Your Questions

Q: Dr. Eppley, My face is marginal and atypical, and it harms my life because people think I am stupid because of my close eyes and very narrow face. I heard that you are the only expert capable of making cranioplasty (heavy surgery) an aesthetic goal. My question: is it possible to reshape my face by widening it and widening the gap between my eyes? And is it risky?”

A:Thank you for your inquiry and sending your picture. I believe you are referring to a decreased intrapupillary distance (IPD), otherwise known as close set eyes. While the definitive treatment his orbital box osteotomies with the expansion as an adult that is a major craniofacial surgery an it must be considered very cautiously. The first question in that consideration is are there other more minor procedures that may provide enough benefit that such a major surgery is not needed. Such minor procedures include narrowing the nasal bones between the eyes and decreasing the medial extension of the lacrimal lake of the inner eyes. This can provide 3 to 4 mm per side of increased IPD that may be enough to make a significant visual difference. I have taken your picture and done some imaging of that change to see how that looks to you.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had cheek implants placed years ago and believe their positioning is off — they create an unnatural, harsh look rather than enhancing my natural bone structure. My primary goal is removal or repositioning to restore a more natural, balanced midface.

Clinically relevant: I can palpate the implants both intra-orally and externally along the inferior border near the lip line. There is noticeable mobility — I can feel movement when pressing from outside. This suggests possible malposition, capsular loosening, or migration.

I also want to note that the distortion I’m experiencing is documented — not self-perceived. I have professional photographs taken within the last seven months where the asymmetry and unnatural contour are clearly visible. This is a structural issue with measurable, photographic evidence, not a body image concern. I’ve included those photos for comparison alongside my current images.

A:Thank you for your inquiry and sending your pictures. When it comes to your cheek implants you are undoubtably have the classic male cheek augmentation problem. The history and design of current off-the-shelf cheek implants is largely more for females than males because of where the implants are designed to be placed and the effect that they are intended to create. By definition most standard style cheek implants are placed with a significant part of the implant off of the bone in an effort to create the apple cheek affect that many females historically have wanted. While there are some males that may see seek a similar aesthetic outcome that would only be in the minority of men in my experience. Thus the symptoms you are experiencing, a non-bony augmentation effect and being able to palpate the implants along with being able to feel the flexion of the implants is consistent with my aforementioned supposition. This can be confirmed by a 3-D CT scan which will clearly show where your implants are placed as well as their size and shape.

That being said the question is not whether you would like these implants to be removed and replaced but what should their replacements be.  Should standard style cheek implants be used and placed in a higher and total bony location or should custom design cheek implants be used? I think the definitive answer in that regard will be guided by what we learn from a 3-D CT scan. This time we have a lot more information to help guide the implant selection process since you have a known implant effect that can be completely understood.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,Do you use MMA skull reshaping method for plagiocephaly (one side back head flat correcting method ) ? if yes most of my skull is corrected but I have a dent small area on back left which is the edge part connects with the left side part the previous Dr left to fill that area coz he ( thinks ) said its very risky to touch the temporalis muscle . Since my case is plagiocephaly I want to know if it’s ok to do it ? Is that going to affect my chewing process or the temporalis muscle movement ? Since there is only a small portion left i want to know the price and how long it will take me to heal ? Thank you !!

A: What you are experiencing with PMMA skull augmentation is the exact limitation of the material. When it comes to treating plagiocephaly implant augmentation is two thirds on the bone but one third onto the temporal muscle on the side of the head. P MMA material must stay on the bone and cannot be placed on top of the muscle. Your surgeon may have told you it was too risky to touch the temporal muscle this is not a remotely accurate statement. I have done hundreds of skull augmentations where is the material used is directly on top of the muscle on the side of the head and it has never caused any temporal muscle movement or functional problems nor would I expect it to do so. The key is not whether you can put an implant material on top of the fascia covering the muscle but what should that material be. Therein lies the limitations of P.MMA bone cement. As the name implies it is a bone cement not a soft tissue cement. It requires a bone surface to which it must be applied. As soon as you need to cross over the bony temporal line anywhere on the skull onto the temporal muscle area this requires a solid silicone material. This is why for almost any significant skull augmentation need the use of custom solid silicone skull implants are far superior as they do not have surface area limitations not to mention preoperative control of the augmentation areas actually needed.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have a bit of a flat face and the outer ends of my eyes hang lower than they should for sure. So I’m wanting to get them lifted a little as shown by my finger in the second picture. I think a lot of people go crazy over wanting cat eyes or siren eyes. That’s not me I still want to look like myself I just want slightly more narrow oval shaped eyes.

