Your Questions

Q: Dr. Eppley, Hello, if I choose to get a genioplasty. Should I remove the plates and screws? If I don’t remove them would I be able to get fillers or Botox in the future? Would there be a potential risk for infection? In addition, how long after genioplasty would you recommend getting fillers or Botox?

A: In answer to your sliding genioplasty questions:

1) Hardware removal later is optional. Most patients never choose to remove it.

2) There is no infectious concerns with injections into or around the fixation hardware.

3) Allow 3 months after the surgery before doing any injectable treatments.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ll explain more in depth what is going on and what I want to accomplish.

Implant used – implantech terino style II size large

Method – inserted from under the chin

Imaging – whatever a maxillifacial surgeon uses. I don’t know the name 

I had the implant placed in October 2020. Haven’t really had any issues with it. I went to a maxillofacial surgeon to discuss my options for issues with my jaw alignment which is causing issues with my molars. Long story short I’ve been told double jaw surgery + sliding genioplasty is the answer. Orthodontists unable to fix the alignment issues.

While doing the scans he incidentally found that I have around 3mm of bone resorption from the implant. Visually it looks no different and I am still quite pleased with the result. 

I was told by the doc who did the chin implant that some “settling” is completely normal. He didn’t seem concerned but I am exploring options in the event the erosion worsens.

I saw your reply to a post on Real Self with some more info about what can be done to remedy the erosion. So this is mainly what I am interested in learning more about. If he has a good solution then I would have no issues with getting a revision done with him in 1-2 years if the erosion continues getting worse. 

A: This is not bone erosion, it is implant settling…a passive self-limiting process that is not progressive. If you are happy with the chin augmentation results there is not need to treat this radiographic phenomenon.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, what procedure is the best for me? My eyes is too bulgy and flat I want feminine eyes how to achieve that?

A: You have a significant undereye (infraorbital-anterior malar) bone deficiency with excessive scleral show (due to lack of lower eyelid vertical height) This makes your eyes appear bulging but the eye position is actual ly normal. (pseudoproptosis) Infraorbital-malar augmentation with lower eyelid reconstruction (spacer grafts and lateral canthoplasties) is needed for an improved appearance.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi there, I’m a 27 year old male, recently gone bald to reveal what seems to me to be a mild case of brachycephaly. It seems like you have treated patients with the same problem to some great results. Looking to discuss possible solutions. I consulted with a craniofacial specialist in the UK and he said he didn’t think there was much he could do, besides shaving down the actual skull, which I wouldn’t do. Hoping there’s a less drastic remedy available. 

A: Brachycephaly implies a flatness to the back of the head for which augmentation would be the best aesthetic procedure…not shaving the bone which is exactly the opposite of what should be done. A custom skull implant works well for this type of augmentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am due to have calf augmentation post Achilles tendon repair due to severe fatty atrophy of the soleus muscle. I saw that you have done this surgery before and the patient is in your photo gallery under Body Implants – Patient 21. Dr Eppley used 2 implants in this circumstance and I was wondering what type/brand of implant they are? The surgeon I am booked in with is willing to do the surgery and we only have the Implantech Calf Implants available here. My question is do you think the Implantech implants are the best ones and, if not, can you suggest any other brands?

A: There is a very broad selection of calf implant shapes and sizes offered by Implantech. Your surgeon can surely find  implants that will suit your individual needs based on leg measurements.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m considering the removal of a silastic implant that was placed under the chin (6mm anterior projection), what realistic complications are there to expect? It was placed 2ish years ago. It’s hard to know what to expect with ptosis, chin balling, nerve damage, and all sorts of complications being thrown around on forums. Could you maybe explain how the time the implant was in, may affect the chances at returning to post-op appearance?

A: I would say the only significant risk, and I would not call it a complication but an expected outcome, is that of soft tissue chin pad ptosis. The question is not whether you will have it but how significant it will be. There is no returning to 100% of your preop appearance. Whether it will be 75, 85 or 95% can not be predicted beforehand.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Really want a consultation for the back of  my neck , you were the only one that seemed available 

A: The ‘triple roll ‘neck poses significant challenges in terms of improvement. One approach is a middle roll excision with undermining on the superior and inferior rolls to bring it together creating an overall flatter effect. Another approach is a dual excision along the two deep inverted horizontal lines. Each approach has advantages and disadvantages but the major difference is the location of the scar lines.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a scapha reduction (macrotia surgery) on both ears. I saw a previous reply on your website to someone interested in the same procedure that the helical rim is crucial for this procedure in order to be able to hide the scar. While I do feel that I have a small helical rim, it’s not as prominent as some, so I am wondering if I am even a candidate for this procedure.

