Your Questions

Q: Dr. Eppley, I am interested in getting XL silicone implants. I currently have  800cc UHP Mentor silicone implants.. I am 5’4” tall and weight 116lbs. I am looking to get at least 1200cc silicone through the areolas.

A: When it comes to XL breast augmentation it is very common to see a patient with 800ccimplants wanting to go beyond that into the > 1000cc range. Well this can be done there’re certain important concepts to understand about doing it.

1)  it is important to recognize that currently you have fairly symmetric implant placement and breasts. In putting larger implants it maybe necessary to expand the existing implant capsules as the base diameters of many XL implants are larger than the current 800 mLcc implants that you have. This runs the risk with much heavier implants (50% heavier)  of developing bottoming out and asymmetries which may require secondary revisional surgery. Such revisional surgery can be very difficult when you have implants with weights of close to 3 pounds. Weight and gravity winout over surgical technique many times. Ideally you would like to have larger breast implants that do not exceed the base diameters of what you have where the increase in volunme is totally in projection which allows you to keep intact your current capsular boundaries. But this often is not the case. Therefore it would be important to know the base diamter of the implants you have compared to the newer larger silicone breast implants that exist so you can properly assess that risk. While breast implant asymmetries are a well-known risk in any breast implant surgery that risk is increased as the implant sizes become larger

2) XL silicone breast implants are currently available but it is important to recognize what the FDA approved indications for their use are. Currently they are approved for breast reconstruction. While it is common to use them now for breast augmentation needs this is done on what is known as an off label basis. This is perfectly legal and medically safe. There are many medical devices that are used on an off label basis.

3) FYI you will not get XL breast implants XL breast implants place through placed through the areola. That is just a physical impossibility unless they are saline and not and silicone implants.

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley,  Can my head shape be fixed? How long does it take for the healing process on the skull to come to fruition after procedure?

A:This appears to be an overgrown frontal bone with a protrusion in front of the coronal skull suture line. This is treated by a frontal bone burring reduction technique. Whether that can be successfully done, AKA enough bone removed to create a smooth contour, requires a preoperative 3-D skull scan with bone thickness measurements.

It generally takes 2 to 3 weeks for most of the swelling from any skull reduction procedure to allow the benefits of the surgery to be seen.to allow the benefits of the surgery to be seen. It takes a full three months for the true final result It takes a full three months for the true final result two BC two BC

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Can My too large chin implant be replaced with a sliding genioplasty keeping the natural shape of my chin?

A:Certainly a sliding genioplasty can be a good substitute for a chin implant as it will also help narrow the chin. On a  technical note you have to realize that a sliding genioplasty alters your natural chin shape rather than keeping it. I think what you meant by preserving as much of your natural chin shape you were referring to keeping the existing horizontal projection.

But in the intent of keeping the same horizontal projection but with a more narrow shape than having the existing implant in place it can be effective.

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’ve noticed that with many wraparound jaw implants (implants that extend along the mandibular body), the final visible contour often doesn’t match the implant design because the soft tissue doesn’t drape tightly enough over the new hard-tissue shape. For an aesthetic lower third, I think soft-tissue tightness and angularity from the antegonial notch through the chin corner is critical. Beyond the obvious masseter dehiscence problem, I’m specifically concerned about the mandibular retaining ligament. In a wraparound dissection, this ligament sits over the inferior lateral mandible where the implant typically lies, so it may be released/detached. My concern is that releasing it without any compensatory/restorative reattachment or pocket control can leave the soft-tissue envelope too loose, allowing bridging/sagging so the implant shape isn’t expressed. When you place this type of implant, do you perform any form of periosteal/soft-tissue resuspension, reattachment, or other technique to recreate the stabilizing effect of that ligament and ensure tight drape? Or do you mainly rely on added volume to stretch the tissues to achieve angularity—and if so, is that only reliable with very large-volume implants?