A:Thank you for sending your pictures. There is a correlation between your flat face and your lower eyelids position as there is a near one-to-one relationship between the position of the lower lid and the shape of the bone that is underneath or supports it. While I have not seen a side view picture you most likely have a negative orbital vector which is the classic indication of a significant skeletal deficiency. This is why to help reposition your eyelids the skeletal deficiency needs to be addressed through custom infraorbital – malar implants. These almost have to be combined with spacer grafts to the lower eyelid and then some form of a lateral canthoplasty. While it is easy to take your finger and push up the lower eye lids it is not so easy to do so surgically and have it stray there over time.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I currently have pectoral implants which are Hansons ACP 2-3 large. I would like to go bigger with new implants.

A:Thank you supplying the information on their existing pectoral implants. Your existing pectoral implant dimensions are 16.5 cm in height by 13.5 cm in width and 2.5 cm in projection and an approximate implant volume of 270 and 300 cc. This manufacturer does have a larger size but it only is adding 0.5 cm of projection and 35 mL of all, a difference that you would not see. When I compare it to the US manufacture, Implantech, I do find that there is one standard pectoral implant that comes reasonably close to your existing implants footprint with 17 cm of height by 14.5cm of width with 3 cm projection for a total implant volume of 410 mL. That is providing a roughly 25% increase in projection. I do have a general rule that if you’re not adding at least 30% of increased volume minute implant you really don’t see that much of a difference. So you can see that the use of that one standard implant is sort of borderline for whether it makes enough of a difference. I think it comes down to her how much augmentation difference you’re seeking. If it’s just a little van this standard implant may suffice. However if you’re seeking something a bit more substantial than we will have to go to custom implant design route. At least we have the exact measurements of your implants so that could be done without the need for 3-D CT scan.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in improving my facial structure and am looking into surgical procedures for that. I have a good amount of facial fat even though I weigh 155 lbs at 5’11” height (age 28). I want to have a defined jaw line and cheeks instead of the oval shape right now. Can you please suggest procedures for me that could achieve this.Thank you!

A:You don’t really have a lot of fat in your face it just appears so because you lack good bone structure. The classic facial masculinization approach is midface (infraorbital-malar) and jawline augmentation. This may or may not be combined with some cheek fat reduction although I would question if you really need it  once you augment the surrounding bone structures.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I saw on Dr. Eppley’s website the different types of implants he uses and I’m also wondering if there’s any connection with the implants and structure of the face over time? Will the implants have to be adjusted over time? Will they be more obvious if skin loses laxity?

A: In answer to your questions:

1) The implant material used has no differences on the bony implantation site. The bone largely remains unchanged underneath it.

2) All implant materials are structurally stable, they did not change position or form over time.

3) This is a central midface position where no significant skin laxity really occurs with aging.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m looking to correct a negative orbital vector and lack of anterior projection and what I suspect is a lack of anterior projection of my cheeks. I understand that in other cases such as these you’ve recommended custom infraorbital malar implants. I would also like to know if paranasal implants would be appropriate for improving my nasolabial area. I would be interested to know your opinion on what the most appropriate course of action would be. Thanks!

A: As you have correctly surmised you have a lack of midface projection which is a major cause of the appearance of your under eye area.  When you have a negative orbital vector by definition it is not limited to just the infraorbital area but includes the cheeks as well. Because it is a generalized lack of midface development there certainly is an argument for paranasal augmentation as well. Many times when you augment the infraorbital-malar areas then the central lower midface deficiency becomes more pronounced.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have long face syndrome and also have a gummy smile (with some gum showing when I smile). I would like to ask whether there is any surgery that can significantly shorten the length of my nasal bone and maxilla. Ideally, I want to shorten it by 2 cm. I am willing to accept extensive soft tissue removal, as well as scarring and possible nerve damage. Is this possible? I have already consulted doctors in South Korea, Japan, and Italy. Their general recommendation is a high LeFort I osteotomy to shorten the midface bone by approximately 10 mm, combined with philtrum shortening and a facelift to reduce the soft tissue. However, I personally really love the appearance of an extremely short maxilla and nasal bone. Those doctors suggested I ask around the world whether shortening more soft tissue or adding a LeFort II osteotomy with nasal root advancement could make the maxilla even shorter. 

A:There is no further midface reduction you can do than a LeFort I impaction and some limited soft tissue adjustments. You’re going to have to realize that there are limits as to how much your midface can be shortened and your ideal goal of a an extremely short maxilla and nasal bones is never going to be able to be achieved. The limitations are primarily in the soft tissues. Many patients erroneouslyview this as an engineering project on the bone when in fact that is not the limiting factor at all. You have fallen into that exact same thinking.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Am I too old for a facial chemical peel?

A:Age is nothing to do with whether one can have a chemical peel or laser resurfacing. The question is not age but effectiveness for what one wants to achieve. Will the procedure and older person be effective or do they really need another procedure such as a facelift to achieve their results.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Is it possible to create a truly “high-set prominent cheekbones” appearance in someone whose cheekbones are both flat and positioned low—and who, despite having very low fat levels, lacks sharp facial contours? I don’t think custom cheek implants can truly solve this problem because the attachment point of the masseter muscle doesn’t change. Additionally, the upper border of the cheek hollows doesn’t change either. In this case, would there be any benefit to first shaving the bone and then using an implant? Or can the bone be lifted vertically upward directly, and if so, what are the limitations of this approach?

A:Achieving a high cheekbones look has nothing to do with trying to move the cheekbones more superiorly… which cannot be done anyway due to the attachments of the masseteric muscle. While you can detach the mesenteric muscle and move the cheekbones higher that would not be a very smart move in disrupting the origin of the muscular attachments. That is going to cause a whole new set of facial contour problems. Thus the proper approach to achieving a very high cheekbone look, which infringes on the lower temporal area, is a custom cheek implant design that can do so far more effectively and without creating other facial contour problems.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have lack of longitudinal growth of the maxilla that makes my face look sunken. I would like to know if these implants could fix the skeletal discrepancy or are good only for people as they age.

A:Thank you for sending your better quality pictures. When it comes to a midface deficiency the indicated treatment depends on what level of the mid \face you were trying to improve. If you have a good occlusion then a total mid face mask implant would be appropriate in fully addressing the lack of forward growth of your mid face from the infraorbital rims and cheeks down to the paranasal area.

Such mid face implants are used almost exclusively in young patients which lack midface projection. They are never used in my experience in older patients for age-related reasons.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I hope you are well. I am writing to inquire about the aesthetic testicular augmentation procedure described on your website, specifically the technique in which an implant encapsulates the existing testicle to increase volume.

While researching this topic, I have noticed that several clinics appear to offer enlargement by placing implants beside the natural testicles. My initial concern with that approach is how it may look or feel to have two separate structures side by side in the scrotum. For this reason, the encapsulating (wrap-around) technique described on your website particularly caught my attention.

At the same time, I also appreciate the benefit of still being able to feel the natural testicles. From the examples I have seen, larger implants sometimes seem to push them out of sight.

Before arranging a consultation, I wondered whether you might have any photographs available of the side-by-side implant approach so that I can better understand the visual differences between the two methods.

I would also be grateful if you could let me know the estimated costs for either procedure, including surgery, anesthesia, and follow-up care. Based on the examples I have seen on your website, I suspect that the 7 cm option might be most suitable for me.

Thank you very much for your time. I look forward to your response.

A:Thank you for your inquiry and your questions to which I can say the following:

1) As you have correctly surmised there are two different techniques first testicular enlargement, the wraparound technique as well as the displacement one. Each approach has their distinct advantages and disadvantages. If one of them was truly perfect that would be the only one that would be offered. Typically the displacement technique is done most of the time for older men who have developed testicular atrophy and have a loose scrotum. The wraparound technique is typically reserved for the younger patient who has a normal size testes and a much tighter scrotum.

2) While I have no long-term concerns about the displacement technique in older man, I do have them for the wraparound technique in younger man. Besides the ability to feel the natural testicles it is unknown long term how this may affect fertility as well as the ability to detect testicular cancer. There is also the risk of displacement or separation of the implant from the testicle secondarily..\ None of these are concerns with the displacement method. For these reasons I’m very cautious about the use of the wraparound technique in men with normal size testicles.

3) Due to patient confidentiality I am not in a position to pass around patient photos.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Can the forehead part above but in between the eye brows be made even.

A:You are referring to the glabella or glabellar valley I assume which in some patients can be quite deep and can be filled in. But without seeing pictures of your forehead concerns I can not how this may apply to you.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am wondering if you’ve ever done iliac crest augmentation with medpor implants. I don’t really know if the shape of the titanium implant would look natural – even in the photo of the implant on the pelvic bone, on your page titled “Pelvic Plasty for Upper Hip Widening – Iliac Crest Plate Design”. … you can see that the implant does not smoothly extend the natural shape of the iliac crest, but instead juts out a little rearwards of the front outer corner of the iliac crest. Are you considering any other types of implants for this procedure outside of the standard titanium shapes on your website?

A: In answer to your Pelvic Plasty questions:

1) I would never consider the use of Medpor on the iliac crest, too brittle in a load bearing area.

2) There are no current plans for modification of the existing titanium iliac crest implants. It is not simple to change the product shape particularly in terms of the economics in a very infrequently performed procedure. For those seeking a different shape that is where the role of custom titanium implant design and manufacture comes into play.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m reaching out because I’m trying to understand whether increasing facial width is a realistic and established option in aesthetic facial surgery, or whether facial width is generally considered something that cannot be meaningfully changed in a natural way. My face reads as narrow in proportion, specifically in that the horizontal width of my face (sideburn to sideburn) is relatively small compared to the vertical height of my face (chin to top of head). From the front, this creates a narrow and elongated appearance rather than balanced proportions. What I’m trying to determine is not a specific procedure, but whether facial width itself is something that surgeons actually evaluate and, when appropriate, increase in order to bring proportions from narrow into the normal male range. I’m not looking to look wide or dramatically different — just to understand whether conservative increases in facial width are something that is realistically achievable in some patients without creating an artificial or overdone result. I’d really appreciate your honest perspective on: whether facial narrowness is something you assess clinically, whether increasing facial width toward normal proportions is something that is sometimes appropriate, and whether this is considered a legitimate, commonly treated concept rather than a theoretical one. My goal is simply to understand what is genuinely possible versus what isn’t

A:In the world of the aesthetic facial reshaping surgery, whose patients are primarily young, the treatment of a narrow face is very common. Whether that is of the forehead, mid face or lower jaw the addition of width , when determined it is aesthetically beneficial by imaging, is commonly done. How much facial with is appropriate is also determined by the same imaging process. In the vast majority of cases this is done using implants although there are some rare exceptions where autologous width augmentations can be done

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hi looking for cartilage  graft removal from a prior rhinoplasty. I do not want the grafts they added in my nose making it bigger. Graft removal possibly shave down of bridge. The bridge looks super strong and unnatural.

A:Thank you for your inquiry and sending your pictures. Many cartlige graphs can be removed from the nose depending upon their size and location. In order to understand how successful that may be it would be important to see the operative note from your surgery. I think the other question to consider is in removing these grafts will they really make the nose smaller. That likely would be true for the bridge but I would be more cautious in that consideration for the tip of the nose unless the cartilage grafts are considerable in that area. The relevancy of that statement requires my reading of your operative note.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have some skull augmentation questions after getting a PMMA bone cement procedure.

1) What is a solid silicone skull implant material you use ?

2) Do you have a picture i can see to have a better understanding ?

3) How can it be attached, screws or glue?

4 Is it going to be stable when pressure applied to it like playing soccer or doing any activities can affect like if i fall is it going to stay stable ?

5) The other point will be infection possibility and risk

6) Is it doable with PMMA bone cement?

7) Finally for the most part is done i would say 20 percent left has a dent . since on left side my temporal muscle is big I don’t want to add on the top of it .roughly 2 to 2.5 inch length triangle part needs to filled outward ( convex ) like a segment of galic or orange shape to make it smoothly rounded . I have to wait few more months in order to make sure there is no swellings but I will forward you some pictures to let you estimate . Thanks in advance for your help .