A: The concept in most macrotia reductions is a combined scaphal and earlobe excisions. In the scaphal reduction it is ideal to have a prominent antihelical fold and/or helical rim for optimal scar placement. While yours is smaller than some in those esr features  (probably because you are a female) it is not contraindicated for the procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Sustained a cheek fracture last year and hospital did not want to intervene! I notice a big difference in facial symmetry with malar depression. Just looking for help because it has caused emotional pain.

A: This is a classic depressed ZMC fracture. At one year after the injury the depressed cheekbone is now healed into this abnormal position. The options now are either to refracture the bone and try to reposition it back closer to normal (secondary osteotomy) or leave the bone where it is and make a custom cheek implant overlay matching the shape of the other side. Each approach has its advantages and disadvantages. But for either one getting a 3D face CT scan is importsnt to have a clear understanding  of the cheekbone’s exact shape. Such an understanding may influence how successful either approach would be, particularly the osteotomy method.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a large head with a dent in the back of my head. I know it’s not possible to make my head smaller, but I want the dent fixed. If I get the dent fixed will it make my head larger?

A: That would depend on the size of the dent and how much volume it would take to fill it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, In determining the best jaw angle width for my custom jawline implant I have read that it is usually better to keep it less side than that of my cheeks. Is that good way to do it?

A: To anatomically understand cheek bone anatomy it has two components which have an anteroposterior orientation, the anterior main zygomatic body and the posterior zygomatic arch. Cheek width is determined by both components of which, in most Caucasians, the lateral zygomatic arch creates the maximum cheek width.

When using cheek width as a determinant of jaw angle width the maxiimum width of the zygomatic arch (lateral cheek width) is what is usually used to help guide its width not the anterior zygomatic body width.

But as you can see it all depends on how one choose to define their cheek width.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am wondering if you could help.My son had ear pinning one year ago. I was not happy with the results straight away, however, the surgeon told me it was impossible to undo the surgery as it would require a rib cartilage to be inserted into my son’s ears and would be too risky.

I would greatly appreciate if you could kindly look at the images attached and advise if there are any procedures that seem to be possible and what the doctor thinks requires to be done esthetically.The top of the ears look like they are glued to the head, the middle is parallel to his head and the bottom part of the ears is very prominent. The ears lack any nice shape.

Would pinning the bottom of the ears correct the overall look of the ears or is it the top part that is required to be corrected to be more prominent?

I am supporting my son and I am telling him how beautiful his ears are after the surgery. He has raised his concerns, but I do not want to book a consultation first as I will prove to him that the surgery did go wrong and that his ears do not look nice. I would like to know first if the doctor believes that there are options to correct the ears, as the last thing I want is to tell him that his ears do need to be corrected and then find it is impossible to do. This would devastate him as he has gone through a lot after the surgery.

I would be very grateful if you could have a look at my son’s photos and advise.

A: The reason his postop ears look like they do is that bottom third of the ear (earlobes) remains unchanged from the surgery. Only the cartilage containing part of the ear (upper 2/3s) has been setback while the earlobes remain protrusive. This is a common surgical oversight. Many otoplasties needs a soft tissue earlobe setback to look harmonious along the helical rim .

This is what I anatomically see. Whether that is his exact concern or whether he is having trouble adjusting to the overall change (missing his old ears) I can obviously not say.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am reaching out to seek advice from you who has a rare expertise in fat grafting and lip surgery. I am 63 years old and underwent a secondary face lift along with lip fat grafting a year and a half ago. Unfortunately, I have been left with a noticeable lump on my upper lip. I understand that such cases are complex and that many surgeons may be reluctant to address them. But I hope that your proficiency in this field could shed light on my condition and offer a potential course of action.

A: Injected fat lumps in the lips always have to be excised, generally through either a vertical vermilion or a vermilion-cutaneous inciosion depending upon its location and size.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, 27 yo female who is unhappy with smile/avoid being in pictures. Desire for upturn of corners of mouth when smiling/more even smile.

A: Smiling is a dynamic facial movement while surgery is a static procedure. Thus at rest the corners must appear more upturned and the mouth wider for a bigger more upturned smile.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have very droopy eyelids and I was wondering if a brow bone implant would raise my eyelids? Because I do want my eyelids reduced sometime in the future and I’m not sure how it would affect it.