A: Adequate subperiosteal dissection and the creation of the implant pocket is critical and, by definition,  implant placement is about ligamentous releases. The ligament to  which you refer is released all the time without any adverse aesthetic effects that I have ever seen. There is no known method to restore it even if one desired to do so.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Hello. My overall goals are to figure out the actual cause of my concerns with my face and figure out the best possible path forward for a natural healthier look and my best overall self but not to a point where I look like a completely different person. I wish to correct poor under eye support, scleral show and negative eye hooding, nasal labial folds and possibly a recessed maxilla, excessive buccal fat since birth thats purely genetic, a large platysma muscle due to low hyoid, thin and downturned lips, and a soft jaw + also potentially getting botox to allow atrophy to occur in the masseter muscle and create a less bulky face look.

A:Thank you for your inquiry and sending your pictures. Your facial problem is fairly straightforward from a diagnostic standpoint. It is a structural issue where your entire mid face is recessed compared to the upper and lower thirds of the face (brow bone and chin projections). Ideally you should have a LeFort one advancement osteotomy followed by secondary infraorbital-malar implant augmentations for total correction of the issue.

The first place to start is to get a maxillofacial consultation to evaluate the potential for upper jaw advancement. Total midface implant augmentation should only be considered if it is determined by a surgeon or you that you do not desire to go through the initial upper jaw advancement surgery.

Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’ve noticed that with many wraparound jaw implants (implants that extend along the mandibular body), the final visible contour often doesn’t match the implant design because the soft tissue doesn’t drape tightly enough over the new hard-tissue shape. For an aesthetic lower third, I think soft-tissue tightness and angularity from the antegonial notch through the chin corner is critical. Beyond the obvious masseter dehiscence problem, I’m specifically concerned about the mandibular retaining ligament. In a wraparound dissection, this ligament sits over the inferior lateral mandible where the implant typically lies, so it may be released/detached. My concern is that releasing it without any compensatory/restorative reattachment or pocket control can leave the soft-tissue envelope too loose, allowing bridging/sagging so the implant shape isn’t expressed. When you place this type of implant, do you perform any form of periosteal/soft-tissue resuspension, reattachment, or other technique to recreate the stabilizing effect of that ligament and ensure tight drape? Or do you mainly rely on added volume to stretch the tissues to achieve angularity—and if so, is that only reliable with very large-volume implants?

A: Adequate subperiosteal dissection and the creation of the implant pocket is critical and, by definition,  implant placement is about ligamentous releases. The ligament to  which you refer is released all the time without any adverse aesthetic effects that I have ever seen. There is no known method to restore it even if one desired to do so.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, What materials do you use for custom facial implants? Some surgeons I’ve spoken to use mirror polished titanium, some use PCL? Thank you.

A: There are four materials available for custom facial implants, solid silicone, PEEK, porous polyethylene and titanium, which all differ in cost.  But it is also relevant that they do not perform equally as each material has its implant design limitations….which most surgeons do not consider due to lack of experience with all implant materials. You don’t want the material to control the design, how it is able to be placed or how effectively it blends into the surroinding bone.

For the infraorbital-malar area solid silicone is ideal most ideal as the need to saddle the rim is almost always needed and the thin eyelid tissues require feathered edging to avoid palpable and/or visible implant show. PEEK can also be used but hard to get feathered edging in a machined implant.  Porous poluyethene and titanium have too many disadvantages to use in this facial area.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’d like to schedule a virtual consultation to discuss options to revise or replace a PEEK wraparound mandibular implant that’s malpisitioned by 3-6mm vertically and 2mm laterally. In the attached pictures, the rough, yellow implant is the 3D render from CT scan of the implant that’s implanted in my head and the smooth, tan implant is the planned position of the implant.

A: Thank you for your inquiry and sending the jawline implant images to which I can say the following:

1) Who designed this implant? As such an implant design was bound to  have a misplacement problem. How they got it even this close to the designed alignment is a miracle in my opinion.

2) I can see that the implant was designed to replace the bone removed in either a prior V line surgery or sagittal split osteotomy. But you never make a pure vertical lengthening implant that only expands the inferior border as exact placement is almost impossible.

3) You have to have at least some lateral flange areas to optimize placement and implant fixation.

4) The only way to salvage this implant is using an external jaw angle incisional approach with plate fixation to the angle.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, So I was thinking of endoscopic brow lift, with pinch blepharoplasty. I don’t like the wrinkles in my forehead, and I would like it to be less heavy. My eyes have quite a bit of crinkling on the sides. I’m also interested in some other procedures, but I’d like to start there. Thank you.

A: Skin wrinkles that occur in the forehead and at the outer eye are not going to be solved by browlifts or blepharoplasty surgery. Those are best treated by Botox injections. Browlifts lift the eyebrows and make them less heavy. Blepharoplasties remove skin and fat.

Both can be useful for you but you have to understand what they can and can not do.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m most concerned about the thickness of the orbital rims. I’ve always felt my eyes looked sunken and I never really understood why, but now that I’ve been researching it seems to be that I have very thick orbital rims.

I feel the center area, at the glabella, is not nearly as prominent as the rest of the orbital rims.

I have had a minor upper blepharoplasty  probably 20 years ago.

And my eyebrows are tattooed.

I have not liked my hairline either and do feel it is pretty high and masculine looking as well.

The only thing I feel I couldn’t do is the type 3 forehead reduction. That just seems too much for me for cosmetics.

I also don’t love the idea of the full hairline incision, but do realize that may be necessary.

A:Thank you for sending your pictures. I can certainly appreciate your orbital rim prominence concerns. Whether they can be reduced by shaving or requires a bone flap setback depends upon which areas of the brow bones you feel need to be reduced. In the attached picture I have noted the two different areas of the brow bones, medial and lateral. Their bony composition is quite different with the medial being created by the aeration of the underlying frontal sinus and the lateral being created by solid bone. As a result the techniques needed to reduce them are different. Medial brow bone prominence reduction requires a bone flap setback while lateral brow bone  prominence reduction can be done by shaving. Well these techniques are different I don’t think to the patient it really makes much difference in terms of the surgical recovery but it could make a big difference in the aesthetic outcome depending upon the brow bone areas that need to be reduced.

With either brow bone reduction technique this does require superior incisional access which in the high frontal hairline would be done through a hairline approach. Given that you already have concerns about a high hairline this does provide the opportunity to do some frontal hairline advancement at the same time. Without a frontal hairline incision this would require a full bicoronal scalp incision placed way behind the hairline from ear to ear.

In addition to the brow bone reduction there probably is also some benefit of upper forehead reduction as well in the spirit of an overall forehead feminization effect.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Does fat transfer to the brow bone area work?

A:Fat injections as a method of brow augmentation can be effective depending upon what your brow augmentation goals are and whether you can accept the variability in terms of take and persistence of the injected at. Like injectable synthetic fillers it can be viewed as a temporary procedure to determine whether you like the effect which can then be converted to a more permanent implant solution later if desired.

As to what these general statements on fat injections to the brows mean for you I would need to see some current pictures of your brows as well as what your brow augmentation goals are. In other words determining whether you are a good candidate for the procedure.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My current alar width is approximately 43.5 mm, and my intercanthal distance is 33 mm. Using a combination of procedures—such as alar base cinch, wedge excision, weir incision, and sill excision—how much reduction in alar width could realistically be achieved? I understand I have thick skin, so I just want to get a sense of what would be possible with the most extensive surgical approach to bring the alar width closer to my intercanthal distance.

A: The question you are asking is whether a 10 mm bi-alar reduction can be achieved. Until I see some pictures of your nose and face I am going to assume that such  nostril width reduction is possible until proven otherwise.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I wanted to inquire about deep neck lift procedure.  Here are the photos of the loose platysma/neck muscles Heres a desired result. 95-105° cervicomental angle Current cervicomental angle  is roughly 130-135°

A:Thank you for your inquiry and sending your pictures. First and foremost you are approaching your neck concerns from an incomplete concept. You first have to go back and make the diagnosis of why does your neck look like it does for an otherwise young person who has yet to develop any significant aging tissue laxity. Your case is a classic example of a lack of bony support (weak roof) for the underlying neck tissues. When you have a short chin and weaker jawline by definition you not going to have a sharp cervicomental angle in most people (imsupported neck tissues). Thus looking at soft tissue procedures alone will not create your desired end result as that is not the sole source of the problem. While you can do various neck procedures you will not achieve that sharp cervicomental angle and it will probably end up being about 50% to 60% of what you want. The only way to achieve that end result is by either chin or  total jawline augmentation combined with lesser neck procedures like a submentoplasty. If you look carefully at your ideal result notice the chin projection and jawline shape on that model patient is quite different than yours.

In short the two effective procedures for the best cervicomental angle improvement are: 1) a sliding genioplasty with a submentoplasty or 2) a custom jawline implant (which may negate the need for any neck work at all is that has a powerful necklifting effect n and of itself)

While there is nothing wrong with neck procedures alone you just have to realize that your expected result is not going to occur.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I’m interested in a consultation with for custom midface implants. Background: I am of SAsian descent. I had a LeFort I advancement ten years that successfully corrected my malocclusion, but my upper midface remains noticeably recessed. The LeFort I advanced the dentoalveolar segment, but everything above the osteotomy line — the infraorbital rims, paranasal area, and cheekbones — was left untouched. 

Mt current concerns: – Significant infraorbital hollowing and a prominent nasojugal groove bilaterally – Flat midface appearance with recessed infraorbital rims – The nose appears flatter than it may actually be due to the lack of surrounding midface projection – Overall midface recession that the LeFort I did not address 

Goals: I’m interested in a custom infraorbital-malar implant (possibly with maxillary extension) to correct the residual upper midface recession. I’ve reviewed Dr. Eppley’s published case studies involving post-LeFort patients receiving custom IOM implants and believe my situation is very similar. I’m also considering rhinoplasty but would like to assess after the midface implant settles whether the improved midface platform reduces or eliminates the need for dorsal augmentation, potentially leaving only a tip refinement.

A:Thank you for your inquiry and sending all of your pictures. Your post LeFort I osteotomy concerns are not uncommon and you are understandably interested in an augmentative effect above the LeFort I level. I think your concept of IOM implants with maxillary extensions, otherwise known as an upper midface mask implant, is appropriate based on your pictures and the prior LeFort I osteotomy. A relevant question, which you have already noted, is what happens to your nose when this augmentation is done around it. This raises the question of whether an augmentation rhinoplasty should be done at the same time or deferred to a secondary basis.

These are all great questions that we can discuss during a virtual consultation.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I want to know what implants would have the highest ROI and would improve me the most. Really looking into getting bigonial implants and potentially chin, infraorbital & malar.

A:In the male seeking facial masculinization there is no question that the two most powerful methods of doing so with the best value are a custom wraparound jawline implant with either custom cheek or customary infraorbital-malar implants depending upon their aesthetic needs. Don’t waste your time or resources on any standard implant unless your aesthetic  needs are very modest and relegated to limited ’spot’ facial augmentations.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, My goal is to have an implant that is identical to my other testicle. Something that is soft (hollowed eppley version), feels as natural as possible, sits and hangs and moves as a normal testicle would. I’m very active, so want to have as short of a recovery time as possible preferably. And also, once healed, that vigorous and extreme-sport type of activities wouldn’t be an issue for it (big wave surfing, as one example).

I’m also wanting to ensure it won’t be a problem for my other testicle/epididymis and that all sexual function won’t be impeded (would the tube that shoots semen be pressured or pinched by the implant? especially since the scrotum would probably be really tight at first due to not having a 2nd buddy in there for my whole life).

A:In answer to your other questions:

1) Once healed there are no physical restrictions afterwards. Remember it is an implant and you really can’t hurt it unlike your natural testicle.

2) As best as it is known currently there are no adverse effects on the function of the opposite testicle whether that be for sexual function or hormonal production. Testicle implant replacement has been around for many decades and to my knowledge there are no reports of any adverse effects on the natural testicle.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Are there emerging technological advances that may improve post-operative outcomes, recovery time, and overall success rates in the near future? For patients considering orbital box osteotomy for cosmetic reasons, what is the likelihood of visible scarring or unintended aesthetic changes to other facial areas following the procedure?

A:The following answers your two questions about orbital box osteotomies for aesthetic purposes:

1) I see no emerging technologies that is going to substantially change the effectiveness or safety of the procedure. We currently have 3-D CT scanning and virtual surgical planning which is the most you can do beforehand. In the end you still have to do the actual procedure on the patient.

2) The potential risks and complications of orbital box osteotomies are relegated to the periorbital bone and soft tissues and do not adversely affect other facial areas.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in brow bone augmentation with bone cement.

A:Be aware that in doing brow bone augmentation with bone cement this is going to require a full bicoronal scalp incision with turndown of the forehead flap. Also depending upon the aesthetic brow bone augmentation objectives bone cement may not be appropriate for them. It’s aesthetic impact is really relegated to very minimal brow bone augmentation effects.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have questions about custom facial implants, specifically about a jawline implant?

• Do you typically use standard implants or custom (3D-designed) implants? 
• What is the earliest availability for consultation, surgery?
• Do you offer virtual consultations initially?
• How many in-person visits are required (pre-op / surgery / post-op)?
• How long should I plan to stay in town after surgery before flying back?

A:In answer to your questions about custom jawline implants:

1) All jaw augmentation done today are done with 3-D custom wrap around jawline implants due to their far superior results.

2) The implant design and fabrication process takes several months to complete and that is the rate limiting step in the availability for surgery.

3) Virtual consultations is how we interact with every single patient.

4) For the vast majority of our patients they only come here for the actual surgery. All other pre-and postoperative sessions are done in a virtual manner unless there are compelling reasons to do otherwise.

5) Most patients arrive one day before the surgery to meet and review the surgical plan. They then returned home 48 hours after the surgery.

6) The cost of surgery is partially influenced by the material chosen for the implant which is largely patient driven. This could include silicone, PEEK, Medpor, or titanium. For an initial quote it will be done in the most economical material which is  silicone and the one about 80% of patients choose for their implant. Each material has their advantages and disadvantages. No implant material is perfect. It all depends on the implant design and its size as to which material may have the most advantages.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am interested in improving my chin implant result as it is too wide. I was also wondering if a lip lift can be done at the same time.

A:Thank you for your inquiry and sending your pictures. This is a classic example of an extended wing chin implant placed in a female providing adequate horizontal projection but at the trade-off of widening the chin. In essence a male style chin implant placed in the female. There are two approaches to your chin implant replacement. One is to make a true custom Chin implant design based on the full knowledge of your existing chin implant utilizing 3-D planning. The alternative is to take a standard anatomic shaped chin implant and modify it into a V-shaped to keep the horizontal projection but dramatically narrow the chin and get you back to the chin shape you originally had. This still requires knowledge of what your existing Shannon plant is and this is where the role of 3-D CT scanning can answer that question very specifically.

Certainly a lip lift can be performed with a chin implant replacement.

Dr. Barry Eppley

Q: Dr. Eppley, Hello, I had silicone infraorbiatl implants which i would like removed. After removal I was wondering does it look worse than before ? I had lower eyelid retraction surgery as well, so how would it look compared to my original? Thanks

A:There are numerous variables are unknown to me in trying to answer your question. Information such as what is the size and shape of these implants, what did your face look like before compared to now etc. Knowing that these were replaced at the same time as lid retraction surgery suggests to me that this was done by an oculoplastic surgeon and that these implants are likely traditional tear trough implants.

Thus I can only conjecture as to how closely you will return to what you look like before. Minus the lid retraction surgery you lightly will come close to, but probably not exactly, what you looked like before.

But that issue aside I think the real question is, regardless if you don’t return exactly to what you looked like before, would you still keep the implants to avoid that outcome. Your very inquiry suggests that you would not.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, i would like to understand how skull implants are adhered to the bone. is the implants. Are they glued? Bolted? And s it easy to damage material and does it loose shape over time? Can it cave and loose shape? Thank you

A: Skull implants are placed directly on top of the bone under the five layers of the scalp. While they are initially secured by small micro screws their long-term position is assured by their sheer size and shap[e under the tight scalp. and the natural encapsulation process

Skull implants are made of permanent materials that can never degrade, breakdown or change shape. Neither can they be damaged by any type of trauma.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I am writing to inquire about infraorbital hollowness and under-eye discoloration.I have moderate under-eye hollowness with dark circles that has been present since my mid-teens. I have a lean build with thin periorbital skin. I recently consulted with a surgeon about fat grafting to the infraorbital area (placed on the bone), and while he felt it could improve the hollowness and discoloration, I want to understand the degree to which my issue is skeletal versus soft tissue before committing to any procedure.

I have attached three photos:

∙ Front-facing (hair pulled back)

∙ Side profile

• Close-up of the under-eye area showing the hollowness and discoloration

My questions:

1. Based on an initial assessment, does my infraorbital hollowness appear to be primarily a bony deficiency (infraorbital rim recession) that would be best addressed by custom infraorbital/ saddled infraorbital-malar implants, or could this be a soft tissue issue where fat grafting may provide a meaningful result?

2. If I proceed with fat grafting first as a less invasive step, would this complicate future custom IOM implant design or surgical placement in any way?

3. What type of scan do you require for a full assessment — would a CBCT from a dental clinic be sufficient, or do I need a full medical 3D CT scan? 

4) I am also considering MARPE for palatal expansion. I understand this should ideally be completed before any midface implant work, as it changes the maxillary anatomy.

Thank you for your time. I look forward to hearing from you.

A:Thank you for your inquiry and sending your pictures. What you have is a classic negative orbital vector which is always indicative of a significant skeletal issue, lack of adequate infraorbital – malar projection. This is an assessment that can clearly be seen in your pictures as your corneal projection lies well in front of the infraorbital rim. This can only be addressed by infraorbital – malar implant augmentation.

In answer to your other questions:

1) There certainly is little harm in doing fat injections although this will prove to be an ineffective maneuver. While complete resorption of the fat is the most likely outcome in a young thin patient there is always the risk of potentially creating fat collections in areas where you don’t want them that will be impossible to remove. But that issue aside it most certainly will not interfere with secondary implant placement

2) The purpose of the 3-D CT scan is to serve as the platform on which the implants are built. They will also only confirm that what is seen on the outside is evident on the bone. In short you don’t really it for a diagnosis. You would only get it because it would be needed for implant design.

3) Any form of palatal expansion is not going to interfere or change what needs to be done to the bone well above it.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I had lambdoidal craniosynostosis. I had surgery to re-open the suture at one year old. I have a noticeable scar in the region. My hope is to correct the asymmetry from the condition as best as possible. I have a depression on the left side where that suture is. And the scar follows from behind the left ear to the middle of the back of the skull. The right side of the head is mostly unaffected aside from consequential shifting or molding.

A: Improvemwent  of the skull shape can certainly be done as an adult through the existing scar. The only question is whether it is best done by a custom skull implant or bone cement. A 3D CT scan is needed to make that determination.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, Am I a good candidate for hip implants?

A:Thank you for sending your pictures. Hip implants compared to all other aesthetic body implants have the highest rate of complications. The key to lowering those risks is to keep the augmentation between the iliac crest and the greater trochanter of the femur as well as to not be too ambitious with the hip augmentation goals. Large hip implants that violate these anatomic guidelines and become too big in projection volume almost always leads to complications. In looking at your hips you seem to be an ideal candidate for safer hip implants as your hip dips are modest in depth and lie exactly between the described anatomic boundaries.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I was wondering if it possible to augment the zygomatic arch with PEEK? I know its possible with silicone since its flexible and easier to get it onto the arch, I have seen many of your design do that. But what about PEEK? I assume that’s not really possible from intra-oral or eyelid incision like silicone? Is it possible to do any other way, perhaps with incision in your sideburns or something? And what about fixation in that area? 

A:it is not a problem with an intraoral or lower eyelid approach for a PEEK zygomatic arch implant placement. Its stiffness provides some advantages over silicone which has the potential to ‘flip an edge’ way back on the posterior arch where you can’t see or feel it in surgery. The key in zygomatic arch implants regardless of the material or approach is that you need a visible flange for screw fixation.

I wouldn’t use a side burn approach, which works well for a posterior zygomatic arch osteotomy, but the access is too limited for the placement of an implant.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley My main concern is that my forehead sticks outward, even though the rest of my head size is normal. Will the surgery make it flatter and more proportionate to my face?

A:With bony forehead reduction the objective is to make it less protrusive and in better proportion to the rest of your face and head. How successful that it will be depends on the thickness of the forehead bone. This requires a 3D skull scan to measure the thickness of the bone to determine if a safe and effective bone reduction can be done.

Dr. Barry Eppley

Plastic Surgeon

Q; Dr. Eppley, I am interested in your rib removal procedure combined with buttock implants. I’m wondering if the rib removal procedure is only really effective if you are already pretty thin, or is liposuction done alongside the procedure to maximize the results?

A:The subcutaneous fat layer is another anatomic barrier in waist line and torso narrowing surgery. You don’t want it to be very thick as it will camouflage any underlying structural modifications from rib removal surgery. In some rib removal patients where there is some fullness in the flanks and along the waistline and there is not a 360° subcutaneous fat layer problem liposuction is combined with the rib removal surgery. However if the fat layer is thick and extensive then it would be prudent to have that reduced first.

To put this statement into context for you I would need to see some body pictures for evaluation.

Dr. Barry Eppley

Plastic Surgeon

Q: Dr. Eppley, I have read many of your online responses and would greatly appreciate your opinion on my situation. Four months ago, I underwent placement of malar/infraorbital implants via an intraoral approach. The implants were removed two months later, also through the intraoral route, meaning they were in place for approximately two months. Since their removal, I have noticed persistent fullness in the midface, along with a change in my upper lip appearance. Specifically, my upper lip now appears narrower, and the corners seem less everted (more tucked in) compared to my pre-operative state.

I am trying to understand the most likely cause of this change. From my perspective, possible explanations may include:

– Residual swelling or soft tissue edema in the midface

– Lack of soft tissue re-adherence to the underlying bone

– Scar tissue formation from the intraoral dissection

– Possible descent or altered positioning of the midface soft tissue

Do these types of upper lip changes typically resolve over time as the tissues settle and reattach, or can they become permanent?

If this does not improve, what treatment options would be available to restore the original upper lip appearance?

Thank you very much for your time and insight.

A:You have already provided the explanation for the residual effect that you have and could be precisely predicted when using the intraoral approach for the placement of such mid face implants.

One of your explanations, possible descent or altered positioning of the midface soft tissue, is exactly the reason why. When you enter the mouth to reach the undereye cheek  areas you have to detach all of the soft tissues including muscle attachments along the way. Then when the implants are removed all of these soft tissue attachments do not return from whence they were and by gravity end up more inferiorly positioned (fallen). This is exactly what happens with any type of midface degloving. This speaks to why I don’t use the intraoral approach for such midface implants as this is going to be a sequelae, even if you didn’t remove the implants, from that surgical approach. This does not occur when you use a more direct lower eyelid approach.

This is not a solvable or an improvable midface soft tissue problem.

Dr. Barry Eppley

Q: Dr. Eppley, I am interested in facial augmentation to achieve a more defined, masculine, and symmetric lower and midface. I’m attaching two photos for your review: The first is my current/original photo (front-facing selfie). The second is an AI-generated reference image showing the look I’m aiming for – a sharper jawline with better angularity and projection, enhanced cheek structure for midface balance, and improved orbital rim/eye area support to address minor asymmetry and overall harmony. Specifically, I’m inquiring about the feasibility of achieving a transformation similar to the reference photo using: Custom jaw implants (e.g., wrap-around jawline or jaw angle + chin for definition and projection) Cheek implants (malar or infraorbital-malar) Orbital eye bone area surgery (infraorbital rim implants or custom orbital rim augmentation for better under-eye support and symmetry correction) I’d like to know: Is this level of change realistically achievable with the above procedures (or any recommended variations/combinations), based on my current anatomy from the attached photos?  I appreciate any guidance you can provide.

A:Thank you for your inquiry and sending your pictures. The purpose of imaging, whether it is done by AI or whether I do the imaging in collaboration with the patient, is to establish targets for the surgery. It is not done to show people actual results that may occur from the surgery. Rather it sets the target for which the surgery is designed to try to achieve as close as possible. That being said an answer to your specific questions:

1) The AI generated image is not a realistic or a completely achievable outcome.

2) What it does tell me, at least in this limited front view, is that the jawline augmentation effect is a high and wide augmentation look and there is a very specific cheek augmentation effect shown which would not be the classic high cheekbone horizontal augmentation look. But it takes additional views in the side and oblique angles to quantify what an implant design may be for this potential type of change.

3) You do have one advantage when it comes to try to get in the ballpark of this type of change and that you are thin with little facial fat. While  you are never going to get  that severe concave contour change between the cheeks and jawline shown in the AI image at least you have a chance to get somewhat of that effect.

Dr. Barry Eppley

Plastic Surgeon