A:Thank you for your inquiry and sending your pictures. When it comes to augmenting the triangular area that you have outlined this can only be effectively evaluated and done by 3-D planning with the custom implant placement. This is the only way to optimize the amount of augmentation, cover the area needed without over or under correction and blending it in to the underlying PMMA bone cement. The first step is always to go to the 3-D CT scan to make all of these evaluations. This will allow the determination as to whether the implant will need to be custom-made, which is optimal, or for the sake of economics be interested in fashioning it from other materials.

Regardless of how the implant is made it will remain structurally and positionally stable, it will feel like bone, is secured to the area with screw fixation, and is not going to prohibit you from ever doing any type of physical activity.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,  I saw your corner mouth widening, and i want to ask you if you perform a corner lip lifting (outer parts of vermillion border) combined with corner mouth lifing, i hope you do that and would like to know how much it would be, i would come from Italy, thanks in advance.

A:Thank you for your inquiry and sending your pictures. First, a sub nasal lip lift is a central upper lip procedure and will not make any changes to the outer mouth corners as you have noted. Secondly the results from another patient you have shown are known as lip curls, a significantly upturned mouth corner which is very popular in Asia but not here in the western world. Thirdly what you are demonstrating manually on your outer lip is a lateral vermilion advancement which is the only effective way to increase the outer third of the lip vermilion fullness and raise the mouth corner to some degree. Can you combine a lateral vermilion advancement with lip curls?  No, as the basis of achieving a lip curl is that the lateral vermilion medial to it is stable so you have a platform on which to turn it from.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m curious about the feasibility of using larger pectoral implant sizes; potentially in the range of 800cc (preferably more )per side. I understand this may be outside typical sizing, so I would really value your professional perspective on what is anatomically achievable and safe.Aesthetically, I’m aiming for a more pronounced and slightly stylized result rather than a strictly natural look.

Specifically, I’m interested in:

Noticeable forward projection of the chest

Clear definition between the pectoral muscles (cleavage)

A somewhat rounder contour rather than a square shape

An overall slightly androgynous, leaning masculine, appearance in shape.

I would appreciate your thoughts on whether this look can be achieved, and if so, what approach or limitations I should be aware of.

Thank you very much for your time, and I look forward to hearing from you.

A:Thank you for your inquiry and detailing your specific pectoral implant augmentation objectives. When it comes to large pectoral implants there is a standard size which fits into that description known as the Powerflex Plus pectoral implant, This has a volume of 600 ccs with a maximum projection of 4 cm. This is usually sufficient for most patient objective of extra large pectoral implants and for the patient that has never had a pectoral implant before may be about the biggest size that will fit. While I have made many custom pectoral implants that are larger those patients have to be selected very carefully to ensure that such a large volume can actually be surgically placed.

How this general statement about large pectoral implants applies to you I do not yet know. This will require seeing pictures of your chest as well as knowing what your body frame is (height and weight)

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’ve found your work and I’d like to inquire about a consultation about a reduction genioplasty. I had double jaw surgery to correct a class 3 underbite in 2015 and since then have had no problems, except aesthetically I do not think the position of the chin highlights my improved bite. I would like to discuss what reduction and shaping would entail. I am a professional musician- I play the clarinet. So this is a high consideration for me and it’s important that I make an informed decision. Hope to hear back soon.

A:Thank you for your inquiry, detailing your prior surgical history and sending your pictures. I can certainly see based on your profile picture of your interest in a reduction genioplasty. I can also see in your x-ray that you had an advancement genioplasty which I presume was done with your double jaw surgery. I don’t know the logic of why that was done at your double jaw surgery, particularly when it was for a class III malocclusion in  a female, but now it is an unfortunate over augmented chin.

In considering bony reduction sliding genioplasty there are two concepts about yours that I know for certain. First in general an intraoral sliding genioplasty reversal is usually a poor aesthetic procedure in that it creates a redundant submental soft tissue problem. Second as a professional musician in which lip sensation and lip competence is critical I would consider any intraoral chin procedure very cautiously. For these two reasons this is not a good approach to your chin reduction and I wouldn’t do it. The  more appropriate approach is that of a submental one where both the bony chin reduction and the resultant soft tissue excess will result can be simultaneously addressed. This is not only the better aesthetic procedure for pure horizontal chin excess but also avoids much of the potential lip issues which are so critical to your profession.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello sir I have scaphocephaly head problem what should I do? What surgery is possible to overcome this problem? 

A:The term scaphocephaly refers to an elongated skull from front to back. By the way you have taken your pictures my assumption is that the most bothersome part is the length on the back of your head. The question is not whether the back of the head squall bone can be reduced in projection/length but whether enough can be taken to make a visible external difference. This is determined from the 3-D CT skull scan with color mapping of the bone sicknesses to make that determination.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’d like to discuss a couple implants like chin implant, jaw implants and cheek implants. I’m not sure I will get all, but some, and I’d like to weigh my options. In combination with those I would really appreciate your input on double jaw surgery with bimaxillary advancement, assymetry correction (slight cant correction, and horizontal repositioning), all of which to align the jaws to facial midline and center it to the eyes. This would be crucial since this surgery would create the foundation for the implants. I plan to get jaw surgery in south korea as aesthetic jaw surgery isn’t done in my country, and your input would be strongly appreciated

A:If you were already certain that upper and lower jaw surgery is needed there is no purpose before that surgery to have some discussion about secondary implant onlay augmentation as the postop aesthetic needs, if any, are yet unknown. As you have correctly pointed out get the skeletal foundation correct first and then evaluate what secondary implant augmentations may be beneficial.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am writing to inquire about your expertise in facial contouring, specifically regarding procedures to achieve a more defined lower third.

I have been researching the various defatting techniques you offer, and I am particularly interested in a combination approach including Buccinator Mucosal Myectomy, buccal lipectomy and perioral liposuction. My primary goal is to address a persistent “baby face” appearance. Despite being very lean overall, I feel I carry a significant amount of fullness in my lower cheeks and jawline that is resistant to diet and exercise.

My main question concerns the extent of buccal fat pad removal. I would like to understand the anatomical limits of the procedure. To put it in concrete terms, if I had, for example, 10cc of buccal fat on each side, what is the maximum percentage or volume that can be safely excised? My aesthetic goal is to achieve the most dramatic reduction possible, as I am not concerned with the traditional risks of looking “gaunt” as I age. My philosophy is that if future volume loss were to become an issue, that could be addressed later with fat grafting.

I am very interested in your perspective on this approach.

Thank you for your time and expertise.

A:When it comes to defatting the face the procedures you have outlined are the appropriate ones including potentially submental liposuction. When it comes to buccal lipectomy in particular you take out as much of the central fat pad as can be safely extracted without injuring the closely attached buccal branches of the facial nerve. In most patients that is somewhere between three and 6 mL per side. I’ve never seen anybody in 40 years and hundreds of buccal lipectomies that had 10 mL on the single side.

That being said, while that is the most fat you can remove in the face, will that achieve your desired effect? No one can say precisely before hand but it’s probably fair to say that it probably won’t achieve as much as you would like simply because you don’t have a fat face. What you do have, is a vertically short chin with a deep labiomental fold, which works against optimal facial contouring. Ideally you need to have the chin vertically lengthened which always makes a major contribution to thinning out the lower face (see attached imaging)

To put that in perspective I would argue the vertical lengthening of the chin makes a more major contribution to thinning out the lower face then the defatting procedures will. Ideally you do both together to achieve a maximum change and that is the best approach.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Can my prominent bony forehead be reduced?

A:The question is not whether you can have bony reduction of your forehead protrusion… as you can. The two pertinent questions are as follows:

1) Is the bone thick enough to allow for an adequate reduction? In other] words is this bump due to thicker bone or is it due to thinner bone in which the brain has merely pushed it out. While in my experience it is always the former it is always prudent to get a 3-D CT scan of your fore head with Color mapping of the bone thicknesses which will clearly show the thickness of the bone and how much can be safely reduced. This then provides one of the qualifiers for forehead bone reduction.