A: A brow bone implant is unlikely to improve droopy eyelids to any significant degree.. Its placement would not affect the ability to perform upper blepharoplasty surgery in the future.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m inquiring about the brow bone augmentation. I’ve been trying to find a way to have deep set eyes. I went to a doctor in L.A. and he suggested orbital decompression, which sounds dangerous. So I’ve been searching around the internet and I found of Dr Eppley’s before/after picture of a patient , under “forehead brow bone and temporal contouring” patient 8 and 9, (esp 8), desire for more prominent brow bones and forehead.

I’m thinking of doing fillers first to see if it would do the same effect, even temporary. In this case at least I know if it would look good on me. Maybe it’s a waste of money and just go straight to the implant.

Thank you,

A: In answer to your questions in regard  to the pursuit of deep set eyes:

1) Orbital decompression is not a dangerous procedure. It is just the lowering of the anterior bony floor of the orbit which allows the eye to drop back and in a few millimeters. It could be a useful adjunctive procedure to brow bone augmentation. But it is unlikely alone to create deep set eyes…but that depends on what your natural anatomy is.

2) Certainly the reverse approach, augmenting the orbital rims , has a more powerful effect…again based on your natural anatomy.

3) A good way to test #2 is with computer imaging using your pictures to look at brow bone augmentation changes. I will need three pictures to do so. (front, side and ¾ views) The latter two are the most important when looking at any type o forehead and/or brow bone augmentation.

4) Injectable fillers can always be a good test of any facial augmentative change provided the volume of filler approximates the volume of the implant that will be used to create the permanent effect. For example in a brow bone implant typical volume is in the 4 to 6cc range. Fillers come in 1cc syringes. So it is easy to see that the effect between fillers and implants are not similar. Thus fillers are fine to try as long as one recognizes that implants have a far more powerful augmentative effect  depending upon the size of the facial area being augmented.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am potentially interested in posterior temporal reduction surgery because I feel that my head is too large. I also feel that I could benefit from anterior temporal reduction surgery because the area from the side of my eye to my hairline is also a bit too large. I attached a photo that shows what I am talking about.

A: Thank you for your inquiry regarding temporal reduction surgery. To better understand such head narrowing surgery I refer you to the following link which explains the important difference between posterior and anterior temporal reduction surgery:

https://exploreplasticsurgery.com/the-anatomy-of-t…or-the-wide-head/

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello there, just a quick question regarding aftercare post surgery from my custom forehead implant. Everywhere else seems to request the patient wears the head bandages after surgery for one week, can I ask why you suggest removal from the next day?

A:I don’t suggest removal of the head dressing the next day, I take it off the next day as the immediate head dressing is very tight and uncomfortable.  A new less tight and more comfortable head dressing  (Coban) is applied thereafter and should be worn until at least the drains comes out…which is usually 2 to 3 days later.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I previously had iliac crest implant surgery and it has left me with very obvious hip dips/ indents, even after a fat transfer. I am very thin, so I need to gain weight before having another fat transfer. I was wondering it custom hip implants might be a better option than another fat transfer? Is it normal for iliac crest implants to create hip dips? How much would it cost for custom hip implants? Thank you!!

A: While not common creating hip dips can occur when the greater trochanter sticks out much further than the natural iliac crest. Iliac crest implants work best in straighter profile hip-thigh patients as opposed to a more triangular profile shape.

In the spirit of ‘past history predicts future behavior’ why would fat grafting work better the second time than the first…particularly when one has to gain weight to undergo the procedure? The point is…it won’t.

Now that doesn’t make hip dip implants perfect and they have their own issues. But that is the only remaining treatment option.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to have an online consultation in relation to an osseous genioplasty procedure or jaw surgery.

Over the past 3 years I have conducted some personal research, ~5 consultations, and also previously had a chin implant a number of years ago which I had removed after a few months of having the implant.

I would greatly like to have an online consult given Dr Eppley’s significant experience- and that I have found where I live.

Regarding my condition, I have a good bite – but heavily proclined lower teeth. Despite the proclination, my soft tissue profile actually does not make this ‘dental bulge’ so distinct (see images) – rather I have mostly a small/backwards lower jaw. The primary medical aspect I consider is not bite but sleep apnea related – which is quite bad and has become significantly worse over the recent years.

I have a good range of pictures + CBCT scan that I can send through/and also live display on my computer during the consult to assist in understanding the situation virtually.

