are classic prominent forehead eminences. (aka forehead horns) These are aesthetic bony prominences so a CT scan is not going to show any abnormality, it will only show how thickness of the bone in that area of the forehead. These are not known to be associated with discomfort so I have no explanation for that symptom. In improving the shape of your forehead there are two very different directions to go, reduction vs augmentation. In a flatter maie forehead reduction of them would be the unequivocal choice of treatment. But your forehead is sloped/narrow so camouflagung them by building out the forehead around them is an option. But in the end the approach is one that the patient aesthetically prefers.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have questions/concerns about my facial implants which were placed six months ago and have healed fine.

1)Are there still risks of infection?

2)If so, what precautions can I take to minimize the risk of an infection occurring?

3)Can a general infection cause an infection in my facial implant?

4)For instance, is it possible for a foodborne infection, like one from eating raw fish such as sashimi, to lead to an infection in my facial implant?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a chin implant with terino style 1 back in February. The issue is that the chin looks pretty different from the front and the mental crease has drastically increased; the bottom part sticks out more than a normal chin should. What can be done, if anything at all to fix this problem?

A:What you have undoubtably discovered is that when considering chin augmentation you need to factor in what it may look like from the front as well as how it looks like in profile. Too many patients and surgeons only make chin implant decisions based on how things may  change in side view. By definition every chin augmentation will deepen the labiomental fold, this is unavoidable. The more horizontal projection the implant has the deeper the fold will get. How much projection a chin should have is open to personal interpretation so this is an important issue to determine before the surgery. I would ask if computer imaging was done before surgery of differing amounts of horizontal chin projection so YOU could provide insight into what looks good to you….but that is a question to which I already know the answer. (it was not done)

That being said the only way to improve your current concerns is to replace the implant with a smaller one.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, In attempting to find a solution for my columella show (image included below) I recently read a paper “Alar Batten Cartilage Graft: Treatment of Internal and External Nasal Valve Collapse” published in Aesthetic Plastic Surgery (paper attached).

My photo below shows my current situation – my previous surgeon seems to have conducted an alar rim reduction in conjunction with the lip lift. As a consequence, I have less support in my sill and very little philtrum. Elevating my columella also raises my upper lip (which is not an entirely unwanted effect [exaggerated below] as it helps to address some asymmetry).

I found the paper very informative, largely because it contains a case showing a nasal sill being elevated and stabilised through the use of an alar batten graft. This is in Figure 11 (shown below), which also demonstrates a case of congenital nasal valve collapse. The postoperative images show a profound improvement in the nasal sill anatomy, which I find quite remarkable. While I understand the primary purpose of the alar batten grafts, I’m curious about the specific forces at play that led to this significant change in the nasal sill.

Do you have any insight into this effect and how it might be applied to my situation? My hope was that through a series of alar grafts and a columella retraction suture(s) I might be able to improve my current situation, though I’m unsure whether increasing the projection may also assist. 

A:The answer to your question regarding nasal sill/rim retraction is that structurally the three maneuvers of alar rim grafts, tip derotation and columellar retraction suturing are all that is possible to try and improve your current situation. All I can say about them is to increase the chance of their success is: 1) all three must be done concurrently (difficult problems require maximal effort)  and 2) a rib graft may be needed to provide adequate material for the grafting. The other alternatives are combined septal and ear cartilage grafts.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have found your website a fantastic source of information. I hope you don’t think I’m taking a liberty by contacting you but I wonder if you would kindly answer a question for me as I can’t find the information elsewhere. My daughter had injectable HA based filler (2ml I think) in her chin about 18 months ago and the effect is still apparent. She’s just had a sliding genioplasty (no jaw surgery because of TMJ problems) as part of orthodontic treatment with the filler in place. The surgeon had plenty of photos of her natural appearance throughout the orthodontic process so he was well aware of her natural chin line and told her not to worry about dissolving the filler first. He did a 10mm advancement only but the result is very dramatic and the chin is too prominent at present. She is 2 weeks post surgery and obviously still has some swelling on her chin but I think the filler is making the chin look over projecting. Psychologically this is having a huge effect on her and she is currently very unhappy with her new look. I have read on your site that the healing process does a good job of dissipating and absorbing the filler but I’d be extremely grateful if you would give me some idea of how long this would take. Would it be along the same time frame as healing, so that in a few months time, the filler would have gone along with the swelling? If she needs to have the filler dissolved, how long after surgery should we wait before having this done?

I think you sincerely in advance for any advice you can give me so that I can put my daughter’s mind at rest. As you can imagine, it is a worry for me too.

A:While the filler will dissolve over the next 6 weeks I would doubt that this dissolution effect will make much of a difference on the true final result. (filler becomes compressed when the bone or an implant is put behind it…..thus its residual effects are not that significant) But it isn early and the true answer about whether the chin is overprotected or not takes a good 6 to 8 weeks to know for sure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley ,10mm chin implant removal and replaced with a 8mm sliding genioplasty… 8 weeks ago. Having discomfort in area under the lip which I try ought was just the scar healing but it seems to be a bit lower than the scar and only on the left side. It is so sensitive that it makes it feel like the whole chin is restricted when I open my mouth to talk. It feels like something needs to be cut to release this tension….

The area you can see where my finger nail covers is very tender and hard/firm to the touch and when I open my mouth and speak/ talk it feels like something is going to rip because it’s all so tight. I really don’t know what it could be. It’s very small area like I can pinch it with two finger tips and get the whole left side of my mouth feels strange. The right side is fine.

A: It certainly sounds like a release is needed with a small fat graft for this spot area of tightness after a sliding genioplasty.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,, I underwent bimaxillary surgery which in my opinion was unsuccessful and after removing the titanium plates I found myself with holes in the central part of my face… I removed the maxillary plates because they gave me a strange appearance but now I find myself worse than before… I see my midface as completely empty, ugly and aged… i ve been thinking to have silicon midface implants but don’t know which specifically…which u suggest in my case.

A:To augment/fill in the maxillary defects you have two basic options:

1) Bone graft the maxillary defects using either allogeneic bone blocks and chips. (you could harvest your own bone but that is probably not too appealing

2) Fill in the defects with hydroxyapatite bone paste/cement

3) Make custom implants to do the contouring.

I would lean towards options 1 or 2 because it is likely there may be bone defects exposing the maxillary sinus cavity of which implants may not do well in that circumstance.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, is there a way to correct nasolabial folds caused by my deep canine fossa ideally something more permanent and not filler. Thanks for your time, have a nice day.

A:Nasolabial folds are largely created soft tissue ptosis. In the upper part of a nasolabial fold near the nose (and over the canine fossa) bone augmentation by an extended paranasal implant can help soften this part of the fold…but I would not call it a complete correction.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is it possible for a head to be too big for reshaping?

A:I think the question you are really asking is whether a skull reduction at certain head sizes would not be particularly effective. (aka nit make much of a difference) Abd that answer would be yes that is possible. Which is why I always try to image what the changes would be using the patient’s pictures before surgery to help them make the decision about the merits of the surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley ,I was wondering if the skull augmentation procedure that will be done will also change my hairline. I was hoping that it would by default as the whole skull would be widened but I wasn’t sure. My hairline is quite feminine due to my narrow skull. I used to shave my hairline to make it more masculine. Anyways I was just wondering if it would aid in that or if I should worry about that after the surgery.

A: In standard skull augmentations the hairline is not changed. In larger two stage skull augmentations it probably will change it a bit in the favorable manner to which you refer…but not drastically.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I read the piece by Dr Barry Eppley concerning removal of a pulsatile facial artery near the mouth. I have had this for about 15 years following an injection of facial filler into the area. It is always visible and it would be a real blessing to me if it could be removed. Please could you get in touch concerning this procedure.

A:Probably developed an aneurysm of the facial artery before it bifurcates near the corner of the mouth. I presume this was from filler injections for the nasolabial folds.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, ( have been interested in getting shoulder reduction surgery for the longest time and want to learn more its recovery.

A:Recovery from shoulder surgery is mainly the restriction in arm motion that is needed. In the first 2 weeks after the surgery I have patients keep their elbows close to their sides as much as possible. In essence you will be short arming with free use of forearms and hands. In the next 2 weeks the elbows can go out to 45 degrees, the following two weeks 90 degrees and thereafter one can have complete range of motion of their arms. More physical activities like sports etc one would be wise to wait to 10 to m12 weeks after the surgery. Thus recovery is not so much about pain  but about the short term arm motion limitations. Such a unique recovery requires some forethought into the immediate postoperative management right after the surgery and how quickly you can return home.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley I have under eye hollows. Can they be improved with laser c02 treatments and plasma under eye injections? Because I had that done recently, no change as of yet.

A:Those are procedures that you have as a first step to see what can be achieved non-surgically for your undereye hollows. You hope that they are effective but, if not, then one proceeds to a surgical approach. (infraorbital implants) In essence you need to ‘prove’ that surgery is needed and would be the only effective treatment.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want to get skull reduction surgery. When I was a child and teenager growing up I was bullied relentlessly for my head being big. The back of my head is so big that everyone says that it looks like a peanut. I think it might be a deformities or something. But I want to get skull surgery so that it doesn’t look like a peanut. I just want the round of my back head to be straight.

A:You have a large occipital bun skull protrusion which can be reduced with an estimated result as shown in the attached pictures. X- rays would be needed to determine the thickness of the bone but in every occipital bun deformity I have seen it is because the bone is thicker not thinner.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Emailing in regards to your shoulder reduction surgery. I’ve been looking extensively into this for the past 3 years and I’ve been hesitating whether to proceed with it due to the lengthy nature of recovery and the overall benefits of how much can be removed. It’s a big factor for me as unfortunately I have very wide shoulders and scapulas. (I was wondering if the scapula can be slightly shortened or manipulated too), I’ve seen that you can remove around 2-3cm on each side (more towards the inch measurement on each side), I am desperate for this but I want to know that I can remain functionality and still be able to move them effectively and that the screws won’t release if I happen to move my arm in a different position by accident? In regards to my height I am 6ft but my shoulder span is very broad. Hopefully you can help me with my queries.

A:In answer to your shoulder reduction questions:

1) At 6′ tall you can remove at least 2.5cms per side, maybe 2.75cms per side. That always makes for a very visible difference as can be seen in the many before and after pictuers of the surgery on one of my websites. (www.eppleyplasticsurgery.com….go to the Shoulder Reshaping page) By looking at other patients you can get a feel for the type of shoulder shape change that occurs. It will also be important to do some imaging of your shoulder pictures as well to see what type of change is realistically possible.

2) In regards to the scapula there are more limited changes that can be there. A prominent spine/ridge can be reduced but you can’t change the width of the scapula…which is usually what is the  aesthetically disturbing feature of it.

3) Of the hundreds of shoulder reductions I have done no patient has experienced postoperative range of motion limitations.

4) The main risk of the surgery is early hardware loosening and non-union…which is why I apply both a superior and anterior plate. No one to date has suffered screw pullout or plate displacement in the early healing phase.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can gynecomastia surgery be combined with chest implants as I think I need both.

A: Thank you for sending your pictures. In your case you could do gynecomastia reduction surgery with pectoral implants and the reality is you really can’t have one by itself with a satisfactory aesthetic result. Your chest lacks volume and has sagging so dual need is present. With teh use of implants y9ur gynecomastia reduction needs (based on pictures alone obviously) would be liposuction with a superior crescent nipple lift. I can not tell at a distance if there is a distinct mass underneath the nipple or not. If there is then this would also require its excision as well.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have Mild plagiochephaly. I’m looking to see what my options are about contouring my orbital rims possible reducing one side and planting and contouring the other , also maybe options about the asymmetry in the forehead to address the protruding side and the flat side

A: The effects of plagiocephaly in the forehead can be treated by reduction of the more prominent side, augmentation of the less projected side or a combination of both. While ultimately the patient must decide of the three approaches is the most aesthetic change, the other important issue to consider is surgical access. (length and location of the incision)  Any bone reduction requires a much larger incision to perform. A custom left forehead-brow bone implant can be placed through a much smaller incision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wanted to ask you if it is possible to use a Funnel for inserting wrap around chin implant through submental incision to reduce the risk of infection and if so do you believe Supore od Medpore (I believe this is the same) material can be utilized? Some doctors (such as Dr. Ramirez) do this, and what is your view on it? The rate of infection with submental approach and keller funell should be close to none so no removal would be presumably required and probably (I assume) recovery is quicker?

A: The funnel insertion device has its merits in body implants but is of little value in facial implants. The device is made to change an implant’s shape so that it can pass through a much smaller opening  than the natural width of the implant. That has great value in round, semiround and oblong ultrasoft body implants who need such deformation to get through a small entrance incision. But facial implants are comparatively smaller, are more rigid, and their shape can easily be changed to fit through a small emtrance incision. The most rigid materials (e.g.,Medpor, PEEK) rely on a segmentalized implant design to bypass a change in shape that they do not permit. Such rigid mat

While a silicone jawline implant can be introduced through a submental incision it still requires intraoral incisions to be pulled through and positioned. This is the most likely source of contamination and a funnel device will not help in that regard. Medpor and PEEK segmentalized jawline implants require the same three incisions with identical intraoral exposure.

While implant placement techniques can drive down the risk of infection to low levels there is no zero risk of infection no matter what techniques are used.

Dr. Barry Eppley

World-Renowned Plastic Surgeon