2) The second question, which is an aesthetic one and it precedes even getting a scan. is where are we going to put the incision to do the forehead reduction. Most four head reductions require a frontal hairline incision for adequate linear access. That obviously is not going to work in your case which means it would have to be a more posterior scalp incision that is adequately long to be able to turn down the forehead flap for access. Whether the scalp scar is a reasonable trade-off for the aesthetic benefits of the forehead bump reduction is one that has to be determined on an individual patient basis.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, The goal is to feminize the body of course.  I will let the doctor tell me how to go about doing that.  Once I have his recommendation I can decide how to proceed.  As of now, I am leaning towards fat transfer to hips/butt/thigh rather than hip/butt implants.  That is a flip from my original thinking.  I think I would rather have a softer body than the firmness that comes with implants.  Of course a combination of implants and fat transfer is possible but the cost of surgery starts biting at some point.  Rib remodeling and clavicle reduction are also something to consider.

Anyway, that’s the laundry list.  I look forward to hearing back.  I will reiterate that I don’t mind making the flight to see the doctor if he believes that it would be helpful.

A:Thank you for sending all of your pictures. My initial reaction is I think your perception of the proper approach, liposuction and fat grafting to the hip and buttocks, would be how to proceed first. While it is always unknown as to how much fat is going to survive in the hip and buttocks. But what is more assured is the reductive effects from the donor sites, abdomen flanks and back, which s going to help with body contouring.

Do this procedure first and then see what you think. The fat harvesting in particular is really necessary before you consider any structural body contouring as that as always the rate limiting step in their effectiveness. Structural body contouring procedures are often combined with liposuction anyway so you might as well get that done before considering any other procedures.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, “Hi, I’m interested in a procedure that isn’t available in my country and exploring options overseas. I’m looking at getting infraorbital rim implants to correct my under eye hollowing permanently. Please get in touch when you get a chance with information regarding the procedure.

A:Thank you for your inquiry and sending your pictures. I can certainly appreciate your objectives given your prominent brow bones, cheeks and jaw with comparatively recessed infraorbital rims. Successful infraorbital rim augmentation requires an implant to saddle the rim and to add increased height as well as horizontal projection. This can only be done by a custom implant design.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,Thanks for taking the time to answer prospective patient questions! I have congenital prominent eyes and 1mm of inferior scleral show. Would lower lid retraction repair with a graft reduce my staring/occasional bug eye look at rest? When I smile or squint, my eyes look much better. However, I’m also wondering if I have a negative orbital vector, and whether this would be the best procedure for long term durability or if I’d be better off with infraorbital implants (if I were to only do one). If a graft- would you you use material like tarsal, hard palate, etc.? If implants, what would be the estimated cost for standard vs custom? Thanks!

A:Thank you for your inquiry and sending your pictures. Quite frankly you have a severe negative orbital vector what I would classify as a type III which is just about as severe as it gets. This fundamentally means this is a skeletal problem of which the live retraction is just a symptom of it. Therefore isolated eyelid surgery alone is the equivalent of putting a Band-Aid on the real problem and its effects would be very modest at best and probably not well-maintained. The correct approach is custom infraorbital-malar implants with lateral canthoplasties and lower eyelid spacer grafts.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have wide side skull (wide face) and flat head. Is it possible to be corrected (change) 

A:Thank you for sending your pictures. What you have is a classic type of head shape that we see and treat. When the back of the head is a bit flat (brachycephaly) the sides of the head will naturally widen during development. This is treated by a combination of a custom back of the head scholar implant combined with Temple reduction on the sides of the head. This creates changes similar to what we see in the imaging done on your attached pictures.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am very much leaning towards keeping my existing medpor implant and adding only custom jaw angle implants. However if a custom implant can be designed to extend from the jaw angles through the chin region, adding vertical dimensions on top of the Medpor, that would be ideal.

A:Trying to make custom jaw angle implants to extend far forward and fit on top of/underneath the existing Medpor chin implant is not a viable option. While that can be designed on paper executing it is fraught with complications particularly with an implant such as Medpor. You either remove the Medpor chin implant and go all the way with the custom wraparound jawline implant or settle for the ajw angle  implants coming forward and touching the back of the Medpor implant.

Dr. Barry Eppley

Plastic Surgeon