Please note some points I would hope to raise/discuss to give some more context given my experience with the situation:

1) The 8mm chin implant I had years ago gave nice projection (see image) – and looked genuinely better overall, but significantly deepened the labiomental fold which led to a somewhat uncanny result – as I understand and have seen other cases – this can be controlled by a genioplasty forward + down movement – hence a key reason for my preference in the procedure.

2) I also have researched and done some consultations for jaw surgery. I hope to avoid jaw surgery because the procedure is more invasive – but open to discussion + have some scans from one other jaw surgery consult.

3) I’d like to discuss some genioplasty cases I have seen online that appear similar to mine (backward and short chin). Some ‘major’ ~8-10+mm advancements in these cases gave surprisingly great results – comparable to jaw surgery advancements. In some cases these people were recommended with jaw surgery as the only solution given their profile (whilst having a decent bite) – but opting for genioplasty still led them to a very good result. Hence a key reason I have been quite interested in osseous genioplasty over jaw surgery.

4) I’d like to get an idea of a procedure plan/cost.

Greatly appreciate your time and look forward to hearing from you.

A: Thank you for your inquiry and detaiilng your concerns and chin implant history. There are three things you have had stated that makes the case for jaw surgery not an isolated chin surgery.

1) ‘Bad’ sleep apnea

2) Heavily proclined lower teeth

3) Deepening of the labiomental fold with the chin implant (the same will happen with a sliding genioplasty)

#1 and #3 are the long term issues that need to be heavily considered. Do you really want to live the rest of your life with that degree of sleep apnea?  If you took out the chin implant because of the labiomental fold change why would you feel any better about that same effect with a sliding genioplasty?

While I can certainly understand  why one would want to avoid jaw surgery if possible but I would question tjhat decision in a young person. I have seen plenty of patients who opt for isolated chin augmentation or aesthetic jaw implant surgery only to reverse those later when they have decided to have jaw surgery…which they should have done so initially.

That being said there is nothing wrong with a sliding genioplasty as long as one has carefully considered the jaw surgery option which does address the fundamental problem.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Should I have a malar fat pad removed by a cosmetic surgeon?

A: I assume you mean by a malar fat pad you mean the buccal fat pad…since that is the cheek fat that can be surgically removed.

I can not speak for the experience of any other surgeon regardless of their training.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m now a year post double jaw surgery. I’m looking at midface implants to address midface recession. I attached a picture of myself from yesterday. I also attached a picture of an implant design I think I’ll need. Is it ok to put all these implants in at the same time as plate removal? The implants would go on top of where the screws were. Will this increase the rate of infection? 

Also I am looking to have rhinoplasty after implants heal. I’m nervous about the transition from midface to nose sides. How is the transition between the cheek and nose area made as natural as possible? Thank you for answering my questions!

A: In answer to your custom midface augmentation questions:

1) I would be very cautious about implant placement at the same time as plate and screw removal.  In removimg certain screws (and sometimes a plate area)  from a Lefort I osteotomy a communication between the maxillary sinus and the implant which increases the risk of infection.. I would have to see x-rays which show the hardware locations which would be very evident in a 3D CT scan. On the one hand you would like to achieve two positive changes during the same surgery as long as does not significantly increase the risk of infection. I have done it many times before and if I see small communication I seal the hole with bone wax and then place the implant at the same time…and it has never caused a problem. But it is still prudent to check and x-ray beforehand.

2) The relevance of a rhinoplasty if an underlying midface implant exists is at the osteotomy line if nasal bone osteotomies are to be done. Thus it relevant in the implant design to keep it away from the nasomaxillary junction.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had read that a chin implant can also widen the chin or make it appear more square. One trade-off it sounds like is that the implant would not reach as much horizontal projection. But if my goal is to also make my chin/jaw appear more masculine overall, would I noticeably be “missing out” on this aspect with the genioplasty rather than implant, or do you feel that wouldn’t be very consequential in overall appearance? Or, would any benefit from the width be negated by added vertical height from the implant (if I already have more than needed)?

A:You have corrected surmised the basic concept of the dimensional differences between an implant vs an osteotomy in your chin augmentation. Neither one is perfect and there are dimensional tradeoffs for each option. You make that decision based on which of their liabilities can you live with the best

IMPLANT = makes the chin square (if it is a custom made implant) but less horizontal projection and keeps the same the same vertical length (and probably risks making it just a bit longer) (particularly if it is not custom made implant)

OSTEOTOMY = maximizes horizontal projection and can reliably keep the same vertical length or even make it vertically short, can not make the wider or more square.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I’m considering a sliding genioplasty to correct lower jaw asymmetry.Was considering a bsso but the procedure seems intensive.What would you suggest?

