Your Questions

Q: Dr. Eppley, Do silicone implants for skull reshaping need to be replaced at some point? What is their longevity and advantages over using PMMA? thank you.

A: Silicone skull implants are permanent, do not fail and never need to be replaced due to any material problem. Bone cements for aesthetic skull augmentation as far as I am concerned are of historic relevance…they have poor shape control, can only provide a very limited augmentation effect and are impossible to revise should that need arise. Like any preformed implant they have numerous advantages over any implant material that has to be applied and shaped during surgery through a limited incision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello I wanted to ask you about a procedure and if you could do it. A reduction in the red marked areas of the pictures I will send.

I want to achieve a very small correction and reduction and to make them even. I read about zygomatic reduction but I dont want the ones that is popular in Korea where they cut the bone and reposition it. 

I think only a shaving of Zygomatic arch is what I am looking for but I am not sure. I will attach some pictures for you to see. The red marked area is where I am talking about but more so the area between the Zygomatic bone and the ears which I think is the Zygomatic arch. That is where I feel it is a little wide and would want it to be more straight.

A: The zygomatic arch can not be surgically reached short of a full transcoronal incision…which no patient is going to do for aesthetic purposes. Furthermore the zygomatic arch is incredibly thin (1 to 2mms) so shaving of it is not possible. As a result the only way to move the zygomatic arch inward is by osteotomies which are done all over the world and not just in South Korea.

That being said when only a few millimeters of inward arch reduction is needed the isolated posterior zygomatic arch osteotomy done through a small sideburn incision works just fine.

Dr. Barry Eppley

World-Renowned Plastic Surgeon 

Q: Dr. Eppley,  Are there any damages of skull implants, do they make the hair sparse, this is very important to me.

A: I am assuming becaiuse you have provided side view pictures that your skull asymmetry is isolated to the back of your head??

Skull implants do not have any adverse effects on the skull nor do they affect overlying hair growth. It takes a very large skull implant to cause any increase in interfollicular hair spacing…an issue I have not yet seen or been reported to me.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, my forehead looks overly wide, compared to the bigonial width and the outer lateral orbital walls. From your experience (and I know it might differ for every human) what is the maximum safe reduction that can be done?

Also, from the side profile my forehead looks straight, from brows to the beginning of the hairline. Could the bony part right at the beginning of the hairline to be reduced as well? (downward direction) 

A: The thickness of the bony temporal line is greater than that of the forehead bone between it….4 to 5mms can be easily reduced. The upper forehead at the transition of the forehead and top of the skull can also be reduced in the 3 to 4mm range.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, a general question possibly be answered before hand? Ive seen that you have performed  submental chin tucks, but are you only able to achieve making the chin shorter, or can he also make it slightly more narrow? (Perhaps by extending out the incision?) I havent seen very many frontal views of these procedures he’s performed, mostly just side views so its hard to tell.

A: The chin can only be made more narrow by bone reduction. It requires a T-shaped submental excision pattern to have a soft tissue narrowing effect…which has its own aesthetic scar tradeoff.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, When do u put the device to hold the bone together in clavicle reductions for shoulder reshaping?  Does it need to be removed or can it stay in for life?

A: The only reason to ever remove clavicle fixation hardware is if it becomes too visible over time (most common reason) or causes discomfort. (rare)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, do you offer custom pectoral implants?

A: For your left Poland’s chest deformity you would need a custom implant design which I have done many times. Most such implants are made from an external moulage technique which is done in the office. The other technique is to use a 3D CT scan which is very good for seeing the ribcage differences.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interested in a knee lift. Can the scar be hidden really well and made super fine? Do you have any photos of knee lifts after a year, after the scars fade? I always see pics with the scars red and the tissue swollen, I’ve never seen an actual year later or more pic. 

A: While you are a good candidate for knee lift surgery (abundant suprapatellar loose skin that is thin) I would have concerns about the scar in your case. The patients who do best with knee lift surgery feel that they would rather have a visible scar than the loose skin…as opposed to a ‘hidden really well and a superfine scar’. The key is these decisions is while a beautiful barely seen scar is the goal in every patient such outcomes can not be assured particularly when the scar is exposed to significant knee flexion.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have recently received submalar implants in aim of more defined cheekbones, after which I recognized that a submalar implant would not achieve what I was looking for, after hearing about your work, I am looking to replace the submalar implant with a custom implant, I believe what I am looking for is something that defines the zygomatic arch and cheekbone. I would like to discuss this further with you to see if this is the correct path, hear your thoughts and find the best way to proceed.

A: If the goal is more defined male cheekbones, submalar cheek implants would definitely not be the implant of choice…nor would any standard cheek implant as that is not what they are designed to do. All of these implants are based one the historic approach to female cheek augmentation or an apple cheek fullness.

When it comes to custom cheek implants the first question is whether this is a cheek augmentation alone or a combined infraorbital-cheek augmentation. Since you havenot mentioned any issues relating to the undereye area I will assume until shown otherwise that it is the former. But pictures of you before your cheek augmentation as well as after along with pictures that show your ideal cheek augmentation shape goal will provide that clarification.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, What is the maximum size of custom jaw implants? How do the soft tissue in our face affect the size of facial implants?

A: This is not a question that can be answered in any meaningful general way. Such custom jaw implants are made individually for each patient, all of whom will have different dimensions throughout the implant design. As a result there is no way to describe them in sizes. Each patient will definitely have implant size limitations…but that has to be determined on an individual design basis and even then this is an estimate which can ultimately only seen when trying to surgically implant it.

The thickness of the facial soft tissiue will definitely influence how well the implant’s shape/features are seen. Thinner facial soft tissue thicknesses get better results in that regard that thicker fuller face patients.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi! I’ve been considering a chin reduction surgery for quite a few years now, but not sure what would work for me. I currently have a fairly defined chin, with a good shape EXCEPT for the vertical length. I used to have a very slight underbite as a child, but it was corrected early on so my bite is fairly normal however my chin is still a bit too long.

Im wondering if theres anything that could be done in my case to remove some of the vertical length. Im curious about how the procedure works, because in my mind, if you burrow down some of the bone, there should be an excess amount of loose skin that has been stretched to wrap around the original length of the chin? 

Very happy to hear if any procedure could help me, what results i could expect, and how it would work.

A: The correct procedure in your case would be an intraoral vertical wedge reduction bony genioplasty. This technique which avoids the loose skin issue as the soft tissues remain attached to the inferior border of the chin and follows it up superiorly as the chin is vertically shortened.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can very high set zygomatic bones (pic) be achieved by combination of shaving off lower part of zygomatic bone and then placing infraorbital rim implant that extend into orbital rim(saddle). Also can zygomatic arch be made higher with custom implant? 

Thank you

A: The zygomatic arch can be made wider but not necessarily higher… although an inverted tear drop shape to the arch component of the infraorbital-malar implant can probably achieve that desired effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Are there any dental concerns with a custom jawline wrap? From the photos of the wrap designs it seems like they are placed close to whether the tooth roots would be, could there be issues with tooth root damage, and if there is bone erosion will that be an issue with the teeth? Also where are the screws placed, would those be in danger of coming into contact with a root as as well? The same question applies to a sliding genioplasty, as the screws are placed close to the tooth roots, how do you make sure in surgery that the screw will not come into contact with the roots? 

Ive also seen online that the jaw shrinks as we age, how would this effect the fit of a custom wraparound implant? 

A: In answer to your custom jawline implant questions:

1) There are no dental concerns with such implants.

2) The tooth roots and most of the length of the inferior alveolar nerve lies within the mandiboe while the implant sits on the outside of the bone.

3) Bone erosion does not occur with jawline implants which is often confused with passive biologic implant settling. The tooth roots are not at risk.

4) Small 2.0mm titanium screws are used which penetrate 1 to 2mms into the bone, well away from the tooth roots and nerve.

5) The superior screws of a sliding genioplasty penetyrate into the outer cortical bone below the tooth roots of the incisors which have the shortest roots of any tooth in the enture dental arch.

6) The jaw only shrinks with age if some or all of the teeth are lost. It doesn’t lose bone mass because of age, it loses it because of loss of functional loading.

Dr. Barry Eppley

World-Renowned Plastic Surgeon 

Q: Dr. Eppley, I have just recently noticed that I have Plagiocephaly. From the research I have done it seems that I have a mild or type 2 form. I also have right-sided plagiocephalic head with slight difference in my forehead protrusion and cheekbone protrusion. The left side of my head is also a bit more slanted than the right. Firstly I was wondering If all these problems are fixable and how risky the procedure would be to fix this. Secondly I was hoping you could provide a cost range for this procedure. 

A: All of the manifestations of plagiocephaly that you are describing which are common, mild as they may be, are improvable. When determining what should be corrected it comes to what are the most bothersome features of it. By your own description you have identified ipsilateral facial protrusion (with a flatter right back off the head) and a left forehead slant. The key question is not whether any of these features can be treated or that it is risky to do but which ones are most important. Patients rarely treat every aspect of their plagiocephaly but only the most significant features of them that bother them the most. Until I know what those features are in your case I could not say how it would be done or what the cost of such surgery would be.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Attached are various angles of my nose. The tip is what I’m really concerned with on how it arrows down- especially when I smile. Also I have a small hump in the middle to straighten. And from frontal view straighten a little as well.

A:The dynamic nasal tip ptosis occurs for two reasons, either one has a hyperactive nasals muscle and/or they have a natural 90 degree or less nasolabial angle nose to lip relationship. In your case that latter clearly applies making you more susceptible to a downward pull on the nasal tip.This is best treated by an open rhinoplasty where the tip position is rotated upwards a bit and supported by caudal septal resection and columellar strut grafting. At the same time the same nasal hump can be reduced.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello I was wondering about reduction of occipital area in the back of my head.I measured the area from top to bottom of the area I would like reduced and it measures 7 cm or 2.75 inches. I am aware you cant reduce much but if it can decrease it by a little I am happy.

– Do you think I would get noticeable results?

– Is it safe? Beside from infection whats the worst case that can happen?

– Can I do it and then go back home to Germany after 2 days?

– Will the scar be noticeable?

A: In answer to your occipital skull reduction questions:

1)  You will get a noticeble change and if the goal is just to ‘reduce it as little’ you will definitely achieve that goal.

2) This is a perfectly safe procedure. I have never yet seen a complication from any autologous skull reshaping surgery.

3) You can return home after 2 days.

4) The small incision used to do the reduction usualy heals well and leaves a minimal scar.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,Among solid silicone, Medpor, PEEK, and titanium custom facial implants, which one can provide the most natural appearance?

A: All materials create the same external facial appearance. It is the design of the implant that will determine whether the change is natural or unnatural looking.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interested in getting custom jawline and midface implants with the aesthetic goals listed below. Are these goals feasible? Are there other procedures either instead of or in conjunction with custom implants that would better achieve these goals? 

For context, I’m also considering septorhinoplasty at a later date to repair a deviated septum and resolve resulting issues with nasal asymmetry. 

Midface 

– Reduce dark circles and hollow appearance under eyes 

– Correct negative orbital vector 

– Augmentation of flat zygomatic arch with increased bizygomatic width (currently ~130 mm, ideally ~136 mm) 

– Modestly increased malar projection 

– Mitigate appearance of long midface and wide-set eyes 

– Improve harmony with upper third (ideal bizygomatic width ~120% of bitemporal width) 

Jawline 

– Improved symmetry, correcting relative deficiency in right gonion (left side of the photo) 

– Harmony with midface (ideal bigonial width 85-90% of bizygomatic width, currently 106 mm) 

– Increased bigonial width with greater visibility of jaw angles 

– Sharper, more angular, less rounded jawline 

– A more square chin with increased width 

– Marginally increased chin forward projection (ideally aligned with lips, currently ~3 mm behind)

A:While you list of aesthetic facial goals is long and comprehensive I don’t see that the majority of them could not be largely achieved with the use of custom midface and jawline implants…and that would be the only way to try to do so. The concept to the facial implant procedures is correct, its ability to achieve will be largely dependent on their designs. (shape, size and various thicknesses)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interested in a vertical lengthening genioplasty (vertical lengthening only). I’m including some photos of myself with notes. 

Thank you.

A: Your chin is higher than your jawline because you have a flat mandibular plane angle. (or close to it) As you have drawn the vertical lengthening bony genioplasty is the correct approach to treat it. The only question is how much vertical lengthening is needed which in your case by your own drawing is in the 8 to 10mm range….which is best done by a vertical opening bony genioplasty.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I will be scheduling my surgery soon, but there is a question I had that came up. When you perform forehead reduction, will there be a chance for unevenness, or it is a smooth transition from the forehead bone burring to the rest of the skull? If my question makes sense. 

A: Good question. Any form of skull reshaping (and the forehead is part of the skull) must be done with a smooth transition from one skull surface to the next adjoining one. This is important whether it is for augmentation or reduction purposes.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My major concern unfortunately, is in the anterior temporal muscle area, but also the bony part ABOVE it. My hairline was straight and low a couple of years ago, but now, i have the typical M shape, because it is now recedded at and above the temples. 

Even if you cauterize the anterior temporal muscle, i thing it is also the bone that makes my forehead soo wide ( the part above the muslce as well) 

From the side view, my forehead is also almost straight instead of sloped towards the back. Is there anything that could be done?

A: You are referring to reduction of the bony temporal line at the sides of the forehead  which is commonly done as part of bony forehead reductions or even as a stand alone procedure. (with or without anterior temporal muscle reduction)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have left deltoid atrophy due to brachial plexus injury long time ago. I m looking for deltoid implant or fat grafting to make left shoulder thick like right shoulder. Now I m 53 year old guy.I m also sending you one picture of patient who had this type of surgery.plz give me the cost and good advice. Thanks

A: There are advantages and disadvantages to both injectable fat grafting and implants for your deltoid deformity….and not to be confusing there is even a third option. (dermal-fat graft which is sort of a cross betwween the two being a solid fat graft much like an implant) The key determinant in your case is that your left shoulder is very scarred from prior injuiry/surgery. This makes it not great for injectable fat grafting. With all of the scars on the shoulder this makes it more ideal for either an implant or a large dermal-fat graft. And those two options are worthy of a more indepth discussion.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I have some questions about the custom jawline wrap. 

1) I see that you’ve noted the typical maximum horizontal lengthening is around 10-12mm for an implant, if I have an indwelling chin implant, can it be assumed the 10-12mm can be added onto whatever implant I have now? 

2) Adding on to the 1st question, can a custom jawline wrap add in the range of 14-16mm in horizontal lengthening with the presence of an indwelling implant? 

3) If it is possible, does such a big horizontal lengthening effect how much gonial width can be added, because the skin will already be stretched too much? 

Thanks

A: In answer to your custom jawline implant questions:

1 and 2) While you may get up to 50% more chin projection by a secondary implant augmentation it will not be a 100% increase as the soft tissues can not tolerate that implant load. If you need that much chin projection increase it should be converted to a sliding genioplasty.

3) Whatever is done at the chin does not impact what can be done at the jaw angles in terms of soft tissue stretch.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I saw your website and send this message to know about your head size reduction surgery. I have quite big head. Circumferences is about 60cm, and overall size of my face and head looks large and big. my heigh is about 170cm So it looks more weird then others. I want to have under 58cm circumstances. Is it possible? I heard there is surgery of botox for temprolis muscle which can make my head smaller. Can I get both of this way? and after surgery is there any issues on Durability of my skull?

A: Temporal reduction can usually reduce the circumferential head measurements by 2cms. It has no negative effect on durability of the skull.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I read your post about rib shaving surgery (https://exploreplasticsurgery.com/case-study-subcostal-ribcage-protrusion-correction/). However when trying to do research online I cannot find any doctors who do this kind of surgery. I have a cartilage protrusion at the connection of my 3rd rib with the sternum, as well as my second rib protruding outwards greatly after an injury. 

I was wondering if you perform this kind of surgery and if you also know of any other doctors that perform this kind of surgery as well. Why is this surgery not more widespread for cartilage protrusions?

A: I have removed hundreds of ribs for aesthetic purposes and may be one of the few, if only, surgeon in the world that does so. But, quite frankly, I can’t imagine the incision and resultant scar to shave down your upper chest rib protrusion (costochondral junction of rib #3) would be a good aesthetic tradeoff… small as that incision may be. So the question is not whether it can be done but whether a small scar in a highly visible location would be viewed as a less noticeable aesthetic problem.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am looking for bivalve testicular enlargement due to testicular atrophy from steroid use years ago. 

A: I assume when you say ‘bivalve’ testicle implant you are referring to a wraparound or hollow chamber implant. Whether that is appropriate for your testicular atrophy depends on the current size of your testicles. The cut off between the wrap around technique and the side by side or displacement technique is 3.5cms in my experience. If the testicles are 3.5cms or smaller than much larger testicle implants will displace them out of the way sufficiently and is the better testicular enlargement method. Such small testicles have a high slippage rate out of the implants. With 3.5cm or larger testicle size the wrap around implant is the better method to avoid a ‘4 ball’ look.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have some questions about my upcoming surgery:

Q1) I am really unfit / mostly sedentary living, then would being under general anesthetic be a risk for me?

Q2) if I decide to go ahead with the buccal fat removal, can the fat extracted be placed where the orbital region is below the eye?

Q3) could having genioplasty combined with a Buccinator myectomy improve the outcome of less rounded cheeks?

A: In answer to your facial plastic surgery questions: 

1) I am not aware that being unfit increases general anesthetic risks.

2) The buccal fat can be recycled and relocated to a facial site of the patient’s choice.

3) A sliding genioplasty always improves the appearance of the rounded face.

Q1) I am really unfit / mostly sedentary living, then would being under general anaesthetic be a risk for me?

Q2) if I decide to go ahead with the buccal fat removal, can the fat extracted be placed where the orbital region is below the eye?

Q3) could having a sliding genioplasty combined with a Buccinator myectomy improve the outcome of less rounded cheeks?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Can you still perform chin and jaw augmentation with coral hydroxyapatite implants ? If yes do you have some before and after pictures on male patients that had this procedure done ? What is the price ? I’m prone to autoimmune issues so i can’t use regular implants.

A: As a general statement HA granules are a very poor method of chin and jaw augmentation….unless the amount of augmentation is very small and localized. (which has not been my experience with most male patients that seek jaw augmentation) The results often are uneven/irregular and extremely modest in its aesthetic effects. Normally I would never consider using it because of these issues. It is very biologically appealing but aesthetically unappealing.

However I can understand why you ask given your autoimmune concerns…which means this is your only onlay jaw augmentation option. (obviously fillers remain a non-surgical option) The question from my standpoint is not whether they can be used but their cost. To do chin and jaw augmentation of any significance you would need 8 to 10cc (syringes) of material and would have to accept that it would need to be placed in a non-linear fashion. (meaning on the chin and jaw angles but don’t try to connect the three areas)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am struggling with plagiocephaly, to be more specific, one side of my face is significantly protruding, which affects almost every aspect that would be responsible for the symmetry of my face, it is rather complex, since it is causing a correlation of many smaller problems that lead to assymetry not only in my eyes, but also nose, forehead, jaw, cheek bones, temple region, eye socket. Is there a possibility to harmonize my face by implants or bone, skin removal, autologous fat injection? 

I went through bimaxillary osteotomy surgery already, but since the doc focused on functionality rather than aesthetics, i am satisfied with the side profile, but definetly not with frontal symmetry, it is hard to compare for me but i have the feeling this surgery worsened my frontal symmetry even more….

A: Plagiocephaly is well known to affect the face with protrusive asymmetries on the ipsilateral side. Like all facial asymmetries the critical question is which side of the face is preferred regardless of the pathology behind the differences. Also it is important to recognize that augmentation improvements usually produce more substantial changes that reductive procedures.

That being said the most meaningful piece of information beside your pictures is a 3D CT scan in the treatment planning process.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi there, I had some issues with my facial asymmetries especially in my jaw. I am a university student in my second year, and am 19 years old. I started to notice it about a year ago where I started to take pictures using the back camera which accentuated the asymmetrical jaw in picture and I grew more insecure because of it. I wanted to simply consult and ask of the severity and if there would be anything I could do as a young man in my final developing stage before it’s fixated and permanent. Would you recommend any types of exercises or medications prior to resorting to plastic surgery? I would highly appreciate an honest assessment and advice. 

A: Bony jaw asymmetry can only be improved by surgery not exercises. Whether that would be by orthognathic surgery or onlay implant augmentation requires a 3D CT scan to evaluate.

Dr. Barry Eppley

World-Renowned Plastic Surgeon