A Forget about whether one procedure is more ‘intensive’ than the other. What counts is what procedure(s) is most effective for correcting the asymmetry. The first step in any facial asymmetry is to understand the exact anatomy of the jaw asymmetry. Before selecting a procedure you have to know the exact shape of the jaw which requires a 3D CT scan. But I don’t need a 3D CT scan to tell you this:

1) Your jaw asymmetry involves the entire lower jaw, not just one part of the lower jaw. The entire lower jaw is tilted/twisted

2) Neither a sliding genioplasty or a BSSO are the correct procedures to improve the asymmetry as they are 2D procedures for a 3D problem. There is not a bone procedure alone that will solve the problem in its entirety.

3) The most effective jaw asymmetry correction comes from a custom jawline implant as it is a 3D procedure built on an exact visualization of the misshapen jaw bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a forehead scar. Had an obagi blue peel for mild acne scars with good results. 4% hydroquinone for 4 weeks then bumped up to 10% compound for several weeks before procedure. Have been wanting scar revision. Assuming similar skin prep. Have had sever attempts at fillers with no results. Would prefer scar revision. Please reach out for consult. 

A:Deep inverted scars in the glabellar furrow area always require excision/scar revision to get the best contour. You simply can’t push them out with filler or fat injections due to their deep inversion. But I also find that scar revision may still be prone to some postop inversion. albeit a lot better than preop. For this reason I will sometimes place an ePTFE implant or a dermal-far graft on the bone below it to help push out and maintain the contour along the w-plasty scar line.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a very large bulbous-shaped head / large forehead that I have been derided all my life over. I never thought there was a corrective surgery though it has always been a dream. Would like to look into what’s available which would be a dream of mine.

A:I believe you are referring to the convexity/width at the sides of the head as one issue for which temporal reduction is the correct surgery. (see attached imaging) You have also referenced a large forehead for which bony forehead reduction can be done as well with the temporal reduction. (see attached imaging)  Besides their aesthetic differences what distinguishes temporal reduction from forehead reductio is the location of the incision. While temporal reduction surgery may be considered ‘scarless’, because the incision is done in the crease of the back of the ears, forehead reduction requires a less hidden incision location.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a 34 y/o male interested in improving the horizontal projection of my chin and the contour of my chin/jawline overall. I’ve read about both chin implants and sliding genioplasty, is there one you would recommend more in my case for superior aesthetic result? Would liposuction be of any benefit in combination? Photos attached. No prior surgery.

A:With a chin that has a horizontal deficiency of 10mms or greater and is rotated backward (long) the best procedure is a sliding genioplasty to bring it forward and make sure it becomes just a bit vertically shorter. Submental liposuction is always concurrently beneficial to achieve the best cervicomental angle improvement.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,Can a supraorbital rim and infraorbital implants (periorbital augmentation) give 1.5cm forward projection or does it need to be combined with a forehead implant to avoid protrusion or bossing?

A: That would depend on doing some side profile computer imaging to see what that change would look like. But as a general rule any periorbital bone augmentation that exceeds 7mms or so (0.7cms) would likely need a forehead augmentation as well.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I was considering a paranasal and premaxillary implant but came across a lot of negative reception regarding how the implants “ruin” your smile. 

1) What kind of ruining would they be referring to? Is it the increased philtrum distance and flattening of the top lip? If so, could this be mitigated via lip lift?

2) Some say that they can see something protruding when they smile, is it because their implant is too large? How many mm would you say is the maximum for an implant?

A: Nasal base implant augmentation has a history in which many of these implants were placed through the nose into the subcutaneous tissues. This has the potential to place a physical block when trying to smile. A more contemporary implant location is in the subperiosteal location through an intraoral approach which lowers this negative smiling effect significantly. Besides placement location the size of the implant also can have an effect if it is too large. While each patient is unique I wold not add more than 6mms of augmentation in the nasal base area….and even less so across the anterior nasal spine area.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I found you online and I read about the reverse frenectomy question and that was exactly what happened to me. My smile has changed drastically and I’d like to see if there is a consult or get more information.

A: You are referring to a central lowering vestibuloplasty procedure…which is the equivalent of a reversal frenulectomy procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon